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Evidence/Recent Findings:
Before treatment for malnutrition can be determined one must be able
to diagnose malnutrition. There are different ways to assess for malnutrition
in the field. The most widely used method to determine malnutrition in
patients is the subjective global assessment tool.
One study used subjective global assessment combined with
biochemical parameters to assess the occurrence of malnutrition in
hemodialysis patients. This study was conducted to determine if biochemical
parameters can be used to diagnose malnutrition compared to the subjective
global assessment, which is a more subjective tool since it is based off the
patients ability to answer questions accurately (Espahbodi, Khoddad, &
Esmaeili, 2014, p1). Malnutrition in hemodialysis patients can lead to
impaired wound healing, poor rehabilitation, fatigue, malaise, and increased
rates of hospitalization, morbidity and mortality (Espahbodi, Khoddad, &
Esmaeili, 2014, p1). The biochemical parameters examined in this study
were serum albumin, hemoglobin, cholesterol, BUN, and creatinine
(Espahbodi, Khoddad, & Esmaeili, 2014, p.2). The main objective of this
provided the correct answers (Karavetian and Ghaddar, 2012, p. 21). The
control group did not receive any educational games, although all groups
were given general information about kidney disease, hyperphosphataemia
and its health-related complications, importance of adherence to dietary
recommendations and phosphate binding therapy, and a list of food items
high and low in phosphorus (Karavetian and Ghaddar, 2012, p. 21). The
results of this study indicated a significant improvement in serum
phosphorus levels in the full intervention group (Karavetian and Ghaddar,
2012, p. 22). Although this was a short study it indicated the benefit of
nutrition education and counseling on the health and dietary intake of
hemodialysis patients.
Limitations in Evidence:
All of these studies illustrated that malnutrition uses a valid yet
subjective test to determine severity of malnutrition in hemodialysis
patients. Nutrition counseling and education are tools that have proved to
be effective in treating malnutrition. Although these studies have illustrated
results the correlate with past studies there were limitations to these studies.
The study conducted in Iran had limitations because there was no indication
to when the participants biochemical parameters were taken and no follow
up to the patients who were diagnosed as malnourished (Espahbodi,
Khoddad, and Esmaeili, 2014, p.3). Without a follow up to the initial
assessment there is no data to assess the outcome of the malnourished
patients in this study because malnutrition has a greater incidence if
Another
limitation in this study was the lack of uniform treatment in the anorexic
participants; some were treated with food diaries, individualized diet
prescription, or enteral nutrition (Molfino, et. al.., 2012, p. 1013). If all
participants were given the same nutrition intervention than the outcomes of
the study may have been different, this limits the studys validity.
Further examination into the benefits of nutrition education and
counseling were conducted in a different study in hemodialysis patients who
were at risk for osteodystrophy. This was one of the strongest studies that
were examined in this paper because it was a nutritional cluster randomized
trial that utilized a double blind design (Karavetian & Ghaddar, 2012, p. 20).
Although this study did have limitations, the largest one being the length of
the study; this study was cut short due to problems within the country, a
longer study period would have strengthened the conclusions of the study.
Another limitation of this study that was also due to the turmoil in the
country was the absence of a post-study follow up (Karavetian & Ghaddar,
2012, p. 24). This study has an intense intervention compared to other
studies examined that did cause some subjects to drop out due to nonadherence (Karavetian & Ghaddar, 2012, p. 21). Besides non-adherence
participants withdrew due to moving, transplantation or death, so ensuring
that participants adhere to nutritional counseling will also strengthen the
findings of the study (Karavetian & Ghaddar, 2012, p. 21). Besides lack of
adherence and shortened study length this was a strong study to test the
effectiveness of nutrition counseling and education in hemodialysis patients.
A limitation that all of the studies shared is that they all had a
subjective form of evaluation to determine participants status at the
beginning of each study.
Extrapolation of Data:
The study conducted in Iran found that subjective global assessment
was a valid way to assess malnutrition in hemodialysis patients. This study
also looked into how malnutrition could be treated for future studies and
practices. This study extrapolated that along with periodic assessments of
nutritional status continuous nutrition education classes and periodic
nutritional counseling with a Registered Dietitian would be helpful in treating
malnutrition in hemodialysis patients (Espahbodi, Khoddad, & Esmaeili,
2014, p.4). This study found the subjective global assessment is a reliable
way to assess malnutrition in hemodialysis patients although another study
found evidence that a different form of assessment may be a more beneficial
way to assess and diagnose malnutrition in hemodialysis patients (KalantarZadeh, Kopple, Block, & Humphreys, 2001, p.1262). This study indicated
that further testing might be needed to validate this study but the subjective
global assessment along with body mass index, serum albumin, and total
iron binding capacity may be a more efficient and effective way to assess
malnutrition and inflammation in hemodialysis patients (Kalantar-Zadeh,
Kopple, Block, & Humphreys, 2001, p.1252). When malnutrition is assessed
proper treatment should be used to help treat malnutrition. According to the
nutrition intervention study, nutrition counseling appears to be the most
cost-effective and best way for improving nutritional status in hemodialysis
patients (Molfino, et. al., 2012, p. 1014). This finding is concurrent with the
hypothesis from the study in Iran that believed that nutrition counseling and
education were the best ways to treat malnutrition in hemodialysis patients
(Espahbodi, Khoddad, & Esmaeili, 2014, p.4). The study that evaluated how
nutrition education and counseling may aid with preventing osteodystrophy
found that patients built a positive rapport with the Registered Dietitian
which lead to feeling more comfortable which may have contributed to the
improvement in their PDnA scores (Karavetian & Ghaddar, 2012, p. 22).
These findings and extrapolations in the studies found that although
malnutrition diagnosis has a subjective diagnosis based off assessments
some clinical data like body mass index, serum albumin, and total iron
binding protein may aid in diagnosis and strengthen assessment of
malnutrition status during treatment, all studies have also indicated the
strength and benefit of nutrition counseling and education on hemodialysis
patients who are at risk or have malnutrition.
Conclusion:
Based on all the studies examined and the statistics patients with
chronic kidney disease who are on hemodialysis are malnourished or at risk
for developing malnutrition. Although subjective global assessment is the
validated way to assess for malnutrition according to KDOQI and the studies
examined clinical assessments along with subjective global assessment may
strengthen the assessment of malnutrition. Although researchers or any
institution has not validated this form of testing, if it could be tested for
reliability and validity this form of assessment may be a better indicator of
malnutrition in hemodialysis patients. I believe that nutrition education and
counseling should be given to all hemodialysis patients at the start of
hemodialysis treatment and throughout treatment. The patients should be
screened twice a year for development of malnutrition and if they do develop
some degree of malnutrition nutrition counseling should increase so that it
does not progress any further and lead to more complications in this patient
population. Overall, all hemodialysis patients should be seeing Registered
Dietitian for nutrition counseling and education, they should also be regularly
screened for malnutrition through the subjective global assessment.
References:
Mortality in Maintenance