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Protein-energy wasting (PEW), manifested by low serum levels of albumin and weight loss, is common in patients with chronic kidney disease (CKD) and is a strong predictor of mortality. The authors of this Review discuss the evidence indicating that dietary interventions and nutritional support can mitigate PEW and improve outcomes in patients with CKD. They also describe how in-center meals and oral supplements during dialysis may improve survival and quality of life in this group of patients.

Although cardiovascular disease is the most common cause of death among people with chronic renal dysfunction, conventional cardiovascular risk factors are paradoxically associated with improved survival in hemodialysis populations. Here, the authors analyze emerging data that support this 'reverse epidemiology'. Confirmation of this phenomenon might lead to the formulation of more effective management strategies, tailored to patient characteristics and disease stage.

Preliminary findings suggest that oral sodium bicarbonate administration could become a major addition to the armamentarium of renoprotective measures for individuals with chronic kidney disease.

Debate exists regarding the safety of metformin and the risk of metformin-associated lactic acidosis, particularly in the setting of kidney dysfunction. Data from two studies examining the interplay between metformin, acute kidney injury, and complications including lactic acidosis suggest that metformin should be used conservatively in patients with kidney dysfunction.

Early initiation of dialysis has been recommended by guidelines over the past two decades, but recent studies and a randomized, controlled trial indicate that patients who start dialysis early might in fact have worse outcomes. The authors of this Review discuss studies of early and late dialysis initiation and highlight factors that influence the association between dialysis initiation and outcomes in transplant-naive patients with chronic kidney disease and in patients with a failed allograft.

Alkaline phosphatase (ALP) drives skeletal mineralization and has a role in vascular calcification and resulting cardiovascular disease in patients with CKD. Here, the authors describe the mechanisms of ALP-mediated vascular calcification and discuss the therapeutic potential of targeting ALP to improve cardiovascular outcomes in these patients.

Concern exists that a sizeable proportion of patients with chronic kidney disease are not adequately prepared for initiating dialysis therapy. In this Review, members of the Dialysis Advisory Group of the American Society of Nephrology discuss the challenges in preparing patients for dialysis therapy and present a practical step-by-step approach to help transition patients to renal replacement therapy.

In diabetic patients undergoing maintenance haemodialysis, extremely high and low glycaemic levels are associated with increased morbidity and mortality owing to vascular and diabetic complications. The prevention of glycaemic disarrays in this population is challenging owing to factors including changes in the metabolism of glucose and drugs, malnutrition and insulin resistance. Here, the authors review the pathophysiology and management of haemodialysis-induced hypoglycaemia and hyperglycaemia in patients with diabetes.