|Year : 2021 | Volume
| Issue : 2 | Page : 445-454
|Assessment of nutritional status in patients with chronic kidney disease in Nigeria
Clement Oyedele Oladele1, Evelyn Unuigbe2, Innocent Ijezie Chukwuonye3, Emmanuel Chukwuebuka Obi3, Kenneth Arinze Ohagwu4, Gloria Oladele5, Louis Ikechukwu Ojogwu2
1 Division of Nephrology, Department of Internal Medicine, Federal Medical Centre, Bida, Niger State, Nigeria
2 Division of Nephrology, Department of Internal Medicine, University of Benin Teaching Hospital, Benin, Edo State, Nigeria
3 Divisions of Nephrology, Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
4 Divisions of Rheumatology, Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
5 Department of Family Medicine, Federal Medical Centre, Bida, Niger State, Nigeria
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|Date of Web Publication||11-Jan-2022|
| Abstract|| |
In Nigeria, there is paucity of data on malnutrition among chronic kidney disease (CKD) patients especially before the initiation of dialysis therapy, necessitating this study. The study subjects consisted of 96 CKD patients recruited from the renal unit of our hospital. Forty age-and sex-matched controls were also studied. Nutritional status was assessed using Subjective Global Assessment (SGA), weight change over six months of follow-up, body mass index, mid-upper arm circumference, triceps skinfold thickness, and serum albumin concentration. A three-day food diary was used to determine the average daily protein intake of the patients. Sixty-six CKD patients completed the study. The age range of CKD patients was 23–65 years with a mean of 47.1 ± 13.2 years while the age range of the controls was 23–65 years with a mean of 44.1 ± 14.3 years. Out of the 66 CKD patients studied, four lost >10% of their body weight. The body mass index (BMI) was low (<20 kg/m2) in eight (12.1%) of CKD patients, while three (7.5%) subjects in the control population had BMI of <20 kg/m2. The serum albumin was less than 3 g/dL in seven (10.6%) of the CKD patients, SGA identified malnutrition in 30 (46%) of the CKD patients. The prevalence of malnutrition in predialysis CKD patients was high in this study.
|How to cite this article:|
Oladele CO, Unuigbe E, Chukwuonye II, Obi EC, Ohagwu KA, Oladele G, Ojogwu LI. Assessment of nutritional status in patients with chronic kidney disease in Nigeria. Saudi J Kidney Dis Transpl 2021;32:445-54
|How to cite this URL:|
Oladele CO, Unuigbe E, Chukwuonye II, Obi EC, Ohagwu KA, Oladele G, Ojogwu LI. Assessment of nutritional status in patients with chronic kidney disease in Nigeria. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 16];32:445-54. Available from: https://www.sjkdt.org/text.asp?2021/32/2/445/335457
| Introduction|| |
The nutritional status of patients with chronic kidney disease (CKD) at the initiation of dialysis therapy and on maintenance dialysis therapy is an important determinant of morbidity and mortality associated with the disease. The assessment of nutritional status of CKD patients is an integral part of care for patients with CKD, more so in patients on hemodialysis (HD) or peritoneal dialysis (PD). Studies have shown that 18%–80% of patients on dialysis have some form of nutritional deficiency. Certain factors influence the nutritional status in CKD patients and these include multiple hormonal disturbances, uremia-induced anorexia, and comorbidities. In addition, low physical activity and persistent inflammation are also implicated. The assessment of energy expenditure in dialysis patients showed a low physical activity and this affects the energy need of the patients. Persistent inflammation which is a common state in CKD patients affects catabolism and nutrient intake., Poor nutritional status, at the start of HD is associated with poor outcome. It is therefore important to assess the nutritional status of patients before commencing dialysis and to adequately manage this condition. There is paucity of studies on nutritional status of CKD patients in Nigeria,, necessitating this study.
| Materials and Methods|| |
The study was carried out at the University of Benin Teaching hospital (UBTH) Benin City, which is a 444 bedded tertiary hospital. It has a renal unit that provides dialysis services. UBTH provides tertiary health care to Edo State and her environs including Ondo, Delta, Anambra, Kogi, and Bayelsa States.
This was a prospective, observational, hospital-based study
Approval for the study was obtained from the Ethics and Research Committee of UBTH, Benin City, Nigeria.
Study population and sampling method
Ninety-six CKD patients who had not commenced dialysis therapy and were attending renal clinics at our hospital were enrolled in the study. Detailed history and physical examination were carried out at the first contact with the patients. The inclusion criteria were adult of 18 years and above with diagnosis of CKD who gave informed consent (either by the patient or a close relative). Patients with nephrotic syndrome, chronic liver disease, human immunodeficiency virus (HIV), evidence of malignancy, history of chronic illness, chronic steroid use, patients unwilling to give informed consent, and patients below 18 years were excluded from the study.
A questionnaire was administered to each of the subjects who met the inclusion criteria, to obtain the following information: age, gender, occupation, marital status, level of education, possible cause of CKD, biochemical parameters, anthropometric parameter, and subjective global assessment (SGA). SGA was carried out for each of the patients, anthropometric and biochemical measurements were also performed at the time of enrolment into the study. The questionnaire was pre-tested using 15 patients with CKD.
The study lasted for six months, and 30 patients dropped out, and the reasons, were the commencement of dialysis therapy before the end of the study, death, default from clinic attendance, and withdrawal of consent given initially. As a result, 66 CKD patients completed the six-month study.
Forty subjects who were age- and sex-matched were recruited as controls. These controls were the normal (non-CKD) relations of patients attending our clinic, hospital staff, and subjects who came to the hospital for pre-employment medical examinations. They were all subjected to the same process as the CKD patients for six months concurrently.
The following indices were measured; body weight, height, mid-arm circumference, triceps skinfolds thickness (TSFT). Measurements were taken at the first visit and six months later. The average values of each parameter were used for the analysis. Weight of the subjects was measured in kilograms (kg), using a weighing scale. Weights were recorded to the nearest 0.1 kg. To determine the percentage weight loss of each patient, the weight was taken at the time of enrolment into the study and at six months after the initial assessment. A stadiometer was used to measure the height in centimeters (cm). BMI was measured with the World Health Organization classification.
Triceps skins fold thickness measurement
The TSFT was measured in the midline of the posterior aspect of the arm, over the triceps muscles at a level halfway between the lateral projections of the acromion process and the olecranon process at the elbow joint. With the elbow flexed to 90 degrees, the midpoint was determined by measuring the distance between the two landmarks using a tape measure which was marked on the side of the arm. The measurements were taken with the subjects standing with the arm hanging loosely and comfortably at the side.
The Harpenden caliper was held in the right hand. A vertical fold of skin and subcutaneous tissue was picked gently with the left thumbs and index finger approximately 1 cm proximal to the marked level, and the tips of the caliper applied perpendicular to the skin fold at the marked level. The left arms of the patients were used. TSFT measurement values of less than 10 mm in men and of less than 13 mm in women were regarded as malnutrition in this study.
The mid-upper arm circumference
This was measured with a measuring tape, mid-way between the olecranon process of the ulna and the tip of the shoulder of the left arm. Values of <22 cm in women and <25 cm in men were considered as malnutrition in this study.
Subjective global assessment
SGA was performed by one observer for all patients. SGA refers to the overall evaluation of a patient by an experienced clinician. This was based on medical history and physical examination. Review of the medical history included an assessment of weight and weight change, dietary intake, gastrointestinal symptoms, disease state, and the patient’s functional capacity related to nutritional status. The physical examination focused on loss of subcutaneous fat and muscle, the presence of ankle edema, and ascites related to nutritional status were evaluated. All these features were categorized as normal O, mild (1+) moderate (2+), severe (3+). On the basis of subjective weighting of the data on medical history and physical examination the patients were classified into three groups “A” well-nourished, “B” mild/moderately malnourished, “C” severely malnourished.
Protein intakes were estimated from three–day food diaries in the week of first contact with the patient. Food intakes were recorded at two days’ interval. With the assistance of the hospital dietitian, using a table of nutrient, due instruction was given to every patient on how to measure his/her food ration.
Chronic kidney disease
CKD is defined by the Kidney Disease: Improving Global Outcome as kidney damage that has continued for more than three months as characterized by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR). It is also defined as GFR <60 mL/min/1.73 m2 for more than three months, with or without structural kidney damage.
Estimation of glomerular filtration rate
The GFR was calculated using the six-variable MDRD study formula by Manjunath et al. This formula is unique as it takes into consideration age, race, gender, serum albumin, serum creatinine, and serum urea nitrogen. Using this equation;
GFR = 170 × (SCr)–0.999 × [Age, (years)]–0.176 × 0.762 (If patient is a female) or × 1.18 (if patient is black) × (BUN)-0.17 × (Alb)+0.318.
SCr = Serum creatinine (mg/dL)
BUN = Blood urea nitrogen (mg/dL)
Alb = albumin (g/dL)
Blood samples were taken on two occasions after an overnight fast from an antecubital vein for the assessment of serum albumin, creatinine, and urea. Normal serum albumin was taken as 3.5–5.2 g/dL.
Determination of malnutrition
A patient was considered malnourished in this study with two or more of the following nutritional parameters. 1. Weight loss of >10% at six months of follow-up.
- Overall subjective global assessment score of B or C.
- BMI <20 kg/m2.
- Mid-upper arm circumference (MUAC) less than 22 cm in females and 25 cm in males.
- TSFT less than 10 mm in males and <13 mm in females.
- Serum albumin concentration <3 g/dL.
| Statistical Analysis|| |
Data were analyzed using the IBM SPSS Statistics version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics such as means and ranges or variables of interest were computed. Statistical comparison of the arithmetic means was determined using Student’s t-test. Comparison of percentages or proportion was done using Chi-square test. Pearson’s correlation coefficient was used to determine the relationship between malnutrition and renal function. A P<0.05 was considered to be statistically significant.
| Results|| |
Characteristics of the subjects studied
A total of 96 patients were enrolled in the study and 66 of them were evaluable. This was made up of 45 (68%) males and 21(32% females). Forty age- and sex-matched controls made up of 21 (53% males) and 19 (47% females) were also studied. The age range of CKD patients was 23 to 65 years with a mean age of 47.1 ± 13.2 years while controls were also aged between 23 and 65 years with a mean of 44.1 ± 14.3 years there was no significant difference (P >0.05). [Table 1] shows the characteristics of both the CKD and control groups.
|Table 1: Characteristics of chronic kidney disease patients and control group.|
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The mean values of GFR were significantly lower in the CKD patients (23.9 + 10.8 mL/ min) than in the control group (115.5 + 16.7 mL/min)
Nutritional status assessment
SGA identified malnutrition in 30 (46%) of CKD patients and none of the subjects among the control population was malnourished by SGA [Table 2].
|Table 2: Distribution of malnourished patients and control by indices of malnutrition.|
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The 30 subjects that were malnourished by SGA 25 (37.9) were mildly/moderately malnourished and five (7.6) were severely malnourished. All the controls were well nourished.
[Table 3] shows the stages of CKD by degree of malnutrition using SGA.
|Table 3: Stages of chronic kidney disease by degree of malnutrition using subjective global assessment.|
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[Table 4] shows SGA of CKD patients and control by age group distribution.
|Table 4: Subjective global assessment of chronic kidney disease patients and control by age group distribution.|
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[Table 5] shows the characteristics of the five patients in stage 5 CKD who were severely malnourished by SGA criteria.
|Table 5: Characteristics of the 5 patients in stage 5 chronic kidney disease those were severely malnourished by subjective global assessment criteria.|
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The percentage weight loss was significant (>10%) in four of these patients.
Nutritional Status Assessment by Other Nutritional Indices
Body mass index
The mean BMI of well-nourished CKD patients was 25.97 + 2.22 kg/m2) was significantly higher than the mean BMI value of 22.31 + 2.79 kg/m2 observed in malnourished patients P <0.001) [Table 6]. There was a significant direct correlation between BMI and eGFR (r = 0.3 P = 0.042), showing that BMI decreased with progressive deterioration of renal function.
|Table 6: Comparison of anthropometric and biochemical characteristics between well-nourished and malnourished chronic kidney disease patients before the commencement of dialysis therapy. |
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Triceps skinfold thickness
The mean TSFT of well-nourished CKD patients of (13.19 + 4.31 mm) was significantly higher than the TSFT of 8.69 + 2.85 mm observed in malnourished patients (P<0.001) [Table 6]. There was a positive correlation between TSFT and the GFR (r = 0.2, P = 0.178) as the renal function decreased, the TSFT also decreased. However, this association was not significant, P = 0.178.
Mid upper arm circumference
MUAC of the CKD patients and controls were 27.8 + 3.8 cm and 29.5 + 3.4 cm respectively, and this difference was statistically significant (P = 0.02. The mean MUAC of well-nourished CKD patients (29.66 + 3.20 cm) was significantly higher than the MUAC of 25.56 + 3.34 cm in malnourished patients P<0.001) [Table 6].
There was indirect, although not significant correlation between MUAC and stages of eGFR (r = 0.2, P = 0.105) such that there was decreasing MUAC with the progression of CKD.
Only four (6%) patients were malnourished by this criterion having lost >10% of their body weight and there was no significant weight loss in the control group during the six months of follow-up [Table 2].
The mean values of percentage weight loss of the well-nourished and malnourished patients were 1.5 + 2.62% and 3.71 + 4.14% respectively [Table 6] and this difference was statistically significant (P = 0.011). There was a negative correlation between the percentage weight loss and GFR (r = -0.4, P = 0.002) such that the percentage weight loss increased with decreasing renal function.
The mean value of serum albumin of 3.6 + 0.7 g/dL observed in the CKD patients was significantly lower than the mean albumin value of 4.3 + 0.4g/dL observed in the non-CKD control group, P <0.001 [Table 1]. There was no significant difference between the mean serum albumin concentration of the well-nourished (3.96 + 0.61 g/dL) CKD patients and the malnourished (3.65 + 0.67 g/dL) CKD patients. There was a positive significant correlation between serum albumin concentration and stages of eGFR (r = 0.4, P = 0.001).
Two or more criteria
Using two or more nutritional parameters to classify patients as being malnourished, 28 (42%) CKD patients were malnourished whereas in the control population five (13%) of the subjects were malnourished. Of all the nutrition markers, TSFT recorded the highest proportion of malnourished patients in the CKD population 34 (52%), followed by SGA 46%, MUAC 23%, and BMI 12%. While serum albumin and weight loss recorded the least (11% and 6%, respectively) [Table 4].
The four patients that recorded significant weight loss in this study were all in stage 5 CRF (GFR <15 mL/min) [Table 6].
[Figure 1] and [Figure 2] show the mean average daily protein intake of CKD patients and control by degree of malnutrition. There was a statistically significant difference between the mean average daily protein intake of the well-nourished CKD patients and control group (t = -2.943, P = 0.004). Protein intake declined as the degree of malnutrition worsened and further showed that patients who were severely malnourished had the least protein intake.
|Figure 1: Mean average daily protein intake by stage of chronic kidney disease.|
CKD: Chronic kidney disease.
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|Figure 2: Mean average daily protein intake of chronic kidney disease patients and control by degree of malnutrition.|
SGA: Subjective global assessment.
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| Discussion|| |
The prevalence of malnutrition in Nigerians with CKD before the initiation of dialysis therapy has not received enough attention and has not been well characterized. This study highlights the prevalence of malnutrition before the initiation of dialysis therapy and its relationship with renal insufficiency. The majority of the patients in this study (53%) were in stage 4 CKD, which suggested that a large proportion of patients with undiagnosed CKD are progressing to end-stage renal disease in our population. It also suggested that many of the patients with CKD in Nigeria present late to renal clinics in the country.
The study showed that malnutrition is common in CKD patients in Nigeria before commencement of renal replacement therapy. Malnutrition was found in 46% of CKD patients studied using the SGA criteria. A higher prevalence was observed in a similar study out by Liman et al, using the SGA criteria in which the patients were also followed up for six months. The prevalence of malnutrition reported was 54.8% in CKD patients. The higher prevalence of malnutrition found in Liman et al study is possibly due to the fact that majority of the patients included in their study were already on HD. Our study observed that the severity of malnutrition increased with advanced stage of CKD in predialysis patients, similar to the observation made by Hyun et al. However, they used the International Society of Renal Nutrition and Metabolism (ISRNM) criteria in their study. Francisco et al in their study on predialysis patients observed that 64% of their patients did not have malnutrition, 31% had mild-to-moderate malnutrition and 5% had severe malnutrition. This result compares with our observation of 54% well-nourished predialysis CKD patients, 38% mild-to-moderate malnourished and 8% severely malnourished patients. They also reported worsening of nutritional status with diminishing renal function. Kopple et al in their study on the evaluation of nutritional status of patients that participated in the feasibility phase of MDRD study reported that patients who are not in need of maintenance dialysis treatment in general, do not suffer from malnutrition. Our study is not in agreement with their observation.
The results of our study suggest that the progression of CKD from stage 3 to stage 5 is associated with spontaneous decrease in dietary protein intake and thus most nutritional indices in CKD patients worsen as the GFR and dietary protein intake decrease. Patients in stages 4 and 5 CKD were more malnourished than those in stage 3 CKD. These patients in stages 4 and 5 CKD also had less protein intake and this was worse with patients in stage 5 CKD. These findings agree strongly with the observations of Ikizler and Hakim that progression of renal failure is associated with a spontaneous decrease in dietary protein intake, especially below creatinine clearance of 25 mL/min and that nutritional status worsens as creatinine clearance and dietary protein intake decrease. Patients with CKD should be advised to control their protein intake to reach optimal body protective value: it is recommended that CKD patients should consume 0.6–0.8 protein/kg/day with or without diabetes mellitus to help prevent malnutrition.
There were variations in the ability of the different nutritional tools to detect malnutrition when compared with the use of subjective global assessment in our study. The use of triceps skinfold thickness overestimated patients with malnutrition. The use of two or more nutritional criteria as well as MUAC compare favorably with SGA in detecting malnutrition. The use of percentage weight loss and serum albumin were the least in detecting malnutrition followed by the BMI. This implies that the use of significant weight loss in pre-dialysis CKD patients has a limited value in detecting malnutrition. The four patients with weight loss in excess of 10% were those in end-stage renal disease who were in need of dialysis therapy.
Among the five patients classified as having severe malnutrition by SGA, 40% of them had serum albumin concentration of at least 4.0 g/dL, this is in keeping with observation made by Covinsky et al. However, using 3.5 g/dL as the cutoff point, the sensitivity was 12.1% which is close to the 14.3% observed by José dos Santos et al using the same cutoff point. The poor sensitivity of albumin in identifying malnutrition might be explained by its large body pool and long half-life, which makes this protein a late marker of malnutrition. The results of this study agree with earlier reports that serum albumin has limited value as a marker of nutritional status.
| Conclusion|| |
In this study, the results showed that malnutrition in CKD starts before end-stage renal disease. However, it is commonly mild-to-moderate and has the propensity to progress to severe malnutrition as the renal function worsens.
| Practical Application|| |
The study showed that reliance on serum albumin as the sole determinant of malnutrition could delay an early nutritional intervention in malnourished CKD patients. It is therefore recommended to associate serum albumin with other nutritional indices to detect early malnutrition. Both serum albumin and SGA are not without their limitations as measures of nutritional status
Conflict of interest: None declared.
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Clement Oyedele Oladele
Division of Nephrology, Department of Internal Medicine, Federal Medical Centre, Bida, Niger, State
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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