Nutritional status assessement in

chronic kidney disease patients

Dr. Cristian Serafinceanu
Institutul de Diabet, Nutriie i Boli metabolice
N. Paulescu
Bucharest

Nutritional care algorithm (nutritional medical therapy)

for renal patients
Nutritional status assessment:
1 nutritional screening
2 nutritional antecedents
3. nutritional behavior
4. clinical examination

Identification of therapeutic goals:

1. Reasonable
acceptable
2. Negotiable
for own
lifestyle
3. Adjustable

Periodic evaluation:
1. results monitoring - redefining goals
2. solving current problems

Nutritional medical intervention:

1. Diet
2. Nutritional supplements

Nutritional assessment clinic objectives (after

Jeejeebhoy KN et col, 1994, modified)
Significant antecedents:

1.

Physiologic
Pathologic
Therapeutic

Known nutritional problems or deficits

Chronic use of drugs with nutritional effects (i.e. chimiotherapy)
Psycho-social antecedents:

2.
3.
4.

Alcohol or drug abuse

Smoking
Financial and social status
Marital status

Specific signs and symptoms for nutritional deficiencies

Subjective global assessment:

5.
6.

Evaluation of muscular waste

Evaluation of subcutaneous tissue
Presence of oedemas
Dialysis related items

Nutritional screening I
Basal (level I): detection of
nutritional risk factors
-body mass index
-eating habits
-living environment
-functional status

Complete (level II): for

patients at nutritional risk
-history of weight changes (6
mo)
-mid-arm circumference
-triceps skinfold
-mid-arm muscle area
-serum albumin
-total plasma cholesterol
-clinical features
-drug prescriptions
-mental/cognitive status

Reference values for classifying severity

of malnutrition in body mass index (BMI)
Age

BMI

Malnutrition

>= 18 years

<16
16 16,9
17 18,5
>= 18,6

Severe
Moderate
Mild
Normal

14 17 years

<16,5

Present

11 13 years

<15

Present

Nutritional screening II
Eating habits (topics)
-not have to eat enough (each day)
-usually eats alone
-poor appetite
-special (restrictive) diets
-does not eat vegetables, fruit or milk at least once
daily
-difficulties in chewing or swallowing
-more than two alcoholic drinks per day (one for
women)
-has pain in mouth , teeth or gums

Nutritional screening III

Living environment

-poor income
-lives alone
-housebound
-is unable (or prefers not) to spend money on food

Nutritional screening IV
Functional status - needs assistance
(usually or always) with:
-bathing
-dressing
-toileting (grooming)
-eating (preparing food)
-walking (traveling)
-shopping (for food)

Nutritional screening V- reference values for

anthropometric measurements in adults
(adapted from Hammond KA et col, 2004)
Target
population

Mid-arm
circumference
(MAC)

Triceps
skinfold
(TS)

Mid-arm
muscle area
(MAMA)

Females 30-40y

28.6

24.2

32.4

Females 60-70y

31.7

14.5

35.4

Males 30-40y

31.9

13

55.8

Males 60-70y

32.8

14.2

51

Nutritional screening VI
Clinical features and mental/cognitive status:
-evident problems with mouth, teeth, gums
-difficulties with chewing
-angular stomatitis
-glossitis
-skin lesions (dry, loose, wounds, etc.)
-history of bone fractures
-clinical evidence of mental status impairment
-depressive illness (Geriatric Depression Scale, etc.)

Nutritional history and detection of deficiency

syndromes I
Mechanism

Inadequate intake

Inadequate
absorption

History of

Suspected
deficiency

Alcohol abuse

Protein, vitamins B

Avoidance of fruits,
vegetables

Vitamin C, folates,
vitamins B

Avoidance of meat ,
eggs

Protein, vitamin B12

Habitual
constipation

Dietary fibre

Poverty, isolation

Energy, protein

Drugs (antacids,
laxatives,
anticonvulsivants)

Various nutrients

Nutritional history and detection of deficiency

syndromes II
Mechanism

Inadequate
absorption

History of

Suspected
deficiency

Malabsorption (diarrhea,
weight loss, steatorrhea)

Liposoluble
vitamins (A,D,E,K),
energy, protein

Parasites
Pernicious anemia

Iron, vitamin, B12

Gastro-intestinal surgery

Decreased
utilization

Drugs (anticonvulsivants,
antimetabolites,
isoniazide)
Inborn errors of
metabolism

Various

Nutritional history and detection of deficiency

syndromes III
Mechanism

Increased losses

History of

Suspected
deficiency

Alcohol abuse

Magnesium, zinc

Blood loss

Iron

Centesis (ascitic,
pleural)

Protein

Uncontrolled
diabetes mellitus

Energy, protein

Diarrhea

Protein, electrolytes

Nephrotic syndrome

Protein

Dialysis

Protein, vitamins
(water soluble)

Nutritional history and detection of deficiency

syndromes IV
Mechanism

Increased
requirements

History of

Suspected
deficiency

Fever,
hyperthyroidism

Energy

Physiologic
demands
(adolescence,
pregnancy, lactation)

Energy, various
nutrients

Surgery, burns,
trauma

Energy, protein,
vitamin C

Infection, hypoxia

Energy

Smoking

Vitamin C, folates

Clinical nutrition examination (Adapted

from Mahan LK, 2004) I
Organ/
system

Nutritional deficiency

Non-nutritional
association

essential fats, vit.A

environmental

hyperpigmentation of
sunlight exposed areas

niacin or tryptophan

chemical burns,
Addisons disease

pallor

iron, vit B12

hemorrhage,
pigmentation disorders

Petechiae,
ecchymoses

Vit K, C

Liver disease, aspirin

overdose

nails

spoon-shaped

iron

pulmonary or heart
chronic disease

hair

lack of shine, easy

pluckable

proteins, Zn, linoleic acid

hypothyroidism,
chemotherapy,
psoriasis

Abnormal finding
dry, scaly

Skin

Clinical nutrition examination (Adapted

from Mahan LK, 2004) II
Organ/system

Abnormal finding

Nutritional
deficiency

Non-nutritional
association

eyes

dry, grayish, night

blindness

Vit A

Gauchers disease

lips

bilateral (angular
stomatitis) or
vertical cracks
(cheilosis)

Vit B2, B6, niacin

dentures problems,
herpes, syphilis,
AIDS

tongue

magenta, loss of
papillae, swollen

Vit B2

Crohndisease,
bacterial or fungal
infections

Vit. C

Drugs (dilantin),
lymphoma,
thrombocytopenia,
aging, poor dental
hygiene

Protein deficiency

Tumors,
hyperparathyroidis
m

gums

spongy, bleeding,
receding

parotid glands

Bilateral
enlargement

Nutritional status assessement

Methods to assess protein and energy status
Protein stores
visceral

somatic

Salb
Sprealb
Stransf
Ret. bind. prot.
IGF-1

Other methods
SGA
Anthropometry
BIA
Nitrogen balance
Densitometry
Creat. Kinetics
Isotope studies
DEXA
NMR
others

Energy balance
expenditure

balance

Markers of visceral protein status I

Parameter

Normal Plasmatic
range
life (d)
(g/l)

Normal
function

Nutritional
significance

Albumin

35-45

18-20

Coloid-osmotic
pressure

late malnutrition marker

Transferrin

2.6-4.3

8-9

plasma iron
carrier

malnutrition (more
early) marker; negative
inflammation marker

Prealbumin
(transthyretin)

0.2-0.4

2-3

Thyroid
hormones
transporter

Malnutrition (early
marker); acute
hypercatabolic states

Rhetynol
binding
protein (RBP)

0.37

0.5 (12h)

Pro-vitamin A
transporter

Proteic intake
markerhypercatabolic
states

Insulin-like
growth factor
1 (IGF 1)

0.55-1.4
UI/ml

2-6 h

Anabolic growth
factor

Immediate proteic
intake marker

Markers of visceral protein status II

Method

Advantages

Disadvantages

Clinical application

Serum albumin

Redily avalable
Inexpensive
Good outcome predictor

Late marker
Influenced by: extracellular
volume, inflammation, renal
function

Screening
Longitudinal evaluation

Serum prealbumin

Readily available
Inexpensive
Excellent outcome predictor
Can detect early changes

Influenced by renal function,

inflammation
No evidence based data

Screening
Longitudinal evaluation

Serum transferrin

Readily available
Inexpensive
Excellent outcome predictor
Can detect early changes

Influenced by iron stores,

inflammation
No evidence based data

Diagnosis or screening
Clinical or research

Retinol-binding protein

Short half-life (can detect early

changes)

Limited availability, expensive

Influenced by renal function,
inflammation
Decreased by hypertiroidism
and vit. A defficiency

Diagnosis or screening
Clinical or research

Serum IGF-1

Good association with other

markers
Very short half-life

Limited availability, expensive

Acute influenced by dietary
intake
No evidence based data

Diagnosis or screening
Clinical or research

Subjective Global Assessment (from Detsky AS, McLaughlin JR,

Baker JP, Johnston N, Whittaker S, 1987, What is subjective global
assessment, Journal of American Medical Association 271:54-58)
1. Weight Change
Maximum body weight _______________
Weight 6 months ago _______________
Current weight

% Wt change

wt 6 months ago current wt

100
wt 6 mos ago

_______________

Overall weight loss in past 6 months _______________

Percent weight loss in past 6 months _______________
Change in past weeks: _______increase

_______no change

________decrease

2. Dietary Intake (relative to normal)

_________ No change

Duration: __________ Weeks

_________Change

Type: __________ Increased intake

__________ Suboptimal solid diet
__________ Full liquid diet
__________ IV or hypocaloric liquids
__________ Starvation

3. Gastrointestinal Symptoms (lasting >2 weeks)

__________ None
__________ Nausea

__________ Vomiting

____________ Diarrhea

___________ Anorexia

Subjective Global Assessment II ( from Detsky AS, McLaughlin JR,

Baker JP, Johnston N, Whittaker S, 1987, What is subjective global
assessment, Journal of American Medical Association 271:54-58)
4. Functional Capacity
___________ NO dysfunction
___________ Dysfunction

Duration: ____________ weeks

Type: ____________ Works suboptimally
____________ Ambulatory
____________ Bedridden

PHYSICAL EXAMINATION
(For each trait specify: 0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe)
__________ Loss of subcutaneous fat (shoulders, triceps, chest, hands)
__________ Muscle wasting (quadriceps, deltoids)
__________ Ankle edema
__________ Ascites

SUBJECTIVE GLOBAL ASSESSMENT RATING (select one)

__________ A = well nourished
__________ B = moderately (or suspected of being) malnourished
__________ C = severely malnourished

Modified SGA score for chronic kidney

disease patients
Parameter
/score

Weight
no
changes/6 mo

5%

5-10%

10-15%

15%

Dietary intake
changes/ 6
mo

no

Suboptimal
solid food

Moderate
global
decrease

Liquid/hypocalor
ic diet

starvation

Digestive
symptoms

no

nausea

Vomiting/other
moderate

Frequent
diarrhea/vomitin
g

Anorexia

Functional
status

Good/normal
for age

Walking
difficulty

Usual efforts
difficulty
(housekeeping)

Minimal efforts
difficulty
(toileting)

Bedriding

Comorbidities*

No

mild

moderate

1 severe

Multiple,
severe

Dialysis
duration**

Less than 12
mo, RRF

Less than 12
mo, no RRF

12-24 mo, RRF

24-48 mo, RRF

More than 48
mo

**: absence of RRF translates the score in the superior class

Modified SGA score for chronic kidney

disease patients-contd
Malnutrition:
-absent: 0 4
-mild:
58
-moderate: 9 14
-severe: 15 -24

Anthropometric assessment of nutritional

status
1.

Reference values for classifying nutritional

deficits in weight - for - height (after Torm B,
Chen F, 1994, modified)

Weight - for - height ratio = actual body

weight/reference weight for height (RWH)
RWH = 50+0,75(H-150)+(Age-20)/4
Normal: 90-110%
Mild deficit: 80-89%
Moderate deficit: 70-79%
Severe deficit: <70% (or with oedemas)

Anthropometric assessment of
nutritional status II
2. Body mass index (BMI, Quetelet index)
3. Tricipital skinfold (TS)
4. Mid-arm circumference (MAC)
5.Mid-arm muscular area (MAMA)
(MAC - TS)2/12.56

All anthropometric measurements must be interpreted for age, sex, race

Biochemical assessment of nutritional status

Indication = patients with significant risk of malnutrition after
nutritional history and physical examination (SGA).
Aim = to detect specific nutritional deficiencies before onset of
clinic or anthropometric manifestations.
Protein status: central for the prevention, diagnosis and treatment of
malnutrition:

1.

Bi - compartmental pattern (of evaluation):

Metabolic active proteins (30 50%)

Muscle (somatic) proteins (75%)

Visceral proteins (25%)

Metabolic inactive proteins (50 70%):

Bones, joints

2.

Iron status.

3.

Calcium and phosphorus status.

4.

Vitamins status.

Protein metabolism status assessment I

a.

Nitrogen balance = ratio between the amount of

nitrogen consumed as proteins and the amount
excreted by the body.

The expected value for healthy adults is 1 the rate of

proteins synthesis (anabolism) equals the rate of protein
degradation (catabolism)
Formula: PRO(g)/6,25 = UUN(g) 4(g), where:
PRO: protein ingestion/24h(g)
6,25: protein nitrogen index
UUN: urinary urea nitrogen/24h (g)
4(g): constant for non urea nitrogen + non urinary
nitrogen (stool, sweat)

Disequilibrium of nitrogen balance need dietary and/or

non dietary correction (i.e.: increased losses in critically
ill patients).

Protein metabolism status assessment II

b.

Somatic protein status

Lean body mass assessment (muscle mass) can

be estimated by the 24h urinary creatinine excretion
comparing with a standard (expected) excretion
based on height

Urinary creatinin excretion:

Is a constant on ideal weight:
23 mg/Kgc/day in men
18 mg/Kgc/day in women

Its variation is exclusively determined by height (see

standards in table)

Expected 24 hour urinary creatinine values for

height in adults (after Blackburn GL, Bistrian
BR, Maini BS et al, 1977)
Males

Females

Height (cm)

Urinary creatinine
/24h (mg)

Height (cm)

Urinary creatinine
/24h (mg)

160

1325

150

851

165

1386

155

900

170

1467

160

950

180

1642

165

1001

185

1739

170

1076

190

1831

175

1141