Table 4.

Recommendations for starting oral nutrition supplements, enteral nutrition, or parenteral nutrition.

Type of Nutrition	Indication
ONS	Poor appetite and failure in spontaneous dietary intake Energy intake < 30 kcal/kg/day and protein intake < 1.2 g/kg/day * Serum albumin < 3.8 g/dL or prealbumin < 28 mg/mL Unintentional weight loss > 5% Diagnosis of PEW using SGA definition
EN	Patients unable to tolerate nutritional supplementation by mouth and failing on dietary intake with ONS Severe PEW Energy intake < 20 kcal/kg/day Undergoing metabolic stress
PN	If all other forms of nutrition failed ^ For patients with spontaneous intake of at least 20 kcal/kg/day and protein intake of 0.8 g/kg/day

Legend: EN, enteral nutrition; ONS, oral nutrition supplement; PEW, protein-energy wasting; PN, parenteral nutrition; SGA, subjective global assessment; * as per ISRNM guidelines; ^ as per EBPG and KDOQI guidelines, while according to ESPEN guidelines, intradialytic parenteral nutrition should be started before starting EN.