Please select the eligibility criteria that correspond to the clinical trial below.
Title: Multimodal Therapeutic Approach by Exercise, Oral Nutritional Supplementation, Omega 3 and Androgen in Undernourished Maintenance Hemodialysis Patients (AMERICANO)
Brief Summary: The aim of the study is to evaluate a 3 months integrated multimodal therapeutic approach including exercise training program with ergocycle during dialysis sessions, oral nutritional supplementation, omega 3 and androgen, on effort tolerance and quality of life of under-nourish maintenance hemodialysis Chronic Kidney Disease (CKD) patient.


Options:
A: Inclusion Criteria:

* Aged \> 18 years old and ≤70 years old
* Undergone dialysis at least for 6 months.
* Categorised as malnourished based on BMI \<24 kg/m² and serum albumin ≤40 g/L criteria
* No incidence of hospitalisation for past 3 months, free of infection/sepsis and have not undergone surgery for past 6 months.

Exclusion Criteria:

* Patients with high inflammatory diseases, malignancy, cancer
* Vegetarian patients
B: Inclusion Criteria:

* On hemodialysis for more than 3 months, on a thrice weekly hemodialysis program;
* Adequately dialyzed (Kt/V \> 1.4).
* Age \> 18 years old.
* Properly functioning AV Graft

Exclusion Criteria:

* Patients unable to perform exercise due to cardiovascular disease, osteoarthritis, etc.
* Pregnant women.
* Severe unstable underlying disease besides commonly associated with ESRD. Cardiac patients that are stable will be included.
* Patients hospitalized within the last month prior to the study.
* Patients will not perform the MRI if contraindication as determined using the VUMC MRI Procedure Screening Form (attached) or prior claustrophobic reaction in an MRI scanner.
C: Inclusion Criteria:

* Hemodialysis patient since at least 6 month
* Patient aged 18 years or older
* Written consent to participate in the study
* No acute infection or hospitalization
* Opinion of Cardiologist saying there is no known evidence against the evaluation of the maximum exercise capacity
* Protein-energy wasting diagnosed if at least two of this characteristics are present
* Serum albumin \<3.8 g per 100 ml (Bromcresol Green)
* Serum prealbumin (transthyretin) \<30mg per 100 ml
* Reduce body mass (BMI \<23)
* Unintentional 10% weight loss over 6 months
* Lean body mass index \< 10th percentile

Exclusion Criteria:

* Presence of comorbidity which compromising the survival within 6 month
* Unintentional low DEI \<20 kcal kg_1 day_1
* HIV or HCV positive
* History of hormone dependent cancer
* Suspected or confirmed prostate cancer or breast carcinoma
* Known hypersensitivity for testosterone
* Presence or history of hepatic tumor
* Inability to follow the rehabilitation program
* Inadequate dialysis dosage (\<12 hours / week or Kt/V index\< 1,2) Pregnant or planning pregnancy and lactating women during study period
* Adult patient protected by law
* Patient who don't sign his informed consent
D: Inclusion Criteria:

1. On hemodialysis for more than 6 months
2. Optimally dialyzed with a biocompatible membrane (URR \> 70% and/or delivered Kt/V \> 1.2)
3. Suboptimal nutritional status identified by:

   * Serum albumin less than or equal to 3.90 g/dl and one of the three following criteria:

     * Protein catabolic rate less than 0.95 g/kg/d calculated by three point urea kinetic modeling on at least 2 occasions over the past 6 months
     * Progressive unintentional weight loss more than 2.5% of the initial or ideal body weight over the past 6 months and/or patients who are less than 90% of standard body weight
     * Biochemical parameters of malnutrition defined by 1 of 2 of the following measurements over the consecutive two months prior to inclusion:

       * Serum transferrin concentration less than 225 mg/dl
       * Serum prealbumin concentration less than 32 mg/dl

Exclusion Criteria:

1. Active auto-immune, inflammatory or infectious disease
2. Documented malignancy within the last 12 months
3. Patients on unusual dietary restrictions
4. Life-expectancy less than 6 months
5. Inability to tolerate nutritional supplements

Answer: C