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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 614-623
A multicenter study of malnutrition status in chronic kidney disease stages I–V-D from different socioeconomic groups

1 Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, India
2 Department of Nephrology, Madras Medical Mission, Chennai; Department of General Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
3 Department of Clinical Nutrition, Madras Medical Mission, Chennai, India
4 Department of Nephrology, Madras Medical Mission, Chennai, India
5 Department of Nephrology, Stanley Medical College Hospital, Chennai, India

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Date of Submission29-Oct-2018
Date of Decision06-Dec-2018
Date of Acceptance06-Dec-2018
Date of Web Publication10-Jul-2020


There is a paucity of data on malnutrition in different socioeconomic status in chronic kidney disease (CKD) patients. Hence, this cross-sectional study was undertaken in CKD-ND and CKD-D. The aim of the study was to assess the prevalence of malnutrition in the various stages of CKD among the various socioeconomic groups, namely the low-income groups and the upper-middle-income groups. This is a cross-sectional study conducted among 394 patients. The patient data were obtained from three institutions: Institution 1, Institution 2, and Institution 3. Patients were predominantly from the South Indian population and were between the age groups of 18 and 80 years. Measurements: malnutrition was assessed using anthropometry, body composition monitor, biochemical parameters, and dietary recall. Subjective Global Assessment Scale for nondialyzed patients and Malnutrition-Inflammation Score for dialyzed patients were also collected . As per the CKD stages, we found the percentage of malnutrition to be 7% in Stage III, 14% in Stage IV, 18% in Stage V, and 68% in Stage V-D in the upper-middle-income group, whereas it was 10% in Stage III, 26% in Stage IV, 40% in Stage V, and 93% in Stage V-D in the low-income group. The severity of malnutrition was stratified according to the stages of CKD, and it was found to be higher in progressive stages of CKD among the low-income groups as compared to the high-income groups.

How to cite this article:
Anupama SH, Abraham G, Alex M, Vijayan M, Subramanian KK, Fernando E, Nagarajan V, Nageshwara Rao PK. A multicenter study of malnutrition status in chronic kidney disease stages I–V-D from different socioeconomic groups. Saudi J Kidney Dis Transpl 2020;31:614-23

How to cite this URL:
Anupama SH, Abraham G, Alex M, Vijayan M, Subramanian KK, Fernando E, Nagarajan V, Nageshwara Rao PK. A multicenter study of malnutrition status in chronic kidney disease stages I–V-D from different socioeconomic groups. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2022 Dec 2];31:614-23. Available from: https://www.sjkdt.org/text.asp?2020/31/3/614/289448

   Introduction Top

Malnutrition is a broad term that covers any nutritional imbalance in both undernutrition and overnutrition. More often, the term malnutrition is used to denote protein-energy wasting (PEW). Being the second most populous country, the Indian diet is diverse in terms of protein, calorie, and other macro- and micro element consumption in vegetarians and non-vegetarians. Unlike developed countries and Africa, meat, fish, and egg consumption is relatively low even in non-vegetarians.

The three national surveys, i.e., National Sample Survey, National Family Health Survey, and National Nutrition Monitoring Board, showed diverse protein intake in both rural and urban India showing intake between <45 and 60 g/day by 73% and 70% in urban and rural areas, respectively. A protein intake of >75 g/day is consumed by 9% and 7% in rural and urban India, respectively.[1]

The causes of malnutrition complicating kidney disease are varied including inadequate dietary intake of nutrients, loss of protein and other micro- and macronutrients through the urine in nephrotic syndrome, dialysate loss, intercurrent illnesses leading to hypercata-bolism, uremia, metabolic acidosis, and endocrine abnormalities such as insulin resistance, hyperglucagonemia, and secondary hyperpara-thyroidism.[2] Malnutrition, existent in the end-stage kidney disease (ESKD) population, is strongly associated with impaired physical performance, poor quality of life, and increased morbidity and mortality.[3] Several vital functions, such as tissue oxygenation, water/electrolyte balance, body temperature maintenance, immune defense mechanisms, and growth in children, are altered in the setting of malnutrition.[4] Malnutrition is a compounding factor in the progression of CKD to ESKD. Hence, early diagnosis and intervention are of utmost importance.

There is no single test as a gold standard for assessment of malnutrition. A combination of dietary recall, anthropometric measurements, biochemical parameters, and imaging studies helps in understanding the status of malnutrition in CKD patients. A study from India reported that PEW is present in 68%–93% of patients on dialysis from middle and lower socioeconomic strata.[5],[6] We undertook this cross-sectional study in CKD patients, classified to Stages I–V, and in Stage V-dialysis patients in a metropolitan city, Chennai, India, with a diverse socioeconomic population to understand their malnutrition status.

   Materials and Methods Top

A cross-sectional study was conducted in 394 CKD patients from two tertiary health-care centers and one free-standing charity hemo-dialysis (HD) unit to identify the nutritional status. Data regarding these patients were obtained from all the three institutions from the outpatient department and inpatient dialysis units by skilled nutritionists over many days by dietary recall for three days, anthropometric measurements, body composition monitor (BCM), Malnutrition-Inflammation Score (MIS), Subjective Global Assessment (SGA), and their biochemical parameters. Patients were informed of the study, and written consent was obtained. We excluded patients with coexisting illnesses that could be responsible for malnutrition such as stroke, malabsorption syndromes, chronic liver disease, tuberculosis, HIV, and cancers. We classified the patient population as a low-income group (LIG) from Institution 1 and Institution 2 and upper-middle-income group (UMIG) from Institution 3. Under the Interest Subsidy for Housing the Urban Poor Scheme, those with monthly income between USD 48.63 and USD 107.57 were termed as LIG.[7] The LIG included 184 patients, whereas the UMIG included 210 patients. Patients were categorized into Stage I–V (according to CKD-EPI Creatinine Equation) and Stage V-dialysis. Malnutrition in CKD of Stages I–V was assessed by SGA and in dialysis patients using MIS. Both the groups included prevalent patients on maintenance HD. Institution 2 patients were on twice-weekly 4-hourly HD, using bicarbonate buffer with reverse osmosis facility, and the dialyzer used was polysulfone membrane measuring 1.3 m2 surface area. Institution 3 patients were being dialyzed for 4 h using polysulfone membrane with a surface area of 1.8 m2. At Institution 3, 60% of the patients were on twice weekly and 40% on thrice-weekly HD for 4 h. The patients at Institution 3 facility had regular twice-weekly skilled nutritionist care and supplemental commercial dietary products when required. Patients were further subdivided into four groups. Group 1 comprised CKD I—II, Group 2 of CKD III—IV, Group 3 of CKD V patients, and Group 4 of CKD V-D. Patients included in this study were between ages of 18 and 80 years. Parameters gauged were as follows: mid-arm circumference (MAC), triceps skinfold thickness (TSF), mid-arm muscle circumference, body mass index (BMI), hemoglobin levels, serum total protein, serum albumin, energy intake, carbohydrate intake, water content, body fat, and resting metabolic rate (RMR). The mean and standard deviation of these nutritional indicators was determined. The means were compared using one-way analysis of variance (ANOVA) and post hoc Tukey’s honestly significant difference (HSD) test for multiple pairwise comparisons. P <0.05 was considered as statistically significant.

   Results Top

The study population consisted of males 263 and females 131. They were predominantly nonvegetarians (88.85%). 43.40% were diabetic and 76.64% were hypertensive. The dialysis population included 208 patients. [Table 1] shows a comparison of the markers of nutrition among the three groups through ANOVA.
Table 1: Comparison of nutritional markers by anthropometric and laboratory indices.

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There was statistical significance in the BMI (P = 0.052), MAC (P = 0.000), TSF (P = 0.000), hemoglobin (P ~0.000), energy intake (P = 0.014), carbohydrate intake (P = 0.004), body fat (P ~0.000), RMR (P = 0.000), and water content (P = 0.000).

[Table 2] shows the post hoc Tukey’s HSD test showing a pairwise comparison of the statistically significant (P <0.05) nutritional parameters studied. The severity of malnutrition as per stages of CKD was assessed in both LIG and UMIG, as depicted in [Figure 1]. MIS was used to assess the nutritional status for the dialysis patients from LIG and UMIG.
Table 2: Post hoc Turkey's honestly significant difference test.

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Figure 1: Assessment of severity of malnutrition as per stages of chronic kidney disease in both lowincome and upper-middle-income groups.

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Severe malnutrition was seen in 15.3% of the patients from LIG and 8.18% from UMIG, 30.61% of the patients from LIG and 10.0% from UMIG were moderately malnourished, 46.93% of the patients from LIG and 50.0% from UMIG were mild malnourished, and 7.14% of patients from LIG and 31.81% from UMIG were well nourished, as shown in [Table 3].
Table 3: Nutritional status of dialysis group by Malnutrition-Inflammation Score.

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SGA was used to assess the nutritional status of nondialysis group LIG and UMIG, respectively [Table 4]. Among the CKD V stage, 60% of the patients from LIG were well nourished and 40% were moderately malnourished and 82% of the patients from UMIG were well nourished and 17.8% were moderately malnourished. Among the CKD IV stage, 74% of the patients from LIG were well nourished and 26% moderately malnourished and 85.7% of the patients from UMIG were well nourished and 14.2% were moderately malnourished. Among the third stage, 90% of the patients from LIG were well nourished and 9.6% were moderately malnourished and 89% of the patients from UMIG were well nourished and 11% were moderately malnourished.
Table 4: SGA score in nondialysis patient as per CKI I-V ND.

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   Discussion Top

The objective of this study was to analyze the distribution and prevalence of malnutrition among the different stages of CKD in diverse economic strata in South India. A previous study in India in 2005 stated that the approximate prevalence of CKD in India was 800 per million people.[8] Although initiatives are taken by the newly formed Society of Renal Nutrition and Metabolism in India, the prevalent CKD population of 17.2% in a country with a population of over 1.32 billion calls for more attention and effort toward reducing the burden of malnutrition.[9],[10] The escalating number of people affected by CKD makes it a major encumbrance for a developing country with 1.4% of the GDP spent by the government on health care. We also assessed the severity of malnutrition among patients belonging to the low- and middle-income groups at each stage of CKD, and we found that 7% and 32% were well nourished, whereas 47% and 50% were mildly malnourished, 30% and 10% were moderately malnourished, and 15% and 8% were severely malnourished in the low- and middle-income groups, respectively. We are handicapped by the scarcity of nephrologists with one nephrologist for every 725682 population and less than 150 skilled renal nutritionists. Unless this situation improves, the extent of malnutrition, which is on the rise, can never be addressed. With a per capita GDP income of USD 1709.00, it is more essential for CKD patients to be provided a cost-effective nutritious diet with high biological value protein, calories, and other micro- and macronutrients. The major cause of morbidity and mortality in Indian CKD patients is infection and cardiovascular diseases, which is attributed to the defective immune status and inappropriate nutrition.[5] As per the CKD stages, we found the percentage of malnutrition to be 7% in Stage III, 14% in Stage IV, 18% in Stage V, and 68% in Stage V-D in the UMIG, whereas it was 13% in Stage III, 26% in Stage IV, 40% in Stage V, and 93% in Stage V-D in the LIG. There are no previous reports of stratification of CKD patients belonging to different socioeconomic status correlating with malnutrition from India.

The causes of malnutrition in CKD are multifactorial. With the decline of kidney function, the symptoms such as vomiting, diarrhea, and loss of appetite predispose these patients to malnutrition. Moreover, dietary restrictions on CKD patients are imposed to control the adverse effects of dyselectrolytemia, metabolic acidosis, uremia, and their potentially detrimental effects.[6] As CKD progresses, in the later stages, hormonal imbalances have been reported to contribute significantly.[11] Carnitine deficiency has been reported to be present in 64.3% of the dialysis population in India.[12] A previous longitudinal study looking at patient survival in HD cohort found that low socioeconomic group population undergoing dialysis at Institution 3, a free-standing dialysis unit, had poor survival.[13] A prospective study by Yuvaraj et al found that both high-protein kitchen feeding and high-protein commercial nutritional supplement cohorts were observed to have improvement in overall nutritional status.[14] This study highlighted the importance of regular nutritional counseling and supplemental diet effective in producing a beneficial impact in malnutrition among upper-middle-income HD group.[14] An earlier study correlating serum inflammatory markers and atherosclerosis in CKD patients from a single center in Chennai reported 67% of the population having an elevated high-sensitivity C-reactive protein level and correspondingly low serum albumin levels and malnutrition belonging to low socioeconomic status.[15] Studies have suggested the prevalence of elevated levels of inflammatory markers in advanced stages of CKD.[16],[17],[18],[19],[20] Interleukin-6 (IL-6), an acute-phase reactant, plays a key role in inflammation and is significantly elevated in ESKD patients. Serum IL-6 levels are indicative of the outcome in HD patients. However, a study by Thandavan showed that periodic assessment of MIS is a more efficient and cost-effective method of prognosticating the outcome in HD patients as compared to IL- 6.[21] The question arises whether malnutrition contributes to decreased immune response in addition to increased inflammatory process in CKD progression among low socioeconomic population.

The anthropometrical measurements are seldom undertaken in CKD patients in India.

The significance of anthropometric measurements in the assessment of renal disease was established by Blumenkrantz et al.[22] Our study emphasizes the importance of anthropometry, MIS, SGA, and BCM which are essential tools in our ongoing prospective study. Various studies have stated the applicability of using SGA and MIS for the assessment of malnutrition in the nondialyzed and dialyzed population, respectively.[23] SGA is an independent predictor of mortality both in CKD nondialysis and dialysis patients and is an excellent nutritional marker for prognostication.[24] Superiority of MIS in assessment of malnutrition in dialyzed patients was reported by Santin et al.[24] It is also important to highlight the fact that when a patient is diagnosed to have CKD, the primary care physician and the nonnephrology physician put them on a very restricted diet without supplements with a goal to slow the progression of CKD leading to under-recognized malnutrition.

The revised criteria for normal BMI in Asian Indians are between 18.5 and 22.9 kg/m2, whereas the International Society of Renal Nutrition and Metabolism states that a BMI of <23 kg/m2 in CKD patients is a marker of PEW.[25] Our study population showed a statistical trend (P = 0.052) in BMI among the four groups with Group 1 and Group 4 below the recommended range. The recommended mean MAC for adults aged 20 years and above is 34.1 cm for males and 31.9 cm for females (NHANES 2003–2006).[26] In our study population, the mean in all four groups was markedly below the recommended guidelines, the lowest being in Group 4, CKD-V-D population. Mean triceps skinfold thickness for adults aged 20 years and above is 14.9 cm in males and 23.9 cm in females. Our study showed statistical significance with the lowest mean in Group 4 patients. These findings are consistent with the fact that muscle wasting and PEW are widely prevalent in our population due to various factors, the most common being unaffordability. According to the KDOQI Guidelines, diagnosis and further evaluation of anemia should be conducted at hemoglobin concentrations <3.5 g/dL in adult males and <12.0 g/dL in adult females.[27] The pattern noticed in the study points toward lesser values of hemoglobin in the entire study population, with the least in Group 4. KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure states that the dietary energy intake for nondialyzed patients with CKD not undergoing maintenance dialysis, age <60 years, is 35 kcal/kg/day and 30–35 kcal/kg/d for those aged or more.[27] The energy intake in our study population shows a marked reduction as the stages of CKD advanced. Protein catabolism and nitrogen balance in CKD are closely associated to energy intake with protein being used for energy supply, resulting in a negative nitrogen balance.[28],[29] Our study shows a statistical significance in the Energy intake (P = 0.014) of CKD patients with Group 3 having a lower intake than Group 1, and post hoc analysis revealed a significance between Groups 1 and 3 (P = 0.025). There is a slight increase noticed in energy intake in Group 4, CKD V-D patients. A similar pattern is seen in the carbohydrate intake (P = 0.004). Patients in Group 3 had a lower intake than Group 1 with a statistical significance between Groups 1 and 3 (P = 0.023) and Groups 2 and 3 (P = 0.017). Again, carbohydrate intake also shows an increase in Group 4 patients. The increase in dietary markers of nutrition in Group 4 CKD V-D patients can be attributed to additional care and attention paid to nutrition in patients on renal replacement therapy (RRT). In healthy individuals, oxygen consumption by the kidneys constitutes about 7.2% of RMR. In patients with CKD, a reduced O2 consumption may account for the decrease in RMR.[30] These findings were harmonious with those in our study, with the RMR being statistically significant (P = 0.000) and a reducing trend seen with progression of CKD.

There is an increase seen in Group 4 patients, again attributable to the focus paid on nutrition in patients on RRT.

There is a scarcity of skilled nutritionists in India which is creating a critical gap in providing substantial nutritional care to the CKD patients. There is a necessity for primary prevention of PEW by dietary counseling and appropriate timely interventions to reduce the mortality and morbidity associated with it.

We were unable to correctly assess the impact of malnutrition on CKD Stages 1–2 in this study since they were managed elsewhere by nonnephrologists. This could be considered as a limitation.

   Practical Application Top

The practical application of this study would be to highlight the prevalence of malnutrition in CKD patients in India where little attention is paid focused to meet the challenge.

   Conclusion Top

This study shows that the degree of malnutrition varies with different socioeconomic groups and progressive CKD. Unless appropriate nutritional care by skilled nutritionists in provided to CKD patients, especially to CKD-dialysis group, the morbidity and mortality is going to be disproportionately high.

Conflict of interest: None declared.

   References Top

Ministry of Statistics and Program Implementation, Government of India; (n.d.). Available from: http://www.mospi.nic.in/ [Last accessed on Accessed 25 June 2020].  Back to cited text no. 1
Blumenkrantz MJ, Kopple JD, Gutman RA, et al. Methods for assessing nutritional status of patients with renal failure. Am J Clin Nutr 1980;33:1567-85.  Back to cited text no. 2
Abraham G, Varsha P, Mathew M, Sairam VK, Gupta A. Malnutrition and nutritional therapy of chronic kidney disease in developing countries: The Asian perspective. Adv Ren Replace Ther 2003;10:213-21.  Back to cited text no. 3
Van den Broeck J. Malnutrition and mortality. J R Soc Med 1995;88:487-90.  Back to cited text no. 4
Varughese S, Abraham G. Chronic kidney disease in India: A clarion call for change. Clin J Am Soc Nephrol 2018;13:802-4.  Back to cited text no. 5
Vijayan M, Abraham G, Alex ME, et al. Nutritional status in stage V dialyzed patient versus CKD patient on conservative therapy across different economic status. Ren Fail 2014;36:384-9.  Back to cited text no. 6
Economically Weaker Sections. (n.d.). Available: http://www.arthapedia.in/index. php?title=Economically_Weaker_Sections_(E WS) [Last accessed on Accessed 25 June 2020].  Back to cited text no. 7
Agarwal SK, Srivastava RK. Chronic kidney disease in India: Challenges and solutions. Nephron Clin Pract 2009;111:c197-203.  Back to cited text no. 8
Singh AK, Farag YM, Mittal BV, Subramanian KK, Keithi Reddy SR, Acharya VN, Almeida AF, et al. Epidemiology and risk factors of chronic kidney disease in India–results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol 2013; 14:114.  Back to cited text no. 9
Ene-Iordache B, Perico N, Bikbov B, et al. Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): A cross-sectional study. Lancet Glob Health 2016;4:e307-19.  Back to cited text no. 10
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Ramalakshmi S, Baben B, Ashok BS, Jayanthi V, Leslie N, Abraham G. Association of carnitine deficiency in Indian continuous ambulatory peritoneal dialysis patients with anemia, erythropoietin use, residual renal function, and diabetes mellitus. Perit Dial Int 2007;27 Suppl 2:S235-8.  Back to cited text no. 12
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Abraham G, Sundaram V, Sundaram V, Mathew M, Leslie N, Sathiah V. C-Reactive protein, a valuable predictive marker in chronic kidney disease. Saudi J Kidney Dis Transpl 2009;20:811-5.  Back to cited text no. 15
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Correspondence Address:
Georgi Abraham
Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.289448

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  [Table 1], [Table 2], [Table 3], [Table 4]


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