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protein - energy malnutrition ( pem ) is highly prevalent in chronic kidney disease ( ckd ) patients on hemodialysis ( hd ) [ 14 ] .
low serum albumin and transferrin are surrogate markers of pem , with low serum albumin being one of the most commonly used in ckd .
the progressive deterioration of kidney function in ckd leads to retention of many substances that are normally excreted by the kidney .
the retention of uremic toxins and other comorbid conditions can lead to a lowered appetite and a decrease in protein and energy intake , which is often compounded by ill - advised imposition of various dietary restrictions .   among the causes of malnutrition in hd patients
, inadequate dietary protein intake appears to be one of the most common and important .
low protein intake and low serum albumin have been shown to be independently associated with increased risk of mortality in patients on dialysis [ 9 , 10 ] .
mortality increases significantly as albumin levels fall below 39  g / l . in the united states
g / l in 50% of hypoalbuminemic dialysis patients could save 1,400 lives and decrease hospitalizations by 6,300 per year , although a causal relationship has not been established .  
the national kidney foundation kidney disease outcomes quality initiative ( nkf kdoqi ) has proposed a minimum intake of 1.2  g protein per kilogram of body weight per day to ensure a neutral protein balance in the hemodialysis population . despite this recommendation ,
inadequate protein intake persists in many chronic hd patients [ 8 , 14 , 15 ] .
moreover , the persistent marked reduction of daily nutrient intake , even if limited to a single day of the week , has been shown to be an independent determinant of reversible impairment of nutritional status .
studies have suggested that individual dietetic counseling has significant potential to decrease the incidence of pem in hd patients [ 16 , 17 ] .
however , standardized approaches to counseling have not been well documented . complicating the problem , increasing dietary protein intake brings about the associated concerns of hyperphosphatemia and hyperkalemia , as potential consequences of increased dietary phosphorus and potassium burden [ 7 , 18 , 19 ] .  
the ep-10 protein counter , a protein exchange list developed for the quantification and education of dietary protein intake during dietetic counseling , has recently been validated in the asian setting .
the purpose of this study was to investigate the effectiveness of using the ep-10 in dietetic assessment and counseling to improve the albumin and transferrin levels of ckd patients on hd .
forty - five patients on stable hemodialysis with serum albumin of less than 38  g / l were enrolled in the study .
forty of these patients were on phosphate binders prior to enrollment into the study .  
data on age , sex , race , other relevant biochemical results , cause of renal disease , medications , years of dialysis , and comorbid conditions were collected at baseline from the patients ' medical and clinical charts .
patients ' dry weight and body mass index ( bmi ) were obtained from the same sources at baseline and at three months after intervention .
serum albumin , serum transferrin , kinetic modeling ( kt / v ) , potassium , and phosphate levels were measured at baseline before nutritional intervention and at three months after intervention .
predialysis serum albumin levels were tested in the laboratory using bromocresol green colorimetric assay at wavelength of 630  nm .  

kt / v was calculated using the following urea kinetic modeling formula [ 21 , 22 ] : 
 ( 1)ktv=ln(r0.008t)+((43.5r)ufw ) , 
 where r is the ratio of postdialysis to predialysis serum urea nitrogen , t is time of dialysis in hours , uf is the amount of ultrafiltration ( in liters ) , and w is the postdialysis weight ( in kg ) .
nutritional intervention was provided to patients by the same clinical dietitian ( sll ) trained in renal nutrition .
areas covered included , but were not limited to , dietary recall , dietary protein intake quantification and assessment , and individualized dietary recommendations based on the eating habits of the patient .
the latter two were done using the ep-10 method as described by lim et al .
patients were educated on the importance of adequate protein intake and the number of protein exchanges required using the ep-10 method . recommended protein intakes
were based on the nkf kdoqi recommendation of 1.2  g protein per kilogram , body weight per day .
these were then explained to the patient using food models and pictures of protein portions based on ep-10 protein exchanges . the ep-10 food exchange list and a written individualized meal plan that included protein distribution were also given to each patient .  
patients whose usual dietary intake provided insufficient calories were educated on ways to increase their caloric intake .
patients assessed as being unable to meet their nutritional requirement through diet alone were prescribed suitable nutritional supplements .
in addition to education on protein and caloric requirements , dietary implications of metabolic disorders such as hyperphosphatemia , hyperkalemia , hyperlipidemia , and diabetes mellitus were addressed during the counseling session when necessary .
all statistical analyses were performed using statistical package for social science ( pasw statistics , rel . 18.0.1 . 2009 .
the mean differences between the biochemical parameters at baseline and at three months postintervention were evaluated using the paired t - test when the normality assumption was satisfied . where the latter was not satisfied , the wilcoxon signed - rank test was used .

 table 1 shows the mean age , age range , gender ratio , diabetic status , and mean duration of hd of the patients . using the ep-10 method ,
the mean daily dietary protein intake of the study subjects was 45  10  g. this was significantly lower than their mean protein requirement , which was 68  9  g per day based on the 1.2  g protein / kg body weight per day as recommended by nkf kdoqi .
of the forty - five patients , 31 ( 69% ) reported no loss of appetite .
eight patients were underweight ( bmi < 20  kg / m ) , 15 patients were of normal weight ( bmi 2024.9  kg / m ) , and 22 patients were overweight or obese ( bmi > 25 
six showed an increase in dry weight of between 0.4 to 4.4  kg three months after intervention while the two remaining underweight patients maintained their dry weight .  
table 2 shows the mean differences between the biochemical parameters at baseline and three months postnutritional intervention .
thirty - eight ( 84% ) patients showed a rise in albumin levels , while two ( 4% ) patients maintained their albumin level .
all eight underweight patients showed an increase in albumin levels between 1.0 to 13.0  g / l ( mean increase of 6.6  4.8 
thirty - six ( 80% ) patients had low transferrin levels ( < 200  mg / dl ) initially .
after nutritional intervention , 28 out of these 36 ( 78% ) patients had an increase in transferrin levels and two maintained their levels .  
there was no significant rise in the mean levels of potassium , phosphate , and kt / v ( table 2 ) .
none of the five patients who were not prescribed phosphate binders had a significant increase in serum phosphorus .
hemodialysis , amongst other renal replacement therapy , is an accepted and successful treatment modality for supporting patients with chronic renal failure .
however , factors like malnutrition , age , and other comorbidities , with emphasis on cardiovascular disease , still cause serious complications and adversely affect quality of life and risk of mortality in this population [ 14 , 20 , 24 ] .
food exchange lists , primarily carbohydrate exchange lists , have been widely used for many years to facilitate meal planning in diabetes and weight reduction .
however , there is a lack of literature showing that exchange lists improve understanding and dietary compliance .
the results of this study show that the ep-10 protein counter , when incorporated into individualized dietetic counseling , can potentially improve the nutritional parameters of hd patients .  
both albumin and transferrin are hepatic transport proteins with transferrin having a shorter half - life than albumin . both reflect protein status and are used extensively as markers of nutritional status . in a study by neyra et al .
( 2000 ) , it was found that changes in albumin can be reliably predicted by earlier changes in serum transferrin .
decreases in serum albumin and/or transferrin can be caused by insufficient protein and/or caloric intake .
these levels are also decreased in inflammation , as both albumin and transferrin are negative acute phase proteins .
however , research has shown that albumin levels in hd patients can respond to nutritional interventions despite high levels of inflammatory markers .
several studies have reported a strong association between hypoalbuminemia and morbidity and mortality rates in hd patients , suggesting that nutritional interventions that maintain or increase serum albumin to normal levels may be associated with improved long - term survival [ 1 , 2631 ] .
( 1993 ) found serum albumin to be the single most powerful predictor of patient survival , with a 2  g / l decrease in serum albumin levels associated with a 25% decrease in survival .
given this strong association between hypoalbuminemia and patient outcomes , an intervention that successfully improves serum albumin levels may exert substantial effects on overall patient health and survival .
there are many barriers to adequate nutritional intake in hd patients , including poor nutrition knowledge , poor appetite , and other functional or lifestyle issues .
targeting nutritional barriers has been shown to increase albumin levels , even in the presence of elevated inflammatory markers . in our study ,
insufficient protein and/or energy intake did not appear to be a consequence of poor appetite , as the majority of our hypoalbuminemic patients reported having a normal appetite .
the significant improvement in albumin and transferrin levels of patients in this study after nutritional intervention suggests that the ep-10 protein counter can be easily understood and used by patients to increase their protein intake and thus overcomes at least one barrier to nutritional adequacy .
the kidney plays an important role in maintaining the homeostasis of phosphorus and potassium in the body .
however , the renal mechanisms that ensure a balance of phosphorus and potassium are impaired in patients with kidney disease , leading to increased risk of hyperphosphatemia and hyperkalemia , both of which are associated with higher mortality in patients on hd [ 32 , 33 ] . while limited evidence is available on the correlation between dietary protein intake and serum potassium , dietary phosphorus intake is strongly and positively correlated with dietary protein intake , and a high protein intake is often associated with the development of hyperphosphatemia .
hyperphosphatemia may worsen hyperparathyroidism and renal osteodystrophy , promote vascular calcification and cardiovascular events , and increase mortality [ 3437 ] . in vivo phosphorus
hence it is naturally found in foods that are rich in protein , and imposing dietary phosphorus restriction is often associated with a reduction in dietary protein intake , leading to an increased risk of pem and mortality .  
the results of this study show that using the ep-10 as a dietary assessment and educational tool to increase dietary protein intake to recommended levels did not cause an increase in serum phosphorous , potassium , or kt / v .
this suggests that patients are able to understand and utilize the ep-10 to meet their recommended protein intake and achieve an improvement in their albumin level yet avoid the associated complications of hyperphosphatemia and hyperkalemia .
it also suggests that restricting dietary protein below the current nkf kdoqi guidelines in an attempt to manage serum phosphorous is not necessary with prescription of and compliance to phosphate binders .  
more research needs to be conducted to understand the reasons for insufficient energy and/or protein intake in ckd patients on hd . amongst many possible reasons , it is important to determine if a relationship exists between a patient 's degree of knowledge and understanding and their dietary compliance , as successful individual dietetic counseling relies on this relationship . as this study does not include
a control group , future research should focus on a randomized control trial to assess the effectiveness of ep-10 versus conventional methods in the clinical setting .
the results of this study show that using the ep-10 as an assessment and educational tool during nutritional counseling of hemodialysis patients has the potential to significantly improve albumin and transferrin levels .
objective . 
 the expedited 10  g protein counter ( ep-10 ) is a quick and valid clinical tool for dietary protein quantification . 
 this study aims to assess the clinical effectiveness of the ep-10 in improving serum albumin and transferrin in chronic hemodialysis patients . 
 methods . 
 forty - five patients with low serum albumin ( < 38  
 g / l ) were enrolled in this study . 
 parameters measured included dry weight , height , dietary intake , and levels of serum albumin , transferrin , potassium , phosphate , and kinetic modeling ( kt / v ) . 
 the nutritional intervention incorporated the ep-10 in two ways ( 1 ) to quantify protein intake of patients and ( 2 ) to educate patients to meet their protein requirements . 
 mean values of the nutritional parameters before and after intervention were compared using paired t - test . results . 
 three months after nutritional intervention , mean albumin levels increased significantly from 32.2    4.8  g / 
 l to 37.0    3.2  g / l ( p < 0.001 ) . 
 thirty - eight ( 84% ) patients showed an increase in albumin levels , while two ( 4% ) maintained their levels . 
 of the thirty - six ( 80% ) patients with low transferrin levels ( < 200  mg / dl ) , 28 ( 78% ) had an increase and two maintained their levels after intervention . 
 mean transferrin levels increased significantly from 169.4    39.9  mg / dl to 180.9    38.1  mg / dl ( p < 0.05 ) . conclusion . 
 nutritional intervention incorporating the ep-10 method is able to make significant improvements to albumin and transferrin levels of chronic hemodialysis patients .