|Year : 2019 | Volume
| Issue : 1 | Page : 23-27
Evaluation of nutritional status among patients undergoing hemodialysis: A single-center study
Gurvinder Randhawa1, Manish Kumar Singla2
1 Dietician, Dietetics and Food Service Management, Kapoor's Kidney and Urostone Centre Pvt. Ltd., Chandigarh, India
2 Senior Consultant Nephrologist, Max Super Specialty Hospital, Mohali, Punjab, India
|Date of Web Publication||15-Nov-2019|
Dr. Gurvinder Randhawa
Dietetics and Food Service Management, Kapoor's Kidney and Urostone Centre Pvt. Ltd., Sector 46D, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: Protein–energy malnutrition (PEM) is a highly prevalent problem affecting the survival of hemodialysis (HD) patients. This study evaluated the nutritional status of HD patients using various assessment methods. Methods: Nutritional status of HD patients was evaluated using assessment tools such as 3-day diet recall, subjective global assessment (SGA), and biochemical and anthropometric measurements. Further, correlation analysis was performed between nutritional marker (serum albumin) and other study variables such as hemoglobin (Hb), protein–calorie intake, and type of diet consumed by the patients. Results: Data from 40 adult patients (aged 22–74 years) on HD were analyzed. The results of our study showed the overall good nutritional status of HD patients. According to SGA ratings, majority of the patient population (82%) was in well-nourished state. Despite lower intake of proteins and calories, serum albumin levels were found to be within normal limits. No significant correlation was found between serum albumin levels and other study parameters, namely, protein intake/kg body weight (BW)/day (r = 0.056, P = 0.73), calorie intake/kg BW/day (r = −0.053, P = 0.74), and Hb levels (r = 0.27, P = 0.18). However, body mass index showed moderately positive correlation with triceps skinfold (r = 0.35, P = 0.03). Further, no significant relationship was observed between the type of diet consumed and serum albumin levels (P > 0.05). Conclusion: The results suggest overall good nutritional status and absence of relationship between nutritional marker, serum albumin, and PEM in HD patients.
Keywords: 3-day diet recall, hemodialysis, protein–calorie intake, serum albumin, subjective global assessment
|How to cite this article:|
Randhawa G, Singla MK. Evaluation of nutritional status among patients undergoing hemodialysis: A single-center study. J Renal Nutr Metab 2019;5:23-7
|How to cite this URL:|
Randhawa G, Singla MK. Evaluation of nutritional status among patients undergoing hemodialysis: A single-center study. J Renal Nutr Metab [serial online] 2019 [cited 2020 Jul 14];5:23-7. Available from: http://www.jrnm.in/text.asp?2019/5/1/23/271038
| Introduction|| |
A number of studies performed in the past clearly show that protein–energy malnutrition (PEM) in patients with chronic kidney disease (CKD) is a common phenomenon. Due to dietary restrictions, especially restricted protein intake, malnutrition starts in later stages of CKD. Some patients spontaneously limit their protein intake even when maintenance hemodialysis (MHD) has been initiated, which further worsen their nutritional status. Hemodialysis (HD) in itself is a catabolic procedure and if protein and energy deficits are not corrected by timely dietary interventions, it leads to a decreased quality of life as well as increased morbidity and mortality. The standard dialysis session is generally of 4 h duration with blood fiow rate 300 ml/min and dialysate fiow rate of 500 ml/min using F6 dialyzer. It usually gives a standard KTV of 1.2 or more.
To correct the deficits, a daily dietary protein intake of 1.1–1.2 g/kg body weight (BW) and calorie intake of 30–35 kcal/kg BW have been recommended for patients on MHD., Due to the obligatory losses caused by the dialysis procedure, these recommendations are slightly higher than those considered appropriate for patients who are not on dialysis. Serum albumin is the most extensively studied serum protein for the assessment of nutritional status and strong correlations have been established between low levels of serum albumin and increase in the risk of morbidity and mortality., Some studies have shown that the relative risk of death increases with low serum albumin level and worsening of nutritional status, as assessed by subjective global assessment (SGA) ratings.,,
For every 1-unit decrease in SGA rating, there is a 25% increase in the relative risk of death. Hence, nutritional screening and assessment of patients are necessary to help understand the importance of dietary intake in the form of appropriate amounts of protein and calorie through timely intervention.
The aim of the present study was to evaluate the nutritional status of patients on HD by using nutritional assessment tools like SGA and 3-day diet recall, which provided useful insights into the patient's dietary habits and the number of calories and proteins consumed by them. As serum albumin is found to be the most commonly used screening tool to detect patients at risk for PEM, further effort has been made to investigate the correlation between the nutritional marker (i.e., serum albumin) and other study variables.
| Methods|| |
The present study was conducted at Mayo Hospital, Mohali, from January 1, 2018 to June 30, 2018.
The study was approved by the Institutional Ethics Committee and was carried out in accordance with the “Ethical Guidelines for Biomedical Research on Human Participants, 2006” by the Indian Council of Medical Research and the Declaration of Helsinki. Written informed consent was obtained from all the participants involved in this study.
A total of 40 adult patients comprising 30 males and 10 females were enrolled. The enrolled patients were selected among the outpatients with various comorbidities, who visited the hospital for dialysis sessions and had been on dialysis for 6 months or more. Existing medical records were reviewed for brief medical history and routine biochemical measurements. Demographic and medical data were collected, including age, gender, blood group, time of initiation of dialysis, and frequency of dialysis attended by the patient per week.
SGA assessment forms available online, designed by “Nutritional Education material, team-online” were used. Face-to-face interviews for SGA and dietary review were conducted with individual patients during the dialysis session. SGA gave an insight into the overall nutrition and health status of the patients. SGA ratings were used to assess the level of nourishment as given below:
- Rating A – well nourished
- Rating B – mild–moderately malnourished
- Rating C – severely malnourished.
Diet review was done to assess the quality of life. Patients were interviewed to assess their daily diet habits, uptake of nutritive supplements, food allergies or intolerance, mental status, quality of sleep, and daily physical workout undertaken.
The 3-day diet recall forms were distributed to each patient to record the meal timings, amounts, type of food, and drinks consumed by them. For accurate calculation of patient's daily intake of proteins and calories, emphasis was given on the importance of recording the size or portion of food that was actually consumed. Using 3-day diet recall forms filled by patients, the protein and calorie intake through the food consumed were calculated by referring to the book “Nutritive Value of Indian foods” by Gopalan et al. These values primarily reported the quality and quantity of protein and energy food consumed by the patients.
Based on the type of diet, the patients were classified into two categories
- Vegetarians: Consuming vegetarian food along with milk
- Nonvegetarians and ovovegetarians: Consuming milk, meat, and egg in addition to vegetarian food.
It is generally recommended that patients on HD should consume 50%–60% of high biological value (BV) protein-rich food such as egg, meat, and milk. Therefore, we further assessed if there was any correlation between the type of diet and the nutritional marker (i.e., serum albumin).
Anthropometric parameters, such as dry weight, body mass index (BMI), mid-upper arm circumference (MUAC), and triceps skinfold (TSF), all of which are good indicators of malnutrition, were measured immediately after the dialysis session.
TSF calipers were used to measure skinfold thickness to assess subcutaneous fat. Metric tape was used to measure MUAC, which represents the muscle and fat stores.
The statistical analysis was conducted using IBM SPSS statistical software (Version 2015, IBM Corp., CA, USA). Standard descriptive statistics were used for data analysis, and results for biochemical and anthropometric measurements and nutrient intake were expressed as mean ± standard deviation. The correlation between the variables of the study was calculated using the Pearson correlation coefficient. Chi-square test was used to assess the relationship between the type of diet, i.e., vegetarian or nonvegetarian and serum albumin. P < 0.05 was accepted as statistically significant.
| Results|| |
Data from 40 adult patients (age range: 22–74 years) on HD was analyzed. [Table 1] shows the number of patients belonging to a particular age category. Majority of the study population belonged to the age category of 50–60 years. All the anthropometric parameters of male and female patients were comparable [Table 1].
|Table 1: Demographics and biochemical measurements of the hemodialysis patients|
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[Table 1] also represents the distribution of the study population according to the BMI limit. Overall, 75% of the patients had BMI >18.5, and as per the SGA rating, they came under Category A (i.e., well-nourished state). However, only 5% of the study population had BMI <16 and belonged to the SGA rating Category C (i.e., severely malnourished state). According to SGA ratings, 82% of the patients came under Category A, 8% belonged to mildly malnourished, and 10% belonged to severely malnourished category.
Observations from the analysis of 3-day diet recall forms are shown in [Figure 1] (protein intake) and [Figure 2] (calorie intake). Protein intake was found to be below 1.1 g/kg BW/day in 85% of the patients and lower than 0.8 g/kg BW/day in 60% of the patient population. Remaining 15% of the study population consumed proteins above 1.1 g/kg BW/day [Figure 1]. In energy intake analysis, 82.9% of the study population reported energy intake lower than 30 kcal/kg BW/day, whereas 17.1% of the study population had calorie intake above 30 kcal/kg BW/day [Figure 2]. Further analysis showed calorie intake below 25 kcal/kg BW/day in 54.3% of the patients. In total, 70% of the study population reported the consumption of nonvegetarian diet (meat plus egg plus veg) and remaining 30% showed intake of vegetarian diet.
[Table 2] describes the association among various study parameters. No significant correlation was found between serum albumin levels and other study parameters, namely, protein intake/kg BW/day (r = 0.056, P = 0.73), calorie intake/kg BW/day (r = −0.053, P = 0.74), and hemoglobin levels (r = 0.27, P = 0.18). However, BMI showed moderately positive correlation with TSF (r = 0.35, P = 0.03). As shown in [Table 3], no significant relationship was observed between the type of diet consumed and serum albumin levels (P > 0.05).
|Table 2: Relationship between Serum Albumin and Protein-Energy intake and Hb|
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| Discussion|| |
PEM is a highly prevalent problem observed in patients with CKD. Published literature has reported its association with the quality of life as well as an increased risk of mortality and morbidity among these patients. The present study intended to evaluate the nutritional status of HD patients using various assessment methods.
The results of our study demonstrate overall good nutritional status in HD patients, most of whom were in stable condition and free from complications. It has been shown earlier that protein and calorie intake in the daily diet of HD patients are inadequate and much lower than the recommended level of 1.1 g–1.2 g per kg of BW., In the present study, despite lower intake of proteins and calories, the nutritional marker (serum albumin) was found to be within normal limits. These results differ with the study findings of Kaynar et al., who found that patients on stable chronic HD with higher protein intake had higher albumin levels.
Further, none of the patients was found to be consuming the recommended 50%–60% of high BV protein food on daily basis. High BV protein food has completed amino acid profiles that match with our body's amino acid makeup and are also called complete proteins. High BV protein sources are meat, fish, egg, and milk. The nutritive value of protein will be high if the amino acid makes up is similar to that of body proteins and will be low if it lacks, partially or completely, any one of the ten essential amino acids. Both animal and human studies investigating the infiuence of specific diet on the survival of patients with kidney disease have reported confiicting results.,, Several observational studies have demonstrated positive effect of vegetarian diet on the delay of progression of the disease, while other studies have shown negative or no effect of the type of diet consumed on the survival of these patients.,,, From our observations, it is evident that more patients were consuming nonvegetarian diet. However, the 3-day diet recall form filled by them suggested that the amount and frequency of eating nonvegetarian food on a weekly basis was not substantial. Most of them were consuming only one serving of nonvegetarian food once a week. Some vegetarian patients were found to have higher serum albumin levels than those taking nonvegetarian food. This suggested that the type of diet and serum albumin had no significant correlation.
To compensate the inadequate dietary protein intake, some oral protein supplements were prescribed to the patients, which were specifically formulated as per their nutrient requirements. It was found that only two patients were taking the prescribed protein supplement in substantial amount. Others were either not taking the supplement at all or taking it in smaller than recommended quantity, which did not make any impact on their overall daily protein intake. However, our findings suggested that serum albumin levels of these two patients who were consuming protein supplement were at par with the rest of the patients who were not consuming it. The most reliable tool for evaluation of nutritional status is the SGA method, which is also a good predictor of survival of the diseased patients. According to SGA, majority of the patient population (82%) belonged to Category A (well-nourished state), which depicted their good nutritional status. Few patients with SGA rating C (10%) had abnormally low body compositions, BMI, and TSF, which are predictive markers of increased mortality risk in dialysis patients.,
BMI is considered as an indirect method of measuring the direct body fat. A recent review by Johansen and Lee suggests that a high BMI is not protective for all patients with CKD and is associated with poor physical functioning and frailty. However, many studies in the past have shown the protective effect of higher BMI in dialysis patients. BMI between 18.5 and 24.9 kg/m is considered to be normal and seems to reduce the risk of morbidity and mortality. Obesity should be considered a health risk in patients on dialysis, as it is for patients who are not on dialysis.,, Due to some constraints, we could not perform the skinfold measurement technique in the right manner on different body sites. In spite of this shortcoming, we were able to establish a significant positive correlation between BMI and TSF (P<0.05).
This study was limited by small sample size, and this sample size may not be representative because of being from a single center and of particular socioeconomic group of the patients coming to a private health-care setup. In addition, there was poor assessment of obesity as our study omitted the measurement of muscle mass. Therefore, studies on a larger sample size demonstrating the feasibility of such an approach over an extended time period are needed to provide more accurate results.
| Conclusion|| |
The present study demonstrated that in spite of lower protein and calorie intake, HD patients had normal levels of the nutritional marker serum albumin. Further, serum albumin levels did not show any significant correlation with protein–calorie intake as well as the type of diet. These findings suggest the need for further research to establish the relationship between nutritional status and health of HD patients in the Indian population.
Financial support and sponsorship
Confiicts of interest
There are no confiicts of interest.
| References|| |
Kopple JD; National Kidney Foundation K/DOQI Work Group. The national kidney foundation K/DOQI clinical practice guidelines for dietary protein intake for chronic dialysis patients. Am J Kidney Dis 2001;38:S68-73.
Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B, et al.
EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22 Suppl 2:ii45-87.
Akirov A, Masri-Iraqi H, Atamna A, Shimon I. Low albumin levels are associated with mortality risk in hospitalized patients. Am J Med 2017;130:1465.e11-19.
Pupim LR, Martin CJ, Ikizler TA. Assessment of protein and energy nutritional status. In: Kopple JD, Massry SG, Kalantar-Zadeh K, editors. Nutritional Management of Renal Disease. Assessment of protein and energy nutritional status. Ch. 10. Academic Press; 2013. p. 137-58.
Steiber AL, Kalantar-Zadeh K, Secker D, McCarthy M, Sehgal A, McCann L. Subjective global assessment in chronic kidney disease: A review. J Ren Nutr 2004;14:191-200.
Lowrie EG, Lew NL. Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990;15:458-82.
Cohen SD, Kimmel PL. Nutritional status, psychological issues and survival in hemodialysis patients. Contrib Nephrol 2007;155:1-7.
Gopalan CV, Sastri BV, Balasubramanian SC. Nutritive Value of Indian Foods. Hyderabad: National Institute of Nutrition; 2007.
Kaynar K, Songul Tat T, Ulusoy S, Cansiz M, Ozkan G, Gul S, et al.
Evaluation of nutritional parameters of hemodialysis patients. Hippokratia 2012;16:236-40.
Ogborn MR, Bankovic-Calic N, Shoesmith C, Buist R, Peeling J. Soy protein modification of rat polycystic kidney disease. Am J Physiol 1998;274:F541-9.
Trujillo J, Ramírez V, Pérez J, Torre-Villalvazo I, Torres N, Tovar AR, et al.
Renal protection by a soy diet in obese Zucker rats is associated with restoration of nitric oxide generation. Am J Physiol Renal Physiol 2005;288:F108-16.
Mitch WE, Remuzzi G. Diets for patients with chronic kidney disease, should we reconsider? BMC Nephrol 2016;17:80.
Rysz J, Franczyk B, Ciałkowska-Rysz A, Gluba-Brzózka A. The effect of diet on the survival of patients with chronic kidney disease. Nutrients 2017;9. pii: E495.
Noce A, Vidiri MF, Marrone G, Moriconi E, Bocedi A, Capria A, et al.
Is low-protein diet a possible risk factor of malnutrition in chronic kidney disease patients? Cell Death Discov 2016;2:16026.
Fouque D, Pelletier S, Mafra D, Chauveau P. Nutrition and chronic kidney disease. Kidney Int 2011;80:348-57.
Moe SM, Zidehsarai MP, Chambers MA, Jackman LA, Radcliffe JS, Trevino LL, et al.
Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease. Clin J Am Soc Nephrol 2011;6:257-64.
Enia G, Sicuso C, Alati G, Zoccali C. Subjective global assessment of nutrition in dialysis patients. Nephrol Dial Transplant 1993;8:1094-8.
Maggiore Q, Nigrelli S, Ciccarelli C, Grimaldi C, Rossi GA, Michelassi C. Nutritional and prognostic correlates of bioimpedance indexes in hemodialysis patients. Kidney Int 1996;50:2103-8.
Chertow GM, Jacobs DO, Lazarus JM, Lew NL, Lowrie EG. Phase angle predicts survival in hemodialysis patients. J Ren Nutr 1997;7:204-7.
Johansen KL, Lee C. Body composition in chronic kidney disease. Curr Opin Nephrol Hypertens 2015;24:268-75.
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.
Leavey SF, McCullough K, Hecking E, Goodkin D, Port FK, Young EW. Body mass index and mortality in 'healthier' as compared with 'sicker' haemodialysis patients: Results from the dialysis outcomes and practice patterns study (DOPPS). Nephrol Dial Transplant 2001;16:2386-94.
Abbott KC, Glanton CW, Trespalacios FC, Oliver DK, Ortiz MI, Agodoa LY, et al
. Body mass index, dialysis modality, and survival: Analysis of the United States renal data system dialysis morbidity and mortality wave II study. Kidney Int 2004;65:597-605.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]