3.34 mmol/L), lifestyle changes may be the initial therapy. If target LDL levels are not achieved (LDL ! 100 mg/dL [2.57 mmol/L]), low-dose statin therapy can be instituted. 2. For patients with LDL R 130 mg/dL (3.36 mmol/L), lifestyle changes alone are likely to be ineffective. Statins can used as initial therapy and the dose titrated to achieve target LDL ! 100 mg/dL (2.57 mmol/L). 3. For patients with triglyceride (TG) R 200 mg/dL (3.36 mmol/L), the goal is to achieve non-HDL cholesterol % 130 mg/dL. Initial treatment comprises lifestyle changes plus a low-dose statin, which is increased as needed to achieve target levels. In summary, patients with CKD have a higher burden of dyslipidemia in comparison with the general population and are at increased risk for cardiovascular morbidity and mortality. This disproportionate cardiovascular disease burden places CKD patients in the highest risk category, as defined by the Adult Treatment Panel III (ATPIII) treatment guidelines. Identification of these patients and intervention via lifestyle and/or pharmacologic therapy is a sound, initial clinical approach. Ongoing randomized trials will provide more definitive data on the risk and benefits of lipid-lowering therapy in this population of patients. Nutritional issues As patients progress through the stages of CKD, nutritional requirements are altered and metabolism of protein, water, salt, potassium, and phosphorus are affected [50]. These changes lead to ineffective energy generation despite adequate intake of protein and carbohydrate substrates. In more extreme manifestations, these alterations in nutrient use cause ‘‘uremic malnutrition,’’ a syndrome that is distinct from malnutrition caused by inadequate nutrient intake. Both inadequate nutrient intake and ineffective nutrient use can contribute to nutritional disorders in CKD patients and we will not distinguish between these etiologies in our discussion. The association between uremic malnutrition and outcomes in the early stages of CKD has not been investigated. However, there is adequate evidence to suggest that a poor predialysis, nutritional status increases patient morbidity and mortality after initiation of renal replacement therapy [51]. Maintenance of neutral nitrogen balance is important for preservation of nutritional health in patients with chronic renal impairment. Treatment goals in this setting should be to establish and maintain optimal nutritional status, minimize uremic symptoms and signs as renal impairment declines, and to establish a nutritional plan that is acceptable to the patient. To accomplish these goals, involvement of a dietician in the care of these patients is often necessary. CHRONIC KIDNEY DISEASE AND ITS COMPLICATIONS 339 The ability of the generalist to assess nutritional status in the setting of CKD is important in addressing the nutritional needs of individuals with CKD. Several nutritional markers can be used to assess nutritional status. Serum albumin is the most extensively studied nutritional marker in all patient populations because of its easy availability and strong association with hospitalization and risk of death [52]. Low levels of serum albumin are highly predictive of poor clinical outcomes in all stages of CKD, and therefore, serum albumin is considered a reliable marker of general clinical status [53]. K/DOQI guidelines recommend maintenance of an albumin value of 4.0 although this has not been proven in randomized, prospective clinical trials. Non-nutritional causes of hypoalbuminemia, such as tissue injury, hepatic disease, gastrointestinal disorders, and volume overload, can affect the specificity of this marker [54]. Moreover, given that serum albumin is a negative acute-phase reactant, its levels decrease in response to inflammatory stimuli such as burns, infection, or trauma [55]. Serum prealbumin is a sensitive marker for assessing subtle changes in visceral protein stores given its low body pool and fairly rapid turnover of 2 to 3 days. Levels less than 30 mg/dL suggest protein depletion [56]. Low serum creatinine concentrations are associated with poor clinical outcome in maintenance of stage 5 CKD. Patients with serum creatinine concentration less than 10 mg/dL should be evaluated for muscle wasting as a result of poor nutrition. Serum cholesterol concentration is an independent predictor of mortality in chronic dialysis patients, and low levels can suggest low dietary and energy intake. Serum cholesterol concentrations less than 150 mg/dL also warrant careful evaluation of nutritional status. Use of Subjective Global Assessment (SGA) as a nutritional assessment tool for various stages of CKD is growing in both clinical and research settings [57]. Studies have demonstrated that SGA can adequately assess nutritional status in the setting of peritoneal and hemodialysis [58]. Prevention and treatment are as important as identifying inadequate nutritional status in CKD patients. Therapy varies with the severity of CKD and no single treatment approach will alleviate the adverse consequences associated with uremic malnutrition [59]. In cases in which low protein and energy intake (as noted in patients on unrestricted diets), a dietary protein intake of less than 0.75 g/kg/d is an early warning sign for the development of uremic malnutrition. For many CKD patients, poor nutrition may warrant initiation of hemodialysis or be