Comparison of the Nutritional Status Assessment Methods for Hemodialysis Patients

Assessment Criteria to Diagnose Malnutrition (Undernutrition and Overnutrition) in Hemodialysis Patients

OBJECTIVE

This study aimed to determine if adapted Global Leadership Initiative on Malnutrition (GLIM) criteria can diagnose overnutrition, in addition to undernutrition, in hemodialysis patients. Additionally, it compared the adapted GLIM criteria with the subjective global assessment (SGA) for diagnosing undernutrition.

METHODS

A cross-sectional, descriptive study design with an analytical component was utilized. An interviewer-administered questionnaire was completed with 116 adult participants from 2 public renal units in Cape Town. Data collection included demographic, medical, and anthropometric information, incorporating the established SGA tool and the adapted GLIM criteria.

RESULTS

Of the participants, 58% were female, with a mean age of 41.04 years (SD 10.6). The primary causes of renal failure were hypertension (38%) and glomerular disease (33%). The median weight was 64.74 kg (IQR 16.4), and the mean body mass index (BMI) was 25.44 kg/m2 (SD 4.66). The prevalence of obesity was 20%, and undernutrition was 4% by BMI. Participants from Groote Schuur Hospital had a higher mean BMI (26.40, SD 4.9) than those from Tygerberg Hospital (P = .0033). Abdominal obesity prevalence was 51%, with a mean waist circumference of 87.06 cm (SD 11.37). Using SGA parameters, undernutrition prevalence was 26%, with all classified as SGA-B, compared to 22% by adapted GLIM. Adapted GLIM classified 69.83% as malnourished (overnutrition 47% and undernutrition 22%). For undernutrition, the adapted GLIM had a sensitivity of 75% (CI 64.04, 85.96), specificity of 77.78% (CI 67.26, 88.3), positive predictive value of 69.23% (CI 57.55, 80.91), and negative predictive value of 82.35% (CI 72.71, 92.00). Among those diagnosed with overnutrition by adapted GLIM, 89% were classified as well-nourished by SGA.

CONCLUSION

The adapted GLIM criteria effectively assessed overnutrition as well as undernutrition in hemodialysis patients. It identified a significant proportion of patients misclassified as well-nourished by SGA who were actually overnourished. The adapted GLIM showed good sensitivity and specificity for diagnosing undernutrition in this population.

Potential Determinants of Subjective Global Assessment Among Patients on Maintenance Hemodialysis

OBJECTIVE

The Subjective Global Assessment (SGA) is a validated tool for identifying nutritional status in patients receiving maintenance hemodialysis (MHD), but it is not without limitations. Current research identifies additional clinical characteristics such as phase angle (PhA) associated with SGA. This study aimed to assess the overall correlation between PhA and SGA; associations between PhA and SGA by body mass index, and to identify clinical characteristics associated with SGA.

DESIGN AND METHODS

This is a secondary analysis of the Rutgers Nutrition & Kidney Database, which enrolled participants from four primary studies that included adults diagnosed with chronic kidney disease who were receiving MHD. Multivariable binary logistic regression analyses were conducted to estimate odds ratio (OR) and corresponding 95% confidence intervals (CIs).

RESULTS

The study sample included 60.0% males with 81.1% of the sample identifying as African American. Additionally, 38.9% were obese according to the body mass index classification, and 57.0% were moderately malnourished. Patients with obesity had 44% lower odds of being moderately malnourished (OR = 0.56, 95% CI = 0.37, 0.85). In the model adjusted for age and ethnicity and other clinical characteristics, increasing PhA values by one unit was associated with 28% lower odds (OR = 0.72, 95% CI = 0.53, 0.97) of being moderately malnourished while increasing waist circumference (WC) values by one unit was associated with 12% higher odds (OR = 1.12; 95% CI = 1.06, 1.19) of being moderately malnourished than well-nourished. In this fully adjusted model, increasing fat free mass (FFM, OR = 0.95, 95% CI = 0.91, 0.99) and fat mass (FM, OR = 0.92, 95% CI = 0.87, 0.97) by 1 kg was also associated with 5% and 8% lower odds of being moderately malnourished, respectively.

CONCLUSION

PhA and SGA were significantly associated only among patients classified as obese. PhA, WC, FM, and FFM were identified as potential clinical determinants of SGA. Patients receiving MHD and who have obesity may benefit from utilizing SGA along with WC, PhA, FM, and FFM to assess nutritional status.

The impact of predialytic oral protein-based supplements on nutritional status and quality of life in hemodialysis patients: a randomized clinical trial

BACKGROUND

Administration of oral nutritional supplements (ONS) inside hemodialysis (HD) units before sessions is an increasingly adopted option. Our aim was to assess the effects of predialytic ONS on nutritional status and quality of life (QOL) in HD patients.

METHODS

One hundred HD patients were enrolled in this prospective, multicentric randomized clinical trial. Patients were assigned to receive ONS (25 gm protein powder) 1 h prior to the start of the HD session (predialytic) or maintained on their routine nutrition regimen for 3 months.

RESULTS

At study end, supplemented patients showed a significant increase in serum albumin (p < 0.001), and a non-significant decrease in the median subjective global assessment (SGA) score. While in the control group, serum albumin remained stable, and the median SGA score increased significantly (p < 0.001). Body mass index and anthropometric measures did not differ between both groups. The supplemented patients showed significant improvement in three subscales of the Kidney Disease Quality of Life-36, without a significant change in QOL in control patients. Supplemented patients had significantly higher blood pressure (BP) (p = 0.037), lower urea reduction ratio (p = 0.020) and Kt/V (p = 0.021), higher serum calcium, lower total cholesterol and lower CRP (p = 0.047) levels compared to controls. There was no significant difference between groups regarding serum sodium, potassium, or phosphorus or adverse events.

CONCLUSIONS

Predialytic ONS administration may contribute to improvements in serum albumin, and QOL. The effects on BP, CRP, and the reduction in dialysis adequacy, should be carefully considered while adopting such strategy.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov NCT05952570.

FIRST REGISTRATION DATE

2/07/2023.

Recent Advances in the Nutritional Screening, Assessment, and Treatment of Japanese Patients on Hemodialysis

Patients on hemodialysis (HD) have a higher rate of protein-energy wasting (PEW) due to lower dietary intake of energy and protein (particularly on dialysis days) and greater loss of many nutrients in the dialysate effluent than other patients. The most well-known method of nutritional screening is the subjective global assessment. Moreover, the Global Leadership Initiative on MalnutIrition has developed the first internationally standardized method for diagnosing malnutrition; however, its use in patients on HD has not been established. In contrast, the nutritional risk index for Japanese patients on HD has recently been developed as a screening tool for malnutrition in patients on HD, based on the modified PEW criteria. These tools are beneficial for screening nutritional disorders, enabling registered dietitians to assess patients' dietary intake on dialysis and non-dialysis days and provide advice on dietary intake, especially immediately after dialysis cessation. Oral supplementation with enteral nutrients containing whey protein may also be administered when needed. In patients that experience adverse effects from oral supplementation, intradialytic parenteral nutrition (IDPN) should be combined with moderate dietary intake because IDPN alone cannot provide sufficient nutrition.