Assessing the prevalence of malnutrition in chronic ...

Nutrition & Food Science Assessing the prevalence of malnutrition in chronic kidney disease patients undergoing hemodialysis in Kushtia District, Bangladesh Hasan Mahfuz Reza, Suvasish Das Shuvo, Tanvir Ahmad,

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NFS 48,1

150 Received 25 May 2017 Revised 24 October 2017 1 November 2017 Accepted 7 November 2017

Assessing the prevalence of malnutrition in chronic kidney disease patients undergoing hemodialysis in Kushtia District, Bangladesh Hasan Mahfuz Reza


Dialysis Unit, Sono Hospital Limited, Kushtia, Bangladesh, and

Suvasish Das Shuvo and Tanvir Ahmad Department of Nutrition and Food Technology, Jessore University of Science and Technology, Jessore, Bangladesh

Abstract Purpose – The purpose of this study is to evaluate the nutritional status of patients with end-stage kidney disease undergoing hemodialysis.

Design/methodology/approach – End-stage renal failure outpatients on hemodialysis were selected using simple random sampling technique from the dialysis unit of Sono Hospital Limited, Kushtia, Bangladesh. The nutritional status of 142 participant, of age 18-65 years, was screened. A direct method of nutritional assessment including anthropometric measurement, biochemical measurement, clinical assessment and dietary method was conducted. A logistic regression was applied to estimate the prevalence of malnutrition in hemodialysis patients. Findings – In total 69.0 per cent participants were men and 31.0 per cent were women, whereas about 65.5 and 16.9 per cent patients of this study had a BMI of less than 23 kg/m2 and 18.5 kg/m2 (p < 0.05) where malnutrition was significantly prevalent. Mean 6 SD hemoglobin level of both men and women participants was below the normal level which might increase the risk of malnutrition (p < 0.05). Of the total number of participants, 97.2 per cent were anemic, 66.9 per cent had anorexia, 63.4 per cent complained of nausea, 58.5 per cent complained of vomiting and 26.1 per cent complained of diarrhea, factors that can increase the risk of malnutrition in hemodialysis patients (p < 0.05). The creatinine and urea levels were higher in both men and women participants (p < 0.05). Results show significant difference in albumin levels among men and women (p < 0.05). The bicarbonate level was lower in both men and women, and the participants were suffering from metabolic acidosis (p < 0.05). About 87.3 per cent participants were taking inadequate amounts of protein which was a significant risk factor of malnutrition in hemodialysis patients (p < 0.01). Originality/value – The result shows that renal failure is prevalent more in men than in women. The majority of patients on hemodialysis were at a risk of malnutrition including being underweight. Most of the patients were anemic. Malnutrition is related to low nutrient intake.

Keywords Malnutrition, Body mass index, Hemoglobin, End-stage kidney diseases, Hemodialysis Paper type Research paper

Nutrition & Food Science Vol. 48 No. 1, 2018 pp. 150-164 © Emerald Publishing Limited 0034-6659 DOI 10.1108/NFS-05-2017-0103

1. Introduction Chronic kidney disease (CKD) is the continuous loss of kidney functions, defined as kidney damage or an estimated glomerular filtration rate of less than 60 ml/min/1.73 m2 (Levey et al., 2005). At present, it is a global public health problem with a rising incidence and


prevalence, poor outcomes and high cost. Kidney failure is the outcome of chronic kidney disease and it includes complications of decreased kidney function (Chugh and Jha, 1995; Kim et al., 2013). If glomerular filtration rate is less than 15 ml/min/1.73 m2, then untreated chronic disease leads to a final stage called end-stage disease. Renal replacement therapy in the form of dialysis or transplantation remains the only treatment option when a patient reaches end-stage renal disease [National Kidney Foundation (NKF), 2010]. Some risk factors including diabetes, hypertension, smoking, hypercholesterolemia, obesity, age, gender and family history also possibly contribute to the development of chronic kidney disease (Levin, 2001; White et al., 2005; Segall et al., 2009; Bossola et al., 2009; Tsai et al., 2016). To remove waste products from the blood of patient with end-stage renal disease, hemodialysis is the long-term form of mechanical renal replacement therapy (Crowley, 2009). The main purpose of hemodialysis is to restore the intracellular and extracellular fluid environment that is characteristic of normal kidney function. This is accomplished by the transport of solutes such as urea from the blood into the dialysate and by the transport of solutes such as bicarbonate from the dialysate into the blood (Locatelli et al., 2002; Oliveira et al., 2012). The prevalence of protein energy malnutrition is high in end-stage kidney disease patients, which is often a sign for kidney replacement therapy. This is characterized by changes to serum proteins and imbalance between the protein and fat components of the organism (Pupim et al., 2006; Piratelli and Telarolli Junior, 2012; Kim et al., 2013). Among the important reasons of protein energy malnutrition in this population are alterations to energy metabolism and calorie levels, poor food intake, anorexia, nausea and vomiting, relating to the constant state of inflammation and uremic toxicity and occurrences of concomitant infection and inflammation (Tayyem and Mrayyan, 2008; National Kidney Foundation, 2002, 2010; Tsai et al., 2016). The cause of malnutrition is multifactorial and includes: inadequate food intake, hormonal and gastrointestinal disorders, dietary restrictions, drugs that alter nutrient absorption, insufficient dialysis and constant presence of associated diseases. Furthermore, uremia, acidosis, low hemoglobin level and hemodialysis procedure per se are hyper catabolic and associated with the presence of an inflammatory state (Shah et al., 2009; Oliveira et al., 2012; Carrero et al., 2013; Tsai et al., 2016). A study of nutritional status should show the relationship between food and nutrients, their use in the body and general health. It may be good, fair or poor, depending on the body ability to utilize these (Overt, 1980). The state of nutritional health of an individual or group of individuals is determined by the process of nutritional assessment. Nutritional status is generally evaluated by anthropometric measurement, clinical examinations for ascertaining nutritional deficiencies and also biochemical assessment (Committee on Goals of Education for Dietetics, 1969). Malnutrition has many adverse consequences, and it is often argued that a malnourished individual is mentally and physically fatigued. He or she lacks in curiosity and is irresponsive to environmental situation. He is also frequently attacked by illnesses, leading to higher absenteeism which is considered as another cause for poor performance (Berg, 1969; Oliveira et al., 2012; Tsai et al., 2016). Protein-restricted diets are prescribed in patients with chronic renal failure (CRF) to alleviate uremic symptoms and to slow the progression of CRF. The potential harmful effects of protein restriction on nutritional status and clinical outcome of patients with CRF have raised concern (Aparicio et al., 2000). Dialysis treatments remove protein waste from blood. A low-protein diet is no longer necessary to control protein waste buildup because this is accomplished by dialysis. A higher protein intake is required to replace protein lost

Prevalence of malnutrition

151

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during dialysis and to support a well-nourished and healthy body. Decreased dietary protein intake may be related with increased mortality risk in individuals with kidney failure undergoing maintenance hemodialysis (Shinaberger et al., 2006; Bossola et al., 2009). In the present context, it is more important to assess the nutritional status of end-stage kidney diseases patients undergoing hemodialysis. As such the present study was undertaken to assess the nutritional status in relation to clinical presentations, anthropometrical measurements and biochemical presentations of end-stage kidney diseases patients undergoing hemodialysis on a selected private hospital in Kushtia district, Bangladesh. 2. Materials and methods 2.1 Study design This cross-sectional study was conducted at hemodialysis units, Sono Hospital Limited, Kushtia, Bangladesh. The research protocol was approved by the Review Board of Human Research Ethics Committee at hemodialysis units, Sono Hospital Limited, Kushtia, Bangladesh, and a signed consent was obtained from each participant. Ethical clearance was obtained from the Sono Hospital Limited, Kushtia, Bangladesh, for use of human subjects. 2.2 Location of the study The hospital-based study was carried out at the dialysis unit of Sono Hospital Limited, Kushtia, Bangladesh. 2.3 Sample size This observational study was carried out to evaluate the nutritional status of end-stage kidney disease undergoing hemodialysis from the dialysis unit from a selected private hospital, Kushtia, during the period from March 2015 to February 2016. In total, 142 adult hemodialysis patients from both sexes were selected for the study by using simple random sampling technique. 2.4 Collection of data All participants were informed of the purpose of the study, and each patient signed a consent form. Data regarding anthropometric information and socioeconomic status like occupation, marital status, education, family size, family type and monthly family income were collected by interviewing the subjects. The study subjects were first interviewed and then a questionnaire was distributed among them to fill up. 2.5 Anthropometric assessment Patient’s weight and height measurements were taken by the following anthropometric procedures after dialysis (World Health Organization, 1995). Body weight was measured with a digital weighting scale in kilograms. Height was taken with a measuring scale in centimeters. BMI was calculated by using the formula: Wt ðin kgÞ=Ht ðin m2 Þ ¼ BMI in kg=m2 Assessment of nutritional status was done by body mass index method (World Health Organization, 1995). Participants having BMI 18.5 were considered as underweight, having


BMI > 18.524.9 as normal weight, having BMI < 259.9 as over-weight, having BMI > 30 as obese and having BMI > 40 as morbidly obese. According to National Kidney Foundation (NKF) nutritional status was also assessed by BMI < 23 and BMI > 23, because mortality and morbidity rate is high in hemodialysis patients having BMI < 23 (Fouque et al., 2007).

Prevalence of malnutrition

2.6 Clinical assessment For clinical assessment, each respondent was interviewed for the uremic symptoms like anorexia, nausea, vomiting, constipation, headache and others. All of those and data on clinical presentation of the nutritional deficiency disorders like presence of anemia, RTI, xerophthalmia, angular stomatitis and glossitis were included in the questionnaire. Data were expressed as percentages.

153

2.7 Biochemical assessment About 4 ml of blood samples were taken from each patient for the determination of kidney profile (blood urea, serum creatinine, serum electrolytes and serum albumin) and for estimation of blood hemoglobin level. Estimation of blood hemoglobin level was done by the Sahli’s Acid Hematin Method (Ghai, 2007). 2.8 Dietary assessment For dietary assessment, each patient was interviewed for the consumption of food and beverages, especially protein, using food frequency questionnaires. Then the recorded responses were converted into percentages. 2.9 Statistical analysis Descriptive statistics (mean, standard deviation, percentage and frequency) were computed for all study variables. Data were analyzed by STATA version 12. Logit regression analysis was used for hypothesis testing to estimate the prevalence of malnutrition in hemodialysis patients, with presence of malnutrition as the dependent variable and different biochemical variables, socio-economic factors and clinical factors as the explanatory variables. Relative risks were estimated by marginal effect of the estimated logistic regression. Statistical tests were two-sided, and p < 0.05 was considered statistically significant. 3. Results Out of 153 initially enrolled participants, 11 patients (4 men and 7 women patients) were dropped, as they were reluctant to continue, and therefore, data from 142 participants were obtained for the study. In this study, Table I shows the demographic and socioeconomic characteristics of endstage kidney disease patients. The result of the study explains that 69.0 per cent of the total participants were men and 31.0 per cent were women. Among 142 cases, 50.0 per cent lived in rural area. Regarding the education level, 10.6 per cent were illiterate, 23.2 per cent were at the primary level and 29.6 per cent were at the secondary level. Furthermore, 83.8 per cent were married and 16.2 per cent were single or unmarried. So, the data in Table I indicated that renal failure was more prevalent among men than in women which was statistically significant (p < 0.05).

NFS 48,1


154

Table I. Demographic and socio-economic characteristics of hemodialysis patients

x 2 test (p-value)

Variable

Frequency (n = 142)

(%)

Gender Men women

98 44

69.0 31.0

0.01

Area Urban Rural

71 71

50.0 50.0

0.02

Subject education Illiterate Up to primary Middle (SSC) Intermediate (HSC) Graduate Postgraduate

15 33 42 29 14 9

10.6 23.2 29.6 20.4 9.9 6.3

< 0.01

Marital Status Single or unmarried Married

23 119

16.2 83.8

0.12

Socioeconomic status Satisfactory Non-satisfactory

76 66

53.5 46.5

0.05

Notes: The result of the study explains that 69.0% of the total participants were men and 31.0% were women. Table I indicates that renal failure is more prevalent among men than among women. x 2 test was applied where p-values of