Nutritional Status , Dietary Practices and Biochemical Parameters of Hemodialysis Patients in Riyadh

Background: Malnutrition is an evident problem in 40-50% of patients with end-stage renal disease (ESRD). Aim: The aim of the present study was to assess the nutritional status and dietary practices of maintenance hemodialysis patients at Prince Salman Center for Kidney Diseases in Riyadh (PSCKD). Subjects and methods: A cross-sectional study was conducted in (PSCKD) for 120 hemodialysis patients who agreed to participate in the study. Malnutrition score was used to quantify the degree of malnutrition. Two parameters from anthropometric and clinical manifestation data were used. Dietary practice score was measured . Results: the data showed that 79.2% of cases had normal nutritional status, while only 6.7% had moderate malnutritional status. Only 18.3% of them had good dietary practices while 65% had fair level. In patients with normal nutritional status, the body mass index (BMI) (29.57±10.34 vs. 17.19±1.80), mean weight (70.38±15.98 vs. 48.04±9.66), dry weight (68.537±15.55 vs.46.188±7.93), mean albumin (35.50±3.63 vs. 35.07±4.06) and low density cholesterol (1.94±1.10vs1.25±0.52) were significantly higher than in moderately malnourished patients. In patients with normal nutritional status, the mean body height (154.67±9.47vs. 162.63±9.87), mean urea level (64.16±18.65 vs. 67.14±22.90) and mean creatinine level (750.94±271vs.926.63±358.79) were significantly lower than in moderately malnourished patients. Patient' age, marital status were significant predictors for nutritional status. Patients aged > 50 years had 8 times the chance to develop malnutrition compared to those < 50 years. Single patients had 11 times the chance of getting malnutrition compared to married. These differences were statistically significant. (OR=8.213, 11.158, P=0.014, 0.011) respectively. Conclusion: Patient and nutrition education must be employed to hemodialysis for recommended dietary needs and for follow up of biochemical parameters.


INTRODUCTION
End-stage renal disease (ESRD) is a major health problem worldwide nowadays.
Conventional hemodialysis (HD) is the most widely used modality physiologic treatment. ( HD will continue to be by far the most widely used treatment for patients with acute renal failure and ESRD. ( When dialysis therapy is started, the uremic symptoms are reduced, the diet is less restricted and some patients may show improved nutritional status. (6)However, the results of cross sectional studies throughout the world indicate that maintenance HD patients are still at risk of malnutrition. (5)This could be due to the losses of nutrients into dialysate, chronic blood loss, inflammation and associated diseases.(7)   The aim of the present study was to assess the nutritional status and dietary practices of all patients with chronic renal failure on maintenance hemodialysis attending the Prince Salman Center for Kidney Diseases in Riyadh.

Subjects and methods:
A cross sectional study was conducted for assessment of the nutritional status and dietary practices of patients of end stage renal disease on maintenance hemodialysis.

Study setting:
The present study was carried out in the Prince Salman Center for Kidney Diseases, Riyadh, Saudi Arabia.

Target population:
The study was conducted on all adult patients, of both sexes, with chronic renal failure who were treated with maintenance hemodialysis.

Sampling design:
All adult patients with chronic renal failure, who were attending Prince Salman Center for Kidney Diseases at Riyadh, for receiving The questionnaire included the following items: 1. Personal characteristics: These included questions about age, sex, marital status and level of education.

Statistical analysis:
The following analyses were performed: Malnutrition score: was used to quantify the degree of malnutrition.Two parameters from anthropometric and clinical manifestation data were used.Each parameter was given score ranged from 3-6.    and in Egypt 2001(10.4%). (15)In the current work, 14.1% of patients suffered from mild malnutrition, which is less than that found in the Egyptian study 2001 (22.9%). (15)While patients with moderate malnutrition, in the present study, were 6.7% which is much lower than that found in the Egyptian study in 2001 (35.4%). (15)Desbrow et al., (2005) found that 20% of the patients were malnourished. (13)On the other hand, Tayem et al., (2008) found that approximately 62% of the participants were malnourished.
The adequate nutrients intake could be attributed to nutrition supervision and counseling, is an important factor, as in the present study, 66.7% of the patients stated that they are following dietary regimen.In addition to the importance of dietary knowledge, 96.7% of the patients mentioned that they have got dietary knowledge.On the other hand, Basaleem et al., (2004) found that only 14% of the studied patients got satisfactory level of knowledge and 58% of them did not follow clear dietary instructions and there was evident poor intake of high dietary protein. ( The present study revealed that mean length, weight, dry (post dialysis) weight of males were significantly higher than females, table 3.This result coincides with that of Basaleem et al., (2004). (16)In the current study, the mean length among patients with normal nutritional status was significantly lower than in moderately malnourished patients.This result is in agreement with that of Basaleem et al., (2004). (16)The results of the present study points out that urea and The results of cross sectional studies indicated that patients on maintenance HD are at risk of malnutrition, (19,20) that is why identification of factors associated with more risk of malnutrition in HD patients are of great importance as they were the predictors of malnutrition in those patients. (21)the most common factors that have been associated with malnutrition in HD are old age.(18,20,22,23 (   The present study shows that 32.73% of patients aged ≥50 years had mild and moderate malnutrition which was significantly higher than those aged <50 years (10.77%).
Moreover, age was the first predictor of malnutrition in stepwise multiple regression analysis and patients aged ≥50 years were 8 times more liable to malnutrition than patients <50 years.Similarly, the results of Basaleem   et al., (2004) study showed that the risk of moderate/severe malnutrition was four times significantly higher among those aged >50 than their younger counterparts.(16)   Other studies revealed that duration of dialysis was significantly correlated with malnutrition score (24) and it was one of its predictors.(15, 24)   Similarly, in the present study mean duration of hemodialysis increased with malnutrition but not to a significant level.
The present study pointed out that interdialytic weight gain (IDWG) decreased with malnutrition but not to a significant level.
On the other hand, other study done in Egypt showed that IDWG (> 2 kg) showed about seven times significant higher risk of malnutrition. (15)Also in Basaleem study, stepwise multiple regression analysis showed that IDWG was the only associating factor with moderate/ severe malnutrition, as those with (> 2 kg) Interdialytic weight gain were 20 times more likely to be moderately/ severely malnourished. (16) Hypoalbuminemia is another problem correlated with malnutrition.It is also a major risk factor for morbidity and mortality dialysis patients. (25)In the present study, serum albumin showed statistically significant difference between the three groups of nutritional status, with the highest mean observed among patients with normal nutritional status, which was significantly slightly different from moderately malnourished patients.Many studies detected low serum albumin level associated with malnutrition in HD patients, and it was proportional to the degree of malnutrition.
(15, 24,26) Although, low mean serum albumin (37±4.5g/l)and low BMI (24.4±5.3) were found to be independent predictors of mortality among HD patients in USA according United State renal data system.(27)   Abnormalities in lipid metabolism are documented in patients with chronic renal failure and patients on dialysis, (28) where high levels of cholesterol (> 250 mg/dl) have been associated with an increased risk of death among HD patients.Therefore, patients with elevated blood cholesterol may benefit from lipid-modifying interventions. ( Both cholesterol and triglycerides levels can be higher in HD patients than healthy people, however; if those patients were malnourished cholesterol level is more likely to be decreased than normal and in proportion to malnutrition grades. (31)In the present study, the mean low density cholesterol level was low among patient with different grades of malnutrition.On the other hand, the mean of total cholesterol was non-significantly higher among malnourished than well-nourished patients.
These are in agreement with the results of a study done in Egypt. (15)Hyperlipidemia is frequently present in chronic HD patients and Bull High Inst Public Health Vol.41 No. 2 [2011]   it is contributing to the presence of cardiovascular diseases (CVD) commonly seen in these patients. ( However hypertension may be an equally important contributing factor. (32,33)This is in agreement with the results of the present study, where hypertension was mentioned as the most common cause of renal failure, and 11.7% of the patients were on CVD diet (Table 2).
Patients on dialysis reduce their energy intake, with significant increase in carbohydrate fraction and decrease in protein and fat fractions, which will also place those patients in the risk zone for developing malnutrition. (34)In the present study the recommended energy requirements was nonsignificantly higher among malnourished patients than normally nourished patients.On the other hand, the recommended protein requirements were non-significantly lower among malnourished patients than normally nourished patients.Reduction of protein intake in patients with chronic renal failure found to correct uremic symptoms, slow rate of progression of renal failure and make these patients more favorable for treatment with HD or transplantation as their nutritional status being preserved. ( The reduction or increase of micronutrients intake and blood levels found in the present study can be related to certain health problems.The increased sodium intake increases the risk of hypertension and cardiovascular diseases. (36)In the present study 50.8%-90.8% of the patients did not use certain food containing sodium.However, the sodium level was significantly higher among moderately malnourished patients (Table 10).
The potassium level was non-significantly lower among moderately malnourished than normally nourished patients (Table 10).The importance of decreased potassium intake is to minimize the risk of metabolic acidosis.(37)   In the present study were not supplemented with either iron or calcium and about two thirds had antacid, whereas 58% did not take vitamin supplement. (16)

CONCLUSION AND RECOMMENDATION
The majority of cases (79.2%) had normal nutritional status, while only 6.7% of them had moderate malnutritional status.Only 18.3% of them had good dietary practices while 65% of them had fair level.In patients with normal hemodialysis treatment and accepted to participate in the study were included in the present work.The total sample amounted to Al-Muammar & Fetohy 221 120 patients.Data were collected from every patient and recorded in predesigned interview questionnaire,
nutritional status, BMI, mean weight, dry weight, mean albumin and low density cholesterol were significantly higher among patients with normal nutritional status than in moderately malnourished patients.In patients with normal nutritional status, the mean length, urea and mean creatinine levels were significantly lower than in moderately malnourished patients.Age of the patients and patients' marital status were significant predictors for nutritional status.Patients aged > 50 years had 8 times the chance to develop malnutrition compared to those < 50 years.Single patients had 11 times the chance of getting malnutrition compared to married.Patient and nutrition education must be employed to hemodialysis for recommended dietary needs and for follow up of biochemical parameters.

Table 1 : Distribution of the hemodialysis patients according to their Sociodemographic characteristics Sociodemographic characteristics No.=120 No %
1. Anthropometric parameter: it was BMI, in this parameter a score of (3) was given when

Table 2 : Distribution of the hemodialysis patients according to the cause of renal failure and type of diets
* Patients had more than one cause, percentage calculated from number in parenthesis.

Table 10 .
The results show that 225.8% of the patients took vitamins, 78.3% of them

Stepwise multiple logistic regression between nutritional status and different factors of the studied patients
On the other hand, this could explain the prescription of antacids to patients on HD, in order to reduce serum phosphate, as 33.3% of patients in the present study stated that they take antacids.The results of the current study showed that 225.8% of patients took vitamins, 78.3% of them took iron and 47.8% took calcium.In contrast, 76% and 60% of patients in the Basaleem study