ASSESSMENT OF

NUTRITIONAL STATUS IN
HEMODIALYSIS PATIENTS

Haerani Rasyid
UNIVERSITAS HASANUDDIN
Nutrition Care
Need “Nutrition Care” because …..

In HD process there are

• Peritoneal protein losses
removal of:
average about 5 to 15
• amino acids (about 10 -
g/24 hours,
12 g per HD),
• During episodes of
• some peptides,
peritonitis, dialysate
• low amounts of protein (<
protein may be
1-3 g per dialysis,
considerably higher.
including blood loss),
• Peritoneal amino acid
• and small quantities of
losses average about 3
glucose (about 12 to 25 g
g/d,145 and some
per dialysis if glucose-free
peptides are dialyzed
dialysate is used)

Ko, Gang Je; Obi, Yoshitsugu et al. 2017. Curr Opin Clin Nutr Metab Care
KDOQI Nutrition in Chronic Renal Failure. AJKD. 2000
 Nutrition Care in Haemodialysis patient
• Integrated Renal Care (HD patients)
• Important of Renal Diet ( Diet on HD
patients )
• Nutrition Counseling
• Nutrition Care Process
 How can we do asessment of the
nutrional status ?
- History and physical examination  weight
loss
- Dietary History  Food recall
- Anthropometry
- Biochemical/Laboratory test
- Tools : SGA/MIS
Information needed for evaluation of diet history
Subjective Global Asessment
Modified SGA
M

MIS > 6  Memerlukan intervensi nutrisi

Most useful methods of nutrition assessment
and suggested frequency
 Table 1. Recommended measurements for monitoring nutritional status of chronic hemodialysis (CHD)
patients from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF/KDOQI),
European Best Practice Guidelines (EBPG) on Nutrition and the International Society in
Renal Nutrition and Metabolism (ISRNM)

National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF/KDOQI) [11]
• Measurements that should be performed routinely in all patients: Predialysis serum
albumin, % of usual postdialysis body weight and nPNA, % of standard body weight,
SGA
• Measures that can be useful to confirm or extend the data obtained from the previous
measures: predialysis or stabilized serum prealbumin, skinfold thickness, mid-arm
muscle area circumference, DXA
• Clinically useful measures, which, if low, might suggest the need for a more rigorous
examination of protein-energy nutritional status: predialysis or stabilized serum:
creatinine, urea nitrogen, cholesterol; and creatinine index
EBPG on Nutrition [12]
Malnutrition should be diagnosed by a number of assessment tools including: dietary
assessment, BMI, SGA, anthropometry, nPNA, serum albumin and serum prealbumin,
serum cholesterol and technical investigations of body composition (BIA, DXA, near 13
infrared reactance)
ISRNM [13]
Potential tools (including those still in development) for the clinical diagnosis of
PEW in individuals with CKD. At least three out of the four listed categories (and
at least one test in each of the selected category) must be satisfied for the
diagnosis of kidney disease-related PEW:
• Serum chemistry: serum albumin,serum prealbumin (transthyretin) and serum
cholesterol.
• Body mass: BMI, unintentional weight loss and total body fat percentage
• Muscle mass: muscle mass (reduced muscle mass over time), reduced mid-
arm muscle circumference area, creatinine appearance
• Dietary intake: unintentional low dietary protein and energy intake
Methods of nutritional assessment directed to
elderly on dialysis
 Table 3. Methods of nutritional assessment directed to elderly on dialysis
Method Aim Notes
Comprehensive tools
SGA and MIS Diagnosis of PEW The physical examination, present in SGA and MIS,
requires special attention when performed in the
elderly. Be aware that the elderly often show
increased body fat in the trunk, even though muscle
mass is decreased. In addition, elderly patients often
show more skin, which should not be confounded with
fat or muscle, mainly around arms and below the
eyes. Adding specific questions related to aging (see
questions placed at the end of this table) is of
importance. Both instruments require training to
diminish intra- and inter-individual variation.
MNA Screening and Developed for non-CKD elderly. The short-MNA is a
diagnosis of PEW screening tool, while the full-MNA has an indicator
score of malnutrition. The full-MNA performed better
than the short-MNA form in PD patients [41]. There
are not many studies applying the MNA in elderly
patients on dialysis.
 Table 3. Methods of nutritional assessment directed to elderly on dialysis

Method Aim Notes

Anthropometry
Skinfold Fat mass When pinching the skinfold, one should be careful not
thicknesses assessment to cofound the excess of skin normally present in the
elderly with fat.

Calf Muscle mass One should be alert for the presence of clinical edema
circumference assessment in the legs, a condition that will mislead the
interpretation of this measurement. This measurement
has been well accepted for the assessment of low
muscle mass in non-CKD elderly [42].

Knee height Stature It is of importance to correct for the difference in

measurement stature that occurs with aging. It is suggested to be
used when using an index, such as BMI, as well in
equations, such as for estimating basal metabolic rate,
often used to calculate the energy needs.
 Table 3. Methods of nutritional assessment directed to elderly on dialysis

Method ` Aim Notes

BIA and BIS Muscle mass By using specific equations well accepted for
assessment sarcopenia assessment, skeletal muscle mass can be
estimated [35]. The assessment of lean body mass by
BIA from equations not validated to dialyzed patients
can lead to misleading interpretation. The estimation
of lean body mass by BIS, on the other hand, has
shown better agreement with reference methods in
dialyzed patients. Studies testing the usefulness of
BIS in elderly patients on dialysis are needed.
Measurements should be performed after the
hemodialysis session or with an empty cavity for PD
patients to diminish the influence of hydration status
[43].

Handgrip strength Muscle strength Assessment of muscle function. Well accepted as a

assessment criterion for the diagnosis of sarcopenia and frailty.
 Table 3. Methods of nutritional assessment directed to elderly on dialysis

Method Aim Notes

Dietary intake
24-h food recall, Estimative of Memory loss and blurred vision, conditions often
food registries energy, observed in elderly, can compromise evaluation by
and protein, electrolytes retrospective methods (24-h food record and semi-
semi-quantitative and vitamins intake quantitative food frequency questionnaire).
food frequency Information provided by the patient’s accompanier,
questionnaire including frequency of meals, portion size, food
preferences and aversions, allergies and food
consistency are important to complement the food
intake assessment of elderly.
PNA Protein intake Under a catabolic condition (inflammation, infection
and concurrent comorbidities), the PNA will be higher
than the actual protein intake. It does not provide
information on the quality of the protein and food
habits. Therefore, the usual methods for the
assessment of dietary intake should not be replaced
for PNA.
 Table 3. Methods of nutritional assessment directed to elderly on dialysis

Method Aim Notes

General questions Complement the Questions related to dentition, maladapted dental
related to aging to nutritional proteases, problems in chewing, social and clinical
be assessment condition (low economic income, living alone,
incorporated of elderly limitations to acquiring and preparing food), presence
in the nutritional of comorbidities and use of medications that interfere
assessment form with nutrients absorption should be included in the
nutritional assessment forms of elderly on dialysis.
Unintentional weight loss over a period of 3–6 months
is commonly assessed in non-CKD elderly and is
highly correlated with higher mortality rates [44].
Serum albumin Mortality prognostic Concentration of serum albumin can be affected by
and factor high volume overload, inflammatory process,
pre-albumin comorbidities and by malnutrition. The inverse
relationship of serum albumin and poor outcome has
been described in several papers in the CKD field, but
not in the elderly on dialysis. Studies on elderly non-
CKD showed that serum albumin tends to be lower
than that in younger individuals.
 Periodic Nutritional Assessment & Dietary Counseling
• Dry weight, lab values (serum albumin) & scores (SGA, MIS)
•Dietary counseling and high protein meals during hemodialysis

Start Oral Nutritional Supplementation 1–2

Indications for an Nutritional
Interventions:
• Poor appetite and/or poor oral intake
• Unintential loss of dry weight
• Serum albumin level <4.0 g/dL
• MIS ≥5 or SGA in malnourished range
servings/day:
• Pre-dialysis patients: Moderately low
protein supplement +/- amino acid or
keto-analogs
• Dialysis patients: Moderate to high protein
supplements, including during dialysis Rx

Monthly Assessment
• Monitor nutritional status for
changes in appetite, food
intake, weight status, serum
albumin level and MIS/SGA No Improvement or
Improvement Deterioration

Adjunct Pharmacologic Intensified Therapy or

Maintenance Therapy
• If improving:
continue supplements and
keto-analogues
Therapies Additional Interventions
• Appetite stimulators • Increase quantity of therapy
• Anti-depressant • Tube feeding
• Anti-inflammatory &/or • Parenteral interventions eg
anti-oxidative IDPN (esp. if albumin<3.0
• Anabolic &/or muscle g/dL)
enhancing
Kalantar-Zadeh et al Nature Review , 2011
 Take Home Message
• The nutritional assessment of individuals on
dialysis requires attention to all aspects
• The development of protocols directed to dialysis
patients including methods that enable the
assessment of nutritional status should be
developed and tested in clinical practice
• It is prudent to use the nutritional assessment
tools such as SGA or MIS to diagnose