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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 2  |  Page : 351-360
The development of malnutrition is not dependent on its traditional contributing factors in patients on maintenance hemodialysis in developing countries


1 Department of Nephrology, Jinnah Hospital Lahore, Lahore, Pakistan
2 Department of Pathology, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Pakistan
3 Department of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA

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Date of Web Publication10-Apr-2018
 

   Abstract 

Malnutrition in dialysis population is associated with significant morbidity and mortality. Nutritional assessment is a neglected area in hemodialysis (HD) patients in developing countries. The aim of the study was to find out whether any traditional parameters have statistically significant correlation with malnutrition. All 58 end-stage renal disease patients on maintenance HD in our dialysis unit were enrolled in this cross-sectional study. The nutritional status was assessed by a predesigned questionnaire including subjective global assessment (SGA). Anthropometric measurements, peripheral neuropathy, and pertinent laboratory parameters were checked. The duration of HD ranged between three months to 10 years (mean 4 ± 1.5 years). Of these 49 patients, 26 (53%) were males with a median age 45 (25–76) years. Fifteen patients (31%) were well nourished and 34 (69%) were undernourished including nine (19%) patients classified as severely malnourished according to SGA. Malnutrition appeared more prevalent in males, however, statistically not significant (P = 0.063). On univariate and multivariate analysis, no significance was found across well-nourished and malnourished patients in terms of age, body mass index, calorie count, duration and frequency of dialysis, dry weight, interdialytic weight loss or gain in the past six months, body fat percentage, serum albumin, blood pressure, intradialytic hypotension, urea reduction ration, Kt/Vurea, peripheral neuropathy, and comorbidities. Psychosocial factors were identified in 24 (49%) patients with 19 (79%) having some degrees of malnutrition, but the finding did not reach the statistical significance. Surprisingly, the traditional factors studied in previous trials have not shown any significant association to malnutrition in our study based on the statistical analysis.

How to cite this article:
Ali Bokhari SR, Faizan Ali MA, Khalid SA, Iftikhar B, Ahmad HI, Hussain AS, Yaqoob U. The development of malnutrition is not dependent on its traditional contributing factors in patients on maintenance hemodialysis in developing countries. Saudi J Kidney Dis Transpl 2018;29:351-60

How to cite this URL:
Ali Bokhari SR, Faizan Ali MA, Khalid SA, Iftikhar B, Ahmad HI, Hussain AS, Yaqoob U. The development of malnutrition is not dependent on its traditional contributing factors in patients on maintenance hemodialysis in developing countries. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2020 Jun 2];29:351-60. Available from: http://www.sjkdt.org/text.asp?2018/29/2/351/229271

   Introduction Top


The prevalence of protein-energy malnutrition is very high in end-stage renal disease (ESRD) patients on maintenance hemodialysis (MHD). Morbidity and mortality of these patients depends on their nutritional status.[1],[2]

There are many factors implicated in malnutrition in the dialysis population. Most notable factor is anorexia (insufficient calorie/protein intake). Other factors such as metabolic acidosis, infection, and inflammation do play their role by stimulating protein breakdown.[3] The nutritional status is also influenced by the efficacy of dialysis in ESRD patients.[4] Hence, to assess and correct malnutrition in HD patients, it is not just a question of provision of enough nutrients, rather a large number of correlated factors explain the problem. These factors make up the causes and effects of malnutrition in these patients.

Although malnutrition has been established as one finding that can be commonly encountered in patients on MHD for a varied amount of time, the factors that correlate to malnutrition have been equivocal. The various factors and parameters have been implicated as cause of malnutrition in various studies. Moreover, nutritional assessment of HD patients is not very well studied in developing countries[5] including Pakistan.

In this study, we tried to find the frequency of malnutrition in HD patients and the possible factors correlating with malnutrition in this region of the world.


   Patients and Methods Top


The factors we studied were anthropometric assessment of patients, calculating body mass index (BMI) and body fat percentages from various anthropometric measurements; medical assessment such as patients’ dry weight, interdialysis weight gain, postural drop, intra dialysis fall in blood pressure (hypotension), peripheral neuropathy, and measurement of comorbidities such as diabetes mellitus (DM), hypertension (HTN), and HCV; biochemical parameters such as albumin, phosphorus, calcium, urea reduction ration (URR), Kt/v to quantify HD, blood urea nitrogen (BUN), and creatinine; dietary survey of the patients assessing their 24 h dietary recall and their daily total caloric intake; compliance to the treatment and lifestyle modifications; last but not the least, the subjective global assessment (SGA) survey of the patients to categorize the patients as well nourished, undernourished, and malnourished.

For a patient to be eligible to participate in this study, the inclusion criteria were as follows: the subject had to be an outpatient who had been undergoing MHD for at least three months, aged at least 25 years, and had given a signed consent. All 58 ESRD patients on MHD in our dialysis unit were eligible for this cross-sectional study; however, nine patients did not give signed consent and were excluded from the study. The 49 patients (26 men and 23 women) participating in the cross-sectional study were treated in the tertiary care dialysis center, Jinnah Hospital, Lahore, Pakistan. The median age was 45 years (range: 25–76 years), and the mean age was 46 years. The background clinical history of each patient on MHD was analyzed by a nephrologist extensively and data related to diabetes, hypertension, ischemic heart disease, hepatitis C, and other comorbid conditions were extracted.

Low-Flux Fresenius F6 Dialyzers with Fresenius Polysulfone membranes were used in all patients. The treatment regimen of the patients remained quite the same throughout the study period.

The nutritional status was assessed by a predesigned questionnaire. The questionnaire included “scored, patient-generated (PG) SGA,[6] a semi-quantitative scale for estimating nutritional status, as well as seven subjective assessments; patient profile, anthropometric assessment, pertinent medical assessment (including peripheral neuropathy), pertinent laboratory parameters, dietary survey, psychosocial assessment, and patients’ complaints in relation to their treatment (if any). The scored PG-SGA included a section of medical history which further included following four subsections; weight, dietary intake, gastrointestinal symptoms, and functional capacity. This section directly depended on patients’ responses and each patient's own judgments and comments (that is why called “PG”). The other sections were completed by the examining doctors (the authors) and included sections on (a) physical examination (including subcutaneous fat, muscle wasting, edema, and ascites (edema and ascites related to malnutrition), (b) comorbidity assessment, and (c) metabolic stress assessment. All the sections and subsections were scored as per the predefined SGA guidelines (that is why called “score”). In the light of above SGA assessments, the patients were categorized into three overall SGA ratings, namely, SGA-A = well nourished, SGA-B = moderate or suspected of being malnourished, and SGA-C = severely malnourished [Table 1]. The scores of each section were added as per the guidelines and the total numerical scores were calculated. The categorical ratings of SGA-A, B, and C provided an overall assessment as to the current condition of the patient and the numerical scores were tabulated into various “Nutritional Triage Recommendations” as shown in [Table 2] and [Table 3].
Table 1: SGA Categorization.

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Table 2: Nutritional triage recommendations on the bases of numerical scores of PG-SGA.

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Table 3: Patients classification as per nutritional triage recommendations.

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Given that one of the indices of malnutrition is few anthropometric parameters as well, nutritional status of the patients was also evaluated using anthropometric parameters such as patient's height (cm), weight (kg), BMI, skinfold thickness (triceps, chest, and thigh for males and triceps, hipbone, and thigh for females) (mm), and mid-upper arm muscle circumference (cm). BMI was calculated using weight and height, skinfold thicknesses was used to calculate body fat, and mid-upper arm circumference was measured to assess muscle mass. Body weight of the patients was recorded before and after each dialysis with the patient lightly clothed and without shoes. The dry weight and the interdialysis sessions’ weight gain were calculated. Dry weight is the weight at which patient has no net fluid retention and patient stays normotensive at the end of dialysis session.[7] The patients’ weights were measured as the appropriate dry weight for each patient and the weight gain between dialysis sessions. Predialysis blood pressure was measured, and any episode of postdialysis postural drop or intradialysis BP fall was noted as well as any symptoms of peripheral neuropathy. Peripheral neuropathy was assessed using Semmes Weinstein Monofilament Examination,[8] and sensation of peripheral touch, superficial pain, and vibration (using a tuning fork) were measured. The neuropathy was assessed during medical assessment as was the blood pressure. The peripheral neuropathy assessment as well as the anthropometric assessment was done during or right after the dialysis of the patients.

The study also included monthly blood levels of the pertinent laboratory parameters, i.e., albumin, phosphorus, calcium, lipid, cholesterol, BUN, and creatinine. These parameters were analyzed with routine methods. Venous blood samples of the patients were collected on a dialysis-free day. Blood samples were also collected before and after the dialysis for determining urea. The outcome single pool Kt/Vurea was calculated according to Daugirdas method.[9] URR was calculated using Lowrie and Lew method.[10] For the dietary survey, we used the 24 h dietary recall by the patients and calculated their total daily calories. The psychosocial reasons for malnutrition in the patients were assessed using a predefined set of questions. In the light of responses of the patients to the questions, they were graded according to the authors’ self-designed Psychosocial Factors Gradation (PSFG) criteria constituting the categories, namely; PSFG-A = no significant psychosocial stress, PSFG-B = distressed, and PSFG-C = severely distressed. This categorization is also shown in [Table 4]. PSFG-A includes the patients who were happy and contended with no significant psychosocial stressors. PSFG-B consisted of those patients who needed attention from time to time for better treatment compliance and to cater challenges due to the effects of dialysis on their lives, whereas PSFG-C included severely distressed patients who being MHD patients were finding it very hard to cope with various psychological and social difficulties. Patients were also inquired of noticing any observable darkening in their complexion after commencement of MHD. Last question in the questionnaire inquired the patients if they were satisfied with their dialysis sessions as well as their treatment as a whole and the responses were made note of and added in result compilation. Everything in the questionnaires was filled by the researchers. In the pertinent sections, the patients were asked questions verbally and the responses were filled in. For the rest of the questionnaire, the researchers themselves filled in according to the data collected.
Table 4: Psychosocial factors gradation.

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The duration of MHD of the study patients ranged between three months to 10 years (mean 4 ± 1.5 years). The Committee of Ethics at Jinnah Hospital, Lahore, approved the protocol for the study. Informed/signed consent by each participant in the study was ensured.


   Statistical Analysis Top


A Chi-square test was used for nonparametric variables such as gender, diabetes, and HTN. Data are presented as mean ± standard deviation. P <0.05 was considered statistically significant.


   Results Top


HD was performed twice (18% of the patients) or thrice (82% of the patients) weekly. Of these 49 patients, 26 (53%) were males with a median age 45 (25–76) years. Sixteen patients (33%) were well nourished, 24 (49%) were undernourished and nine (18%) patients were classified as severely malnourished according to SGA [Table 5]. Sixteen percent patients had DM and 91.8% had HTN. The average age of the patients was 46.6 years and average duration of dialysis was 48 months. The patients’ average Kt/Vurea (single-pool; 38) was 1.22. There was no significant difference found between the three SGA groups in relation to dialysis vintage or dose. The laboratory values reflecting nutritional status such as albumin, lipid, and cholesterol showed no correlation with the SGA groups [Table 6]. The patients’ malnutrition appeared more prevalent in males (80% vs. 56%); however, this did not reach statistical significance (P = 0.063). On univariate and multivariate analysis, no significant between-group differences were found across well-nourished and malnourished patients in terms of age, BMI, calorie count, duration and frequency of dialysis, dry weight, intradialytic weight loss or gain in the past six months, body fat percentage, albumin, blood pressure, intradialytic hypotension, URR, Kt/V, peripheral neuropathy, and comorbidities. Psychosocial factors were identified in 24 (49%) patients with 19 (79%) having some degrees of malnutrition, but the findings did not reach the statistical significance.
Table 5: Patients classification as per SGA categories.

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Table 6: Patients' classification, comorbidities, and laboratory parameters with statistical significance.

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   Discussion Top


In our study, we observed a significant correlation between malnutrition and HD. However, various factors that may influence malnutrition could not be ascertained since most of these factors did not correlate statistically to the frequency of malnutrition. In our study, cohort we were able to include 49 patients out of total 58 due to inability to get consent from remainning 15% of population. However, results can be generalized as these patients were sharing the same mean age, racial characteristics, and almost similar clinical presentation. The correlation of various factors and parameters in our MHD patients revealed different outcome as compared to different studies done in the past. This underscores the need for future studies for exploring more causative factors for assessing malnutrition in this group of patients.

Two-third of the patients was malnourished ranging from undernourished to severely malnourished according to SGA. This shows very high percentage of malnutrition in ESRD patients as compared to previous studies depicting 50%[5] and 29% of the patients were malnourished, respectively.[11] In another study from South Asia (precisely India), a significant number of MHD patients were found to have mild-to-moderate malnutrition as well.[12] It can be attributed to the fact that, in a developing country like Pakistan, where a majority population lives below the poverty line, there is a limited access to balanced diet. Similarly, the MHD patients’ diet also gets neglected, leading to comparatively greater frequency of malnutrition in this patient population. Moreover, the difference of these results from previous studies is understandable as we do not have a single specific test as the best predictor of malnutrition and various indices of nutritional status are assessed and collectively interpreted to predict malnutrition.[13] Thus, this deficiency poses a limitation.

According to Marcén et al, malnutrition in terms of gender was prevalent in 51.6% of the males and 46.3% of the females,[13] whereas in our study, malnutrition was much more prevalent in male patients (80%) than in female patients (46%). The various anthropometric parameters were easier to measure and analyze in males compared to females in our patient setting. The low frequency of malnutrition in our female population could be related to our limitation, i.e., most of our female patients followed a strict Islamic dress code; they were slightly reluctant and not comfortable while various anthropometric measures were being taken. This made it more difficult for us to take these measures even in the presence of female nurses. This may have led to underestimation of malnutrition in females and hence limiting the validity of number of malnourished female MHD patients in our study.

Our findings were corresponding to the similar findings in another study[14] where no such correlation was found. It can be explained by the fact that due to greater mortality in patients on longer durations of MHD, the proportion of such elderly patients was reduced in the study, or it can be due to better nutritional awareness of older patients on dialysis over a longer duration. All the patients on MHD, whether of short or long duration, have equal malnutrition risk; a risk that needs to be rectified. However, the level of health consciousness of patients with different duration on MHD may have influenced our results as these results were computed without considering this variability.

There was no correlation between age and malnutrition in our study which contrasts the results of a previous study which showed that increasing age was directly related to worsening malnutrition.[15] Morais et al attributed malnutrition to more comorbidities with increasing age, catabolism of muscle protein, and loss of body fat secondary to longstanding dialysis. However, a Jordanian study showed inverse relationship between age and grade of malnutrition.[16] In that studies, the younger patients were found to be noncompliant to the treatment regimens and dietary restrictions, causing them to have more malnutrition. In our current study, we could not find any correlation between the two variables, i.e., malnutrition and age, a finding that was also there in study of Espahbodi et al.[14] Lack of correlation may be due to the presence of cumulative effect of factors discussed. Thus, just like duration on HD, age has no effect on the level of susceptibility to malnutrition and across the board; all patients are at an equal threat to this problem. For more specific results, the above mentioned patient-specific variability needs to be made constant, which was not the case in our study.

The frequency of dialysis had no correlation with malnutrition. Hence, increasing the number of dialysis sessions does not improve nutritional status of MHD patients. This indicates that even a more efficient dialysis session regimen, keeping the biochemical parameters within the normal range for longer periods of time, also has no impact on nutritional status of the patient. These results were established considering the “Kt/v” as consistently optimum (i.e., more than 1.3 of every session of dialysis) throughout the study period.

Serum albumin studies were not found to be associated with malnutrition as observed in an American study.[17] It can be explained by the fact that hypoalbuminemia in MHD patients is not caused due to malnutrition rather it may be caused by underlying inflammatory conditions to which patients with ESRD are prone. Thus, the use of albumin as an indicator of malnutrition in ESRD patients needs to be discouraged. A normal level may indicate good health; however, a decreased level does not necessarily mean malnutrition and need of dietary protein supplementation. We did not account for any underlying inflammatory condition in our studies.

The correlation between URR, Kt/v, and malnutrition in HD patients has been equivocal. It was observed by Dewar et al in Jamaica[18] where a significant correlation could not be established. Our study followed the same pattern and did not come forth with any correlation between these parameters and malnutrition. The reason for this lack of correlation is same as mentioned earlier where frequency of dialysis was not having any influence on prevalence of malnutrition. In other words, uremia is not the only controlling factor of malnutrition in MHD patients so improving or worsening uremia alone will not impact malnutrition to a very significant extent.

In many studies, comorbidities such as DM, HTN, and IHD and malnutrition were found to be related in terms of occurrence in MHD patients; these two factors were also found in a study by Qureshi et al.[19] However, no such correlation was found in our study. Malnutrition was prevalent in equal proportions in both our patient populations, i.e. with and without comorbidity. DM and HTN showed up as being most common causes of renal failure and need for permanent dialysis in our study as in many previous studies.[20] Peripheral neuropathy was found in 12% of the patient population in our study [Table 7]. Peripheral neuropathy was found in a significant number of patients in a previous study as well.[21] No correlation was found between peripheral neuropathy and malnutrition similar to previous studies.[21] Peripheral neuropathy might be related to underlying pro-inflammatory state secondary to MHD. Hence, peripheral neuropathy does not influence the nutritional status of a patient on MHD and vice versa. However, eight out of 49 ESRD patients had preexisting diabetes, which might be considered as a confounding factor and, thus, limiting the credibility of this association.
Table 7: Patients having peripheral neuropathy, complexion change.

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Episodes of intradialysis hypotension were found in a significant number of patients and it was similar to a finding in a previous study.[22] Intradialysis hypotension is a predictor of mortality but not of malnutrition. Hence, intradialytic hypotension and malnutrition are independent factors in HD patients.

Skin manifestations included change of skin complexion, observed in 41% of our patients who reported darkening of their sun-exposed skin surfaces. This finding was in concordance with a similar finding in a study in India[23] where 43% of the patients reported the same change. Defective kidneys are unable to remove beta melanocyte-stimulating hormone, leading to its accumulation in the dermis and causing hyperpigmentation and darkening in complexion. However, similar to intradialysis hypotension, hyperpigmentation had no correlation to malnutrition indicating that this factor is also independent of malnutrition in MHD patients. In our study, the complexion change was ascertained solely by the patient's personal observation and peer's opinion; hence, a bias cannot be totally overruled.

According to our psychosocial analysis, a significant amount of patients showed depressive symptoms affecting their moods and day-today activities. Almost all patients were satisfied with the standard of medical care they were being provided. Depression was found prevalent in many previous studies as well.[24],[25],[26],[27] However, similar to our study, a positive correlation between malnutrition and depression could not be established ruling out depression as a mainstay factor causing malnutrition. It is very difficult to distinguish anorexia secondary to depression, uremia, or chronic inflammatory process. A more sophisticated questionnaire including questions about patients’ discernment, with a particular emphasis upon thoughts of being worthless, thoughts of guilt and death, may help distinguishing between lesser food intake due to depression, and not due to uremia. However, our research had a limitation of not having these specific questions. Moreover, many of the self-report measures, which were used in many previous studies such as Beck Depression Inventory, the Cognitive Depression Index (CDI), the Zung Scale, and questions from Kidney Disease Quality of Life questionnaire,[28],[29],[30],[31],[32] were not employed in our study and results were completely dependent on more baseline questions addressed by the patients, about their mood and energy level in general, and general feeling of tiredness.

Out of the total 49 patients in our study group, nine patients (18.4%) were on suboptimal (2/week) HD due to various reasons. This subgroup of patients showed more inter-dialysis weight gain compared to those having HD thrice a week. However, the weight gain pattern could not be associated with malnutrition. In a previous study, similar pattern was observed at least in the age group younger than 65; however, certain degree of correlation was found in the older age group. Malnutrition Inflammation Score (MIS) was used as an indicator of malnutrition in this study.[33] Higher MIS score was seen in the elderly with suboptimal dialysis. In our study, however, interdialytic weight gain had no correlation with malnutrition in terms of SGA scores and anthropometric assessments. Hence, whether the malnutrition predictor be the MIS score as in the previous study[33] or the SGA and anthropometric assessments as in our study, it does not correlate with the interdialysis weight gain indicating that both are independent factors.

Body fat percentages did not reflect any correlation with malnutrition. There have been studies showing positive correlation between leptin levels and body fat percentages and its inverse relationship with albumin levels. These studies used albumin level as a representative of malnutrition.[34] Our study ruled out albumin level as a marker in the first place. As mentioned earlier, albumin level does not correlate with malnutrition in our study.

To conclude, in our cohort, two-third of the patients had malnutrition. Surprisingly, traditional factors studied in previous trials, which were analyzed in our study as well, have not shown any significant association with malnutrition in our study.

Conflict of interest: None declared.

 
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Correspondence Address:
Dr. Usman Yaqoob
Department of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
USA
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DOI: 10.4103/1319-2442.229271

PMID: 29657203

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