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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 6  |  Page : 1105-1109
Biochemical nutritional parameters and their impact on hemodialysis efficiency

Department of Renal Medicine, The Kidney Center, Post Graduate Training Institute, Karachi, Pakistan

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Date of Web Publication27-Oct-2009


To determine the nutritional status of chronic hemodialysis (HD) patients and the association of changes in serum albumin levels, C-reactive protein (CRP), Low Density Lipoprotein (LDL) cholesterol and body mass index (BMI) as indicators of nutritional status with the urea reduction ratio (URR) during dialysis, we studied 201 chronic HD patients (97 males and the mean age was 51 ± 15 years). Diabetes was the cause of chronic kidney disease (CKD) in 34% of the pa­tients, hypertension in 57%, chronic glomerulonephritis in 12%, and obstructive uropathy in 10%. BMI less than 18.5 (under weight) was found in 17% of patients, more 18.5 but less than 25 (nor­mal) in 56%, more than 25 but less than 30 (overweight) in 21%, and more than 30 (obese) in 6%. The laboratory investigations revealed hypercalcemia in 62% of the patients (15 patients were found to have tertiary hyperparathyroidism), total cholesterol less than 100 mg/dL in 6% (mean 152 ± 37.5 mg/dL), and URR of less than 60% in 12% of patients and greater than 60 but less than 65% in 33%. Hypoalbuminemia was associated with poor URR (P< 0.05), whereas no statistically signi­ficant correlation was found between URR and iPTH, LDL cholesterol, CRP and body mass index. We conclude that poor nutritional status was detected among a significant number of our patients with poor dietary education. Increased risk of malnutrition was significantly associated with older age and inadequate dialysis dose. Hypoalbuminemia was the single most important factor associated with poor URR.

How to cite this article:
Abbas HN, Rabbani MA, Safdar N, Murtaza G, Maria Q, Ahamd A. Biochemical nutritional parameters and their impact on hemodialysis efficiency. Saudi J Kidney Dis Transpl 2009;20:1105-9

How to cite this URL:
Abbas HN, Rabbani MA, Safdar N, Murtaza G, Maria Q, Ahamd A. Biochemical nutritional parameters and their impact on hemodialysis efficiency. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2022 Aug 13];20:1105-9. Available from: https://www.sjkdt.org/text.asp?2009/20/6/1105/57278

   Introduction Top

Renal replacement therapy by dialysis is essen­tial for the survival of patients with end-stage renal disease (ESRD). [1] Malnutrition is an evi­dent problem in 40-50% of patients with ESRD, and it is associated with increased infection; poor wound healing, muscle wasting and increased mortality.

Malnutrition is caused by inadequate dietary intake, anorexia, gastrointestinal disturbances, psychosocial and socioeconomic factors or un­met increased nutritional requirements due to im­paired protein or energy and/or concomitant di­seases namely cardiovascular disease, sepsis and inflammation. [2] When dialysis therapy is started, the uremic symptoms are reduced, the diet is less restricted, and some patients may show im­proved nutritional status. [3] However, the results of cross-sectional studies throughout the world indicate that maintenance HD patients are still at risk of malnutrition. [4] This could be due to the losses of nutrients into dialysate, chronic blood loss, inflammation and associated diseases. [4] We conducted this study to assess the nutritional status of our ESRD patients on maintenance HD and the association of changes in serum al­bumin levels, C-reactive protein (CRP), Low Density Lipoprotein (LDL) cholesterol, and body mass index (BMI) as indicators of nutritional status with urea reduction ratio (URR) during dialysis

   Patients and Methods Top

We studied the records of 201chronic HD patients at our dialysis center from October 1, 1990 till September 2004. We excluded from the study the patients who were on maintenance hemodialysis for less than six months, not re­ceiving their prescribed dialysis dose, showed persistent non-compliance with their dialysis the­rapy, or were diagnosed with liver cirrhosis and proteinuria. The analysis of the data included pri­mary causes of kidney disease, co-morbid condi­tions, age, sex, duration on dialysis, frequency of hemodialysis, dialyzer size, dialyzer membrane, reprocessing details, Hepatitis B and C status, average blood flow, height, weight, etc. Relevant laboratory investigations included serum albu­min, cholesterol, CRP concentrations, and urea reduction ratio (URR) (defined as the percent reduction in blood urea nitrogen concentration during a single dialysis treatment).

   Statistical Analysis Top

The data feeding and analysis were done on computer package "EPI-info" version 6.0 soft­ware of CDC (Centre for Disease Control, Atlanta, USA).

The results were expressed as the mean ± stan­dard deviation (SD). Chi-square and student's "t" test were used for comparison of quanti­tative variables, whereas Pearson Co-efficient correlation was used to determine the associa­tion between the markers of nutritional status and URR. A P-value of < 0.05 is considered statistically significant.

   Results Top

The 201 study patients included 97 male and 69 (34%) diabetics. The mean age was 51 ± 15 years. [Table 1] shows the characteristics of the study patients. The cause of kidney disease was hypertension in 57% of the patients followed by diabetes in 34%. Of the patients, 83% received hemodialysis therapy thrice a week, 35% re­ceived dialysis for more than 5 years, 95 % used 1.5 m 2 dialyzers, 74% re-used dialyzers, 97% received regular erythropoietin therapy, 8% was hepatitis BsAg positive, and 16% was Hepatitis C antibody positive.

Sixty two percent of the patients was unem­ployed and a 65% of them was supported by welfare department of hospital for coverage of hemodialysis costs. Weekly meat consumption was reported by more than 95% of patients, and weekly egg consumption in more than 90%. In 74% of the patients dialysis was initiated as an emergency and in 26% as a planned interven­tion; the main reasons were acidosis (35%), pul­monary edema (32%), uremic symptoms (25%) and hyperkalaemia (3%). In 91% of patients tem­porary access was used at the time of dialysis initiation. More than 80% of patients had some form of sexual dysfunction.

[Table 2] shows the means of the biochemical parameters of the study patients. Hb less than 10 gm/dL was found in 10% of the patients, 10­12 gm/dL in 54%, and greater than 12 gm/dL in 36%. Hypoalbuminemia (serum albumin less than 3.8 gm/dL) was revealed in 73% of patients and hypercalcemia in 62%. Tertiary hyperpara­thyroidism was found in 15 patients and secon­dary hyperparathyroidism in 31. Total cholesterol less than 100 mg/dL was found in 6% of the patients, more than 100 but less than 150 mg/dL in 46%, and more than 150 mg in 48%. BMI was less than 18.5 in 17% of the patients (under weight), more than 18.5 but less than 25 (nor­mal) in 56%, more than 25 but less than 30 (overweight) in 21%, and more than 30 (obese) in 6%. CRP was found elevated in 18% of the patients. URR less than 60% was found in 12% of the patients, greater than 60 but less than 65% in14%, and greater than 65 but less than 71% in 32%, and greater than 70% in 41%. Hypo­albuminemia and elevated CRP were associated with poor URR (P< 0.05), whereas no statis­tically significant relationship was found bet­ween URR and iPTH and LDL cholesterol [Table 3].

   Discussion Top

The incidence of ESRD patients in Pakistan, who are maintenance hemodialysis dependant (MHD) for their survival, is estimated to be 100 patients/million population. [5]

These patients experience a low quality of life, increased hospitalizations, and a high mortality rate; currently 20% annually in the USA. The causes of deaths in MHD patients are diverse, however, at least half of them die of cardiovascular disease. [3] Up to 40-67% of patients have Protein energy malnutrition (PEM), a complica­tion that appears to be associated with increased mortality. [6] In addition to high prevalence of PEM in MHD patients, its strong association with underlying inflammatory/infective process (as indicated by C-reactive protein [CRP] has become an established fact. ESRD associated chronic inflammation as assessed by CRP level has been reported in 30-60% of North Ameri­can and European dialysis patients. [7]

Hypocholesterolemia, a strong mortality risk factor in dialysis patients and a marker of poor nutritional status was present in 52% of our patients. One of the possible factors that result in hypocholesterolemia is believed to be due to inflammation. [8] In addition, 73% of our patients revealed hypoalbuminemia, which is the single laboratory finding most closely associated with an increased mortality. [6]

BMI was less than 18.5 in 17% of patients (under weight), and more than 30 in 6% (obese). It correlates directly with body fat and can be used as a marker of energy nutritional status. [9]

Numerous studies have documented the rela­tionship between poor outcome in MHD pa­tients with inadequate urea reduction ratio(URR), [10],[11] probably secondary to reappearance of a more subtle form of the uremic syndrome with progressive catabolism and PEM, while increased KT/V results in a significant reduc­tion of mortality. [1],[12] Increasing the URR from 61 to 70 percent reduced mortality rate from 22.5 down to 18.1 percent per year; [13] the improve­ment was achieved with standard cellulosic bio­incompatible membranes. In our study, 45% of patients had URR less than 65.

In contrast to general population, where mar­kers of over nutrition are associated with in­creased risk of cardiovascular disease, decrease nutritional measures in dialysis patients are strongly correlated with increased morbidi­ty/mortality, including a higher risk of cardio­vascular events and death. These paradoxical observations have been referred to as "reverse epidemiology" or "risk factor-paradox". [14] This may not necessarily indicate that the principles of vascular pathophysiology are different in the ESRD patients but may denote other superim­posed and more dominant factors that cause ap­parent reversed relationship between risk fac­tors and outcome. [2] It has been suggested, but remains unproven, that this paradoxical asso­ciation is spurious and results from either rever­sed causation in which cardiovascular disease leads to inflammation and/or malnutrition and lower cholesterol levels, or a confounding ef­fect of inflammation and/or malnutrition, which leads to lower cholesterol levels and higher mortality. [15]

In our dialysis population only 6.5% of our patients had high serum cholesterol (> 200 mg/ dL), whereas 17% of patients had high LDL levels (> 100 mg/dL), which has been con­sistently associated with lower mortality in pros­pective studies in dialysis patients with marked contrast to the prospective studies and clinical trial findings in the general population. [4],[16]

Currently, it is not clear how cardiac disease, inflammation, hypoalbuminemia and other mea­sures of PEM in dialysis patients are interre­lated. [17] It has been postulated that inflammation is the common link. [17] A common mechanism for the development of CVD and PEM in dia­lysis patients may be the cytokine activation that is associated with reduced renal function or other pro-inflammatory conditions in dialysis patients such as the frequent contact with dia­lyzer membranes, vascular access grafts, cathe­ters, or dialysate; each may constitute a pro-in­flammatory factor. [18] Increased release or acti­vation of inflammatory cytokines, such as inter­leukin-6 or tumor necrosis factor-alpha, may suppress appetite, cause muscle proteolysis and hypoalbuminemia, and lead to atherosclerosis. [19] Nevertheless, the degree to which PEM in dia­lysis patients is caused by inflammation is not clear. Some studies suggest that PEM and in­flammation each independently contribute to hypoalbuminemia and subsequently increase morbidity/mortality. [20]

We conclude that poor nutritional status was detected among a significant number of our pa­tients with poor dietary education. Increased risk of malnutrition was significantly associated with older age and inadequate dialysis dose. Hypoalbuminemia was the single most impor­tant factor associated with poor URR.

   References Top

1.Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition inflame-mation Complex Syndrome in dialysis patients:Causes and Consequences. Am J Kidney Dis 2003;42: 864-81.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. Reverse epidemiology of cardio­vascular risk factors in maintenance dialysis patients. Kidney Int 2003;63:793-808.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.US Renal Data System. US RDS 1999 annual data report. Am J Kidney Dis 1999;34(2 suppl 1):s87-94.  Back to cited text no. 3      
4.Iseki K, Yamazato M, Tozawa M, Takishita S. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int 2002;61:1887-93.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Naqvi SA. Nephrology services in Pakistan. Nephrol Dial Transplant 2000;15:769-71.  Back to cited text no. 5      
6.Owen WF, Lew NL, Liu Y, et al. The urea re­duction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 1993;329:1001.  Back to cited text no. 6      
7.Yeum JY, Levine RA, Mantadilok V, Kaysen GA. C-Reactive Protein predicts all cause and cardiovascular mortality in hemodialysis pa­tients. Am J Kidney Dis 2000;35:469.  Back to cited text no. 7      
8.Liu Y, Covesh J, Eustace JA, et al. Association between cholesterol level and mortality in dia­lysis patients, role of inflammation and malnu­trition. JAMA 2004;291:451.  Back to cited text no. 8      
9.Leavey SF, Strawderman RL, Jones CA, Port FK, Held PJ. Simple Nutritional Indicators as Independent predictors of Mortality in hemo­dialysis patients. Am J Kidney Dis 1998;31(6): 997-1006.  Back to cited text no. 9      
10.Held PJ, Levin NW, Borbjerg RR, et al. Morta­lity and duration of hemodialysis treatment. JAMA 1991;265:871.  Back to cited text no. 10      
11.Woods JD, Port FK, Stannard D, Blagg CR, Held PJ. Comparison of mortality with home hemodialysis and centre hemodialysis: A natio­nal study. Kidney Int 1996;49:1464.  Back to cited text no. 11  [PUBMED]    
12.Hakim RM, Breyer J, Ismail N, Schulman G. Effect of dose of dialysis on mortality and morbidity. Am J Kidney Dis 1994;23:661.  Back to cited text no. 12  [PUBMED]    
13.Parker TF 3rd, Husni L, Huang W, et al. Survival of hemodialysis patients in the United States is improved with a greater quantity of dialysis. Am J Kidney Dis 1994;23:670.  Back to cited text no. 13  [PUBMED]    
14.Rabbani MA, Ahmad B. Cardiovascular risk factors paradox in maintenance dialysis patients. A spurious hypothesis or a hard core reality? J Pak Med Assoc 2006;56(1):48.  Back to cited text no. 14      
15.Baigent C, Wheeler DC. Should we reduce blood cholesterol to prevent cardiovascular di­sease among patients with chronic renal failure? Nephrol Dial Transplant 2000;15:1118-9.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.National Kidney Foundation. K/DOQi clinical practice guidelines for managing dyslipidemias in chronic kidney disease. Am J Kidney Dis 2003;41(4 suppl 3):s22-9.  Back to cited text no. 16      
17.Bergstorom J, Lindholm B. Malnutrition Cardiac disease and mortality: An integrated point of view. Am J Kidney Dis 1998;32:1-10.  Back to cited text no. 17      
18.Kaysen GA. The micro inflammatory state in uremia: Causes and potential consequences. J Am Soc Nephrol 2001;12:1549-57 .  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Stenvinkel P, Heimburger O, Lindholm B, et al. Are there two types of malnutrition in chronic renal failure? Evidence for relationships b/w malnutrition, inflammation and atherosclerosis (MiA Syndrome). Nephrol Dial Transplant 2000;15:953-60.  Back to cited text no. 19      
20.Kaysen GA, Chertow GM, Adhikarla R, et al. Inflammation and dietary protein intake exert competing effects on serum albumin and crea­tinine in hemodialysis patients. Kidney Int 2001;60:333-40.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  

Correspondence Address:
Malik Anas Rabbani
Kidney Center, Post Graduate Training Institute, 197/9, Rafiqui Shaheed Road Karachi-75530
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Source of Support: None, Conflict of Interest: None

PMID: 19861885

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  [Table 1], [Table 2], [Table 3]


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