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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 697-701
Nutritional assessment and its correlation with anthropometric measurements in hemodialysis patients

1 Department of Nutrition, Health Faculty, Yasouj University of Medical Sciences, Yasouj, Iran
2 Biochemistry and Genetics Department, Arak University of Medical Sciences, Arak, Iran
3 Anatomy Departments, Arak University of Medical Sciences, Arak, Iran

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Date of Web Publication8-Jul-2015


One of the most important problems in patients on hemodialysis (HD) is chronic malnutrition. This study is aimed to assess the prevalence of malnutrition using a subjective global assessment (SGA) in HD patients referred to the Valie ASR Hospital, Arak, Iran. In this descriptive analysis study, 190 HD patients were selected with random sampling. SGA and anthropometric and biochemical measurements were assessed in all patients. Data were analyzed with the Chi-square and t-tests and Pearson correlation coefficient. P <0.05 was considered statistically significant. Of the 190 patients studied, 78 patients (41.1%) were male and 112 patients (58.9%) were female. Sixteen patients were detected to have adequate nutritional status (8.4%), 90 (47.4%) had mild malnutrition and 84 patients (44.2%) had moderate malnutrition. We found a significant negative correlation of SGA score with patient's weight (r = -0.147) and patient's body mass index (BMI) (r = -0.238). Also, it correlated significantly with duration of dialysis treatment (years) (r = 0.404). The SGA score showed a significant negative correlation with mid-arm circumference (MAC) (r = - 0.152). No significant correlation was found between SGA score and mid-arm muscle area. Our study showed that >50% of patients on maintenance HD had mild or moderate malnutrition. There was no case of severe malnutrition. Duration of dialysis treatment and some anthropometric indices (weight, BMI and MAC) also showed a significant correlation with SGA score, which are important to determine the nutritional status of HD patients.

How to cite this article:
Koor BE, Nakhaie MR, Babaie S. Nutritional assessment and its correlation with anthropometric measurements in hemodialysis patients. Saudi J Kidney Dis Transpl 2015;26:697-701

How to cite this URL:
Koor BE, Nakhaie MR, Babaie S. Nutritional assessment and its correlation with anthropometric measurements in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Nov 26];26:697-701. Available from: https://www.sjkdt.org/text.asp?2015/26/4/697/160146

   Introduction Top

Malnutrition is a common problem in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) and may occur secondary to several factors such as [1] inadequate food intake secondary to anorexia caused by uremic state, altered taste sensation, concurrent illness, emotional distress, impaired ability to procure prepared or mechanically ingested foods, unpalatable prescribed diets, the catabolic response to superimposed illness, the dialysis procedure itself, which may promote wasting by removing nutrients and may promote protein catabolism due to bio-incompatibility, conditions associated with chronic inflammatory state that may promote hyper-catabolism and anorexia, loss of blood due to gastrointestinal bleeding, frequent blood sampling, blood sequestered in hemodialyzer and tubing, endocrine disorders of uremia and possibly the accumulation of endogenously formed uremic toxins or the ingestion of exogenous toxins. [2] Early identification of patients who are malnourished or at risk of malnutrition and intervening at an early stage will improve the overall prognosis of the patients and will reduce the overall cost incurred. Many validated tools for screening of nutrition risk and nutrition assessment exist for the accurate identification, referral and treatment of patients who are malnourished or at risk of malnutrition. Nutrition screening is a process of identifying characteristics known to be associated with malnutrition risk while nutrition assessment is a diagnostic tool to determine whether a patient is currently malnourished. [3] For these findings, the evaluation of nutritional status is necessary. [4] Nutritional status is frequently ignored in many dialysis centers, while simple methods of nutritional assessment could have a favorable impact on patient management. [2] The methods of assessment of nutritional status include measurement of actual body weight, ideal body weight, triceps skin fold, mid-arm circumference (MAC), bioimpedance, serum albumin, urea and nitrogen levels and the rate of urea production. [5] Also, subjective global assessment (SGA) is useful for the assessment of nutritional status. [6] It is a well-validated tool for screening for malnutrition. Although the SGA scores are determined in a subjective manner, it is the only screening tool recommended by the American Society for Parenteral and Enteral Nutrition (ASPEN). [7] Moreover, it has been recommended by the National Kidney Foundation (NKF) and Kidney Disease/Dialysis Outcomes and Quality Initiative (K/DOQI) for use in nutritional assessment in the adult dialysis population. [8] The aim of this study is to assess malnutrition using SGA and to identify its correlation with anthropometric and biochemical measurements in HD patients referred to the Valie Asr Hospital, Arak, Iran.

   Materials and Methods Top

In this cross-sectional descriptive study, 190 patients with a minimum age of 18 years who had completed at least eight weeks of dialysis were selected by the random sampling procedure. None of the study patients had severe psychological disorders like schizophrenia. [6],[9] The questionnaire sheet included socio-demographic data, medical history of current disease status, subjective assessment of the nutritional status using patients' history and examination and objective assessment through anthropometric measurements (weight, height) and biochemical parameters (plasma creatinine, blood urea nitrogen and creatinine clearance).

SGA questions included weight loss during the previous six months, symptoms of gastrointestinal tract such as anorexia, nausea, vomiting, diarrhea and food intake, functional capacity (related to power failure), the history of dialysis, loss of subcutaneous fat in the mid-arm muscle area and arm muscle area of the lateral line of the body and the muscles in the shoulder and quadriceps muscle of the thigh. The SGA score varied from seven, indicating normal nutrition, to 31, indicating severe malnutrition. Scores of eight to 12 suggested mild malnutrition, 13-25 suggested moderate malnutrition and 26-31 indicated severe malnutrition. [7]

All data collection were performed by a specially trained medical officer with close supervision of clinical nutrition and nephrology experts. All patients who provided informed written consent were screened for malnutrition using an interviewer-administered questionnaire. Data entry and statistical analysis were performed using the SPSS version 11.05 statistical package. T-test was used to make comparisons and Chi-square and Pearson coefficient were used to analyze the correlations. P <0.05 was considered statistically significant. [10]

   Results Top

In our descriptive analysis study, 190 HD patients [78 males (41.1%) and 112 females (58.9%] undergoing HD, with a mean age of 59.98 ± 17.4 years, were involved. The duration on HD in the study patients ranged from eight months to seven years, with a mean duration of 4.3 ± 3.04 years. The principal co-morbidities in the study population included diabetes in 77 patients (40%) and hypertension in 49 patients (29.3%). Based on the SGA score, 16 patients (8.4%) were found to have adequate nutritional status, 90 patients (47.4%) had mild malnutrition and 84 patients (44.2%) had moderate malnutrition.

The SGA score had no significant correlation with age and sex, suggesting that both males and females had an equal tendency toward malnutrition. A significant correlation was found between SGA and duration on dialysis (r = 0.404; P = 0.001). Also, the SGA score showed a significant negative correlation with weight (r = -0.147; P = 0.047) and body mass index (BMI) (r = -0.238; P = 0.001). Pearson correlation showed a significant negative correlation between MAC and triceps skinfold with SGA score (r = -0.152; P = 0.021) as shown in [Table 1].
Table 1: Frequency distribution of nutritional status of patients on hemodialysis and mid-arm circumference.

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Pearson correlation showed a negative, but not significant, correlation between mid-arm muscle circumference (MAMC) and SGA score. Also, Chi-square test showed no significant correlation, as shown in [Table 2]. Pearson correlation showed a negative, but not significant, correlation between muscle mass and SGA score.
Table 2: Frequency distribution of nutritional status of patients on hemodialysis and mid-arm muscle circumferences.

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   Discussion Top

In this study, based on the SGA score, which is a common method for evaluating protein- calorie malnutrition in HD patients, [11] we found that 6.3% were well nourished, 50% had mild malnutrition and 43.8% suffered from moderate malnutrition; we found no case of severe malnutrition in our study patients. Mojahedi et al [12] in Iran showed that 20% of patients on peritoneal dialysis and 13.2% of patients on HD had mild malnutrition.

In the study by Qureshi et al [13] based on the SGNA group, 36% of HD patients had normal nutritional status, 51% had mild malnutrition and 13% had severe malnutrition. Tayyem et al in Jordan, [14] using the SGA score, showed that in their study population, 38.2% were well nourished, 56.2% had moderate malnutrition and 5.6% were severely malnourished. The combined prevalence of malnutrition (moderate and severe) in their study was approximately 61% in private and 63% in public hospitals. The results of Tayyem et al were similar to the report by Qureshi et al. In our study, severe malnutrition was not found and the prevalence of malnutrition was greater in males than in females (97.4% vs. 87.5%). In the study of Tayyem et al, the prevalence of malnutrition was greater in women than in men (71% vs. 54%). In addition, they showed that there was no significant difference between age and prevalence of malnutrition in their patients. [7] In most studies, the nutritional status of older patients was poorer than their younger counterparts. [6] Some studies have shown that there was a negative correlation between age and prevalence of malnutrition. [15] Mojahedi et al, in their study, showed that there was no relationship between age and prevalence of malnutrition. [12] In our study, there was a positive and significant correlation between hospitalization and prevalence of malnutrition assessed by the SGA score. The mean duration on dialysis in patients with good nutritional status was significantly lower compared with malnourished patients. Other studies have shown similar results. [6],[9]

In our study, the SGA score showed a significant correlation between BMI and MAC. Some other studies have shown similar results. [2] We suggest measuring the muscle mass instead of BMI based on our results. The MAC reflects the skeletal mass and the MAMC measures the protein status in the body. This study showed that a significant correlation existed between MAC and the prevalence of malnutrition in patients. Chen et al [16] found a significant difference of MAC between two nutritional groups (well nourished, malnourished), while no significance of MAMC was found. Their studies showed that both the anthropometric assessments (MAC and MAMC) had a significant negative correlation with malnutrition-inflammation score MIS and positively correlated with BMI. They suggested that MAC is a good marker for nutritional and inflammatory status than MAMC, although MAMC is also significantly associated with MIS. [16] In the study of Qureshi et al, anthropometric factors associated with malnutrition included low body weight, skinfold thickness, MAMC and hand-grip strength. [13]

   Conclusion Top

Our study showed that on the basis of SGA, greater than half of patients on HD had mild malnutrition and others (less than half of patients) had moderate malnutrition; nobody had severe malnutrition. These data show that appropriate assessment of nutritional status in patients on HD is important. Some anthropometric indices like MAC also showed significant effects on the SGA score. Thus, besides laboratory data to determine the nutritional status, anthropometric indices are also important.

   Acknowledgment Top

This article is the result of research conducted by the Assistant Professor Mahmoud Reza Nakhaei and Behrooz Ebrahimzadeh Koor. The study protocol was approved and the funding was supported by the Arak University of Medical Sciences.

   References Top

Espahbodi F, Khoddad T, Esmaeili L. Evaluation of malnutrition and its association with biochemical parameters in patients with end stage renal disease undergoing hemodialysis using subjective global assessment. Nephrourol Mon 2014;6:e16385.  Back to cited text no. 1
Janardhan V, Soundararajan P, Rani NV, et al. Prediction of Malnutrition Using Modified Subjective Global Assessment-dialysis Malnutrition Score in Patients on Hemodialysis. Indian J Pharm Sci 2011;73:38-45.  Back to cited text no. 2
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Pathirana AK, Lokunarangoda N, Ranathunga I, Santharaj WS, Ekanayake R, Jayawardena R. Prevalence of hospital malnutrition among cardiac patients: Results from six nutrition screening tools. Springerplus 2014;3:412.  Back to cited text no. 3
Kalantar-Zadeh K, Kuwae N, Wu DY, et al. Associations of body fat and its changes over time with quality of life and prospective mortality in hemodialysis patients. Am J Clin Nutr 2006;83:202-10.  Back to cited text no. 4
Kondrup J, Allison SP, Elia M, Vellas B, Plauth M, Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003;22: 415-21.  Back to cited text no. 5
Yamada K, Furuya R, Takita T, et al. Simplified nutritional screening tools for patients on maintenance hemodialysis. Am J Clin Nutr 2008;87: 106-13.  Back to cited text no. 6
Kalantar-Zadeh K, Kleiner M, Dunne E, Lee GH, Luft FC. A modified quantitative subjective global assessment of nutrition for dialysis patients. Nephrol Dial Transplant 1999;14:1732-8.  Back to cited text no. 7
Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis 2000;35 Suppl 2:S1-140.  Back to cited text no. 8
Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. Association among SF36 quality of life measures and nutrition, hospitalization, and mortality in hemodialysis. J Am Soc Nephrol 2001;12:2797-806.  Back to cited text no. 9
Ebrahimzadehkor B, Dorri AM, Yapan-Gharavi AH. Malnutrition-inflammation score in hemodialysis patients. Zahedan J Res Med Sci 2014; 16:25-8.  Back to cited text no. 10
Chauveau P, Naret C, Puget J, Zins B, Poignet JL. Adequacy of haemodialysis and nutrition in maintenance haemodialysis patients: Clinical evaluation of a new on-line urea monitor. Nephrol Dial Transplant 1996;11:1568-73.  Back to cited text no. 11
Mojehedi M, Behroozhdam A, Hekmat R. Malnutrition prevalence among hemeodialysis patients, Mashhad. J Med Fac Mashhad Univ Med Sci 2005;47:121-77.  Back to cited text no. 12
Qureshi AR, Alvestrand A, Danielsson A, et al. Factors predicting malnutrition in hemodialysis patients: A crosssectional study. Kidney Int 1998;53:773-82.  Back to cited text no. 13
Tayyem RF, Mrayyan MT. Assessing the prevalence of malnutrition in chronic kidney disease patients in jordan. J Ren Nutr 2008;18: 202-9.  Back to cited text no. 14
de Mutsert R, Grootendorst DC, Boeschoten EW, et al. Subjective global assessment of nutritional status is strongly associated with mortality in chronic dialysis patients. Am J Clin Nutr 2009;89:787-93.  Back to cited text no. 15
Chen J, Peng H, Yuan Z, et al. Combination with anthropometric measurements and MQSGA to assess nutritional status in Chinese hemodialysis population. Int J Med Sci 2013;10:974-80.  Back to cited text no. 16

Correspondence Address:
Mohammad Reza Nakhaie
Nakhaie Biochemistry and Genetics Department, Arak University of Medical Sciences, Arak
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.160146

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