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Saudi J Kidney Dis Transpl 2011;22(4):675-681

2011 Saudi Center for Organ Transplantation

Saudi Journal
of Kidney Diseases
and Transplantation

Original Article
Nutritional Assessment of Patients on Hemodialysis in a Large
Dialysis Center
Khalid Al Saran, Sameh Elsayed, Azeb Molhem, Areej AlDrees, Huda AlZara
Prince Salman Center for Kidney Diseases, Riyadh Saudi Arabia
ABSTRACT. Management of the nutritional aspects of chronic kidney disease (CKD) presents a
number of challenges. This study was performed to assess the nutritional status among patients on
maintenance hemodialysis at the Prince Salman Center for Kidney Diseases, Riyadh, Saudi Arabia.
The study included 200 patients with a mean age of 50 16 years; there were 108 males (54%)
and 92 females (46%). Nutritional assessment was made by the Subjective Global Assessment
(SGA) score. In the present study, 4% of the patients were found to be underweight, 49% had
average weight, 27.5% were overweight, 14% were obese, and 5.5% had morbid obesity. Severe
malnutrition by SGA significantly correlated with duration on dialysis, functional capacity, and
associated co-morbid diseases. The number of patients included in this study was small and we
recommend multi-center studies with a larger number of patients for better evaluation. Also, we
recommend a survival trial to evaluate the relationship between low serum albumin and patient
survival in the Saudi population.
Introduction
Management of the nutritional aspects of patients with chronic kidney disease (CKD) presents a number of challenges. Malnutrition can
occur in up to 40% of the patients with renal
failure, and is associated with increased mortality and morbidity. Most of the standard methods used for assessing nutritional status can
be applied to patients with renal failure, although
some of these parameters may get altered by
Correspondence to
Dr. Khalid Al Saran,
Prince Salman Center for Kidney Diseases,
P.O. Box 52948, Riyadh 11573, Saudi Arabia
E-mail: Khalid_al@hotmail.com

uremia.1 Currently, it is widely believed that

wasting and malnutrition are no longer prevalent in patients undergoing maintenance dialysis. However, there is evidence suggesting
that many factors that promote malnutrition in
renal failure persist even with modern methods
of dialysis treatment. There is no single measurement that can be used to determine or
exclude the presence of malnutrition. Therefore,
a panel of measurements is recommended,
including measurement of body composition,
measurement of dietary protein intake, and at
least one measure of serum protein status.2,3
Aim of the Study
The purpose of nutritional screening in hemo-

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676

Al Saran K, Elsayed S, Molhem A, AlDrees A, AlZara H

dialysis (HD) patients is to predict the probability for a better or worse outcome due to
nutritional factors and to determine the prevalence of nutritional disorders (malnutrition,
overweight, and obesity) per facility standards.
Additionally, it helps to examine interventions
that can be used to manage malnutrition and
obesity, share experiences, concerns, and solutions to the problems in the management of
nutritional disorders in Saudi patients.
Methodology
The subjects included in this cross-sectional
study were patients on chronic HD at the Prince
Salman Center for Kidney Diseases (PSCKD),
Riyadh city, a center that is well equipped for
dialysis, either peritoneal dialysis (PD) or HD,
and can cater to up to 600 patients with ESRD.
The study was performed during the period
from September 2007 to September 2008, and
included 200 patients with a mean age of 50
16 years; there were 108 males (54%) and 92
females (46%). Patients who were hospitalized
for more than two weeks for a non-vascular
access complication or had signs of active infection were excluded from the study. All enrolled patients should have completed a minimum of six months duration on HD in our
center. All subjects were evaluated and examined by two physicians and two registered
dietitians. A complete medical history, including details of the patients diet and physical
examination, and recording of the dry body
weight was performed. The baseline laboratory
tests included serum protein and albumin, fasting lipid profile [total cholesterol, triglycerides, high-density lipoprotein (HDL) and lowdensity lipoprotein (LDL)], serum creatinine,
serum calcium and phosphorus, white blood
cell count, fasting glucose, HbA1c, and preand post-dialysis blood urea nitrogen (BUN) to
determine normalized protein catabolic ratio
(nPCR) and urea kinetics by single pool Kt/v.
The nutritional state was assessed using the
Subjective Global Assessment (SGA) score that
was originally developed to assess post-operative nutritional state. The SGA comprises of
five criteria, and includes weight loss in the

preceding six months, gastro-intestinal tract

(GIT) symptoms such as anorexia, nausea, vomiting, and diarrhea, the type of dietary food
intake, functional capacity of the patients, and
associated co-morbidities. Physical examination in SGA includes three items: loss of subcutaneous fat over the triceps and mid-axillary
line of lateral chest wall, muscle wasting in the
deltoid and quadriceps, and the presence of
ankle edema and/or ascites. The patients were
classified into normal, mild to moderate, or
severely malnourished. The total lymphocytic
count (TLC) was calculated using the following
equation: TLC = (% lymphocytes WBC)/100;
TLC less than 900 indicates severe depletion,
9001500 is moderate, and 15001800 is mild
depletion. The cause of chronic renal failure
included the following: diabetic nephropathy in
82 patients (41%), hypertension in 40 patients
(20%), chronic glomerulonephritis in 12 patients (6%), hypoplastic kidney in 4%, lupus
nephritis in 3%, unknown etiology in 22%, obstructive uropathy in 2%, and tubulo-interstitial
nephritis and contrast nephropathy in 1% each.
All patients received four-hours HD per session,
thrice-weekly, using bicarbonate-buffered dialysate and polysulfone dialyzer membranes.
Statistical analysis was performed using SPSS
software (Statistical Package for Social Science,
version 14, SPSS Inc., Chicago, IL, USA). All
values are expressed as mean SD, and P
<0.05 was considered statistically significant.
Optimal protein and energy intake
There is no metabolic or pathological reason
for not giving a standard energy intake to
stable adults on maintenance dialysis. Indeed,
their metabolic needs, based on resting energy
expenditure, are similar to those of normal
adults, i.e. 35 kcal/kg body weight/day. Energy
balance studies, mainly in PD patients, confirmed that a positive nitrogen balance could
only be attained with energy intakes >30
kcal/kg/day.4 Although a level of 0.70.8 g of
protein/kg body weight (BW) may be sufficient to permit a neutral nitrogen balance in a
pre-dialysis-stable adult, the dialysis procedure
itself increases protein demands. The Dialysis
Outcome Quality Initiative (DOQI) guidelines

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Nutritional assessment of HD patients

677

Table 1. Recommended nutritional parameters in patients with different stages of chronic kidney disease and
those of hemodialysis and peritoneal dialysis.
Nutritional
Stages 1-4 CKD
Stage-5 (Hemodialysis)
Stage-5 (Peritoneal Dialysis)
Parameter
Calories
35 (< 60 yrs)
35 (< 60 yrs)
35 (< 60 yrs)
(kcal/kg/d)
30-35 ( 60 yrs)
30-35 ( 60 yrs)
30-35 ( 60 yrs), include kcals
from dialysate
Protein (g/kg/day)
0.6-0.75
1.2
1.2-1.3
Fat (% total kcal)
For patients at risk for CVD, <10% saturated fat, 250-300 mg cholesterol/day
Sodium (mg/day)
2000
2000
2000
Potassium (mg/day)
Match to lab values
2000-3000
3000-4000
Calcium (mg/day)
1200
2000 from diet and meds
2000 from diet and meds
Phosphorus
Match to lab values
800-1000
800-1000
(mg/day)
Fluid (mL/day)
Unrestricted w/normal
1000 + urine
Monitor; 1500-2000
urine output

in nutrition have proposed that, based on nitrogen studies in HD and PD patients, a minimum
of 1.2 g in HD and 1.3 g of protein/kg BW in
PD represent the minimum daily intake to ensure
a neutral protein balance. Half of this intake
should be made-up by proteins of high biological value from animal origin, e.g. meat, fish,
or dairy products.5 The current K/DOQI guidelines 2007 divide patients into five stages, based
on decreasing glomerular filtration rate (GFR).
In stage-5, when patients are receiving dialysis, increased protein intake is suggested
(approx. 1.2 g/kg/day).1
Table 1 represents the recommended nutritional parameters according to the stage of CKD
and the type of dialysis, either HD or PD. These
are initial guidelines; individualization to patients own metabolic status and co-existing metabolic conditions is essential for optimal care.1

Results
The 200 HD patients in this study included
108 males and 92 females with a mean age of
50 16 years. Subjects in this study had a
mean single pooled Kt/v of 1.4 0.15 and a
mean nPCR of 1.13 0.2. Tables 2 and 3 show
the demographic data of the studied population. Table 4 shows the relationship between
body mass index (BMI) and gender. In the present study, 4% of the patients was underweight,
49% had average weight, 27.5% were overweight, 14% were obese, and 5.5% had morbid
obesity. Regarding diet changes, 89% had minimal or no change in their diet, while 9% had
mild to moderate decrease in their diet. Subjective Global Assessment (SGA) classified
patients into normal in 68%, mild to moderately malnourished in 24%, and severely mal-

Table 2. Demographic and laboratory findings in the study patients.

Min.
Max.
Age/years
18
82
Body Mass Index
15.5
45
nProtein Catabolic Rate
0.7
1.86
Kt/v
0.97
1.9
Dialysis Duration (month)
6
300
Calcium (mmol/L)
1.85
2.6
Phosphorus (mmol/L)
0.7
2.6
Cholesterol (mmol/L)
2.3
7
Triglyceride (mmol/L)
0.4
5.8
High density lipoprotein (mmol/L)
0.4
3
Total protein (g/L)
47
87
Albumin (g/L)
22
43
Lymphocytic count
1570
3890

Mean
50
25.2
1.13
1.4
23.4
2.25
1.5
4.6
1.9
0.96
69.7
34
1820

Std. deviat
16
5.5
0.06
0.15
3.9
0.16
0.4
0.87
0.96
0.3
8.7
4.4
752

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678

Al Saran K, Elsayed S, Molhem A, AlDrees A, AlZara H

Table 3. Body mass index in the study patients.

BMI
Male
Female
Total
<18.5
3.5%
0.5%
4%
18.524.9
29%
20%
49%
2530
16.5%
11%
27.5%
30.535
4.5%
9.5%
14%
>35.5
0.5%
5%
5.5%
BMI: body mass index

nourished in 8%. Severe malnutrition by SGA

sig-nificantly correlated with male sex, (P =
0.04). The mean duration on dialysis was 23
months, and ranged from six to 300 months.
The co-morbid diseases in the study patients
were viral hepatitis, either B or C, in 26%, cardiovascular diseases in 13%, central nervous
system disorders in 8%, GIT diseases in 3.5%,
malignancy in 3%, collagen diseases (SLE,
scleroderma) in 3%, and chronic respiratory
diseases (bronchial asthma, bronchiectasis) in
4% of the patients. Severe malnutrition by SGA
significantly correlated with duration on dialysis, functional capacity, associated comorbid
diseases, and nPCR. The total cholesterol level
correlated significantly with serum albumin
level, patients age, and presence of diabetes
mellitus (DM) and ischemic heart disease
(IHD).
Discussion
The reported prevalence of chronic renal
failure in the Kingdom of Saudi Arabia is 80
to 120 per million population (pmp).6 Malnutrition is present in approximately 40% of the
patients treated with maintenance HD.7 The
NKF-K/DOQI Clinical Practice Guidelines for
nutrition in patients on maintenance dialysis
and for evaluation of proteinenergy malnutrition and nutritional status recommended assessment with a combination of valid, and complementary, measures rather than any single
measure alone as malnutrition may be identified with greater sensitivity and specificity
using a combination of factors.8,9 Nut-ritional
assessment ideally should be used to determine the nutritional requirements for all patients taking into account their nutritional and
metabolic status, and should be used to monitor

Table 4. Demographic findings regarding smoking

habit and presence of diabetes mellitus, hypertension, and ischemic heart disease.
%
Number of
patients
Smoking
33
16.5
Diabetes mellitus
88
44
Hypertension
162
81
Ischemic heart disease
54
27

the patients progress and any alteration in

requirements. In addition, nutritional assessment should be able to identify groups of patients at risk from the effects of malnutrition.
Finally, the parameters used for assessment
should be simple, yet effective, and readily
available in any hospital.10 Because of the complexity of the nutritional management of CKD
patients, registered dietitians should be consulted, especially for nutritional counseling of the
patients. Physicians and other clinical personnel
should also strongly encourage dietary compliance of the patients because dietary adherence can determine outcomes in CKD.11
Serum albumin concentration, even when only
slightly less than 4.0 g/dL, is one of the most
important markers of protein energy malnutrition (PEM) in patients with CKD. It is a very
reliable indicator of visceral protein, although
its concentration is also affected by its rate of
synthesis and catabolism (half-life 20 days),
which is altered negatively in the presence of
inflammation.12,13 Hypoalbuminemia is highly
predictive of future mortality risk when present at the time of initiation of chronic dialysis
as well as during the course of maintenance
dialysis.13 The increased mortality with hypoalbuminemia, which is seen in 6067% of the
patients on maintenance HD,14 appears to occur
even at a near-normal albumin level (35 g/L).
However, the risk is greater with more severe
hypoalbuminemia, being greatest in patients
with a plasma albumin concentration below 30
g/L.13,15 Our results support previous results of
Nabil Akash and his colleagues in 1999,16 which
state that among Saudi HD patients, despite
efficient dialysis prescription indicated by mean
Kt/v of 1.4 0.15, the mean serum albumin
level is low (mean 34 4 g/L).

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Nutritional assessment of HD patients

Despite their clinical utility, serum protein

levels (e.g., albumin, transferrin, and pre-albumin) may be insensitive to changes in nutritional status, do not necessarily correlate with
changes in other nutritional parameters, and
can be influenced by non-nutritional factors.17
The height and weight allow calculation of
the body mass index (BMI) and its classification into normal range (2025), obesity (>30),
borderline underweight (18.520), and severe
underweight (<18.5/m2).18 It is recommended
that the BMI of maintenance dialysis patients
be maintained in the upper 50th percentile for
normal individuals, which would mean a BMI
for men and women not lower than approximately 23.624.0 kg/m2. This recommendation
also appears appropriate for patients with CKD
with significant reduction in glomerular filtration rate (GFR) (stages 35).19 In the present
study, it was observed that 47% of the patients
were either overweight or obese, and 4% were
underweight. Five percent of women in the
studied population had morbid obesity, which
could be attributed to hormonal factors or,
possibly, lack of physical activity among women in the Saudi society, and warrant further
studies. Additionally, although renal transplantation offers an overall better quality of life
compared with HD, severe obesity with BMI
greater than 35 kg/m2 is associated with wound
infection, multisystem organ failure, and increased transplantation costs, and can also result in a delay in transplantation.20
Serum cholesterol is an independent predictor
of mortality in patients on maintenance HD.
The relationship between serum cholesterol
and mortality has been described as either Ushaped or J-shaped, with increasing risk for
mortality as the serum cholesterol rises above
the 200300 mg/dL range or falls below
approximately 200 mg/dL.21 The mortality risk
in most studies appears to increase progressively as the serum cholesterol decreases to, or
below, the normal range for healthy adults
(<200 mg/dL). Pre-dialysis serum cholesterol
is generally reported to exhibit a high degree
of co-linearity with other nutritional markers
such as albumin, pre-albumin, and creatinine,
as well as age.22,23 Our results are supported by

679

the findings of Cano et al, 1988 and Avram et

al, 1995.24
Patients on maintenance HD have normal
energy expenditure and approximately normal
requirements for maintenance of protein balance, body weight, and body fat. An average
energy intake of about 38 kcal/kg/day may be
necessary to maintain nitrogen balance in these
patients.25 The protein catabolic rate (PCR),
also called the protein equivalent of nitrogen
appearance (PNA), is the parameter used in
most HD units to assess dietary protein intake
in patients who are in a steady state. Increased
mortality was observed with a nPNA of less
than 0.8 or greater than 1.4 g/kg per day, while
the best survival was noted with levels between 1.0 and 1.4 g/kg per day.26 It is recommended that a minimal nPCR, not less than 0.8
g/kg per day, but a target of 1.01.2 g/kg per
day or higher, is recommended.27 Our results
support previous studies, and indicate adequate
protein intake in our patients as the mean
nPCR was 1.13 0.06.
It is well known that malnutrition leads to a
decline in immune function. The TLC is a clinical measure of immune function that is often
used in nutritional assessment. TLC is an indicator of immune function that reflects both B
cells and T cells. TLC is increased with infection and leukemia, and decreased following
surgery, and in chronic disease states. Because
TLC is not specific to nutritional status, it is
not useful for assessment of a hospitalized
patient.28 In our study, we could not demonstrate any correlation between TLC and any
other variants related to nutritional state.
SGA is a clinical evaluation of proteinenergy malnutrition (PEM) based on evidence of
edema, ascites, muscle wasting, subcutaneous
fat loss, changes in functional capacity, and
gastrointestinal symptoms of diarrhea, nausea,
vomiting. This tool has also been studied for
use in assessing patients on dialysis.29 Based
on the results of this history and physical
assessment, patients can be placed into nutritional risk categories of well nourished, mildly
to moderately malnourished, or severely malnourished.30 Moreover, the SGA has been validated prospectively in both uremic and non-

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Al Saran K, Elsayed S, Molhem A, AlDrees A, AlZara H

uremic patient populations, and also predicts

the likelihood of complications and poor outcome, allowing implementation of preventive
interventions. Studies by McCann, 1996, Chertow et al, 1997, and Kalantar et al, 1999, support our results regarding the correlation of
SGA with impaired functional capacity and
associated co-morbid diseases.31-33

7.

8.

9.

Limitations of the Study and

Recommendations
This study was performed in a tertiary
referral center for HD. Thus, the patient sample may not represent the typical HD population seen in the Saudi Kingdom. Also, the
number of patients included in this study was
small and we recommend multi-center studies
with a larger number of patients for better evaluation. Also, we recommend a survival trial to
evaluate the relationship between low serum
albumin and patient survival in the Saudi population.
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