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 Table of Contents  
Year : 2020  |  Volume : 20  |  Issue : 3  |  Page : 179-185

Assessment of malnutrition in patients with chronic kidney disease undergoing hemodialysis

1 Department of Clinical Pharmacy & Pharm D, Vaagdevi College of Pharmacy, Kakatiya University, Warangal, Telangana, India
2 Department of General Medicine, Kakatiya Medical College, Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India

Date of Submission18-Mar-2020
Date of Acceptance11-Jun-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Venkateshwarlu Eggadi
Department of Clinical Pharmacy & Pharm D., Vaagdevi College of Pharmacy, Kakatiya University, Warangal-506001, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jesnt.jesnt_7_20

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Background Malnutrition is the utmost predominant problem that arises in patients undergoing hemodialysis. Muscle wasting arises as a prevailing case, and so, it acts as a crucial indicator of morbidity and mortality in hemodialysis patients.
Patients and methods This study encompasses 175 participants for a period of 6 months. Graded questionnaires and clinical findings were used to assess nutritional status.
Results The mean age was 49.26±13.35 years, and 73% were males. Mean serum albumin and hemoglobin levels were 2.78±0.75 and 9.01±1.60 g/dl, respectively. According to the National Kidney Foundation, 49.71% of participants were malnourished whose BMI was less than 20. The results of mini-nutritional assessment scores revealed that a greater number of patients were at risk of malnutrition (56.5%) and subjective global assessment scores showed a moderate risk (63.4%). On assessing the clinical findings, 96% were anemic, 90.2% were fatigue, 62.8% complained of headache, and 69.1% had anorexia.
Conclusion It is necessary to have the right amount of nutrition each day as it boosts the quality of life and further research should pinpoint the management strategies to control malnutrition in patients with chronic kidney disease.

Keywords: chronic kidney disease, hemodialysis, malnutrition, mini-nutritional assessment, subjective global assessment

How to cite this article:
Racha A, Kanthala MR, Komuravelly S, Eggadi V, Bandaru SB, Prasad R. Assessment of malnutrition in patients with chronic kidney disease undergoing hemodialysis. J Egypt Soc Nephrol Transplant 2020;20:179-85

How to cite this URL:
Racha A, Kanthala MR, Komuravelly S, Eggadi V, Bandaru SB, Prasad R. Assessment of malnutrition in patients with chronic kidney disease undergoing hemodialysis. J Egypt Soc Nephrol Transplant [serial online] 2020 [cited 2020 Sep 19];20:179-85. Available from: http://www.jesnt.eg.net/text.asp?2020/20/3/179/290016

  Introduction Top

Chronic kidney disease (CKD) is marked as a gradual loss of kidney function or lessened glomerular filtration rate of 60 ml/min/1.73 m2 for at least 3 months, which is portrayed by loss of nephrons, cutback of functional renal mass, and irreversible sclerosis, leading to a radical decline in glomerular filtration rate [1].

According to the global concern of disease, CKD will be the fifth most leading cause of death by 2040 [2]. Its prevalence is one in ten adults globally and is 24.7% in hypertensive and 16.6% among diabetic patients, with significant morbidity and mortality [3]. Men were at increased risk of hypertension (HTN) and HTN-related end-stage renal disease (ESRD) when compared with women [4]. Deaths owing to CKD have increased by 41.5% from the past years, because of further risks associated with poverty like infections, improvised education, unhealthy works, and poor maternal health combined with the increased cost of screening and treatment [5]. Risk factors for CKD include HTN, diabetes mellitus (DM), cardiovascular diseases (CVDs), sex, obesity, social history, and family history of kidney disease [6].

Malnutrition occurs mainly in patients with ESRD undergoing hemodialysis and is correlated with increased mortality and morbidity and may occur owing to uremic conditions or incorrect dietary choices [7],[8]. Protein-energy malnutrition is characterized as a pathological condition that emerges owing to short of dietary protein and/or energy (calories) in fluctuating proportions [9],[10]. It include dietary restrictions, hormonal and gastrointestinal disorders, insufficient food intake, drugs that alter nutrient absorption, inadequate dialysis, and constant existence of associated diseases [11]. Assessment of malnutrition can be done by various methods. subjective global assessment (SGA) scale is recommended by National Kidney Foundation kidney disease − dialysis outcomes and quality initiative for nutritional assessment in the adult dialysis population for its reproducibility, authenticity, and reliability. It is simple, inexpensive, non-invasive, and rapid to conduct at the bedside [12]. Mini-nutritional assessment (MNA) is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) for assessment of nutritional and health conditions, quality of life, cognition, mobility, and subjective health [13]. It is a brief, noninvasive, decisive, and broadly evaluated nutritional assessment tool used clinically [14]. Clinical assessment was performed to interview each participant for uremic symptoms [11].

  Aim Top

This work aimed to assess the nutritional status and also to encounter the aspects affecting hemodialysis patients based on their level of significance.

  Materials and methods Top

Site and study design

This was a prospective observational study carried out in the nephrology unit of MGM Hospital, Warangal, and Vishwas Super Specialty Hospital, Hanamkonda, Telangana, India. The approval from the Ethical Committee was obtained for the study IHEC/VCOP/PHARMD/2019-20/NCT10. Informed consent was taken from the patients.

Study population

Patients with CKD undergoing hemodialysis, who were visiting MGM Hospital, Warangal, and Vishwas Super Specialty Hospital, Hanamkonda, were considered as the study participants. A total of 208 participants undergoing hemodialysis during our study who met our inclusion criteria were approached and asked to participate in the study. We included the following participants: age greater than or equal to 18 years and on hemodialysis for greater than or equal to 6 months. We excluded the following patients: on hemodialysis for less than 6 months, patients diagnosed with anemia before ESRD, and patients who are unable to respond to the questions. We invited 175 hemodialysis participants to participate in the study based on our inclusion and exclusion criteria.

Data collection tools were graded questionnaires. First, we used a demographic questionnaire that includes personal characteristics like age, sex, height, weight, occupation, region, duration of hemodialysis, social history, educational status, and comorbidities. Nutritional assessment was rendered by anthropometric assessment (BMI), biochemical assessment (serum albumin and hemoglobin level), and SGA scale, which does not use a specific scoring system based on specific criteria. It includes the participant’s weight change in the past 6 months, dietary intake, gastrointestinal symptoms, current functional capacity, loss of fat stores, and signs of muscle wasting. It includes 14 items, and each item ranges from 0 to 5 score, and items 1 through 14 are summed to provide a total score. Scores less than 15 indicates=no change, 15–30 indicate mild malnutrition, 30–50 indicate moderate malnutrition, and 50–70 indicate severe malnutrition. MNA is a well-validated tool for assessing malnutrition. It includes 18 self-reported questions derived from general, anthropometric, dietary, and self-assessment, and each item ranges from a score of 0 to 2, and items 1 through 18 are summed to provide the total score. Scores greater than or equal to 24 indicate well nourished, 17–23.5 indicate at risk of malnutrition, and less than 17 indicate malnourished. Clinical examination for uremic symptoms was performed to assess the malnutrition and these include 16 findings. The presence of most of these symptoms indicates malnutrition. We also assessed nutritional status by considering BMI according to the National Kidney Foundation.

Linear logistic regression stepwise was executed to determine the distinct factors affecting the participants undergoing hemodialysis. It indicates the order of inclusion factors affecting based on the level of significance.

Statistical analysis

The data were analyzed using Microsoft excel 2019 (Microsoft, Redmond, Washington, U.S. SPSS 22.0: IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) and SPSS 22.0 at the significance level of P<0.0001. Descriptive statistics (mean, SD, percentage, and linear logistic regression) were computed for study variables.

  Results Top

Demographic characteristics

Our study included 175 participants. The mean age was 49.26±13.35 years, and the majority of the participants (28.5%) belonged to the age group 49–58 years. We documented 73% males against 27% females. There was a rural preponderance, constituting 64.57%, and 29.14% were illiterate, whereas 25.71 and 12% had primary and secondary level of education, respectively. Only 33.13% received any mode of a college education. From the selected participants, 55% had social habits of drinking and smoking. The patients who were under dialysis for less than 3 years represented 74.28%. HTN presented a high risk with 93%. DM and CVDs reported by the population represented 26.28 and 14.28%, respectively ([Table 1]).
Table 1 Demographic characteristics of the study population (n=175)

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Nutritional status based on BMI distribution

In this study, nutritional status was classified based on BMI according to the National kidney foundation. From the 175 participants, 56 males and 31 females (49.71%) were malnourished, with BMI less than 20; 35 males and nine female (25.14%) patients were at risk of malnutrition, with BMI 20–23; and 37 males and nine females (25.14%) were well nourished with BMI more than 23 ([Figure 1]).
Figure 1 Nutritional status based on BMI distribution.

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Biochemical parameters

Mean serum albumin was 2.78±0.75 g/dl. It is higher in males (2.90±0.76 g/dl) than females (2.46±0.60 g/dl). Mean hemoglobin was 9.01±1.60 g/dl. It is higher in males (9.25±1.62 g/dl) than females (8.37±1.35 g/dl) and 96% of participants had anemia.


According to SGA, 63.4% (males 70 and females 41) were moderately malnourished, 34.8% (males 55 and females 6) were mildly malnourished, and 1.71% (males two and females one) were severely malnourished ([Table 2]).
Table 2 Sex distribution according to subjective global assessment and mini-nutritional assessment score

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According to MNA, 56.5% (males 82 and females 17) were at risk of malnutrition, 39.4% (males 38; females 31) were malnourished, and 4% (males 7seven were well nourished ([Table 2]).

There is a significant correlation between males and females in the SGA score. R2 values of males and females are 0.9814 and 0.0061, respectively ([Figure 2]). There is a correlation between males and females in the MNA score. R2 values of both males and females are 1 ([Figure 3]).
Figure 2 Sex-wise severity of malnutrition (subjective global assessment).

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Figure 3 Sex-wise severity of malnutrition (mini-nutritional assessment).

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Clinical findings

Approximately 96% of participants had anemia, 69.1% had anorexia, 49.7% had nausea, 31.4% had vomiting, 21.7% had heartburn, 36% had constipation, 54.8% had dizziness, 28.5% had chest pain, 22.8% had dysphasia, 90.2% had fatigue, 62.8% had headache, 18.2% had diarrhea, 48% had pruritus, 54.2% had shortness of breath, 53.7% had respiratory tract infection, and 5.7% had glossitis ([Table 3]).
Table 3 Clinical findings of hemodialysis patients

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  Discussion Top

In the present study, the incidence of CKD was higher in males (73%) than in females (27%), consistent with the results observed in a study conducted by Reza et al. [11], as they observed that 69% males and 31% females.

According to these data, the incidence was higher in the age group 49–58 years (28.5%) followed by a slight decrease, that is, 21.1, 18.8, 16.5, 7.4, 6.2, and 1.1%, in the age groups of 39–48, 59–68, 29–38, 18–28, 69–78, and greater than or equal to 79 years, respectively, whereas the two major community studies (National Health and Nutrition Examination Survey and the NKF’s Kidney Early Evaluation Program)have documented the prevalence of CKD rises with increasing age [15].

According to the data obtained in our study, maximum numbers of patients were found to be in rural area (64.57%), which states that they had low socioeconomic conditions (the results obtained were close to the study conducted by Reza et al. [11] which is 60%), and only 33.13% had received any mode of a college education, and this shows that they had a lack of knowledge regarding proper nutritional intake.According to the data obtained, the incidence is higher in the patients who were neither alcoholics nor smokers (42%). The incidences regarding alcoholics were 38%, smokers were 17%, and others (gutka and paan) were 3%.

From the obtained data, 49.71% of patients were malnourished, 25.14% of patients were at the risk of malnutrition, and 25.14% of patients were well nourished. The studies conducted by Reza et al. [11] and Agboton et al. [16] concluded that nutritional status is high in hemodialysis patients having BMI greater than 23, which is 31.54%.

Among all participants, 93% had HTN, 26.28% had DM, and 14.28% had CVDs. These data indicate that HTN is the major risk factor for CKD.

Overall, 37.71% (n=66) of the patients have been undergoing hemodialysis for 6 months less than 1 year, 28.57% (n=50) of the patients for 1 to less than 3 years, 22.28% (n=39) of the patients for 3 to less than 6 years, 8.50% (n=15) persons for 6–9 years, and 2.85% (n=5) of the patients for greater than or equal to 9 years. We did not observe any statistically significant relationship between the duration of dialysis and malnutrition.

Lower albumin levels and mean hemoglobin levels reported by our study are 2.78±0.75 and 9.01±1.60 g/dl, respectively, which are close to those of the study by Nagabhushana et al., [17], which is 2.66±1.86 and 8.21±2.57 g/dl, respectively.

Based on SGA, the maximum numbers of participants were moderately malnourished (63.4%), 34.8% were mildly, and 1.7% were severely malnourished.

Based on MNA, maximum numbers of participants were at the risk of malnutrition (56.5%), 39.4% were malnourished, and 4% were well nourished.

Our study showed a significant correlation between SGA and the dialysis in males and females. Likewise, a significant correlation was also seen between MNA and the dialysis in both sexes (R2: 0–1).

Of 175 patients, the majority of them presented with clinical findings of anemia, fatigue, anorexia, dizziness, headache, SOB, and respiratory tract infection.

Multivariate linear logistic regression analysis (P<0.05) has proved that some of the factors significantly affect malnutrition in individuals undergoing hemodialysis.

  Conclusion Top

We analyzed graded questionnaires by logistic regression, and P less than 0.05 ([Table 4]) was considered statistically significant. Patients with CKD on hemodialysis showed malnutrition, which must be monitored and managed to avoid further complications associated with it. Future research must be focused on therapeutic interventions and nutritional aspects to overcome malnutrition.
Table 4 Inclusion of the variables based on their order of influence

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

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


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