To investigate of nutritional status in maintenance hemodialysis patients by indicators: anthropometric, dietary energy, and protein intake, dialysis malnutrition score, serum albumin, prealbumin levels. To Understand the relationship between nutritional status and some clinical and laboratory characteristics, initially assessing the results of an oral nutritional supplement on nutritional status in 12 weeks in maintenance hemodialysis patients.
Trang 1ABSTRACTChronic kidney disease (CKD) has an increasing incidence. The annual incidence and prevalence of CKD using kidney replacement methods are increasing, reflecting advances in the treatment of this disease Malnutrition is common in patients with CKD with and without kidney replacement methods Malnourished and CKD interact with each other to increase morbidity, reduce the quality of life, prolong hospital stay, increase treatment costs, and mortality in this population.
Malnutrition in CKD patients has more than one factor alone. Present, diagnostic of malnutrition in this object does not have a
“gold standard”. However, a list of signs and indicators to assess and diagnose malnutrition status can be used, including assessments on a diet, anthropometric measurements, laboratory parameters, and other tools Diagnostic of malnutrition status is necessary for selecting nutritional supplements for patients to solve the above issues.
In Vietnam, there were some studies on evaluating nutritional status, but there has not been any comprehensive research on the issue of nurturing for CKD patients. To contribute to further clarifying this problem, we proceed to the thesis: “A study on nutritional status,
the results of an oral nutritional supplement on maintenance hemodialysis patients.” with two objectives:
1 To investigate of nutritional status in maintenance hemodialysis patients by indicators: anthropometric, dietary energy, and protein intake, dialysis malnutrition score, serum albumin, prealbumin levels.
Trang 22 To Understand the relationship between nutritional status and some clinical and laboratory characteristics, initially assessing the results of an oral nutritional supplement on nutritional status in 12 weeks in maintenance hemodialysis patients.
2. Summary of new main scientific contributions of the thesis:Determine the malnutrition rate as well as some factors affecting nutritional status in hemodialysis patients. Besides, initially evaluating the results of oral dietary supplements for 12 consecutive weeks in this subject. This thesis will contribute to clinical practice and propose solutions to improve nutritional status for malnourished patients.
3. Thesis layout:
The thesis consists of 125 pages, including sections and four chapters: Introduction 02 pages; Literature Review 33 pages; Methodology 25 pages; Results 26 pages; Discussion 36 pages; Conclusions 02 pages; Recommendations 01 page
Refer to 150 documents (141 English, 11 Vietnamese)
ABBREVIATIONSAMA: Upper Arm muscle area
DPI: Dietary Protein Intake PEW: Protein Energy WastingHBV: High Biological value RBC: Red blood cell
ISRNM: International Society of
Renal Nutrition & Metabolism
SGADMS: Subjective Global Assessment Dialysis Malnutrition score
K/DOQI: Kidney /disease TSF: Triceps Skinfold
Trang 3CHAPTER 1LITERATURE REVIEW
1.1 A BRIEF HISTORY OF CHRONIC KIDNEY DISEASE
According to the K/DOQI 2002, CKD is defined as having kidney damage or glomerular filtration rate below 60 ml/min/1.73 m2
of at least three months. In 2002, the KDIGO gave a similar but more concise definition. CKD is an abnormality in kidney structure and function that lasts more than three months, and effects on patient health. CKD is categorized based on etiology, glomerular filtration rate, and albuminuria Renal replacement therapy, including peritoneal dialysis, hemodialysis, or kidney transplantation
The primary cause of CKD is diverse, depending on the region, continent, economic status, and medical development of each country. The incidence and treatment of endstage chronic kidney disease are increasing in countries over the world
* Renal replacement therapy by hemodialysis
Hemodialysis continues to be the most common treatment for endstage chronic kidney disease in all countries, which is a method
of dialysis outside the body, by creating an external circulating body, leading blood to the filtration system to filter metabolic products and excess water The blood is returned to the body Hemodialysis procedure only replaces the renal excretion function, so patients still need internal medical treatment: medical nutritional therapy, treatment
of hypertension, anemia, vitamins, and mineral supplements
Trang 41.2.MALNUTRITION IN PATIENTS WITH CHRONIC KIDNEY DISEASE
According to the definition of the WHO, malnutrition is a state
of deficiency, excess, or imbalance in the energy and, or nutrients of
a person. The ISRNM 2008 uses the term proteinenergy wasting (PEW) in chronic kidney disease
Evidence suggests that malnutrition is common in patients with CKD conserving treatment, hemodialysis, or peritoneal dialysis. There are many possible causes of malnutrition in hemodialysis patients, including low nutrient intake, increased metabolism, acidosis, inflammation, anemia, oxidative stress, changes in response
to anabolic hormones, increased retention of toxic substances, loss of nutrients in dialysis, and comorbidities There are independent, overlapping, complementary, or antagonistic mechanisms that it difficult to troubleshoot their effects on protein metabolism and energy balance.
Malnutrition cause increasing in morbidity and mortality, poor quality of life, length of stay, and readmission in CKD patients
* Methods of assessing nutritional status
There are many methods for evaluating malnutrition in patients with CKD However, useful clinical tools are illustrated by the nutrition care guidelines developed by K/DOQI
Anthropometric measurements: weight, body mass index, skinfolds thickness, midarm circumference, midarm muscle circumference, and arm muscle area.
Diet and food use
Subjective global assessmentDialysis malnutrition score
Trang 5 Proteinenergy wasting, according to ISRNM 2008 criteria
* The nutritional requirement in hemodialysis patients
Dietary energy intake (DEI): K/DOQI 2000 recommends DEI 30 to
35 kcal/kg/day (over 60 years old), at least 35 kcal/kg/day (under 60).Dietary protein intake (DPI): K/DOQI 2000 recommends DPI at least 1.2 g/kg/day
* Eggs are a rich source of dietary cholesterol and are a nutritious whole food, so they should be judged based on total intake rather than specific components, like cholesterol. Although there are concerns about regular egg consumption that may be associated with
a risk of cardiovascular disease due to cholesterol levels Most epidemiological studies were claiming to use one egg a day did not increase cardiovascular disease, coronary artery disease, or stroke
* Treatment of hemodialysis patients with malnutrition
In hemodialysis patients who are malnourished or at risk of malnutrition, there is no single treatment approach that significantly reduces the negative consequences of malnutrition, including
Nutritional counseling
Oral nutritional supplement
Intradialytic parental nutrition
Enteral and total parental nutrition
Trang 62.1. RESEARCH SUBJECT
Maintenance hemodialysis patients
Location: Department of Nephrology and Hemodialysis, 103 Military Hospital
Study period: from March 2016 to January 2018
2.1.1. Subject criteria for evaluation of the nutritional status
Inclusion criteria: Over 18 years of old patients; at least three months of dialysis, dialysis three times a week, 4 hours each time
Exclusion criteria: severe acute illness, severe chronic heart failure, severe liver failure, advanced cancer, deaf and dumb, or noncooperative research
2.1.2. Subject criteria for the intervention study
Inclusion criteria: Patients with energy and protein intake below recommended; malnutrition is determined by BMI, SGADMS, serum albumin, prealbumin level
Exclusion criteria: Having surgery three months before, during,
or dying during the intervention; are allergic to milk, eggs; disagree to participate in intervention research, or did not fulfill commitments.2.2. RESEARCH METHODOLOGY
2.2.1. Research design
The study design consists of two consecutive research methods: the crosssectional descriptive study and intervention study
2.2.2. Sample sizes and sampling methods
Trang 7 Crosssectional study: the whole sample, according to the chronological order, 173 patients.
Intervention study: 79 patients were divided into intervention group and control group according to their dialysis schedule: patients with dialysis schedule on Monday/Wednesday/Friday of the week were enrolled in the intervention group, while those on Tuesday, Thursday, and Saturday of the week were into the control group. Thirtynine patients participated in supplementation of diet (intervention group); 40 patients did not participate in supplementation (control group)
2.2.3. Implementation of the intervention study
* Research materials:
The supplementary diet consisted of 48 g of Nepro2 and one chicken egg (average 42 g) daily for 12 consecutive weeks This regimen provides about 259 kcal, 14.9 g of high biological value protein
* Implement supplement intervention
Treatment for both groups: according to a uniform procedure
Intervention group: patients were advised on a daily diet, oral supplementation diet, for 12 consecutive weeks.
Control group: patients were only counseled on a regular diet and did not participate in the dietary supplement
Compliance assessment: sitting and watching them, make sure that they ate the entire supplement, or ate at least 70% of the dietary supplement. Also, call, remind, and return the package to the next filtration. 2.2.4. Data collection
* The patients’ information
* Some diagnostic criteria used in the study: CKD and some cause.
Trang 8 Anthropometric indicators: dry weight, height, calculation
of BMI, triceps skinfold, midarm circumference, calculation of the midarm muscle circumference, and arm muscle area BMI is classified by the WHO. Body composition indexes are categorized
by Blackburn and Harvey, and Frisancho
Dietary energy and protein intake
Evaluation by the 24hour recall for three days. The calculation
is based on the Vietnam Food Ingredient Table 2016, average over three days, based on ideal body weight. Compare with K/DOQI
Subjective global assessmentDialysis malnutrition scoreThis tool consists of seven components. Each part is rated on a scale of 1 to 5. The total score ranges from 7 to 35, the higher the score, the worse the nutritional status is. Classification of nutritional status into the healthy group (710 points), mild and moderate malnutrition (1121 points), and severe malnutrition (2235 points)
Laboratory parameters
The venous blood sample is taken before the start of the dialysis section, including the concentration of serum albumin, prealbumin. Besides, the evaluation of serum protein, total cholesterol, urea, creatinine, and high sensitive CRP. Hematological indicators such as red blood cell, hemoglobin, lymphocytes. Classification of serum albumin and prealbumin levels based on K/DOQI 2000 guidelines
Diagnosis of malnutrition, according to the International Society of Renal Nutrition & Metabolism (ISRNM 2008)
* Evaluation of the results of an oral nutritional supplement
Patients were assessed for nutritional status and general features
at baseline and after 12 weeks of supplementation diet in the
Trang 9intervention and control group with the following indicators BMI, SGADMS, the concentration of serum protein, albumin, total cholesterol, red blood cell count, and hemoglobin level.
CHAPTER 3RESULTS
3.1. GENERAL CHARACTERISTICS OF STUDY SUBJECTS3.1.1. Characteristics of age and gender
The mean age of subjects was 53.0 ± 14.6 years old, ranging from 24 to 89. The under65 group accounted for 73.4% of patients (n=127). Males accounted for 62.4% (n=108) of patients
3.1.2. Cause of chronic kidney disease
Chronic glomerulonephritis causes CKD, with a majority with 57.2%, diabetes mellitus accounted for 13.9% of patients
3.1.3. Features of the hemodialysis vintage
The median, quartiles dialysis time was 23 (1055) months. The under five year HV group accounted for mainly 77.4% (n=134) of patients
3.1.4. Characteristics of appetite status
Patients with normal appetite status (good and very good) accounted for 22.0% of patients, and loss appetite status accounted for 78.0% (very poor, poor, and fairly).
3.1.5. Characteristics of dietary energy and protein intake
The means DEI, DPI, and HBV protein of patients were 24.9 ± 4.2 kcal/IBW/day, 0.95 ± 0.17 g/IBW/day, and 52.9 ± 6.7%, respectively. There were 67.6% of patients prioritizing using high biological value protein in their diet (≥ 50%)
Trang 10requirements according to K/DOQI 2000
93.1% of patients did not meet both DEI and DPI requirements. 3.1.6. Characteristics of some laboratory parameters
The percentage of patients with serum total cholesterol concentration, red blood cell count, hemoglobin concentration, count, and percentage of peripheral blood lymphocytes below the standard threshold were high, with 57.8%, 89.0%, 91.3%, 35.8%, and 60.7%, respectively
Trang 11The prevalence of malnutrition, according to TSF, MAC, MAMC, AMA criteria, was 11.6% (n=20), 30.6% (n=55), 16.2% (n=28), and 60.7% (n=105) of patients, respectively
3.2.3. SGADMS
Table 3.2. Nutritional status according to SGADMS (n=173)SGADMS, score Number Prevalence % X ± SD
The prevalences of malnutrition, according to serum albumin and prealbumin criteria, were 67.6% (n=117) and 57.6% (n=98) of patients
3.2.5. Nutritional status when combining indicators
The percentage of malnourished patients, when all four criteria are present, is 16.5% — meanwhile, 4.1% of patients in the normal range for all four indicators
Trang 12The prevalence of PEW, according to ISRNM criteria (including BMI, AMA, DPI, and serum albumin), was 24.3% (n=42).
3.3 RELATIONSHIP BETWEEN NUTRITION INDICATORS WITH SOME CLINICAL AND LABORATORY FEATURES, AND INITIAL RESULTS OF AN ORAL NUTRITIONAL SUPPLEMENT
DEI (kcal/kg/day)
DPI (g/kg/day) sAlbumin (g/l)
SGADMS score were negatively correlated with BMI, DEI, DPI, serum albumin, prealbumin level BMI was positively correlated with DEI, DPI, and serum albumin level. DEI and DPI were positively correlated, positively correlated with serum albumin and prealbumin levels
Trang 133.3.2 Relationship between nutrition indicators and some variables
3.3.2.1. Body mass index with some features
There is no difference in BMI with age (over and under 60 years old), duration of dialysis (over and under five years), causes (diabetes and others), appetite status (normal and decreased), the concentration of hsCRP (normal and high).
3.3.2.2. Dialysis malnutrition score with some features
SGADMS score in over60 yearold patients, dialysis over five years, anorexia status, are statistically higher than other patients
3.3.2.3. Dietary energy and protein intake with some features
DEI and DPI in patients over 60 years old, diabetes mellitus, and loss appetite are statistically less than in patients under 60 years old, nondiabetic etiology, and healthy appetite status
3.3.2.4. Biochemical parameters with some features
The concentration of serum albumin, prealbumin in patients over 60 years old, diabetes, anorexia, and hsCRP over 5 mg/l were significantly lower than that of the other patients
3.3.2.5. Multivariate logistic regression analysis
Multivariate analysis results showed an independent relationship between patients over 60 years old (OR=3.11; 95%CI: 0.080.37; p<0.05) with PEW criteria according to ISRNM 2008.3.3.3 Initial results of oral nutritional supplementation on nutrition status in hemodialysis patients
3.3.3.1. General characteristics of the intervention and control group
at baseline
The gender distribution, mean age, and duration of dialysis, causes of CKD at baseline (T0) in the intervention group were