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Year : 2015  |  Volume : 18  |  Issue : 5  |  Page : 8-11

Prevalence of malnutrition in chronic kidney disease: A study of patients in a tertiary Hospital in Nigeria

1 Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Medicine, National Hospital, Abuja, Nigeria
3 Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria

Date of Web Publication19-Jan-2015

Correspondence Address:
H M Liman
FMCP, Department of Medicine, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1118-8561.149496

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Background: The nutritional status of patients with chronic kidney disease is an important determinant of the morbidity and mortality associated with the disease. Materials and Methods: We studied the baseline nutritional status of 62 patients with chronic kidney disease using several parameters. Nutritional status was assessed using Subjective global assessment (SGA), weight change over six months of follow up, body mass index (BMI), triceps skin fold thickness (TSF), mid upper arm circumference (MUAC) and serum albumin. Data obtained was analyzed using EPIINFO version 6.04. Nutritional status of patients on haemodialysis was compared with those who are yet to commence haemodialysis. Results: Malnutrition was observed in 54.8% of the patients studied based on SGA criteria, 41.9% based on weight loss over six months, 48.4% based on MUAC, 17.7% based on BMI, 85.5% based on TSF, 24.2% based on serum albumin and 69.4% based on two or more criteria. The prevalence of malnutrition in patients who have commenced haemodialysis was significantly higher when assessed using weight change over 6 months. The incidence of malnutrition in our patients with chronic kidney disease is high, especially in patients on haemodialysis. Conclusions: Efforts at detecting early malnutrition, as well as correcting factors associated with it are recommended.

Keywords: Chronic kidney disease, haemodialysis, malnutrition, prevalence

How to cite this article:
Liman H M, Anteyi E A, Oviasu E. Prevalence of malnutrition in chronic kidney disease: A study of patients in a tertiary Hospital in Nigeria. Sahel Med J 2015;18, Suppl S1:8-11

How to cite this URL:
Liman H M, Anteyi E A, Oviasu E. Prevalence of malnutrition in chronic kidney disease: A study of patients in a tertiary Hospital in Nigeria. Sahel Med J [serial online] 2015 [cited 2024 Feb 23];18, Suppl S1:8-11. Available from: https://www.smjonline.org/text.asp?2015/18/5/8/149496

  Introduction Top

Many of the major medical problems of public health importance, including chronic kidney disease, have either a nutritional basis or at least an important nutritional contribution.

There is a general consensus that there is no single marker of nutritional status in patients with chronic kidney disease, and therefore several nutritional markers should be evaluated together. [1],[2],[3] The assessment of nutritional status is based on clinical, biophysical and biochemical parameters. Clinical assessment of subcutaneous fat, muscle mass and history of weight loss are important parts of routine nutritional assessment. Most studies have used body mass index (BMI), skin fold thickness, mid arm circumference and mid-arm muscle circumference to assess patient's nutritional status. [3],[4],[5],[6],[7]

The most commonly used laboratory parameters for routine assessment of nutritional status are plasma concentrations of albumin, transferrin, and other liver-derived proteins. 3 In recent years, subjective global assessment of nutritional status (SGA) has been used increasingly to assess nutritional status in many studies of dialysis patients and in patients with chronic kidney disease at start of dialysis therapy. [8],[9],[10] SGA correlates well with other nutritional markers in patients with chronic renal disease. [8],[9],[10]

It is generally recommended that a nutritional assessment including a nutritional care plan should be performed not later than 1-2 weeks after the start of dialysis, and should thereafter be repeated periodically. [11],[12],[13],[14]

In Nigeria, there is paucity of data on the nutritional status of patients with chronic kidney disease. This study was therefore carried out with the objective of assessing the prevalence of malnutrition using multiple parameters in patients with chronic kidney disease.

  Materials and Methods Top

The study population was made up of patients diagnosed to have chronic kidney disease (serum creatinine persistently greater than 1.7 mg/dl or 150 μmol/l, for 3 or more months) attending the renal unit of the National Hospital, Abuja. It included both patients enrolled into haemodialysis programme and patients who are yet to commence dialysis. The research was a prospective observational study.

Sixty two consecutive patients who met the criteria for chronic kidney disease were recruited. A total of 51 patients were on haemodialysis. The remaining 11 patients were recruited prior to initiation of haemodialysis.

Patients on peritoneal dialysis, patients with Nephrotic syndrome, recent peritonitis (less than 4 months), malignancy and infectious diseases (tuberculosis, HIV), patients under 18 years of age and patients on steroid therapy were excluded from the study. Approval for the study was obtained from the Ethical Committee of the National Hospital, Abuja.

A questionnaire was designed to record the demographic characteristics of the study group, subjective global assessment, anthropometric parameters (BMI, mid-upper arm circumference, and skin fold thickness) and biochemical nutritional parameter (serum albumin). Triceps skin fold thickness was measured with Harpenden skinfold caliper. Each patient was followed up for a period of 6 months in order to assess the weight loss over the period. At the end of the six months, all the parameters were assessed twice, and the mean was recorded.

Specimen collection

Blood samples were taken on two occasions after an overnight fast from an ante-cubital vein, on a non-dialysis day, for the assessment of serum albumin. For patients on haemodialysis, pre dialysis sample was taken. The average serum albumin was used for the analysis.

Laboratory analysis

The serum albumin was analyzed using a Hitachi 747 Autoanalyzer. Malnutrition in this study was considered in patients with two or more of the following indices of malnutrition: [15]

  • Overall subjective global assessment score of B or C
  • Weight loss > 10% during last 6 months
  • BMI < 20
  • Triceps skin fold thickness <5 th percentile (less than 10mm in males and 13 mm in females)
  • Serum albumin < 30g/L
  • Mid upper arm circumference less than 22 cm in females and 25 cm in males.

Statistical analysis

Data obtained was analyzed using EPIINFO version 6.04. Descriptive statistics such as means and ranges of variables of interest were computed. Comparison of means was done using student's t-test. Comparison of percentages or proportions was done by the use of Chi-square test. All tests of statistical significance were 2-sided, with a P < 0.05 considered to be significant.

  Results Top

Socio-demographic variables

Of the 62 patients studied, 71% were males (n = 44) with a mean age of 45.2 + 11.2 years (range 18-65 years), with chronic kidney disease being more common in the 45-59 years age group, n = 29 (46.8%).

Weight loss

Using weight loss as a criterion, [Table 1] shows that 25 (49%) patients on haemodialysis had significant weight loss during the study period compared to only one dialysis naïve patient (9.1%).
Table 1: Distribution of malnourished patients by indices of nutrition

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Mid upper arm circumference

Overall, 26 (51%) patients on haemodialysis were malnourished while 4 (34.4%) dialysis naïve patients were malnourished using the mid upper arm circumference as a criterion, as shown in [Table 1].

Body mass index

[Table 1] also shows that a total of 11 dialysis patients (17.7% of all patients) were classified as being malnourished using the body mass index as a criterion. No dialysis naïve patient was malnourished by body mass index criterion.

Triceps skin fold thickness

[Table 1] shows that a total of 53 (85.5%) patients were malnourished using the triceps skin fold as a criterion.

Serum albumin

Using serum albumin as a criterion, a total of 15 (24.2%) patients had serum albumin <30g/L. Fourteen (93.3%) of these patients were on haemodialysis.

Nutritional status by SGA criteria

Out of 51 patients on haemodialysis, 20 (39.2%) were well nourished, 30 (58.8%) were moderately malnourished and one patient (2%) was severely malnourished. Out of 11 dialysis naïve patients, 8 (72.7%) were well nourished, while 3 (27.3%) were moderately malnourished. No dialysis naïve patient was rated as severely malnourished by SGA criterion. Overall, 33 (53.2%) patients were rated as being moderately malnourished and only one patient (1.6%) was severely malnourished by SGA criterion.

Two or more criteria

Using two or more nutritional parameters to classify patients as being malnourished, this study identified a total of 43 patients (69.4%) as being malnourished. Out of these, 38 patients (88.4%) were on haemodialysis.

Of all the indices of malnutrition, only weight loss showed a significant difference between the CKD patients on haemodialysis and those who are yet to commence dialysis (49% vs 9.1%; P = 0.0185).

  Discussion Top

In this study, chronic kidney disease is more common in patients in the 45 to 59 years age group (mean 45 + 11.2 years). CKD therefore occurs at an earlier age compared to the findings reported in the United States with an average age of 63 years [16] Malnutrition is a common problem in chronic kidney disease patients as seen in this study in which 54.8% of the patients were rated as being malnourished using SGA as a criteria. This result compares with similar studies that have shown high incidence of malnutrition ranging from 24% to 74% in CKD patients. [17],[18],[19],[20],[21],[22]

However, out of all the nutritional indices assessed in this study, it is only weight loss over a period of six months that has shown significant difference between chronic kidney disease patients on conservative treatment and those on haemodialysis. Al Saran and his colleagues reported that moderate malnutrition was seen in 24% of patients with chronic kidney disease in their study done in Saudi Arabian patients using SGA as a nutritional evaluation tool. Severe malnutrition was also seen in 8% of the chronic kidney patients in the same study. [10]

Al Saran and his colleagues similarly reported malnutrition of only 4% of the patients using BMI as a nutritional assessment tool. [10 This is in sharp contrast to 17.7% as seen in our study. Agaba et al. also reported a malnutrition prevalence rate of 21.6% using BMI in a sample of chronic kidney patients who are yet to commence dialysis in Jos, Nigeria. [23]

In the same study, Agaba et al. reported a malnutrition prevalence rate of 43.2% using serum Albumin as a nutritional assessment tool. This contrasts with our study which reported a prevalence rate of 24.2%. [23]

Several reasons have been suggested as possible causes of malnutrition in patients with chronic kidney disease. These include inadequate dietary intake of calories and protein as well as increased catabolism of protein from chronic inflammation. [24],[25],[26],[27] Malnutrition is associated with poor quality of life, impaired immune defense mechanism, as well as poor clinical outcomes. [5],[25]

In conclusion, this study showed that malnutrition is a common problem in our patients with chronic kidney disease. This is particularly so in patients on haemodialysis. The prevalence however varies according to the nutritional parameter utilized. We hereby recommend that the assessment of nutritional status should be part of routine evaluation of all CKD patients.

  References Top

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Kondrup J, Allison SP, Elia M, et al. ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:0415-21.  Back to cited text no. 2
Kopple JD. National Kidney Foundation K/DOQI Clinical Practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 2001;37:S66-70.  Back to cited text no. 3
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De Mutsert R, Snidjer MB, Van Der Sman-de Beer F, et al Association between body mass index and mortality is similar in the haemodialysis population and the general population at high age and equal duration of follow-up. J Am Soc Nephrol 2007;18:967-74.  Back to cited text no. 6
Cano NJ, Roth H, Aparicio M, et al Malnutrition in haemodialysis diabetic patients: Evaluation and prognostic influence. Kidney Int 2002;62:593-601.  Back to cited text no. 7
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Laws RA, Tapsell LC and Kelly J. Nutritional Status and its relationship to quality of life in a sample of chronic haemodialysis patients. Journal of Renal Nutrition 2000;3:139-47.  Back to cited text no. 9
Al Saran K, Elsayed S, Molhem A, Al Drees, Al Zara H. Nutritional assessment of patients on Haemodialysis in a large Dialysis Center. Saudi J Kidney Transpl 2011;22:675-81.  Back to cited text no. 10
Localetti F, Fouque D. Nutritional status in dialysis patients: A European consensus. Nephrol Dial Transplant 2002;17:563-72.  Back to cited text no. 11
Fouque D, Vennegoor M, ter Wee P, et al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007; 22 Suppl 2: ii45-ii87.  Back to cited text no. 12
Cano NJ, Miolane-Debouit M, Leger J, et al. Assessment of body protein: Energy status in chronic kidney disease. Semin Nephrol 2009;29:59-66.  Back to cited text no. 13
Mitch WE. Malnutrition: A frequent misdiagnosis for haemodialysis patients. J Clin Invest 2002;110:437-9.  Back to cited text no. 14
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Gelber RP, Kurth T, Kausz AT, et al. Association between body mass index and CKD in apparently healthy men. Am J Kidney Dis 2005;46:871-0.  Back to cited text no. 16
Shaheen FA, Al-Khadeer AA. Preventive strategies of renal failure in the Arab World. Saudi Centre for Organ Transplantation, Riyadh, Kingdom of Saudi Arabia. Kidney Int 2005;Suppl:S37-40.  Back to cited text no. 17
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Agaba E.I. and Agaba P.A. Prevalence of malnutrition in Nigerians with chronic renal failure. Int J Urol and Nephr 2004;36:89-93.  Back to cited text no. 23
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Kaysen GA, Dubin JA, Muller HG, et al. Inflammation and reduced albumin synthesis associated with stable decline in haemodialysis patients. Kidney Int 2004;65:1408-15.  Back to cited text no. 26
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