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Introduction:

There are many causes for malnutrition in patients undergoing dialysis.


Malnutrition is a treatable and preventable illness. The main causes of
malnutrition in dialysis patients are inadequate nutrient intake caused by
anorexia or diet restrictions, nutrient loss during dialysis, hyper catabolism
due to comorbid illnesses, hyper catabolism associated with dialysis
treatment, endocrine disorders of uremia, academia with metabolic acidosis,
and concurrent nutrient loss with frequent blood losses (In Byham-Gray, In
Burrowes, & In Chertow, 2014, p. 220). Change in nutrition intake or change
in nutrient status are the two largest contributors to the development of
malnutrition therefor it stands to reason that nutrition counseling can
prevent or treat malnutrition in these patients.
Significance of Problem:
Currently there are 398,861 (American Kidney Fund, 2012)
people in the United States that are on dialysis. Out of all the people on
dialysis 95% are on hemodialysis and 5% are on peritoneal dialysis
(American Kidney Fund, 2012). The prevalence of malnutrition in people
undergoing dialysis ranges from 18 to 75% (In Byham-Gray, In Burrowes, &
In Chertow, 2014, p.220). Since there is a larger patient population
undergoing hemodialysis it reasons that malnutrition is a larger problem in
the hemodialysis population so this paper will focus on malnutrition in
hemodialysis patients. Malnutrition is defined as a state of diminished
functional capacity, which is caused at least partly by inadequate nutrient

intake relative to nutrient demand and/or which is improved by nutritional


repletion in patients with CKD (In Byham-Gray, In Burrowes, & In Chertow,
2014, p.221). Malnutrition is a preventable and treatable condition with the
proper care and treatment. One way to prevent or treat malnutrition is
through nutrition counseling.

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

study is to see if it is possible to predict malnutrition based on biochemical


parameters instead of the subjective global assessment tool (Espahbodi,
Khoddad, & Esmaeili, 2014, p2). This was a cross-sectional, descriptiveanalytic study that was performed on all patients with End Stage Renal
Disease who were undergoing hemodialysis at the dialysis centers of Imam
Khomeini and Fatemeh Zahra Hospitals of Mazandaran University of Medical
Sciences in Sari, Iran (Espahbodi, Khoddad, & Esmaeili, 2014, p2). There
were 105 people enrolled in this study with 60 males and 45 females
(Espahbodi, Khoddad, & Esmaeili, 2014, p2). The only criterion for this study
was that the participants were patients at the dialysis units at Mazandaran
University of Medical Sciences (Espahbodi, Khoddad, & Esmaeili, 2014, p2).
The patients age, sex, duration of hemodialysis, and biochemical
parameters were recorded. Then, a general practitioner under observation
of a nephrologist conducted the subjective global assessment interview
(Espahbodi, Khoddad, & Esmaeili, 2014, p2). The subjective global
assessment uses a semi quantitative scoring system focuses on seven
different variables to assess if there is any malnutrition and to what degree
the malnutrition is present (Espahbodi, Khoddad, & Esmaeili, 2014, p2). The
subjective global assessment focuses on weight change in the past six
months, change in dietary intake, presence of gastrointestinal symptoms,
change in functional capacity, subcutaneous fat loss, muscle wasting, and
edema (Espahbodi, Khoddad, & Esmaeili, 2014, p2). Based on the answers
given by the patients they were assigned to three different groups; healthy,

mild to moderately malnourished, and severely malnourished. Out of the


105 participants in this study 101 participants showed various degrees of
malnutrition (Espahbodi, Khoddad, & Esmaeili, 2014, p2). There was no
significant relationship between age and length of dialysis with malnutrition
occurrence. There was a significant relationship between gender and
occurrence of malnutrition; females were associated with a higher incidence
of malnutrition (Espahbodi, Khoddad, & Esmaeili, 2014, p2). The results also
indicated no association between biochemical parameters an occurrence of
malnutrition (Espahbodi, Khoddad, & Esmaeili, 2014, p2). The results of this
study indicated that the subjective global assessment is still the best tool to
use to assess malnutrition in patients undergoing hemodialysis.
A similar study was conducted to measure the effect of malnutrition in
hemodialysis patients. This study tested for protein-energy malnutrition and
inflammation in patients, which can lead to malnutrition inflammation
complex syndrome (Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001,
p.1251). Patients featuring malnutrition inflammation complex syndrome- a
term coined by different researchers-is a strong predictor of degrees of
sickness, morbidity and mortality in hemodialysis patients (Kalantar-Zadeh,
Kopple, Block, & Humphreys, 2001, p.1251). Currently the measures of
malnutrition is not indicated in clinical conditions, in this way a quantitative
tool would be a practical and easy tool to measure the risk of malnutrition in
end stage renal disease patients (Kalantar-Zadeh, Kopple, Block, &
Humphreys, 2001, p.1252). This study attempted to develop a scoring

system that is both comprehensive and semiquantitative to evaluate


malnutrition in patients with end stage renal disease (Kalantar-Zadeh,
Kopple, Block, & Humphreys, 2001, p. 1252). This study attempts to validate
these study tools in hemodialysis patients by comparing measures of
nutritional state, inflammation, risk for hospitalization, and mortality
(Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001, p.1252). This study was
conducted at an outpatient chronic dialysis program in San Francisco General
Hospital (Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001, p.1252). The
inclusion criteria was that patients were undergoing hemodialysis for at least
3 months and were 18 years old or older (Kalantar-Zadeh, Kopple, Block, &
Humphreys, 2001, p.1252). Three participants did not meet this criterion, so
there was a total of 88 participants eligible to participate in this study,
although two patients were hospitalized in different centers and three
patients did not agree to participate, therefor 83 individuals participated in
the study; 44 men and 39 women were enrolled in this study (KalantarZadeh, Kopple, Block, & Humphreys, 2001, p. 1252). This study combined
the subjective global assessment tool and the dialysis malnutrition score to
create a different assessment and scoring tool known as the malnutrition
inflammation score (Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001,
p.1252). The malnutrition inflammation score attempts to make a more
comprehensive and quantitative scoring system using the components;
weight change, dietary intake, gastrointestinal symptoms, functional
capacity, comorbidity, subcutaneous fat loss, and signs of muscle wasting

(Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001, p. 1252). This


assessment added three more items of criteria to assess, which were, body
mass index, serum albumin levels, and total iron-binding capacity (KalantarZadeh, Kopple, Block, & Humphreys, 2001, p.1252). The scoring of
malnutrition inflammation score ranges from 0 to 30, with malnutrition more
severe as the score increases (Kalantar-Zadeh, Kopple, Block, & Humphreys,
2001, p.1252). A trained physician interviewed all participants and then
anthropometric measurements were performed, the same physician reevaluated the participants to evaluate the degree of reproducibility in the
malnutrition inflammation score test (Kalantar-Zadeh, Kopple, Block, &
Humphreys, 2001, p. 1254). The results of this study indicated that the
malnutrition inflammation score was the largest predictor of prospective
hospitalization for participants compared to the subjective global assessment
and dialysis malnutrition score (Kalantar-Zadeh, Kopple, Block, & Humphreys,
2001, p.1255). The subjective global assessment had a stronger correlation
with skinfold thickness, while the malnutrition inflammation score was
strongly associated with laboratory values, and dialysis malnutrition score
was not strongly associated with any of the assessments conducted
(Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001, p.1255-1256). Overall,
this study concluded that the malnutrition inflammation score assessment is
the best model to use, measuring overall outcome, indices of inflammation,
anthropometric values, and anemia (Kalantar-Zadeh, Kopple, Block, &
Humphreys, 2001, p. 1260). This study indicated that although subjective

global assessment is a beneficial tool to use to assess malnutrition there are


other factors that can indicate malnutrition and inflammation in participants.
Having a reliable way to measure malnutrition in hemodialysis patients
allows researches to research the safest and most effective way to treat
malnutrition. A study conducted to test the effect of nutritional counseling
and support on hemodialysis patients exhibiting anorexia (Molfino, et. al.,
2012, p. 1012). Since anorexia has been reported in approximately 40% of
all hemodialysis patients and since it is one of the leading causes of
malnutrition this study took into account the symptoms of anorexia in their
assessment of the participants (Molfino, et. al., 2012, p. 1012). This study
was conducted to prospectively evaluate whether the correction of
hypophagia might positively influence the clinical outcome of hemodialysis
patients (Molfino, et. al., 2012, p. 1013). The study was conducted at the
Hemodialysis Unit of the Fatenefratelli Isola Tiberina Hospital in Rome
(Molfino, et. al., 2012, p. 1013). The exclusion criteria for this study was the
presence of diseases associated with wasting, the use of hemodialysis for
less than three months, and a body mass index of less than 18.5 kg/m^2 or
greater than 30 kg/m^2 (Molfino, et. al., 2012, p. 1013). 34 patients were
enrolled in the study, all receiving hemodialysis and receiving weekly
injections of erythropoietin (Molfino, et. al., 2012, p. 1013). All of the
participants had their dry weight, eight changes in the previous 6 months,
height, body mass index, fat free mass, fat mass, serum albumin, total
lymphocyte number, C-reactive protein, cholesterol, hemoglobin, hematocrit,

Kt/V, and time on dialysis were assessed at baseline, 12 months and 24


months (Molfino, et. al., 2012, p. 1013). Besides these assessments the
participants were evaluated for presence of anorexia in participants by
evaluating symptoms like meat aversion, taste and smell alterations, nausea
and/or vomiting, and early satiety; participants reporting one or more of
these symptoms were considered to be anorexic (Molfino, et. al., 2012, p.
1013). The participants who were considered anorexic were assigned to a
Registered Dietitian and their dietary intake was assessed using a 3 day food
record every four months, if the participants were in taking less than 30
kcal/kg body weight/day they were given an individualized diet based on
participants specific needs and food preferences (Molfino, et al., 2012, p.
1013). If the participant was still not intaking enough calories or protein they
were put on enteral nutrition to supplement oral intake (Molfino, et al., 2012,
p. 1013). There were 14 anorexic patients in this study, four received
individualized dietary prescriptions and four patients received enteral
nutrition for four months of the study (Molfino, et al., 2012, p. 1013). This
study concluded that nutrition intervention and counseling increased the
participants fat free mass and morbidity did not differ between anorexic and
non-anorexic participants (Molfino, et. al., 2012, p. 1013). This study
indicated that diet intervention and counseling aids in the treatment of
malnutrition in hemodialysis patients, but can nutrition counseling prevent
malnutrition from occurring in hemodialysis patients at risk, another study

measuring the effect of nutrition counseling and education was conducted to


test this.
A study conducted in 2012 studied the effects of dietary counseling
and education on hemodialysis patients who were at risk for developing
osteodystrophy (Karavetian and Ghaddar, 2012, p. 19). This study was
conducted because past studies have shown low adherence to diet in renal
patients (Karavetian and Ghaddar, 2012, p. 19). This was an eight-week
nutritional cluster randomized trial with a double blind design with 122
participants in the study (Karavetian and Ghaddar, 2012, p. 20). The
participants were randomly assigned to three groups; full intervention,
partial intervention, and control (Karavetian and Ghaddar, 2012, p. 20).
Inclusion criteria for this study were stable patients on hemodialysis for at
least three months, were at least 18 years old, Lebanese origin, had full
cognitive, psychiatric, and physical capability for self care and
communication (Karavetian and Ghaddar, 2012, p. 20). The participants
medical data and biochemical parameters, educational level, primary
diagnosis of kidney disease, and co-morbidities were taken before the trial
started along with the participants dietary intake (Karavetian and Ghaddar,
2012, p. 20). The full intervention group received two 20 minute nutrition
sessions a week during the eight week study, games were graded and
discussed during sessions along with the participants monthly laboratory
results (Karavetian and Ghaddar, 2012, p. 21). In the partial intervention
group the participants received study educational games but they were not

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

hospitalization and death (Espahbodi, Khoddad, and Esmaeili, 2014, p.3).


Through this studies limitations it also discussed how the data obtained in
this study could be extrapolated to further research and practice.
A follow up is an important component with any study. The study that
tested a new way to asses malnutrition in hemodialysis patients a 12 month
follow up study was conducted to test the correlation between malnutrition
and hospitalization in hemodialysis patients (Kalantar-Zadeh, Kopple, Block,
& Humphreys, 2001, p. 1260). The major limitation in this study was that
one of the assessments used was not a validated assessment test to
evaluate malnutrition and degree of malnutrition (Kalantar-Zadeh, Kopple,
Block, & Humphreys, 2001, p.1251). Although the malnutrition inflammation
score is based on the subjective global assessment it uses criteria not in the
assessment, including albumin. (Kalantar-Zadeh, Kopple, Block, &
Humphreys, 2001, p.1260). Serum albumin is a strong laboratory indicator
of mortality in hemodialysis patients but it is not always the best indicator of
nutritional status in patients (Kalantar-Zadeh, Kopple, Block, & Humphreys,
2001, p.1260). Although the malnutrition inflammation score did illustrate a
strong correlation with anthropometric values and laboratory indicators it is
not a validated form of malnutrition assessment (Kalantar-Zadeh, Kopple,
Block, & Humphreys, 2001, p.1261). The malnutrition inflammation score
appears to be a more inclusive marker and a reflection of all aspects of
nutrition and inflammation in dialysis patients, it should be re-evaluated to
test for validity and reliability so this assessment can be utilized in further

research and practice (Kalantar-Zadeh, Kopple, Block, & Humphreys, 2001,


p.1261-1262). This study illustrated the complications that can arise in
malnourished hemodialysis patients; it also introduced a different way to
assess malnutrition in this patient population.
The study that examined nutrition intervention had a 12 and 24 month
follow up which strengthened the findings in the study but there we some
limitations as well. The study had a very small study group with only 34
participants enrolled (Molfino, et. al., 2012, p. 1013). There was no
difference in the mortality rates between the anorexic and non-anorexic
groups which indicates that correcting the hypophagia in hemodialysis
patients yet a longer study and follow up period will allow a more definite
conclusion to be reached (Molfino, et. al., 2012, p. 1014).

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:

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