Assessment of nutritional status in hemodialysis patients
- Shweta Bansal, MD, FASN
Shweta Bansal, MD, FASN
- Associate Professor of Medicine
- Division of Nephrology, UT Health Science Center at San Antonio
- Monique E Cho, MD
Monique E Cho, MD
- Division of Nephrology and Hypertension
- University of Utah School of Medicine
- Srinivasan Beddhu, MD
Srinivasan Beddhu, MD
- Professor of Medicine
- University of Utah School of Medicine
Dialysis patients are commonly depleted of protein and energy stores [1-5]. The degree to which protein and energy depletion is the result of deficient nutrition or, alternatively, protein and energy wasting is unclear. In 2009, the International Society of Renal Nutrition and Metabolism (ISRNM) recommended the terminology protein-energy wasting (PEW) syndrome to describe the loss of body protein mass and fuel reserves in patients with end-stage renal disease (ESRD) .
The assessment of nutritional status is a routine part of the care of maintenance dialysis patients in order to allow early recognition and treatment of PEW syndrome. Markers of PEW are among the strongest predictors of morbidity and mortality in ESRD patients [3,7].
This topic reviews our approach to the assessment of nutritional status among hemodialysis patients. The pathogenesis and treatment of PEW among hemodialysis patients are discussed elsewhere. (See "Pathogenesis and treatment of malnutrition in maintenance hemodialysis patients".)
The assessment of nutritional status and the prevention and treatment of malnutrition among peritoneal dialysis patients are discussed elsewhere. (See "Nutritional status and protein intake in peritoneal dialysis patients".)
OUR APPROACH TO THE CLINICAL ASSESSMENT OF NUTRITIONAL STATUS
We perform monthly nutritional assessments of all hemodialysis patients. Our approach includes a dietary assessment, physical examination, and laboratory examination.
- Thunberg BJ, Swamy AP, Cestero RV. Cross-sectional and longitudinal nutritional measurements in maintenance hemodialysis patients. Am J Clin Nutr 1981; 34:2005.
- Schoenfeld PY, Henry RR, Laird NM, Roxe DM. Assessment of nutritional status of the National Cooperative Dialysis Study population. Kidney Int Suppl 1983; :S80.
- Owen WF Jr, Lew NL, Liu Y, et al. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 1993; 329:1001.
- Aparicio M, Cano N, Chauveau P, et al. Nutritional status of haemodialysis patients: a French national cooperative study. French Study Group for Nutrition in Dialysis. Nephrol Dial Transplant 1999; 14:1679.
- Keshaviah PR, Nolph KD, Moore HL, et al. Lean body mass estimation by creatinine kinetics. J Am Soc Nephrol 1994; 4:1475.
- Fouque D, Kalantar-Zadeh K, Kopple J, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008; 73:391.
- Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15:458.
- Wolfson M. Management of protein and energy intake in dialysis patients. J Am Soc Nephrol 1999; 10:2244.
- Akar H, Akar GC, Carrero JJ, et al. Systemic consequences of poor oral health in chronic kidney disease patients. Clin J Am Soc Nephrol 2011; 6:218.
- Iseki K, Kawazoe N, Fukiyama K. Serum albumin is a strong predictor of death in chronic dialysis patients. Kidney Int 1993; 44:115.
- Kopple JD, Jones MR, Keshaviah PR, et al. A proposed glossary for dialysis kinetics. Am J Kidney Dis 1995; 26:963.
- Salahudeen AK. Obesity and survival on dialysis. Am J Kidney Dis 2003; 41:925.
- Kalantar-Zadeh K, Abbott KC, Salahudeen AK, et al. Survival advantages of obesity in dialysis patients. Am J Clin Nutr 2005; 81:543.
- Stevens J, Nowicki EM. Body mass index and mortality in asian populations: implications for obesity cut-points. Nutr Rev 2003; 61:104.
- Wong JS, Port FK, Hulbert-Shearon TE, et al. Survival advantage in Asian American end-stage renal disease patients. Kidney Int 1999; 55:2515.
- Kalantar-Zadeh K, Kopple JD, Kilpatrick RD, et al. Association of morbid obesity and weight change over time with cardiovascular survival in hemodialysis population. Am J Kidney Dis 2005; 46:489.
- Keys ABJ, Henschel A, Mickelsen O, Taylor HL. The Biology of Human Starvation, University of Minnesota, Minneapolis 1950.
- Beddhu S, Kaysen GA, Yan G, et al. Association of serum albumin and atherosclerosis in chronic hemodialysis patients. Am J Kidney Dis 2002; 40:721.
- Kalantar-Zadeh K, Kilpatrick RD, Kuwae N, et al. Revisiting mortality predictability of serum albumin in the dialysis population: time dependency, longitudinal changes and population-attributable fraction. Nephrol Dial Transplant 2005; 20:1880.
- Kaysen GA, Stevenson FT, Depner TA. Determinants of albumin concentration in hemodialysis patients. Am J Kidney Dis 1997; 29:658.
- Ballmer PE, McNurlan MA, Hulter HN, et al. Chronic metabolic acidosis decreases albumin synthesis and induces negative nitrogen balance in humans. J Clin Invest 1995; 95:39.
- Han DS, Lee SW, Kang SW, et al. Factors affecting low values of serum albumin in CAPD patients. Adv Perit Dial 1996; 12:288.
- Wells FE, Addison GM, Postlethwaite RJ. Albumin analysis in serum of haemodialysis patients: discrepancies between bromocresol purple, bromocresol green and electroimmunoassay. Ann Clin Biochem 1985; 22 ( Pt 3):304.
- Maguire GA, Price CP. Bromcresol purple method for serum albumin gives falsely low values in patients with renal insufficiency. Clin Chim Acta 1986; 155:83.
- Joseph R, Tria L, Mossey RT, et al. Comparison of methods for measuring albumin in peritoneal dialysis and hemodialysis patients. Am J Kidney Dis 1996; 27:566.
- Pinnell AE, Northam BE. New automated dye-binding method for serum albumin determination with bromcresol purple. Clin Chem 1978; 24:80.
- Hakim RM, Levin N. Malnutrition in hemodialysis patients. Am J Kidney Dis 1993; 21:125.
- Panzetta G, Tessitore N, Faccini G, Maschio G. The protein catabolic rate as a measure of protein intake in dialysis patients: usefulness and limits. Nephrol Dial Transplant 1990; 5 Suppl 1:125.
- Lorenzo V, de Bonis E, Rufino M, et al. Caloric rather than protein deficiency predominates in stable chronic haemodialysis patients. Nephrol Dial Transplant 1995; 10:1885.
- Chauveau P, Naret C, Puget J, et al. Adequacy of haemodialysis and nutrition in maintenance haemodialysis patients: clinical evaluation of a new on-line urea monitor. Nephrol Dial Transplant 1996; 11:1568.
- Eknoyan G, Levin NW, Steinberg EP. The dialysis outcomes quality initiative: history, impact, and prospects. Am J Kidney Dis 2000; 35:S69.
- Rationale and methods for the determination of the protein equivalent of nitrogen appearance (PNA). 2000.
- Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987; 11:8.
- Steiber A, Leon JB, Secker D, et al. Multicenter study of the validity and reliability of subjective global assessment in the hemodialysis population. J Ren Nutr 2007; 17:336.
- Cooper BA, Bartlett LH, Aslani A, et al. Validity of subjective global assessment as a nutritional marker in end-stage renal disease. Am J Kidney Dis 2002; 40:126.
- Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol 1996; 7:198.
- Kwon YE, Kee YK, Yoon CY, et al. Change of Nutritional Status Assessed Using Subjective Global Assessment Is Associated With All-Cause Mortality in Incident Dialysis Patients. Medicine (Baltimore) 2016; 95:e2714.
- Pifer TB, McCullough KP, Port FK, et al. Mortality risk in hemodialysis patients and changes in nutritional indicators: DOPPS. Kidney Int 2002; 62:2238.
- Moreau-Gaudry X, Jean G, Genet L, et al. A simple protein-energy wasting score predicts survival in maintenance hemodialysis patients. J Ren Nutr 2014; 24:395.
- Chertow GM, Ackert K, Lew NL, et al. Prealbumin is as important as albumin in the nutritional assessment of hemodialysis patients. Kidney Int 2000; 58:2512.
- Cano N, Di Costanzo-Dufetel J, Calaf R, et al. Prealbumin-retinol-binding-protein-retinol complex in hemodialysis patients. Am J Clin Nutr 1988; 47:664.
- Chertow GM, Goldstein-Fuchs DJ, Lazarus JM, Kaysen GA. Prealbumin, mortality, and cause-specific hospitalization in hemodialysis patients. Kidney Int 2005; 68:2794.
- Kalantar-Zadeh K, Kleiner M, Dunne E, et al. Total iron-binding capacity-estimated transferrin correlates with the nutritional subjective global assessment in hemodialysis patients. Am J Kidney Dis 1998; 31:263.
- Rambod M, Bross R, Zitterkoph J, et al. Association of Malnutrition-Inflammation Score with quality of life and mortality in hemodialysis patients: a 5-year prospective cohort study. Am J Kidney Dis 2009; 53:298.
- Iseki K, Yamazato M, Tozawa M, Takishita S. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int 2002; 61:1887.
- Rich-Edwards JW, Manson JE, Hennekens CH, Buring JE. The primary prevention of coronary heart disease in women. N Engl J Med 1995; 332:1758.
- Lobo RA. Hormones, hormone replacement therapy, and heart disease. In: Cardiovascular Health and Disease in Women, Douglas PS (Ed), Saunders, Philadelphia 1993. p.153.
- Li TY, Rana JS, Manson JE, et al. Obesity as compared with physical activity in predicting risk of coronary heart disease in women. Circulation 2006; 113:499.
- Sanches FM, Avesani CM, Kamimura MA, et al. Waist circumference and visceral fat in CKD: a cross-sectional study. Am J Kidney Dis 2008; 52:66.
- Postorino M, Marino C, Tripepi G, et al. Abdominal obesity and all-cause and cardiovascular mortality in end-stage renal disease. J Am Coll Cardiol 2009; 53:1265.
- Durnin JV, Womersley J. Body fat assessed from total body density and its estimation from skinfold thickness: measurements on 481 men and women aged from 16 to 72 years. Br J Nutr 1974; 32:77.
- Chertow GM. Estimates of body composition as intermediate outcome variables: are DEXA and BIA ready for prime time? J Ren Nutr 1999; 9:138.
- Stall S, Ginsberg NS, Lynn RI, Zabetakis PM. Bioelectrical impedance analysis and dual energy x-ray absorptiometry to monitor nutritional status. Perit Dial Int 1995; 15:S59.
- Erlichman M, Holohan TV. Bone densitometry: patients with end-stage renal disease. Health Technol Assess (Rockv) 1996; :1.
- Woodrow G, Oldroyd B, Smith MA, Turney JH. Measurement of body composition in chronic renal failure: comparison of skinfold anthropometry and bioelectrical impedance with dual energy X-ray absorptiometry. Eur J Clin Nutr 1996; 50:295.
- Kamimura MA, Avesani CM, Cendoroglo M, et al. Comparison of skinfold thicknesses and bioelectrical impedance analysis with dual-energy X-ray absorptiometry for the assessment of body fat in patients on long-term haemodialysis therapy. Nephrol Dial Transplant 2003; 18:101.
- Formica C, Atkinson MG, Nyulasi I, et al. Body composition following hemodialysis: studies using dual-energy X-ray absorptiometry and bioelectrical impedance analysis. Osteoporos Int 1993; 3:192.
- Sjöström L. A computer-tomography based multicompartment body composition technique and anthropometric predictions of lean body mass, total and subcutaneous adipose tissue. Int J Obes 1991; 15 Suppl 2:19.
- Martinson M, Ikizler TA, Morrell G, et al. Associations of body size and body composition with functional ability and quality of life in hemodialysis patients. Clin J Am Soc Nephrol 2014; 9:1082.
- Morrell GR, Ikizler TA, Chen X, et al. Psoas Muscle Cross-sectional Area as a Measure of Whole-body Lean Muscle Mass in Maintenance Hemodialysis Patients. J Ren Nutr 2016; 26:258.
- Isoyama N, Qureshi AR, Avesani CM, et al. Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. Clin J Am Soc Nephrol 2014; 9:1720.
- Vengata SUBRAMANI Manoharan, Jason IJ. Factors affecting hand grip strength and its evaluation: A systemic review. Int J Physiother Res 2015; 3:6.
- OUR APPROACH TO THE CLINICAL ASSESSMENT OF NUTRITIONAL STATUS
- Dietary assessment
- Physical assessment
- Laboratory assessment
- - Serum albumin
- - Urea nitrogen and protein nitrogen appearance
- DIAGNOSIS OF PROTEIN-ENERGY WASTING
- PROPOSED CRITERIA FOR PROTEIN-ENERGY WASTING SYNDROME
- International Society of Renal Nutrition and Metabolism
- Subjective global assessment
- French protein-energy wasting score
- OTHER METHODS
- SUMMARY AND RECOMMENDATIONS