Assessment of nutritional status of maintenance hemodialysis patients by anthropometric examinations and subjective global assessment-dialysis malnutrition score

To assess the nutritional status of patients on maintenance hemodialysis by using anthropometric measurements and subjective global assessment-dialysis malnutrition score.

ASSESSMENT OF NUTRITIONAL STATUS OF MAINTENANCE

HEMODIALYSIS PATIENTS BY ANTHROPOMETRIC

EXAMINATIONS AND SUBJECTIVE GLOBAL ASSESSMENT-DIALYSIS MALNUTRITION SCORE

Nguyen Duy Dong 1 ; Nguyen Thanh Cho 1 ; Ha Hoang Kiem 1

SUMMARY

Objectives: To assess the nutritional status of patients on maintenance hemodialysis by using anthropometric measurements and subjective global assessment-dialysis malnutrition score Subjects and methods: Descriptive study on 173 patients with renal failure undergoing maintenance hemodialysis at Department of Nephrology and Hemodialysis, 103 Military Hospital by using subjective global assessment-dialysis malnutrition score, anthropometric like post-dialysis weight, body mass index, triceps skin-fold thickness, arm circumference, mid-arm muscle circumference and mid-arm muscle area Results: Based on subjective global assessment-dialysis malnutrition score criteria, 85.5% of patients suffered from malnutrition and 14.5% were well nourished (mean score 15.2 ± 4.3) There were statistically negative significant correlations between body weight, body mass index, mid-arm circumference, mid-arm muscle circumference, arm muscle area and subjective global assessment-dialysis malnutrition score

In addition, there was a statistically positive significant correlation between age, duration of dialysis (vintage) and subjective global assessment-dialysis malnutrition score Conclusion: Malnutrition was found to be almost in patients undergoing hemodialysis Anthropometric measurements like body mass index, triceps skin-fold thickness, arm circumference, mid-arm muscle circumference, and mid-arm muscle area were negatively correlated with subjective global assessment-dialysis malnutrition score

* Keywords: Anthropometric; Subjective global assessment-dialysis malnutrition score; Hemodialysis.

INTRODUCTION

Good nutritional status is a well-known

marker of well-being in patients with chronic

kidney disease (CKD) Protein-energy

malnutrition (PEM) develops during the

course of CKD and is associated with

adverse outcomes [1] Although most of

the overt symptoms of uremia diminish or disappear after the commencement of

maintenance hemodialysis (MHD), the

dialysis procedure in itself may promote wasting by various mechanisms The pathogenesis of PEM in MHD patients is multifactorial in which acidosis and increased catabolism play an important roles [2]

1 103 Military Hospital

Corresponding author: Nguyen Duy Dong (dnduydong157@gmai.com)

Date received: 30/05/2019

Date accepted: 08/08/2019

Several methods are used to evaluate

the nutritional status of hemodialysis

patients Among these nutritional assessment

tools, the widely used are subjective

global assessment, and subjective global

assessment-dialysis malnutrition score

(SGA-DMS) [3, 4] Subjective global

assessment (SGA) tool was developed by

Detsky et al in 1984 that comprises

subjective and objective aspects of

nutritional status [5] National Kidney

Foundation Kidney Disease/Dialysis

(NKF/KDOQI) recommends assessing

nutritional status of patients undergoing

MHD by using SGA at least every six

months [6] Kalantar-Zadeh et al developed

a fully quantitative method to assess

nutritional status in MHD patients in a

practical and inexpensive way [3] This

new tool relies on clinical judgment

derived from grading scales calculated

from a brief history and physical examination

Thus, the purpose of this study is to:

Assess nutritional status by SGA-DMS

score and several anthropometric

examinations in MHD patients

SUBJECTS AND METHODS

1 Subjects

The study population composed of 173

patients (108 males and 65 females) who

fulfilled the following inclusion criteria:

- On maintenance conventional

hemodialysis as a constant modality of

renal replacement therapy, 3 times/week

and duration of hemodialysis at least

3 months

- Absence of active infection, chronic

inflammation disease of unknown origin,

malignancy history, major adverse cardiovascular events, severe gastrointestinal and hepatic diseases, ongoing treatment with immunosuppressive medications

- Consent is given for participation in the study

2 Methods

This cross-sectional, descriptive-analytic study was conducted from March 2016

to October 2017 at the Department of Nephrology and Hemodialysis, 103 Military Hospital

* Clinical assessment:

Patient’s medical history, demographics, and duration of dialysis were obtained from the historic registry On the day of evaluation, patients were interviewed during dialysis for their dietary habit, change in weight, gastrointestinal symptoms, and all other information relevant to the SGA-DMS tool [3]

Anthropometric measurements were carried out after completion of hemodialysis Height and post-dialysis weight were measured with light clothing BMI was calculated as the ratio of end dialysis body weight and the square of the height

in meters (kg/m2) Measurements of skin fold in the area of triceps muscle (TSF) were done with a caliper (Abbott Japan)

to estimate body fat Measurement of mid-arm circumference (MAC) was done with an inserted tape (Abbott Japan) on the non-access arm to estimate muscle mass MAC signifies the thickness of subcutaneous fat and muscle Mid-arm muscle circumference (MAMC) and arm

muscle area (AMA), which reflects the

protein store in the body, was calculated using the following formula [7]: MAMC =

MAC-(3.1415 x TSF) and AMA =

MAMC2/4π-10 (male), MAMC2/4π-6.5

(female)

* Evaluation of nutritional status by

SGA-DMS method:

Nutritional status was assessed by

SGA-DMS that relied on seven components-

weight change, dietary intake, gastrointestinal

symptoms, functional capacity, comorbidity

and duration of dialysis, subcutaneous fat,

and signs of muscle wasting Each

component was given a score from 1

(normal) to 5 (very severe) [3] Thus, the

SGA-DMS, sum of all components,

ranged from 7 (normal) to 35 (severely

malnourished) Patients were categorized

into three groups: Normal nutrition (score

of 7 - 10), mild-to-moderate malnutrition (score of 11 - 21), and severe malnutrition (score of 22 - 35)

* Statistical analysis:

Statistical analysis was done using SPSS software v 20.0 (SPSS Inc., Chicago, IL) All categorical variables are expressed as percentages and compare across cohorts using the χ2 test Continuous variables are expressed as mean ± standard deviation (SD) and the statistical significance of mean differences is compared using t-test or Mann-Whitney test in the study as appropriate Pearson’s correlation/Spearman are used to assess the correlation between variables p-values

< 0.05 are considered statistically significant

RESULTS

The study sample included 173 patients, 108 males, and 65 females with the mean age of 53.0 ± 14.6 years (24 to 89 years) Median and quartiles of MHD vintage were

23 months (10 - 55) and chronic glomerulonephritis frequency among patients was 57.2%

Table 1: Demography and anthropometric measurement of study population

(c: t-student test; d: Mann Whitney U test)

Mean BMI was 19.7 ± 2.6 kg/m2 The bodily measurements such as weight, BMI, MAC, MAMC, AMA were statistically significant higher in male, while TSF did not differ

by gender

Table 2: Nutritional status according to SGA-DMS score (n = 173)

Overall, SGA-DMS in the study population was 15.2 ± 4.3 12% of the study population were classified as normal nutritional status, and 85.5% were classified as malnutrition Of them, 76.9% of patients were mild-moderate malnourished, 11.1% of patients were severely malnourished There were no significant statistical differences between males and female

Table 3: Correlation between malnutrition score and patient parameters

SGA-DMS Variables

(b: Spearman correlation)

Figure 1: Regression line of SGA-DMS by duration of dialysis

Y=0.027 X + 14.12

Figure 2: Regression line of SGA-DMS by BMI

Figure 3: Regression lines of SGA-DMS by AMA

All assessed anthropometric measurements were statistically negative significant correlated with SGA-DMS While there were positive significant correlated with duration

of dialysis and age

DISCUSSION

Malnutrition is a common problem in

dialysis patients [3, 8] It has a direct

relationship with the quality of life and is

associated with increased risk of mortality

and morbidity in these groups of patients

Despite this, the nutritional status of

dialysis patients is frequently ignored

Some literature shows that the prevalence

of PEM in dialysis patients is high ranging

from 23% to 94% being malnourished [8,

9, 10] Kalantar-Zadeh et al [3] showed that the Pearson correlation coefficients between the SGA-DMS score and biceps skin-fold (r = -0.32), MAC (r = -0.55), MAMC (r = -0.66), BMI (r = 0.35), and the serum albumin (r = -0.36) were all significant The SGA-DMS also showed a significant correlation with age (r = +0.34) and dialysis duration (r = +0.28) Asgarani

et al [11] showed that SGA-DMS correlated

Y = -0.425 X + 23.552

Y = -0.168 X + 19.411

with weight, BMI, TSF, BSF, MAC, MAMC

(p < 0.01), transferrin serum (p < 0.05)

Vanitha et al [12] showed there were

negatively correlated between anthropometric

measurements like BMI, TSF, MAC, MAMC,

AMA, serum albumin and SGA-DMS score

In the present study, 78.4% of patients

were malnutrition according to SGA-DMS

score (table 2) Strong negative correlation

of SGA-DMS score with all anthropometric

parameters (table 3 and figure 1) like

weight, BMI, TSF, MAC, MAMC, and AMA

in the current study were similar to previous

studies, suggesting that decrease in

anthropometric measurements is associated

with increased SGA-DMS score indicating

a smaller these anthropometric parameters

for patients having a higher nutritional

score or a stronger tendency towards

malnutrition Therefore, combination of

these anthropometric assessments may

be as effective as SGA-DMS for evaluation

of malnutrition of hemodialysis population

We showed that the SGA-DMS is

compatible with the anthropometric

measurement results and can be used as

a reliable, rapid, and precise method for

nutritional assessment in office, hospital

and hemodialysis centers It is preferred

in comparison with other time-consuming

methods for nutritional assessment Also,

SGA-DMS score had positive correlation

with age and duration of dialysis It means

that older age and longer vintage, higher

SGA-DMS score and higher risk of

malnutrition

Average values of anthropometric

measures differ significantly by gender,

except for TSF and this is appropriate with

characteristic anthropometric by gender

[13] This shows that anthropometric

measures can be used independently of gender Anthropometric assessment tools like BMI, MAC, MAMC, TSF, AMA are relatively easier, cheaper, and practical markers of nutritional status

CONCLUSION

This study shows that the prevalence

of malnutrition according to SGA-DMS score is very high (accounting for 85.5%),

of which mainly is mild to moderate malnutrition (77.5%) Several anthropometric examinations also show a significant inverse correlation to the SGA-DMS score Therefore, in addition to the valuable SGA-DMS score in the assessment of nutritional status in patients with end-stage chronic kidney disease undergoing maintenance hemodialysis, the anthropometric indicators are also important due to its benefits in clinical practice

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