Renal dietitians carry a heavy load: direct patient care, administrative work, and continuing education to maintain credentials. Amid coaching patients
on sodium and fluid intake, phosphate additives, and CKD-MBD goals, other conditions can develop quietly, easy for the RD and the rest of the care team
to miss.

Think of a minor complaint about creeping fatigue or a shift in energy. Clothes that gradually fit loose over months. A patient who is hospitalized more often, easy to overlook in a population where frequent hospitalization is already common. Or the patient who used to putter around the house and go to weekly bingo but is now glued to a chair at home and hasn’t mentioned it to anyone on the care team. These are subtle signs your patient may be
experiencing frailty.

Some problems on dialysis are hard to miss, thanks to monthly labs, pre- and post-dialysis weights, and other routine measures. Frailty is different,
it’s inherently easy to overlook and isn’t routinely measured in practice.

A few simple questions about weight loss, exhaustion, and physical activity, adapted from the Fried Frailty Phenotype, can be built into your practice
to help monitor at-risk patients:

  1. Weight Loss
    1. In the last year, have you lost more than 10 pounds unintentionally?
      If not, how much weight have you lost, if any?
    2. Check the patient’s BMI: a value under 18.5 kg/m² is a risk factor.
  2. Exhaustion
    1. Do you feel full of energy?
    2. During the last 4 weeks, how often have you rested in bed during the day?
      (Every day / Every week / Once / Not at all)
  3. Physical Activity
    1. Do you walk for more than 30 minutes per day?
    2. Do you sit for most of the day?

Patients with unintentional weight loss or a low BMI, who don’t feel full of energy and rest in bed routinely, or who are more sedentary than active,
are at risk of being pre-frail or frail, and should be addressed right away with nutrition intervention.

Dietitians can help a great deal by prioritizing high protein and adequate calorie intake, in the range of ≥1.2 g/kg/day of protein and 30–35 kcal/kg/day,
higher than KDOQI guidelines recommend for metabolically stable patients.

Encouraging healthy fats like omega-3 fatty acids, and ensuring adequate micronutrient balance, especially Vitamins D, C, and E, also helps combat frailty.

Frailty, sarcopenia, and protein-energy wasting overlap considerably, but you don’t need to wait for all three to appear before addressing patient needs.
Each is independently associated with poor outcomes and warrants intervention on its own.

To support patients, clinicians can do three things:

  1. Incorporate routine frailty screening into practice.
  2. Intervene early with available nutrition support tools:
    power packing, diet liberalization, oral nutrition supplements,
    IDPN therapy, enteral nutrition, and total parenteral nutrition as needed.
  3. Collaborate with the interdisciplinary team on other frailty interventions.

To learn more about frailty and how PCA may be able to help your pre-frail and frail patients, visit pcacorp.com.

References

  • Chan, G. C. K., Kalantar-Zadeh, K., Ng, J. K. C., Tian, N., Burns, A., Chow, K. M., … & Li, P. K. T. (2024).
    Frailty in patients on dialysis. Kidney International, 106(1), 35-49.
  • Wadhwa, A., Balbale, S. N., Palleti, S. K., Samra, M., Lopez-Soler, R. I., Stroupe, K. T., … & Huisingh-Scheetz, M. (2023).
    Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit.
    BMC Nephrology, 24(1), 371.
  • McAdams-DeMarco, M. A., Law, A., Salter, M. L., Boyarsky, B., & Gimenez, L., Segev, D. L. (2013).
    Frailty as a Novel Predictor of Mortality and Hospitalization in Hemodialysis Patients of All Ages.
    Journal of the American Geriatrics Society, 61(6), 896-901.
  • Sy, J., Streja, E., Grimes, B., & Johansen, K. L. (2020).
    The marginal cost of frailty among Medicare patients on hemodialysis.
    Kidney International Reports, 5(3), 289-295.
  • Ikizler, T. A., Burrowes, J. D., Byham-Gray, L. D., Campbell, K. L., Carrero, J. J., Chan, W., … & Cuppari, L. (2020).
    KDOQI clinical practice guideline for nutrition in CKD: 2020 update.
    American Journal of Kidney Diseases, 76(3), S1-S107.
  • Li, W., Chen, S., Wan, J., Chen, L., Xing, L., Gao, Z., & Chen, L. (2025).
    Comprehensive dietary antioxidant index and chronic kidney disease: mediating role of frailty and its impact on mortality outcomes in adults.
    Frontiers in Nutrition, 12, 1679774.

We thank our guest blogger Maiya Hogan, MS, RDN, CD, CNSC, Director, Research and Education for sharing her knowledge and writing this blog post!