Determinants of hypoalbuminemia in hemodialysis patients: A literature review
DOI:
https://doi.org/10.35335/midwifery.v14i4.2486Keywords:
Chronic Inflammation, Hemodialysis, Hypoalbuminemia, Nutritional Status, Protein IntakeAbstract
Hypoalbuminemia was a frequent nutritional complication among patients undergoing hemodialysis and was associated with unfavorable clinical outcomes. This review aimed to identify factors associated with hypoalbuminemia in adult hemodialysis patients. A literature search was conducted in July 2026 in PubMed, selected for its indexed biomedical coverage, and Google Scholar, selected to capture regional and Indonesian-language publications. Observational studies published from 2021 to 2026 that examined serum albumin in adults receiving hemodialysis were screened by title, abstract, and full text. Six studies from Colombia, Jordan, Indonesia, the Republic of the Congo, and China were synthesized narratively: one retrospective multicenter cohort and five cross-sectional studies, including one machine-learning analysis. Inadequate protein intake and chronic inflammation were the most consistently reported correlates of low albumin. Evidence linking dialysis frequency and adequacy to albumin was limited to descriptive findings, and poor dietary adherence was associated with protein-energy wasting rather than independently with hypoalbuminemia. The contribution of this review is an integrated framework of nutritional, inflammatory, treatment-related, and behavioral determinants for Indonesian hemodialysis practice, where local studies have so far examined single determinants. Albumin monitoring should be combined with assessment of dietary intake and adherence, inflammation, and delivered dialysis. The small number of studies and heterogeneous outcome definitions limit the certainty of these conclusions.
Downloads
References
Adrianto, Y., & Utari, D. M. (2024). Malnutrition inflammation in chronic kidney disease undergoing hemodialysis in Cipto Mangunkusumo Hospital. The Indonesian Journal of Nutrition) Jurnal Gizi Indonesia, 13(1), 25–34. https://doi.org/10.14710/jgi.13.3.25-34
Alp Ikizler, T., Burrowes, J. D., Byham-Gray, L. D., Campbell, K. L., Carrero, J.-J., Chan, W., Fouque, D., Friedman, A. N., Ghaddar, S., Jordi Goldstein-Fuchs, D., Kaysen, G. A., Kopple, J. D., Teta, D., Yee-Moon Wang, A., & Cuppari, L. (2020). KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD: 2020 UPDATE. In AJKD (Vol. 76, Nomor 1).
Carrero, J. J., Thomas, F., Nagy, K., Arogundade, F., Avesani, C. M., Chan, M., Chmielewski, M., Cordeiro, A. C., Espinosa-Cuevas, A., Fiaccadori, E., Guebre-Egziabher, F., Hand, R. K., Hung, A. M., Ikizler, T. A., Johansson, L. R., Kalantar-Zadeh, K., Karupaiah, T., Lindholm, B., Marckmann, P., … Kovesdy, C. P. (2018). Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies From the International Society of Renal Nutrition and Metabolism. Journal of Renal Nutrition, 28(6), 380–392. https://doi.org/10.1053/j.jrn.2018.08.006
Castillo, J. C., Vesga, J., Rivera, A., Rutherford, P., Sanchez, R., Oliveros, H., Lindholm, B., Sanabria, M., Camargo, D., Martinez, A., Quiñones, S., Ducuara, D. A., Munevar, M., Martinez, E., Dazzarola, M. P., Gomez, R., & del Castillo, A. (2025). Variations in Serum Albumin Levels Over Time in Patients Treated With Conventional Hemodialysis or Expanded Hemodialysis: A Cohort Study. Hemodialysis International, 29(3), 327–334. https://doi.org/10.1111/hdi.13232
Chen, X., Wang, G., Yin, X., Liu, W., Huang, H., & Li, D. (2025). Inflammatory and nutritional indices for overall survival in Hemodialysis patients: a multicenter cohort study. BMC Nephrology, 26(1). https://doi.org/10.1186/s12882-025-04121-3
Dewi, N. K. P. A., & Lestari, N. M. D. A. (2024). Nutritional therapy in hypoalbuminemia patient with chronic kidney disease on hemodialysis. Intisari Sains Medis, 15(3), 1320–1323. https://doi.org/10.15562/ism.v15i3.2240
Farrah, D., Hammad, S. S., Awwad, A., Alnadi, S. A., & Al-Btoush, A. (2025). Protein-energy wasting risk in end-stage renal disease patients undergoing haemodialysis and patients’ adherence to dietary recommendations in Jordan: A cross-sectional study. BMJ Open, 15(3). https://doi.org/10.1136/bmjopen-2024-094530
Fiaccadori, E., Sabatino, A., Barazzoni, R., Carrero, J. J., Cupisti, A., De Waele, E., Jonckheer, J., Singer, P., & Cuerda, C. (2021). ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clinical Nutrition, 40(4), 1644–1668. https://doi.org/10.1016/j.clnu.2021.01.028
Hamdan, Z., Nazzal, Z., Al-Amouri, F. M., Ishtayah, S., Sammoudi, S., Bsharat, L., & Badrasawi, M. (2025). Factors associated with malnutrition inflammation score among hemodialysis patients: A cross-sectional investigation in tertiary care hospital, Palestine. PLoS ONE, 20(1 January). https://doi.org/10.1371/journal.pone.0317132
Hanna, R. M., Ghobry, L., Wassef, O., Rhee, C. M., & Kalantar-Zadeh, K. (2020). A Practical Approach to Nutrition, Protein-Energy Wasting, Sarcopenia, and Cachexia in Patients with Chronic Kidney Disease. In Blood Purification (Vol. 49, Nomor 1–2, hal. 202–211). S. Karger AG. https://doi.org/10.1159/000504240
Indonesian Renal Registry. (2022). Number of Renal Units Report Data Number of Renal Units by Institutional Type in Indonesia in 2022 Renal unit. https://www.indonesianrenalregistry.org/media/2022 15th Annual Report of Indonesian Renal Registry English .pdf
Jiwintarum, Y., Anindita, K., Yustin Tatontos, E., Anggit Jiwantoro, Y., Teknologi Laboratorium Medis, J., Kemenkes Mataram, P., & Keperawatan, J. (2026). Analysis Of The Effect Of Hemodialysis Frequency On Hemoglobin, Ureum, Creatinine And Albumin Levels In Chronic Kidney Failure Patients At Praya Hospital. Jurnal Analis Medika Biosains (JAMBS), 13(01), 33–36. https://doi.org/10.32807/jambs.v13i01.569
Kalantar-Zadeh, K., Jafar, T. H., Nitsch, D., Neuen, B. L., & Perkovic, V. (2021). Chronic kidney disease. In The Lancet (Vol. 398, Nomor 10302, hal. 786–802). Elsevier B.V. https://doi.org/10.1016/S0140-6736(21)00519-5
Karabelas, A. J. (2024). On the total albumin losses during haemocatharsis. In Journal of Artificial Organs (Vol. 27, Nomor 2, hal. 91–99). Springer. https://doi.org/10.1007/s10047-023-01430-y
Kaysen, G. A., Greene, T., Larive, B., Mehta, R. L., Lindsay, R., Depner, T. A., Hall, Y. N., Daugirdas, J. T., & Chertow, G. M. (2012). The effect of frequent hemodialysis on nutrition and body composition: Frequent Hemodialysis Network Trial. Kidney International, 82(1), 90–99. https://doi.org/10.1038/ki.2012.75
Kolak, E., Radić, J., Vučković, M., Bučan Nenadić, D., Begović, M., & Radić, M. (2022). Nutritional and Hydration Status and Adherence to Dietary Recommendations in Dalmatian Dialysis Patients. Nutrients, 14(17). https://doi.org/10.3390/nu14173553
Kovesdy, C. P. (2022). Epidemiology of chronic kidney disease: an update 2022. In Kidney International Supplements (Vol. 12, Nomor 1, hal. 7–11). Elsevier B.V. https://doi.org/10.1016/j.kisu.2021.11.003
Liu, P. J., Guo, J., Zhang, Y., Wang, F., & Yu, K. (2023). Effects of oral nutritional supplements on the nutritional status and inflammatory markers in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials. Clinical Kidney Journal, 16(11), 2271–2288. https://doi.org/10.1093/ckj/sfad130
Navaneethan, S. D., Bansal, N., Cavanaugh, K. L., Chang, A., Crowley, S., Delgado, C., Estrella, M. M., Ghossein, C., Ikizler, T. A., Koncicki, H., St. Peter, W., Tuttle, K. R., & William, J. (2025). KDOQI US Commentary on the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD. American Journal of Kidney Diseases, 85(2), 135–176. https://doi.org/10.1053/j.ajkd.2024.08.003
Puspitasari, M., Afiatin, Oktaria, V., Wardhani, Y., & Wijaya, W. (2024). Five-year survival analysis and predictors of mortality of adult hemodialysis patients in Indonesia: a nationwide database analysis. International Urology and Nephrology, 56(11), 3657–3664. https://doi.org/10.1007/s11255-024-04118-1
Rami Arab, L., Dabernat, S., Boutin, J., Bordenave, C., Karmani, M., Colombiès, B., Delmas, Y., De-La-Faille, R., De Précigout, V., Rubin, S., Moreau, K., & Bats, M. L. (2023). Impact of Albumin Assays in the Diagnosis of Malnutrition in Hemodialysis Patients: A Cohort Study. Journal of Renal Nutrition, 33(2), 332–336. https://doi.org/10.1053/j.jrn.2022.10.001
Selvianita, D., Hidayat, N., Puspaningtyas, D. E., & Hilman, H. (2025). Selvianita_Asupan Protein Dan Kadar Albumin Pasien Gagal Ginjal Kronik dengan Hemodialisis. Jurnal Kesehatan Perintis, 2(12), 169–176. https://doi.org/https://doi.org/10.33653/07smt727
Sinomono, D. T. E., Bangui, O., Mponguili, T., Ngabé, E. P. G., Mahoungou, G. H., Onguemby, P. E., & Loumingou, R. (2026). Inflammatory Syndrome and Malnutrition in Chronic Hemodialysis Patients in Brazzaville: Prevalence and Factors Associated with Hypoalbuminemia. Open Journal of Nephrology, 16(02), 311–320. https://doi.org/10.4236/ojneph.2026.162028
Yang, C. H., Chen, Y. S., Chen, J. B., Huang, H. C., & Chuang, L. Y. (2023). Application of deep learning to predict the low serum albumin in new hemodialysis patients. Nutrition and Metabolism, 20(1). https://doi.org/10.1186/s12986-023-00746-z
Zhang, J., Xu, F., Qing, W., Zhuang, P., & Xu, X. (2025). Research progress on influencing factors and intervention methods of protein-energy wasting in maintenance hemodialysis patients: A literature review. In Medicine (United States) (Vol. 104, Nomor 8, hal. e41592). Lippincott Williams and Wilkins. https://doi.org/10.1097/MD.0000000000041592
Zhang, K., Qu, X., Xu, S., Xu, L., Li, X., & Liu, L. (2025). Construction and validation of a cross-sectional risk classification model for hypoproteinemia in single-center maintenance hemodialysis patient. Scientific Reports, 15(1). https://doi.org/10.1038/s41598-025-19913-8
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Fatimah Az Zahra, Indiarto Nindyo Prasetyadi, Juni Chudri
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
