ARE HAEMODIALYSIS PATIENTS MORE PRONE TO MALNUTRITION?

INTRODUCTION

Malnutrition continues to be a significant problem all over the world. Kozier et. al
(2004) defined malnutrition as the lack of necessary or appropriate food substances, but
in practice includes both undernutrition and overnutrition. Malnutrition is also defined as
the condition that results from taking an unbalanced diet in which certain nutrients are
lacking, in excess, or in the wrong proportions. A number of different nutrition
disorders may arise, depending on which nutrients are under or overabundant in the diet.

According to the National Institute for Clinical Excellence (2006) the reported
consequences of malnutrition include delayed wound healing, impaired respiratory and
immune function, muscle weakness, depression, increased frequency and duration of
hospital and premature death. In adequate nutritional knowledge among nursing and
medical staff, partly because of the low emphasis given to nutrition education in
undergraduate training have led to lack of awareness and recognition of malnutrition

Malnutrition is thus a health outcome as well as a risk factor for

disease and exacerbated malnutrition, and it can increase the risk both
of morbidity and mortality. Malnutrition is seemingly associated with
haemodialysis. Haemodialysis is a method for removing waste products such
as creatinine and urea, as well as free water from the blood when the kidneys are in renal
failure.

The main emphasis of this essay is to explore the nutritional status of

haemodialysis patient and those issues that may lead to malnutrition.

The scale of the problem threatens to overwhelm already stretched renal units,
according to the National Kidney Federation (NKF). Around 20,000 patients receive
dialysis every year in Britain, but the NKF predicts that number will rocket to 40,000 by
2018. Already the number of kidney failure patients, increasing by around 6.5 per cent
each year, is stretching some renal centres to breaking point. (Kate Devlin, 2008). With
the increasing number of patients with kidney failure there will also be an increase in
patients receiving haemodialysis.

In European hemodialysis patient, in spite of continuous progress in renal

replacement therapy, a 10% annual mortality rate is still reported. The role of
undernutrition in this increased death risk is now admitted. Malnutrition in dialysis
patients has been attributed to insufficient nutrient intake, dialysisinadequacy, acidosis,
hormone derangement and, more recently, to uremia- and dialysis-induced inflammation.
Malnutrition in haemodialysis patients has been attributed to three main mechanisms:
insufficient feeding, abnormal nutrient metabolism and nutrient losses due to dialysis
procedures. (Nefrologia, Vol. XXI. Número 5, 2001)

According to the National Kidney Foundation (2005), malnutrition is common in

haemodialysis patients and is a powerful predictor of morbidity and mortality. Although
much progress has been made in recent years in identifying the causes and pathogenesis
of malnutrition in haemodialysis patients, as well as recognizing the link between
malnutrition and morbidity and mortality, no consensus has been reached concerning its
management.

There are at least two fundamentally different types of malnutrition in patient with
chronic renal insufficiency. The first is related to low energy intake. In this context, co-
morbid conditions are uncommon and serum albumin may be normal or slightly
decreased. This type of malnutrition may be amenable to adequate nutritional support and
dialysis support. In contrast, the second type of malnutrition is associated with
inflammation and atherosclerotic cardiovascular disease (MIA syndrome). Co- morbid
conditions are common and serum albumin levels are usually decreased. This type of
malnutrition is much more difficult to reverse with nutritional support and dialysis
therapy, unless the underlying co-morbid conditions and chronic inflammatory response
are adequately treated. Obviously, these two types of malnutrition are often combined in
clinical setting.
EVIDENCE BASED PRACTICE

Evidence based nursing is a conscientious explicit and judicious use of theory

derived, research based information in making decision about care delivery to individual
or group of patients and in consideration of individual needs and preferences (McEwen
and Wills 2002). Sackett et al (1996) describes evidence base as practice attempts to
inject clinical decision making further prevention, detection and care of health disorders
with the systematically ordered knowledge derived from both the inductive and deductive
reasoning that has been accrued in the process of research.

Nurses are responsible for the care they provide for their patient. They have to be
active, competent and autonomous in providing this care and be able to justify what they
do. They must be able to justify the decision they have made about appropriate care and
treatment on the basis of professional expertise which include using research evidence to
inform practice. A knowledge and understanding of the relevant research that supports
clinical and other nursing practice is only one element of being a critical practitioner,
but it is the fundamental one. In other words, evidence-informed nursing is the
integration of professional judgment and research evidence about effectiveness of
interventions. (McSherry et .al 2002)

Factors Causing Malnutrition in Haemodialysis Patient

Malnutrition can be secondary to, (1) poor nutritional intake: due to overzealous
dietary restrictions, delayed gastric emptying and diarrhea, intercurrent illnesses and
hospitalization, decreased food intake on hemodialysis days, medication causing
dyspepsia (phosphate binders, iron preparation), inadequate dialysis, monentary
restrictions, depression, altered sense of taste; (2) increased losses (via dialysate) : due to
gastro intestinal blood loss , intradialytic nitrogen losses (hemodialysis 6-8g amino acid
per procedure) and finally (3) increased in protein catabolism: due to intercurrent
illnesses and hospitalizations, metabolic acidosis (promotes protein catabolism),
catabolism associated with hemodialysis, dysfunction of growth hormone –insulin growth
factor endocrine axis, catabolic effects of other hormones (parathyroid hormone, cortisol,
glucagon). (Daugirdas, 2007)

Nutritional Assessment

Adequate treatment with maintenance haemodialysis requires a careful

assessment and monitoring of patient nutritional status. Aside from decreased
nutritional intake, the dialysis patient is prone to wide variety of factors that may lead to
malnutrition.There are no special requirement for the assessment of nutritional status of
the elderly. The methodology used in assessing nutritional status in elderly are the same
with the younger patient. As some elderly are quite fragile, it may be more important to
recognize and treat malnutrition earlier in older dialysis patients. (Wolfson 2002)

One hospital in London, the Nutrition and Dietary department used the following
assessment tools in diagnosis and monitoring of malnutrition is based on EBPG
Guideline on Nutrition. The following tools are: 1. Dietary assessment, 2. Body mass
index, 3. Subjective global assessment (SGA), 4. Anthropometry, 5. Normalized protein
nitrogen appearance(PNA), 6. Serum albumin and serum prealbumin, 7. Serum
cholesterol, and 8. Technical investigation. The assessment of nutritional status should be
based on clinical assessment and biochemical parameters, including history of weight
loss , per cent standard weight, body mass index, muscle mass, subcutaneous fat mass
and plasma albumin, creatinine, bicarbonate and cholesterol. Co-morbid conditions
should be assessed and C-reactive protein (CRP) measured as marker of inflammation –
as there is a close relation between malnutrition, on one side and co-morbid conditions
and inflammation on the other .For more detailed assessment, subjective global
assessment of nutritional status is well –validated tool, and dual energy X-ray
absorptiometry (DEXA) is a useful method for routine assessment of lean body mass.
Anthorpometric methods are also useful. They are cheap and easy to apply, although less
than DEXA. (Locatelli et al 2002).
 To ensure that all haemodialysis patient achieve the recommended energy intake
for that individual. It is advised to haemodialysis patient an energy intake of
35kcal/kgIBW/day aiming for over all nutritional adequacies. And for the elderly
haemodialysis patient with reduced activity a reduce energy intake of 30-35kcal/kg/IBW.
Its important to accurately assess energy and protein requirement to prevent
malnutrition .The recommended protein intake of haemodialysis active, non –catabolic
patients is 1-1.2g/KgIBW/DAY.The haemodialysis process contributes to the
requirement for dietary protein . Dialysate losses of protein, including amino acids,
peptides and whole proteins, are estimated to be approximately 10-12g per session.
However, there is much evidence to indicate that many patients have sub-optimal intakes
of protein, typically less 1.0/kg/day. This may be associated with other powerful
indication of morbidity and mortality such as hypoalbuminaemia. (European guidelines
for Nutritional Care of Adult Renal Patient, 2002)

Since protein –energy malnutrition is one of the most powerful predictors of poor
outcome in patient on maintenance dialysis, regardless of age. It is important to recognize
PEM in elderly dialysis patients in a timely manner since a debilitated nutritional status
may lead to downward spiral in health. (Burrowes, 2003)

Research Method

To gather relevant data needed for the literature studies of the stated topic, the
author used the databases medline, pubmed, advanced google and other related journals.
The key words used were, nutrition, haemodialysis, malnutrition, renal diet, renal
nutrition, nutritional support, nutritional status, malnutrition in uraemia, nutritional
assessment and management. Since the data gathered for this study is more on dietetics
the author did not find any nursing literature but collected studies about the causes,
assessment and nutritional requirement of malnutrition in dialysis patient. To find
relevant contribution of nursing role in renal nutrition the author expounded her data
collection using related text books and the internet.
Review of Literature

Hemodialysis

Healthy kidneys clean your blood and remove extra fluid in the form of urine.
They also make substances that keep your body healthy. Dialysis replaces some of these
functions when your kidneys no longer work. There are two different types of dialysis -
hemodialysis and peritoneal dialysis. You need dialysis if your kidneys no longer remove
enough wastes and fluid from your blood to keep you healthy. This usually happens when
you have only 10 to 15 percent of your kidney function left. You may have symptoms
such as nausea, vomiting, swelling and fatigue.

In hemodialysis, a dialysis machine and a special filter called an artificial kidney,

or a dialyzer, are used to clean your blood. To get your blood into the dialyzer, the doctor
needs to make an access, or entrance, into your blood vessels. This is done with minor
surgery, usually to your arm.

The dialyzer, or filter, has two parts, one for your blood and one for a washing
fluid called dialysate. A thin membrane separates these two parts. Blood cells, protein
and other important things remain in your blood because they are too big to pass through
the membrane. Smaller waste products in the blood, such as urea, creatinine, potassium
and extra fluid pass through the membrane and are washed away.

Hemodialysis can be done in a hospital, in a dialysis center that is not part of a

hospital or at home. You and your doctor will decide which place is best, based on your
medical condition, and your wishes. (National Kidney Foundation 2010)

In European hemodialysis patient, in spite of continuous progress in renal

replacement therapy, a 10% annual mortality rate is still reported. The role of
undernutrition in this increased death risk is now admitted. Serum albumin less than 35
g/l was shown to be associated with a mortality rate of 60% after one-year and 80% after
2 years. Similarly, prealbumin less than 300 mg/l was shown to be associated with a
mortality rate of 20% after one-year and 50% after 3 years. Malnutrition in dialysis
patients has been attributed to insufficient nutrient intake, dialysis inadequacy, acidosis,
hormone derangement and, more recently, to uremia- and dialysis-induced inflammation.
Moreover, the frequency and the severity of the association of malnutrition, inflammation
and atherosclerosis during chronic renal failure have been underlined. The present short
review adresses: 1) the prevalence of malnutrition and its prognostic influence in
hemodialysis patients, with respect to recent French Cooperative series; 2) the role of
inflammation in the occurrence of malnutrition; 3) the management of malnutrition.
(Nefrologia, Vol. XXI. Número 5, 2001)

According to Cano (2001) in Nefrologia, Vol. XXI. Número 5, malnutrition in

hemodialysis patients has been attributed to three main mechanisms: insufficient feeding,
abnormal nutrient metabolism and nutrient losses due to dialysis procedures. The dietary
approach in the different phases of chronic renal insufficiency (CRI) is one of the most
important, and yet controversial, topics in the whole history of nephrology, since the time
(35 years ago) when dialysis facilities were not yet easily available and a low protein diet
was the only means to delay the occurrence of uraemic symptoms. In the subsequent
decades of the dialysis era, low protein diets (varying from 0.85 to 0.3 g/kg/day with
supplementation of essential amino acids and ketoanalogues) were given emphasis, in
order to slow the progression rate of CRI, until two large prospective randomized
controlled clinical trials published in the early 1990s, one Italian and the other American,
showed that dietary protein restriction had little effect on the progression rate of CRI.
Even more disturbingly, the American trial showed that the development of malnutrition
could be a possible drawback of protein restricted diets. Both malnutrition, defined by
insufficient protein calorie intake, and cachexia, defined by defective food assimilation or
utilization in the presence of hypercatabolism and systemic inflammation, are highly
prevalent in dialysis patients from the very beginning of substitutive treatment. They are
due to uraemia itself (loss of appetite), dialytic treatment (loss of amino acids and
proteins, bioincompatibility of treatments, quality of the dialysate), as well as the
premature ageing of dialysis patients and the increased burden of comorbidity factors,
with consequent patient invalidity and inflammatory triggers.
 While much progress has been made in recent years in recognizing the link
between malnutrition, inflammation, cardiac disease, and increased mortality, no
consensus has yet been reached concerning the best assessment and management of
nutritional status in dialysis patients.

Prevalence of Malnutrition

Malnutrition is common among patients on maintenance hemodialysis.

A 40% prevalence of malnutrition was found in patients with advanced renal
failure at the beginning of dialysis treatment. Signs of malnutrition are
observed in 10-70% of hemodialysis patients and in 18-51% of patients on
continuous ambulatory peritoneal dialysis. In other studies, it has been
demonstrated that about one-third of patients have mild to moderate malnutrition, and 6
to 8% have severe malnutrition. (Bossola et. al, 2001)

Causes and Pathogenesis of Malnutrition

There are many possible causes for protein malnutrition in

patients receiving maintenance hemodialysis. These patients are
chronically exposed to the risk of inadequate diet counselling or self-
designed restrictions, repeated hospitalizations which disturb dietary
habits and reduce dietary nutrient intake, and superimposed acute or
chronic illnesses. Before starting maintenance dialysis therapy, low
protein and low phosphate diets are routinely prescribed. These diets
may sometimes be hypocaloric and therefore may be deleterious to
the patient's nutritional status if not adequately monitored by skilled
dieticians. Recent evidence suggests that protein calorie malnutrition
often begins incipiently when the glomerular filtration rate (GFR) is
about 28 to 35 mL/min/1.73 m2 or even higher and continues to fall
gradually as the GFR decreases below these values. However, patients
do not usually become truly malnourished until the GFR is 4 to 5
ml/min/l.73 m2 or lower. (Bossola et. al, 2001)

Methods to Assess nutritional status in dialysis patient

The assessment of nutritional status should be based on a combination of clinical

parameters with biophysical and biochemical parameters. Malnourished dialysis patients
often have protein energy malnutrition with a reduction of both fat mass (FM) and lean
body mass (LBM). Therefore, clinical assessment of subcutaneous FM and muscle mass
and a history of weight loss are important parts of routine nutritional assessment.
Percentage of standard weight and body mass index (BMI) are also important and easy to
measure, although BMI is more useful for assessment of obesity than of malnutrition.
Most dialysis patients with malnutrition also have comorbid diseases, in particular
cardiovascular disease and inflammation, and the assessment of comorbid conditions is
an important part of the nutritional assessment of dialysis patients. The most commonly
used laboratory parameters for routine assessment of nutritional status are plasma
concentrations of albumin, prealbumin, transferrin, and other liver derived proteins.
Although serum albumin is by far the most commonly used nutritional marker in dialysis
patients, its value has been questioned as low serum albumin levels not only reflect poor
nutritional status, but also albumin losses in urine (and/or dialysate) and, as albumin is a
negative acute phase protein, the presence of an inflammatory process. Therefore, other
visceral proteins have been used, including prealbumin, transferrin, and retinol binding
protein. For these proteins in general, there is considerable overlap between malnourished
and wellnourished patients. Pre albumin has a shorter half life than albumin, has a close
relationship with nutritional status and is a good predictor of clinical outcome. Therefore,
it is likely that in the near future pre albumin will be established as a valuable additional
marker for routine assessment of nutritional status in dialysis patients. However, it should
be noted that prealbumin is a negative acute phase protein as well. Measurement of CRP
is important for the assessment of inflammatory co morbid conditions, as well as for the
interpretation of albumin and pre albumin levels. Additional biochemical nutritional
markers, with low values indicating poor nutrition and poor outcome, include serum
creatinine and total cholesterol. The creatinine level before dialysis is a strong predictor
of low muscle mass and poor outcome. Serum total cholesterol is a less sensitive
nutritional marker, but is cheap and easily available. Acidosis is a strong catabolic factor
in uraemia and serum bicarbonate monitoring is recommended for routine follow up of
the acid–base status. (Locatelli et. al, 2002).

According to Bossola et. al (2001), no single method is available in order to

evaluate nutritional status in hemodialysis patients. Most authors agree that a
multiparametric evaluation in which various assessments are included is appropriate (1).
The validity of each single nutritional assessment is presented as follows:

Assessment of dietary intake performed by a skilled dietician. It is very useful

and one of the most important aspects of nutritional assessment.
Body weight Monitoring the patient’s body weight over a period of time is very
useful. Because fluid is usually retained during the interdialytic period and edema is often
present, the “dry weight” is generally used. Dry weight is the weight obtained by the end
of dialysis without causing hypotension and/or cramps. Changes in dry body weight over
time are reliable indices of alterations in nutritional status.
Skinfold thickness and arm muscle circumference. In the presence of edema,
which occurs frequently in hemodialysis patients, skinfold thickness may give a falsely
high estimation of body fat. Arm muscle circumference is a reliable index of lean body
mass, though it may be influenced by overhydration.
Serum albumin. Serum albumin is a prognostic index in ESRD patients and in
patients on maintenance hemodialysis . It must be borne in mind that fluid retention and
extracorporeal losses may influence serum albumin levels. It is also important to note that
the serum albumin varies according to the method of measurement (bromcresol green
technique, bromcresol purple technique, immunonephelometry).
 Serum prealbumin. Although the serum prealbumin levels are elevated in ESRD
patients even in the presence of malnutrition (because of reduced filtration and
diminished tubular metabolism), it seems that monitoring serum prealbumin in stable
hemodialysis patients is useful.
Serum transferrin. It has a short half-life and may be a more sensitive indicator
of acute changes in protein metabolism. However, it is influenced by iron status,
infections and inflammation. In this regard it must remembered that hemodialysis is
characterized by a latent chronic inflammatory state.
Subjective global assessment (SGA). It involves the judgement of malnutrition by
several markers but is overall dependent on body weight and gastrointestinal symptoms,
not on serum albumin. The subjective measures include the patient’s history of weight
loss, anorexia, and vomiting and the physician’s estimate of muscle wasting, edema and
loss of subcutaneous fat. Its validity has been established using objective measures, in
CAPD patients and in hemodialysis patients.

Strategies to Prevent or Treat Malnutrition in HD Patients

According to Bossola et. al (2001), the approach to prevent or treat protein

malnutrition in HD patients includes various and progressive steps. First of all, a
nutritional program can lead to the improvement of nutritional status only when the
catabolic stimulus that may be present has been counteracted, and drugs that reduce
appetite have been avoided. Thereafter, patients must be prescribed an adequate dialytic
dose. This appears a reasonable policy, although it remains controversial whether the
dose of dialysis has an impact on nutrition and whether the correction of underdialysis
improves the nutritional status. In a retrospective analysis of laboratory data from more
than 12,000 hemodialysis patients, Owen et. al. reported an increased risk of death in
patients with low serum albumin and with a low dose of dialysis. However, they did not
find any correlation between the dialytic dose and the serum albumin levels, suggesting
that malnutrition and underdialysis were two independent mortality risk factors.
Thus, the nutritional intervention includes:
• A comprehensive nutritional, diet and appetite assessment to assess whether nutritional
status is too low; definition of problems related to self feeding, access to food,
gastrointestinal distress; identification of active psychic, social, medical, dialytic or
medicinal related issues that could affect food intake;
• Dietary counselling performed by a nutritionist to correct reduced or unhealthy nutrient
intake. If malnutrition is moderate, oral nutrition supplements could be considered. Some
nutritional supplements have been designed specifically for HD patients and are available
as energy sources or combination of protein and energy sources. Supplements are in the
form of solid food, powders or liquid formulations. There are few studies on their use in
hemodialysis patients on maintenance hemodialysis. Few of these studies are randomized
and/or prospective. It seems that oral nutritional supplementation increases nutritional
parameters, while the effects on morbidity, quality of life and survival are essentially
unknown.
• Outside of pediatric nephrology, where the use of enteral tube feeding is common
practice, there is no documentation of the use of enteral nutrition through a nasogastric
tube in hemodialysis patients;
• Intradialytic parenteral nutrition (IDPN) has the advantage of providing calories and
proteins during hemodialysis treatment without the need for establishing a central venous
line. Studies that have examined the potential benefits of intradialytic parenteral nutrition
in hemodialysis patients are characterized by various and numerous biases: a randomized
control group was absent; dietary intake of food was not controlled or monitored; the size
of the study population was too small for a valid statistical analysis; data were not
adjusted for the comorbid conditions of the patients; outcome measures were in most
studies nutritional while morbidity and mortality were evaluated rarely; energy and
protein intake were often inappropriate. On this basis, it can only be underlined that in
some studies intradialytic parenteral nutrition increases nutritional and immunological
status.
• Appetite stimulants. The use of the appetite stimulant megestrol acetate has been
recently investigated in two randomized studies. Megestrol acetate may help stimulate
appetite in hemodialysis patients, increasing the energy and protein intakes. However, in
one study these changes were at the expense of altering body composition. Indeed, an
increase in fat mass and a decrease of fat-free mass was observed. Moreover, in the
second study, in which megestrol acetate was administered longterm, many side effects
such as headaches, dizziness, confusion, diarrhoea, and hyperglycemia, were observed.
• Administration of anabolic hormones has been used to improve nutritional status in
malnourished patients on maintenance hemodialysis. Many years ago, androgens were
shown to reduce net protein catabolism in patients with acute renal failure and with
chronic renal failure. However, because of masculinizing effects, risk of toxicity
(particularly hepatic) and apparent transience of anabolic response, their use has not
become widespread. Indeed, it seems that growth hormone (GH), alone or in adjunct to
IDPN, may be of benefit to hemodialysis patients. The effects of growth hormone in
hemodialysis patients have been prospectively evaluated in numerous randomized
controlled studies. GH improves nitrogen balance, dietary protein utilization, serum and
IGF-1 levels, and body weight, and increases lean body mass with a contemporary
decrease of body fat mass. It remains to be clarified if the administration of GH,
ameliorating the nutritional status, may also reduce the nutrition-related morbidity
and mortality of hemodialysis patients. Administration of IGF in
hemodialysis is being actively researched. However, its dosing
schedule (probably twice daily) and its toxic profile, which includes jaw
pain, nausea, hypoglycemia, occasional altered mentation and cardiac
arrhythmia, probably make hIGF-I less desiderable than GH.

CONCLUSION

Malnutrition still remains a serious concern in patients on

maintenance hemodialysis since is not uncommonand is a risk factor of
morbidity and mortality. Nutrition and diet therapy are adjunctive intervention that
can improve out comes of medical treatment among individuals. Proper nutrition prevents
health problems; it improve health, help avert impairments in functional status and
increase quality of life and well being. Haemodialysis is known to affect nutritional
intake and nutritional requirements of patient . Malnutrition is common consequence of
patients inability to meet their requirements and has been shown to be a strong predictor
of both morbidity and mortality in haemodialysis patients.(European Guidelines for the
nutritional care of adult renal patients 2002)

Since many studies have reported on the presence of malnutrition in a large

number of dialysis patient therefore this problem needs special attention in terms of
nutritional history, nutritional care and nutritional education.

The nutritional management of hemodialysis patients now appears of the first

importance. A regular nutritional assessment is necessary in order to verify the diet
adequacy and to detect malnutrition.

RECOMMENDATION

Malnutrition is a common problem in patients. It is important to the nurses to

perform routine nutritional screening of patient on admission to hospital to detect those
who are at risk of malnutrition or who are already malnourished. Once these patients are
identified a nutritional care plan can be developed and a referral to a dietitian for
nutritional assessment (Holder 2002). The British Association for Parenteral and Enternal
Nutritions 2009 recommended that all patients should be screened for malnutrition on
admission to hospital and given a follow-up monitoring.(Maud et al 2009)
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