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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 675-681
Nutritional assessment of patients on hemodialysis in a large dialysis center


Prince Salman Center for Kidney Diseases, Riyadh, Saudi Arabia

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Date of Web Publication9-Jul-2011
 

   Abstract 

Management of the nutritional aspects of chronic kidney disease (CKD) presents a number of challenges. This study was performed to assess the nutritional status among patients on maintenance hemodialysis at the Prince Salman Center for Kidney Diseases, Riyadh, Saudi Arabia. The study included 200 patients with a mean age of 50 ± 16 years; there were 108 males (54%) and 92 females (46%). Nutritional assessment was made by the Subjective Global Assessment (SGA) score. In the present study, 4% of the patients were found to be underweight, 49% had average weight, 27.5% were overweight, 14% were obese, and 5.5% had morbid obesity. Severe malnutrition by SGA significantly correlated with duration on dialysis, functional capacity, and associated co-morbid diseases. The number of patients included in this study was small and we recommend multi-center studies with a larger number of patients for better evaluation. Also, we recommend a survival trial to evaluate the relationship between low serum albumin and patient survival in the Saudi population.

How to cite this article:
Al Saran K, Elsayed S, Molhem A, AlDrees A, AlZara H. Nutritional assessment of patients on hemodialysis in a large dialysis center. Saudi J Kidney Dis Transpl 2011;22:675-81

How to cite this URL:
Al Saran K, Elsayed S, Molhem A, AlDrees A, AlZara H. Nutritional assessment of patients on hemodialysis in a large dialysis center. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Jul 22];22:675-81. Available from: http://www.sjkdt.org/text.asp?2011/22/4/675/82643

   Introduction Top


Management of the nutritional aspects of patients with chronic kidney disease (CKD) presents a number of challenges. Malnutrition can occur in up to 40% of the patients with renal failure, and is associated with increased mortality and morbidity. Most of the standard methods used for assessing nutritional status can be applied to patients with renal failure, although some of these parameters may get altered by uremia. [1] Currently, it is widely believed that wasting and malnutrition are no longer prevalent in patients undergoing maintenance dialysis. However, there is evidence suggesting that many factors that promote malnutrition in renal failure persist even with modern methods of dialysis treatment. There is no single measurement that can be used to determine or exclude the presence of malnutrition. Therefore, a panel of measurements is recommended, including measurement of body composition, measurement of dietary protein intake, and at least one measure of serum protein status. [2],[3]


   Aim of the Study Top


The purpose of nutritional screening in hemodialysis (HD) patients is to predict the probability for a better or worse outcome due to nutritional factors and to determine the prevalence of nutritional disorders (malnutrition, overweight, and obesity) per facility standards. Additionally, it helps to examine interventions that can be used to manage malnutrition and obesity, share experiences, concerns, and solutions to the problems in the management of nutritional disorders in Saudi patients.


   Methodology Top


The subjects included in this cross-sectional study were patients on chronic HD at the Prince Salman Center for Kidney Diseases (PSCKD), Riyadh city, a center that is well equipped for dialysis, either peritoneal dialysis (PD) or HD, and can cater to up to 600 patients with ESRD. The study was performed during the period from September 2007 to September 2008, and included 200 patients with a mean age of 50 ± 16 years; there were 108 males (54%) and 92 females (46%). Patients who were hospitalized for more than two weeks for a non-vascular access complication or had signs of active infection were excluded from the study. All enrolled patients should have completed a minimum of six months duration on HD in our center. All subjects were evaluated and examined by two physicians and two registered dietitians. A complete medical history, including details of the patient's diet and physical examination, and recording of the dry body weight was performed. The baseline laboratory tests included serum protein and albumin, fasting lipid profile [total cholesterol, triglycerides, high-density lipoprotein (HDL) and low-density lipoprotein (LDL)], serum creatinine, serum calcium and phosphorus, white blood cell count, fasting glucose, HbA1c, and preand post-dialysis blood urea nitrogen (BUN) to determine normalized protein catabolic ratio (nPCR) and urea kinetics by single pool Kt/v. The nutritional state was assessed using the Subjective Global Assessment (SGA) score that was originally developed to assess post-operative nutritional state. The SGA comprises of five criteria, and includes weight loss in the preceding six months, gastro-intestinal tract (GIT) symptoms such as anorexia, nausea, vomiting, and diarrhea, the type of dietary food intake, functional capacity of the patients, and associated co-morbidities. Physical examination in SGA includes three items: loss of subcutaneous fat over the triceps and mid-axillary line of lateral chest wall, muscle wasting in the deltoid and quadriceps, and the presence of ankle edema and/or ascites. The patients were classified into normal, mild to moderate, or severely malnourished. The total lymphocytic count (TLC) was calculated using the following equation: TLC = (% lymphocytes × WBC)/100; TLC less than 900 indicates severe depletion, 900-1500 is moderate, and 1500-1800 is mild depletion. The cause of chronic renal failure included the following: diabetic nephropathy in 82 patients (41%), hypertension in 40 patients (20%), chronic glomerulonephritis in 12 patients (6%), hypoplastic kidney in 4%, lupus nephritis in 3%, unknown etiology in 22%, obstructive uropathy in 2%, and tubulo-interstitial nephritis and contrast nephropathy in 1% each. All patients received four-hours HD per session, thrice-weekly, using bicarbonate-buffered dialysate and polysulfone dialyzer membranes. Statistical analysis was performed using SPSS software (Statistical Package for Social Science, version 14, SPSS Inc., Chicago, IL, USA). All values are expressed as mean ± SD, and P <0.05 was considered statistically significant.

Optimal protein and energy intake

There is no metabolic or pathological reason for not giving a standard energy intake to stable adults on maintenance dialysis. Indeed, their metabolic needs, based on resting energy expenditure, are similar to those of normal adults, i.e. 35 kcal/kg body weight/day. Energy balance studies, mainly in PD patients, confirmed that a positive nitrogen balance could only be attained with energy intakes >30 kcal/kg/day. [4] Although a level of 0.7-0.8 g of protein/kg body weight (BW) may be sufficient to permit a neutral nitrogen balance in a pre-dialysis-stable adult, the dialysis procedure itself increases protein demands. The Dialysis Outcome Quality Initiative (DOQI) guidelines in nutrition have proposed that, based on nitrogen studies in HD and PD patients, a minimum of 1.2 g in HD and 1.3 g of protein/kg BW in PD represent the minimum daily intake to ensure a neutral protein balance. Half of this intake should be made-up by proteins of high biological value from animal origin, e.g. meat, fish, or dairy products. [5] The current K/DOQI guidelines 2007 divide patients into five stages, based on decreasing glomerular filtration rate (GFR). In stage-5, when patients are receiving dialysis, increased protein intake is suggested (approx. 1.2 g/kg/day). [1]

[Table 1] represents the recommended nutritional parameters according to the stage of CKD and the type of dialysis, either HD or PD. These are initial guidelines; individualization to patient's own metabolic status and co-existing metabolic conditions is essential for optimal care. [1]
Table 1: Recommended nutritional parameters in patients with different stages of chronic kidney disease and those of hemodialysis and peritoneal dialysis.

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   Results Top


The 200 HD patients in this study included 108 males and 92 females with a mean age of 50 ± 16 years. Subjects in this study had a mean single pooled Kt/v of 1.4 ± 0.15 and a mean nPCR of 1.13 ± 0.2. [Table 2] and [Table 3] show the demographic data of the studied population. [Table 4] shows the relationship between body mass index (BMI) and gender. In the present study, 4% of the patients was underweight, 49% had average weight, 27.5% were overweight, 14% were obese, and 5.5% had morbid obesity. Regarding diet changes, 89% had minimal or no change in their diet, while 9% had mild to moderate decrease in their diet. Subjective Global Assessment (SGA) classified patients into normal in 68%, mild to moderately malnourished in 24%, and severely malnourished in 8%. Severe malnutrition by SGA significantly correlated with male sex, (P = 0.04). The mean duration on dialysis was 23 months, and ranged from six to 300 months. The co-morbid diseases in the study patients were viral hepatitis, either B or C, in 26%, cardiovascular diseases in 13%, central nervous system disorders in 8%, GIT diseases in 3.5%, malignancy in 3%, collagen diseases (SLE, scleroderma) in 3%, and chronic respiratory diseases (bronchial asthma, bronchiectasis) in 4% of the patients. Severe malnutrition by SGA significantly correlated with duration on dialysis, functional capacity, associated comorbid diseases, and nPCR. The total cholesterol level correlated significantly with serum albumin level, patient's age, and presence of diabetes mellitus (DM) and ischemic heart disease (IHD).
Table 2: Demographic and laboratory findings in the study patients.

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Table 3: Body mass index in the study patients.

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Table 4: Demographic findings regarding smoking habit and presence of diabetes mellitus, hypertension, and ischemic heart disease.

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   Discussion Top


The reported prevalence of chronic renal failure in the Kingdom of Saudi Arabia is 80 to 120 per million population (pmp). [6] Malnutrition is present in approximately 40% of the patients treated with maintenance HD. [7] The NKF-K/DOQI Clinical Practice Guidelines for nutrition in patients on maintenance dialysis and for evaluation of protein-energy malnutrition and nutritional status recommended assessment with a combination of valid, and complementary, measures rather than any single measure alone as malnutrition may be identified with greater sensitivity and specificity using a combination of factors. [8],[9] Nutritional assessment ideally should be used to determine the nutritional requirements for all patients taking into account their nutritional and metabolic status, and should be used to monitor the patient's progress and any alteration in requirements. In addition, nutritional assessment should be able to identify groups of patients at risk from the effects of malnutrition. Finally, the parameters used for assessment should be simple, yet effective, and readily available in any hospital. [10] Because of the complexity of the nutritional management of CKD patients, registered dietitians should be consulted, especially for nutritional counseling of the patients. Physicians and other clinical personnel should also strongly encourage dietary compliance of the patients because dietary adherence can determine outcomes in CKD. [11] Serum albumin concentration, even when only slightly less than 4.0 g/dL, is one of the most important markers of protein energy malnutrition (PEM) in patients with CKD. It is a very reliable indicator of visceral protein, although its concentration is also affected by its rate of synthesis and catabolism (half-life 20 days), which is altered negatively in the presence of inflammation. [12],[13] Hypoalbuminemia is highly predictive of future mortality risk when present at the time of initiation of chronic dialysis as well as during the course of maintenance dialysis. [13] The increased mortality with hypoalbuminemia, which is seen in 60-67% of the patients on maintenance HD, [14] appears to occur even at a near-normal albumin level (35 g/L). However, the risk is greater with more severe hypoalbuminemia, being greatest in patients with a plasma albumin concentration below 30 g/L. [13],[15] Our results support previous results of Nabil Akash and his colleagues in 1999, [16] which state that among Saudi HD patients, despite efficient dialysis prescription indicated by mean Kt/v of 1.4 ± 0.15, the mean serum albumin level is low (mean 34 ± 4 g/L).

Despite their clinical utility, serum protein levels (e.g., albumin, transferrin, and pre-albumin) may be insensitive to changes in nutritional status, do not necessarily correlate with changes in other nutritional parameters, and can be influenced by non-nutritional factors. [17]

The height and weight allow calculation of the body mass index (BMI) and its classification into normal range (20-25), obesity (>30), borderline underweight (18.5-20), and severe underweight (<18.5/m 2 ) . [18] It is recommended that the BMI of maintenance dialysis patients be maintained in the upper 50 th percentile for normal individuals, which would mean a BMI for men and women not lower than approximately 23.6-24.0 kg/m 2 . This recommendation also appears appropriate for patients with CKD with significant reduction in glomerular filtration rate (GFR) (stages 3-5). [19] In the present study, it was observed that 47% of the patients were either overweight or obese, and 4% were underweight. Five percent of women in the studied population had morbid obesity, which could be attributed to hormonal factors or, possibly, lack of physical activity among women in the Saudi society, and warrant further studies. Additionally, although renal transplantation offers an overall better quality of life compared with HD, severe obesity with BMI greater than 35 kg/m 2 is associated with wound infection, multisystem organ failure, and increased transplantation costs, and can also result in a delay in transplantation. [20]

Serum cholesterol is an independent predictor of mortality in patients on maintenance HD. The relationship between serum cholesterol and mortality has been described as either "U-shaped" or "J-shaped," with increasing risk for mortality as the serum cholesterol rises above the 200-300 mg/dL range or falls below approximately 200 mg/dL. [21] The mortality risk in most studies appears to increase progressively as the serum cholesterol decreases to, or below, the normal range for healthy adults (<200 mg/dL). Pre-dialysis serum cholesterol is generally reported to exhibit a high degree of co-linearity with other nutritional markers such as albumin, pre-albumin, and creatinine, as well as age. [22],[23] Our results are supported by the findings of Cano et al, 1988 and Avram et al, 1995. [24]

Patients on maintenance HD have normal energy expenditure and approximately normal requirements for maintenance of protein balance, body weight, and body fat. An average energy intake of about 38 kcal/kg/day may be necessary to maintain nitrogen balance in these patients. [25] The protein catabolic rate (PCR), also called the protein equivalent of nitrogen appearance (PNA), is the parameter used in most HD units to assess dietary protein intake in patients who are in a steady state. Increased mortality was observed with a nPNA of less than 0.8 or greater than 1.4 g/kg per day, while the best survival was noted with levels between 1.0 and 1.4 g/kg per day. [26] It is recommended that a minimal nPCR, not less than 0.8 g/kg per day, but a target of 1.0-1.2 g/kg per day or higher, is recommended. [27] Our results support previous studies, and indicate adequate protein intake in our patients as the mean nPCR was 1.13 ± 0.06.

It is well known that malnutrition leads to a decline in immune function. The TLC is a clinical measure of immune function that is often used in nutritional assessment. TLC is an indicator of immune function that reflects both B cells and T cells. TLC is increased with infection and leukemia, and decreased following surgery, and in chronic disease states. Because TLC is not specific to nutritional status, it is not useful for assessment of a hospitalized patient. [28] In our study, we could not demonstrate any correlation between TLC and any other variants related to nutritional state.

SGA is a clinical evaluation of protein-energy malnutrition (PEM) based on evidence of edema, ascites, muscle wasting, subcutaneous fat loss, changes in functional capacity, and gastrointestinal symptoms of diarrhea, nausea, vomiting. This tool has also been studied for use in assessing patients on dialysis. [29] Based on the results of this history and physical assessment, patients can be placed into nutritional risk categories of well nourished, mildly to moderately malnourished, or severely malnourished. [30] Moreover, the SGA has been validated prospectively in both uremic and non-uremic patient populations, and also predicts the likelihood of complications and poor outcome, allowing implementation of preventive interventions. Studies by McCann, 1996, Chertow et al, 1997, and Kalantar et al, 1999, support our results regarding the correlation of SGA with impaired functional capacity and associated co-morbid diseases. [31],[32],[33]


   Limitations of the Study and Recommendations Top


This study was performed in a tertiary referral center for HD. Thus, the patient sample may not represent the typical HD population seen in the Saudi Kingdom. Also, the number of patients included in this study was small and we recommend multi-center studies with a larger number of patients for better evaluation. Also, we recommend a survival trial to evaluate the relationship between low serum albumin and patient survival in the Saudi population.

 
   References Top

1.Matthew D, Beekley National Kidney Foundation. Clinical practice guidelines for nutrition in chronic renal failure. Available at: http://www.kidney.org/professionals/kdoqi/gui delines_updates/doqi_nut May 17, 2007.   Back to cited text no. 1
    
2.Marsha W, Christy JS, Minturn D, Gray DK, Kopple JD. Nutritional status and lymphocyte function in maintenance hemodialysis patients. Am J Clin Nutr 1984;39(4):547-55.  Back to cited text no. 2
    
3.Kopple JD, Swendseid ME. Protein and amino acid metabolism in uremic patients undergoing maintenance hemodialysis. Kidney Int 1975;7 (suppl.2):564-72.  Back to cited text no. 3
    
4.Bergström J, Fürst P, Alvestrand A, Lindholm B. Protein and energy intake, nitrogen balance and nitrogen losses in patients treated with continuous ambulatory peritoneal dialysis. Kidney Int 1993;44(5):1048-57.  Back to cited text no. 4
    
5.Locatelli F, Fouque D, Nutritional status in dialysis patients: A European consensus. Nephrol Dial Transplant 2002;17:563-72.  Back to cited text no. 5
    
6.Shaheen FA, Al-Khader AA. Preventive strategies of renal failure in the Arab world. Saudi Center for Organ Transplantation, Riyadh, Kingdom of Saudi Arabia. Kidney Int 2005;Suppl(98):S37-40.  Back to cited text no. 6
    
7.Wolfson M. Effectiveness of nutrition interventions in the pre-ESRD and the ESRD population. Am J Kidney Dis 1998;32(6 Suppl 4):S126-30.  Back to cited text no. 7
    
8.Leavey SF, Strawderman RL, Jones CA, et al. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis 1998;31:997.  Back to cited text no. 8
    
9.Leavey SF, Strawderman RL, Jones CA, et al. Simple nutritional indicators as independent predictors of mortality in hemodialysis patients. Am J Kidney Dis 1998;31:997.  Back to cited text no. 9
    
10.Chang RW, Richardson R. Nutritional assessment using a microcomputer Programme evaluation. Clin Nutr 1984;3(2):75-82.  Back to cited text no. 10
    
11.Kopple JD. National Kidney Foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 2001;37:S66-70.  Back to cited text no. 11
    
12.Ikizler TA, Hakim RM. Nutrition in end stage renal disease. Kidney Int 1996;50:343-57 .  Back to cited text no. 12
    
13.Lowrie EG, Huang WH, Lew NL. Death risk predictors among peritoneal dialysis and hemodialysis patients: A preliminary comparison. Am J Kidney Dis 1995;26:220.  Back to cited text no. 13
    
14.Owen WF, Lew NL, Liu Y, et al. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 1993; 329:1001.  Back to cited text no. 14
    
15.Stenvinkel P, Barany P, Chung SH, Lindholm B, Heimbürger O. A comparative analysis of nutritional parameters as predictors of outcome in male and female ESRD patients. Nephrol Dial Transplant 2002;17(7):1266-74.  Back to cited text no. 15
    
16.Akash N, Ghnaimat M, Haddad A, El-Lozi M. Functional status of patients on maintance hemodialysis. Saudi J Kidney Dis Transpl 1999;10(4):481-6.  Back to cited text no. 16
    
17.Jones CH, Newstead CG, Will EJ, Smye SW, Davison AM. Assessment of nutritional status in CAPD patients: Serum albumin is not a useful measure. Nephrol Dial Transplant 1997; 12(7):1406-13.  Back to cited text no. 17
    
18.Kondrup J, Allison SP, Elia M, et al. ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22(4):415-21.  Back to cited text no. 18
    
19.Kopple JD, Zhu X, Lew NL, Lowrie EG. Body weight-for-height relationships predict mortality in maintenance hemodialysis patients. Kidney Int 1999;56:1136-48.  Back to cited text no. 19
    
20.Rebecca AW, Sandeep M, et al. Nutritional requirements of adults before transplantation. www.emedicine.com, Last Updated: July 19, 2006.  Back to cited text no. 20
    
21.Goldwasser P, Mittman N, Antignani A, et al. Predictors of mortality in hemodialysis patients. J Am Soc Nephrol 1993;3:1613.  Back to cited text no. 21
    
22.Piccoli GB, Quarello F, Salomone M, et al. Are serum albumin and cholesterol reliable outcome markers in elderly dialysis patients? Nephrol Dial Transplant 1995;10:S72.  Back to cited text no. 22
    
23.Avram MM, Mittman N, Bonomini L, et al. Markers for survival in dialysis: A seven-year prospective study. Am J Kidney Dis 1995;26: 209.  Back to cited text no. 23
    
24.Cano N, Di Costanzo- Dufetel J, Calaf R, et al. Prealbumin-retinol-binding protein complex in hemodialysis patients. Am J Clin Nutr 1988; 47:664.  Back to cited text no. 24
    
25.Slomowitz LA, Monteon FJ, Grosvenor M, Laidlaw SA, Kopple JD. Effect of energy intake on nutritional status in maintenance hemodialysis patients. Kidney Int 1989;3(2):704-11.  Back to cited text no. 25
    
26.Kloppenburg WD, Stegeman CA, Hooyschuur M, van der Ven J, de Jong PE, Huisman RM. Assessing dialysis adequacy and dietary intake in the individual hemodialysis patient. Kidney Int 1999;55(5):1961-9.  Back to cited text no. 26
    
27.Robert EC, William LH. Protein catabolic rate in maintenance dialysis. www.uptodate.com, 2007.  Back to cited text no. 27
    
28.Gross RL, Newberne PM. The role of nutrition in immunologic function. Physiol Rev 1980; 60:188.  Back to cited text no. 28
    
29.Gordon S, Dearman K. Use of Subjective Global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents. J Am Col Nutr 2000;19(5):570-7.  Back to cited text no. 29
    
30.Enia G, Sicuso C, Alati G, Zoccali C. Subjective global assessment of nutrition in dialysis patients. Nephrol Dial Transplant 1993; 8(10):1094-8.  Back to cited text no. 30
    
31.McCann L. Subjective global assessment as it pertains to nutritional status of dialysis patients. Dial Transpl 1996;25:190-203.  Back to cited text no. 31
    
32.Chertow GM, Jacobs DO, Lazarus JM, et al. Phase angle predict survival in hemodialysis patients. J Renal Nutr 1997;7:204-7.  Back to cited text no. 32
    
33.Kalantar KZ, Kleiner M, Dunne E, et al. A modified quantitative subjective global assessment of nutrition for dialysis patients. Nephrol Dial Transplant 1999;14:1732-8.  Back to cited text no. 33
    

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Correspondence Address:
Khalid Al Saran
Prince Salman Center for Kidney Diseases, P.O. Box 52948, Riyadh 11573
Saudi Arabia
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PMID: 21743210

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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