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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 4  |  Page : 455-462
Assessment of the Nutritional Status of End-Stage Renal Disease Patients on Maintenance Hemodialysis


1 Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Aden, Yemen
2 Department of Internal Medicine and Public Health, Faculty of Medicine and Health Sciences-Aden University, Aden, Yemen
3 Dialysis Unit, Al-Gamhouria Teaching Hospital, Aden, Yemen
4 Dr. Amin Nashar Higher Institute of Health Sciences, Aden, Yemen

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   Abstract 

We assessed the nutritional status of 50 patients on maintenance hemodialysis by performing anthropometric measurement (pre and post dialytic weight, height, mid-upper arm circumference (MUAC) and related biochemical analysis. The malnutrition score was calculated from the body mass index (BMI), MUAC, hemoglobin, clinical signs of nutritional deficiencies and gastrointestinal manifestations. Stepwise multiple logistic regression analysis was carried out with malnutrition as a dependent variable. There was equal number of men and women in the study with a mean age of 39.5±12.1 years. The main cause of renal failure was arterial hypetension (30%), followed by glomerulonephritis (22%). The mean period of hemodialysis was 1.2 ± 0.9 years. The mean total knowledge score about avoidable food was 2.86±1.59 (Total=6) and only 14% have a satisfactory knowledge score. A significant difference between men and women was found in the mean predialytic (52.1±9.6 kg) and post dialytic weight (50.0±9.7 kg) P<0.05, while there was insignificant difference in the mean MUAC (22.6±3.3 centimeters) and BMI (20.3±2.9 kg/meter 2 ). The malnutrition score showed 70% of moderately malnourished patients and 20% severely malnourished. Abnormal biochemical parameters were encountered in the majority of patients. Old age (≥50 years) was significantly associated with malnutrition. All the patients received only six hours of dialysis a week, which was inadequate dose and had the major impact on the patient's nutritional status. We conclude that poor nutritional status was detected among a significant number of patients with poor dietary knowledge and practices. Increased risk of malnutrition was significantly associated with older age (≥50 years) and inadequate dialysis dose.

Keywords: Nutritional status, End-stage renal diseases, Hemodialysis

How to cite this article:
Basaleem HO, Alwan SM, Ahmed AA, Al-Sakkaf KA. Assessment of the Nutritional Status of End-Stage Renal Disease Patients on Maintenance Hemodialysis. Saudi J Kidney Dis Transpl 2004;15:455-62

How to cite this URL:
Basaleem HO, Alwan SM, Ahmed AA, Al-Sakkaf KA. Assessment of the Nutritional Status of End-Stage Renal Disease Patients on Maintenance Hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2014 Oct 24];15:455-62. Available from: http://www.sjkdt.org/text.asp?2004/15/4/455/32877

   Introduction Top


Renal replacement therapy by dialysis is essential for the survival of patients with end-stage renal disease (ESRD) all around the world. [1],[2] Malnutrition is an evident problem in 40-50% of patients with ESRD. Malnutrition is associated with increased infection, poor wound healing, muscle wasting and increased mortality. It is caused by inadequate dietary intake, anorexia, gastrointestinal disturbances, psychosocial and socioeconomic factors or unmet increased nutritional requirements due to impaired protein or energy and/or concomi­tant diseases namely cardiovascular disease, sepsis and inflammation. [3],[4]

When dialysis therapy is started, the uremic symptoms are reduced, the diet is less restri­cted and some patients may show improved nutritional status. [5] However, the results of cross-sectional studies throughout the world indicate that maintenance HD patients are still at risk of malnutrition. [4] This could be due to the losses of nutrients into dialysate, chronic blood loss, inflammation and associated diseases. [6] .

We conducted this study to assess the nutri­tional status of ESRD patients on maintenance HD attending our dialysis unit to evaluate the major factors that result in malnutrition in our population.


   Methods and patients Top


We conducted this cross-sectional study on all the 50 patients on maintenance hemo­dialysis in the dialysis unit at Al-Gamhouria Teaching Hospital. The patients consented to participate in the study. The patients were interviewed and the collected data included history and physical exam including special attention to the dietary history and anthro­pometric measurements (Pre and post dialytic weight, height, body mass index (BMI) calcu­lated from post-dialytic weight and height (Kg/m2) and mid upper arm circumference (MUAC) measured by measuring tape according to the recommendations. [7],[8]

The biochemical analysis included urea, creatinine, hemoglobin (Hb), calcium, phosphorus, potassium, sodium, albumin, total cholesterol level, total triglyceide level, and random blood sugar.

Statistical Analysis

Data was analyzed using SPSS software version 9.0 that included:

  1. Knowledge score: for the knowledge about avoidable foods: score (0) for the wrong answer or don't know (poor level), score (1) for the knowledge of less than three correct types (<50%) from the six types of avoidable fruits, vegetables of pulses (acceptable level), score (2) for the know­ledge of three or more correct types (>50%) (Satisfactory levels).
  2. Malnutrition score was used to assess the degree of malnutrition. Five parameters from anthropometric, clinical, and bioche­mical data were used. Each parameter was given a score ranged from 3-6. These parameters were BMI, MUAC, Hb, clinical examination for signs for nutri­tional deficiencies, and the presence of gastrointestinal (GIT) manifestations.


For BMI and MUAC, a score of (3) was given when the measurement was > 90% of normal, score (4) for 80-90%, score (5) for 70-<80% and score (6) for <70%.

Hb score was considered as (3) for levels ≥13 g/dl for men and ≥12g/dl for women, score (4) for 10.5 < 13 for men and 9.5 <12 for women, score 95) for 8-<10.5 for men and 7-<9.5 for women, and score (6) for <8 for men and < 7 for women.

For clinical examination of diagnosis of nutritional deficiencies, a score of (3) was given when there are no signs of nutritional deficiencies, score (4) when only one sign inspected, score (5) for two inspected signs and score (6) if more than two signs inspected.

For GIT manifestation: score (3) was given for the absence of any manifestations, score (4) for the presence of one manifestation, score (5) for two manifestations and score (6) for more than two.

The total score of malnutrition ranged from a minimum of 15 to a maximum of 30, and was divided as follows: Normal (27-30), mild malnutrition (24-<27), moderate malnutrition (21-24), and severe malnutrition (15-<21). [9]

Quantitative variables were expressed as the mean and standard deviation (SD). For com­parison of means, Student's t-test was used to compare two groups, and ANOVA (one way analysis of variance) to compare three groups. This was followed by Scheffe test as post­hoc test for pair comparisons. The statistical significance was set at P<0.05.

Odds ratio (OR), as an estimate of relative risk, was calculated to determine the risk of malnutrition among HD patients in relation to socioeconomic and dialysis characteristics. OR was considered significant if its 95% confidence interval (CI) did not include one.

The basic analysis was followed by stepwise multiple logistic regression analysis to estimate the magnitude of the association between the studied independent variables and the degree of malnutrition as a dependent variable.


   Results Top


The mean age of patients was 39.5±12.1 years and 25(50%) of them were women. The majority of the patients were married (78%). Residency distribution shows that Laheg Governorate comes in the first rank (44%) followed by Aden Governorate (36%). Thirty-two percent of the patients were illite­rate and only 10% were university graduates. Sixty-four percent of patients were unem­ployed, retired or housewives).

Arterial hypertension was the first cause of renal failure (30%), followed by glomerulo­nephritis (22%), while diabetes mellitus was the cause in 8% of the patients. All patients had bone pain and arthralgia, whereas 52% of patients had gastrointestinal manifestations, and the most reported one was vomiting (32%).

All patients were on twice weekly dialysis and each for three hours. The mean period of dialysis was 1.2±0.9 years and the mean weight gain in between dialysis (interdialytic weight gain) was 1.4±0.8 kilograms.

Of the study patients, 42% did not follow dietary regimen, and 48% consumed more than one liter of water daily; the same percen­tage did not drink milk at all, whereas 26% of the patients did not consume eggs. The mean intake of meat, fish or poultry was 86.3±0.67 grams daily. Forty-eight percent of the patients restricted their salt intake, whereas 58% did not take vitamins supplements. A high percen­tage of patients were not supplemented with either iron or calcium (76% and 60% respe­ctively), and about two-thirds had antacid.

The mean total knowledge score about avoidable food items was 2.85±1.59 and only 14% of the patients had satisfactory score. Furthermore, satisfactory level was in 24% of the patients for avoidable fruits and 12% for avoidable vegetables.

In [Table - 1] a significant difference was detected between males and females in pre­dialytic weight, post-dialytic weight and height (P<0.05), whereas no significant difference was observed regarding MUAC and BMI.

[Table - 2] shows that none of the patients had normal nutritional status and the majority of them (70%) were moderately malnourished.

[Table - 3] shows that all nutritional parameters worsened as the degree of malnutrition increased from mild, moderate to severe. However, significant differences was observed only in the height and MUAC (F=2.15 and 2.3; P<0.05 respectively).

Serum urea, creatinine cholesterol and trigly­ceride were all above normal and increased with the advancement in the degree of mal­nutrition, whereas Hb level was low and the severity of anemia worsened with the degree of malnutrition. On the other hand, hypoalbu­minemia (serum albumin <3.5 mg/dl) was found in moderately and severely malnourished patients. However, none of these parameters could reach statistical significance, [Table - 4].

The risk of moderate/severe malnutrition was four times significantly higher among those ≥50 years than their younger counterparts (OR: 4.10, 95% CI: 1.72-89.71), and was 19 times higher among those with more than two kilograms interdialytic weight gain than those with lesser weight gain (OR:19.7, 95% CI:1.02-378.4), [Table - 5].

However, stepwise multiple regression analysis shows that interdialytic weight gain was the only significant association with moderate/severe malnutrition, as those with >2 Kg interdialytic weight gain were 20 times more likely to be moderately/severely malnourished compared to those with lower weight gain (OR:20.01:95% CI:1.52-308.92).


   Discussion Top


Our study is the first one of the nutritional status of ESRD patients on maintenance HD in the dialysis unit of Al-Gamhouria Teaching Hospital. Malnutrition is a major comorbid condition in patients with ESRD. [10]

Nutritional status is an important predictor of outcome in ESRD patients on maintenance HD. [11] Assessment of the nutritional status needs a systematic nutritional evaluation based on anthropmetric, laboratory, and clinical parameters from which a malnutrition score can be calculated. [12],[13]

The poor nutritional status of HD patients is the result of several interrelated factors. Apart from the catabolic effect of dialysis, nutrients loss to dialysate, and uremic toxicity, several co-morbid conditions may also contri­bute to malnutrition including chronic infection and superimposed diseases that result in anorexia and inadequate food intake. [3],[4],[6]

Inadequate intake was found in our study patients as 58% stated that they did not follow clear dietary instructions and the evident poor intake of high quality protein. Patients with ESRD are better to be on mild degree of protein restriction (0.8-1.0 gram/kg) than sever restriction (0.6-0.3 gram/kg) as the benefit of severe restriction is marginal when compared with usual risk of malnutrition commonly observed even under close dietetic supervision. However, patients who are maintained on dialysis should be on 1-1.2 gram/kg with 75% of protein from those of high quality (eggs, meat, fish, poultry and milk). This amount can be obtained according to the intake reported from our patients.

Satisfactory knowledge score for avoidable food was found among only 14% of our study patients, which coincides with the high per­centage of moderately or severely malnourished patients (70% and 20%, respectively). Com­paring our results with international figures shows that 50% of maintenance HD patients are malnourished and severe malnutrition affects only a small percentage (6-8%). [14],[15] On the other hand, a study in Alexandria Egypt shows that at least 10.4% was classi­fied as normally nourished. [16]

It is well documented that nutritional status of patients on hemodialysis is affected by their nutritional status before dialysis; many patients who commence dialysis are already malnourished. [17],[18] This could be true in our patients as observed in our daily experience. In addition, 52% patients suffered from gastro­intestinal symptoms, which may impair food intake and worsen the nutritional status.

Abnormal biochemical parameters are usually encountered in patients with ESRD, some of which are predictors of mortality such as high blood urea and creatinine. 5 In the present study, all patients showed increased level of these two parameters.

Dyslipidemia is reported to be a universal characteristic in ESRD with hypercholestero­lemia in about 50%. This is an important risk factor for atherosclerotic heart diseases in HD patients that usually require lipid-lowering intervention in most cases. [19] Our study showed increased level of cholesterol and triglyceride among all patients that impose on them further risk of morbidity.

Anemia almost invariably develops in patients with chronic renal insufficiency and is asso­ciated with a wide range of complications. [20],[21] Unfortunately, all our study patients were anemic with the lowest mean Hb among severely malnourished. Meanwhile, the results showed that only 24% and 42% were taking iron or vitamin supplements, respectively.

Our study also showed that hypoalbumenemia was present in the moderately and severely malnourished patients. Serum albumin is the commonest nutritional marker that strongly predicts death in HD patients. [22] However, hypoalbumenemia has been criticized as it is so closely related to infection and other non nutritional factors. [3]

Several factors are associated with malnutri­tion in HD patients, [3] such as old age, increased duration of dialysis, [23] increased interdialytic weight [16],[24] and low anthropometric measure­ments. [3],[13] In the present study, univariate analysis showed that older age and interdialytic weight gain more than 2 Kg were significantly associated with increased risk of moderate/ severe malnutrition. In the Egyptian study, older age was significantly associated with malnutrition, in addition to the duration of dialysis (>5 years period). Elderly patients are more prone to malnutrition. [25] On regression analysis, only interdialytic weight gain showed a significant association with moderate/severe malnutrition. Interdialytic weight gain may be associated with protein energy malnutrition; it reflects the nutritional status of HD as well as the level of compliance with fluid restri­ction. [26] All the patients received only six hours of dialysis a week, which was inadequate dose and could explain the interdialytic weight gain.

We conclude that the majority of our dialysis patients were moderately to severely malnouri­shed. Poor dietary knowledge and practices were encountered among these patients with poor biochemical parameters among the majority of them. Older age (≥50 years) and increased interdialytic weight gain (>2 Kg) are significantly associated with the risk of moderate/severe malnutrition, whereas inter­dialytic weight gain >2 Kg was the only signi­ficantly associated factor with malnutrition. This could be related to the inadequate frequency of dialysis (twice a week) and time of the sessions (three hours each time), which reflects inadequate dose of dialysis.

For the improvement of nutritional status of these patients the adequate dialysis of at least four hours three times per week of high efficient dialysis can not be overemphasized. There should be nutrition education and counseling of the patients and their families in individualized and flexible form to meet the individual dietary needs. Furthermore, there should be periodical assessment of these patients using anthropometric, clinical, biochemical, and dietary parameters for identifying malnourished patients and those at risk of malnutrition. Finally, the patients should receive nutritional supplementation with vitamins, minerals and recombinant erythropoietin to alleviate nutritional deficiencies and improve their general health.


   Acknowledgements Top


We are very grateful to Dr. Naseem Gazem and Mr. Jamal Al-Alawi and all physicians and staff of the dialysis unit in Al-Gamhouria Teaching Hospital as well as Dr. Hanan H. Omer, head of the Central Blood Bank, Mr. Murad Mohammed Ali and the staff of the blood bank for their unlimited help to accom­plish this work. We also greatly acknowledge Dr. Hussein Al-Kaff, Prof. of urology, head of the Yemeni Kidney Diseases and trans­plantation center, and Dr. Mohammed Al­Saadi, Director of Al-Gamhouria Teaching for their financial support. Special thanks for Dr. Abdullah Alkhader for his keen and critical review of the manuscript.

 
   References Top

1.Nahas AM, Winerals CG. Chronic renal failure and its treatment. In: Weatherall DJ, Ledingham JGG, Warrell DA, eds. Oxford Textbook of Medicine 3 rd ed. Oxford, New York, Tokyo: Oxford University Press, 1996:3294-306.  Back to cited text no. 1    
2.Watanabe E, Suzuki M, Hirasawa Y. Nutritional status evaluations of protein metabolism among chronic dialysis patients: from the aspects of Kt/V, protein catabolic rate, creatinine height index and serum albumin or creatinine concentrations. Jap J Clin Dialysis 2002;17(12):15-21.  Back to cited text no. 2    
3.Stenvinkel P, Barany P, Chung SH, Lindholm B, Heimburger O, Slenvinkel P. A comparative analysis of nutritional parameters as predictor of outcome in male and female ESRD patients. Nephrol Dial Transplant 2002;17:1266-74.  Back to cited text no. 3    
4.Laville MA, Fouue D. Nutritional aspects in Hemodialysis. Kidney Int 2000;76 (Suppl):133-9.  Back to cited text no. 4    
5.Bartram J. Nutrition on dialysis. In: Levy J, Morgan J, Brown E, eds. Oxford handbook of dialysis. Great Britain: Oxford University Press, 2000:377-404.  Back to cited text no. 5    
6.Lim VS, Kopple JD. Protein metabolism in patients with chronic renal failure: role of uremia and dialysis. Kidney Int 2000; 58(1):1-10.  Back to cited text no. 6    
7.World Health Organization. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert committee. Geneva: WHO, WHO Tech Rep Ser No. 854, 1995.  Back to cited text no. 7    
8.World Health Organization Obesity. Preventing and managing the global epidemic: Report of a WHO consultation on obesity. Geneva WHO, Tec Rep Ser No.894, 2000.  Back to cited text no. 8    
9.Rodriguez-Carmona A, Perez-Fontan M, Cordido F, Garcia-Falcon T, Garcia-Buela J. Hyperlepinemia is not correlated with markers of protein malnutrition in chronic renal failure. A cross-sectional study in predialysis, peritoneal dialysis and hemo­dialysis patients. Nephron 2000,86:274-80.  Back to cited text no. 9    
10.Naiker S. Nutritional Problems associated with end-stage renal disease in the developing world. Artf Organs 2002;26(9):757-9.  Back to cited text no. 10    
11.Schulman G. Nutrition in daily hemodialysis. Am J Kidney Dis 2003;41(3 Suppl 1):S112-5.  Back to cited text no. 11    
12.Kuhlmann MK, Winkelspecht B, Hammers A, Kohler H. Malnutrition in hemodialysis patients. Self-assessment, medical evaluation and "verifiable" parameters. Med Klin 1997; 92:13-7.  Back to cited text no. 12    
13.Rutledge C, McMahon LR. Relationship between dialysis and nutritional adequacy in hemodialysis patients. Nephrology 2000; 5:27-32.  Back to cited text no. 13    
14.Holley JL, Kirk J. Enteral tube feeding in a cohort of chronic hemodialysis patients. J Ren Nutr 2003;12(3):177-82.  Back to cited text no. 14    
15.Cianciaruso B, Brunori G, Kopple JD, et al. Cross-sectional comparisons of malnutrition in continuous ambulatory peritoneal dialysis and hemodialysis patients. Am J Kidney Dis 1995;26:475-86.  Back to cited text no. 15  [PUBMED]  
16.Al-Etriby HT. Assessment of the nutritional status of end-stage renal failure patients on maintenance hemodialysis. Thesis, MPH, Alexandria, Egypt: University of Alexandria, Faculty of Medicine, 2001:47-94.  Back to cited text no. 16    
17.Chung SH, Lindholm B, Lee HB. Influence of initial nutritional status on continuous ambulatory peritoneal dialysis patient survival. Perit Dial Int 2000;20:19-26.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Backwell A, Higgins R, Edmunds M. Nutrition, adequacy of dialysis and clinical outcome in Indo Asian and White European patients on dialysis. Q J 2002;95:811-20.  Back to cited text no. 18    
19.Saltisi D, Morgan C, Rigby RJ, Westhuyzen J. Safety and efficacy of simvastatin in hypercholesterolemic patients undergoing chronic renal dialysis. Am J Kidney Dis 2002;39(2):283-90.  Back to cited text no. 19    
20.Obrador GT, Roberts, St Peter Wl, Frazier E, Pereira BJ, Collins AJ. Trends in Anemia at intitation of dialysis in the United States. Kidney Int 2001;60:1875-84.  Back to cited text no. 20    
21.Collins AJ. Influence of target hemoglobin in dialysis patients on morbidity and mortality. Kidney Int Suppl 2002;80:44-8.  Back to cited text no. 21  [PUBMED]  
22.Don BR, Rosales LM, Levine NW, Mitch W, Kaysen GA. Leptin is a negative acute phase protein in chronic hemodialysis patients. Kidney Int 2001;59(3):1114-20.  Back to cited text no. 22    
23.Markus MP, Jager KJ, Dekher FW, De Haan RJ, Boeschoten EW, Krediet RT. Predictors of poor outcome in chronic dialysis patients: The Netherlands Cooperative Study on the Adequacy of Dialysis. Am J Kidney Dis 2000;35:69-79.  Back to cited text no. 23    
24.Mak SK, Wong PN, Lo KY, Tong GM, Fung LH, Wong AK. Randomized pro­spective study of the effect of increased dialytic dose on nutritional and clinical outcome in continuous ambulatory peritoneal dialysis patients. Am J Kidney Dis 2000; 36:105-14.  Back to cited text no. 24  [PUBMED]  
25.Chauveau P, Combe C, Laville M, et al. Factors influencing survival in hemodialysis patients aged older than 75 years: 2.5 years outcome study. Am J Kidney Dis 2001; 37:997-1003.  Back to cited text no. 25    
26.Chertow GM, Johansen KL, Lew N, Lazarus JM, Lowrie EG. Vintage, nutritional status, and survival in hemodialysis patients. Kidney Int 2000;57:1176-8.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Huda O Basaleem
Department of Community Medicine and Public Health, Faculty of Medicine and Health Sciences, Aden University, Aden
Yemen
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