To assess the nutritional status of patients on maintenance hemodialysis by using anthropometric measurements and subjective global assessment-dialysis malnutrition score.
Journal of military pharmaco-medicine no6-2019 ASSESSMENT OF NUTRITIONAL STATUS OF MAINTENANCE HEMODIALYSIS PATIENTS BY ANTHROPOMETRIC EXAMINATIONS AND SUBJECTIVE GLOBAL ASSESSMENT-DIALYSIS MALNUTRITION SCORE Nguyen Duy Dong1; Nguyen Thanh Cho1; Ha Hoang Kiem1 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, mid-arm circumference, midarm muscle circumference and 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, mid-arm circumference, midarm muscle circumference, and 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] 103 Military Hospital Corresponding author: Nguyen Duy Dong (dnduydong157@gmai.com) Date received: 30/05/2019 Date accepted: 08/08/2019 147 Journal of military pharmaco-medicine no6-2019 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 Outcomes and Quality Initiative (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 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, times/week and duration of hemodialysis at least months - Absence of active infection, chronic inflammation disease of unknown origin, 148 malignancy history, major adverse cardiovascular events, severe gastrointestinal and hepatic diseases, ongoing treatment with immunosuppressive medications - Consent is given for participation in the study 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 SGADMS 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 = Journal of military pharmaco-medicine no6-2019 MAC-(3.1415 x TSF) and AMA = MAMC /4π-10 (male), MAMC /4π-6.5 (female) * Evaluation of nutritional status by SGA-DMS method: Nutritional status was assessed by SGA-DMS that relied on seven componentsweight 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 (normal) to (very severe) [3] Thus, the SGA-DMS, sum of all components, ranged from (normal) to 35 (severely malnourished) Patients were categorized into three groups: Normal nutrition (score of - 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 Variables Male (n = 108) Female (n = 65) All (n = 173) p 52.2 ± 14.3 54.2 ± 15.1 53.0 ± 14.6 > 0.05 25 (11 - 61.8) 16 (9 - 44.5) 23 (10 - 55) > 0.05 Weight (kg) 55.9 ± 7.7 44.2 ± 5.9 51.5 ± 9.1 < 0.01 c BMI (kg/m ) 20.5 ± 2.6 18.5 ± 2.0 19.7 ± 2.6 < 0.01 c TSF (mm) 8.6 ± 3.9 9.4 ± 4.1 8.9 ± 4.0 > 0.05 MAC (cm) 24.3 ± 2.7 21.7 ± 2.3 23.3 ± 3.0 < 0.01 MAMC (cm) 21.6 ± 2.3 18.7 ± 1.8 20.5 ± 2.5 < 0.01 c 27,6 ± 7.9 21.7 ± 5.4 25.3 ± 7.6 < 0.01 c Age (years) Vintage (months) AMA (cm ) c d d d (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 149 Journal of military pharmaco-medicine no6-2019 Table 2: Nutritional status according to SGA-DMS score (n = 173) SGA-DMS Male Female All p Mean ± SD 15.6 ± 4.6 1.,4 ± 3.9 15.2 ± 4.3 > 0.05 Groups Male, n (%) Female, n (%) All, n (%) p - 10 13 (12.0) 12 (18.5) 25 (14.5) 11 - 21 83 (76.9) 51 (78.5) 134 (77.5) 22 - 35 12 (11.1) (3.1) 14 (8.1) d b > 0.05 (b: χ test; d: Mann Whitney U test) 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 Variables SGA-DMS b p Age (years) 0.24 < 0.01 Vintage (months) 0.32 < 0.01 BMI (kg/m ) -0.22 < 001 TSF (mm) -0.17 < 0.01 MAC (cm) -0.26 < 0.01 MAMC (cm) -0.24 < 0.01 -0.29 < 0.01 2 AMA (cm ) r (b: Spearman correlation) Y=0.027 X + 14.12 Figure 1: Regression line of SGA-DMS by duration of dialysis 150 Journal of military pharmaco-medicine no6-2019 Y = -0.425 X + 23.552 Figure 2: Regression line of SGA-DMS by BMI Y = -0.168 X + 19.411 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 151 Journal of military pharmaco-medicine no6-2019 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 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 152 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 endstage chronic kidney disease undergoing maintenance hemodialysis, the anthropometric indicators are also important due to its benefits in clinical practice REFERENCES National Kidney Foundation K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification, Part 4: Definition and classification of stages of chronic kidney disease Am J Kidney Dis 2002, 39 (Suppl 1), S43-S79 Toigo G, Aparicio M, Attman P.O et al Expert Working group report on nutrition in adult patients with renal insufficiency (Part of 2) Clin Nutr 2000, 21, pp.197-207 Kalantar-Zadeh K, Kleiner M, Dunne E et al A modified quantitative subjective global assessment of nutrition for dialysis patients Nephrol Dial Transpl 1999, 14 (7), pp.1732-1738 SteiberA L, Kalantar-Zadeh K, Secker D et al Subjective Global Assessment in chronic kidney disease: A review J Ren Nutr 2004, 14 (4), pp.191-200 Journal of military pharmaco-medicine no6-2019 Detsky A S, McLaughlin J R, Baker J P et al What is subjective global assessment of nutritional status? J Parenter Enteral Nutr 1987, 11 (1), pp.8-13 National Kidney Foundation K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure I Adult guidelines A maintenance dialysis Am J Kidney Dis 2000, 35 (6, Supplement 2), S17-S55 Heymsfield S B, McManus C, Smith J et al Anthropometric measurement of muscle mass: Revised equations for calculating bonefree arm muscle area Am J Clin Nutr 1982, 36 (4), pp.680-690 Aparicio M, Cano N, Chauveau P et al Nutritional status of haemodialysis patients: A French national cooperative study French Study Group for Nutrition in Dialysis Nephrol Dial Transpl 1999, 14 (7), pp.1679-1686 Koor B, Nakhaie M & Babaie S Nutritional assessment and its correlation with anthropometric measurements in hemodialysis patients Saudi J Kidney Dis Transpl 2015, 26 (4), pp.697-701 10 Morais A A, Silva M A, Faintuch J et al Correlation of nutritional status and food intake in hemodialysis patients Clinics (Sao Paulo) 2005, 60 (3), pp.185-192 11 Asgarani F, Mahdavi-Mazdeh M, Lessan-Pezeshki M et al Correlation between modified subjective global assessment with anthropometric measurements and laboratory parameters Acta Medica Iranica 2004, 42 (5), pp.331-337 12 Vanitha R N, Kavimani S, Soundararajan P et al Correlation between anthropometry, biochemical markers and subjective global assessment–dialysis malnutrition score as predictors of nutritional status of the maintenance hemodialysis patients J Med Res Health Sci 2015, (4), pp.852-856 13 World Health Organization WHO Expert Committee on Physical Status: The use and Interpretation of Anthropometry WHO Technical Report Series, Geneva 1995 153 ... 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. .. anthropometry, biochemical markers and subjective global assessment dialysis malnutrition score as predictors of nutritional status of the maintenance hemodialysis patients J Med Res Health Sci 2015,... 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