ORIGINAL RESEARCH

HYDRATION AND NUTRITIONAL STATUS IN PATIENTS ON

HOME-DIALYSIS—A SINGLE CENTRE STUDY

1
Janet S.C. Li , John Y.H. Chan1, Mandy M.Y. Tai2, So M. Wong2, S.M. Pang1, Fanny Y.F. Lam1, Carmen H.M. Chu1,
Chris S.Y. Ching , Joseph H.S. Wong1, W.L. Chak1
1
1
Renal Unit, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
2
Central Nursing Division, Queen Elizabeth Hospital, Hong Kong

Li J.S.C., Chan J.Y.H., Tai M.M.Y., Wong S.M., Pang S.M., Lam F.Y.F., Chu C.H.M., Ching C.S.Y., Wong J.H.S., Chak W.L. (2018).
Hydration and nutritional status in patients on home-dialysis—A single centre study. Journal of Renal Care XX(XX),1–10.
SUMMARY
Background: Over-hydration (OH) and malnutrition are prevalent among patients on dialysis therapy. The prevalence of OH
and malnutrition as well as the risk factors associated with OH and malnutrition in our patients on home peritoneal dialysis
(PD) and home haemodialysis (HD) are examined.
Design and Methods: This was a cross-sectional study. The hydration and nutritional status of the study groups were
assessed by a Body Composition Monitor. Patients who were stable on home dialysis therapy for over one year were invited
to participate. Univariate and multivariate analyses were performed to identify associated factors and determine the
predictors of OH and malnutrition, respectively.
Results: Eighty-eight patients (41 PD and 47 home HD) were recruited. A 32.95% of our patients on home dialysis therapy
were in OH status. There was a significance difference in the prevalence of hydration status between patients on PD and
home HD (p = 0.014), as overhydration was more common in patients on PD than home HD (46.34 vs. 21.28%).
Dehydration was more common in patients on home HD than PD (29.79 vs. 9.76%). Male gender, decreasing haemoglobin
level and presence of diabetes mellitus (DM) were risk factors of OH on multivariable analysis. There was no significance
difference in the prevalence of malnutrition between patients on PD and home HD (p = 0.27). Increasing Fat Tissue Index
(FTI), height and patients on PD therapy were at higher risk of malnutrition.
Conclusion: OH and malnutrition were prevalent patients on home dialysis therapy.

K E Y W O R D S Haemodialysis
Home therapies
Nutrition/malnutrition
Peritoneal dialysis
Treatment outcomes

INTRODUCTION based dialysis treatments. Standard PD treatment includes both

Over-hydration (OH) and protein energy malnutrition (PEM)
are prevalent among patients receiving dialysis. Both home
Peritoneal Dialysis (PD) and home Haemodialysis (HD) are home
BIODATA
Janet was the Nurse Consultant in Renal
Care of Queen Elizabeth Hospital, Hong
Kong (HK) before her retirement in 2016.
She had been working in different renal
centres in HK and Toronto, Canada since
1983. The focus of her current study is
on the care of Home Dialysis patients.
CORRESPONDENCE
Janet S.C. Li,
Renal Unit, Department of Medicine,
Queen Elizabeth Hospital, Hong Kong
Tel: +1 852 3506 6506
Fax: +1 852 3506 6517
Email: liscj001@gmail.com
Continuous Ambulatory Peritoneal Dialysis (CAPD) and Auto-
mated Peritoneal Dialysis (APD). In our centre, the standard CAPD
regimen is to perform dialysis exchange manually 3–5 times a day
with a dialysis dose of 6–8 l per 24 hours. For APD therapy, the
exchange of dialysis fluid is carried out by an automated machine
while asleep at night with a dialysis dose of about 10–12 l in 8–10
hours. Some patients may require additional day dwell if their
adequacy of dialysis cannot achieve the target Kt/v 1.7. In Hong
Kong, the standard treatment for home HD is to perform HD on
alternate days for 6–8 hours preferably at night. In this study, we
ascertain the hydration and nutritional status of the stable home
dialysis population (home HD and PD) in Hong Kong by using
the Body Composition Monitor (BCM) and examine the possible
risk factors associated with OH and malnutrition on home dialysis
therapy.
LITERATURE REVIEW
Previous studies demonstrated that OH and PEM were strong
predictors of mortality in patients on PD and HD (CANUSA
Peritoneal Dialysis Study Group 1996; Combe et al. 2001; Segall

© 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association Journal of Renal Care 2018 1
 Li et al.
et al. 2009; Zoccali et al. 2017). There are not many studies to
assess the hydration and nutritional status of the patients on
home HD. Recently, body composition analysis by bio-imped-
ance spectroscopy using BCM for assessment of hydration and
nutritional status has been introduced into clinical practice
providing an invaluable tool to assess fluid status of patients on
dialysis (Dumler & Kilates 2003; Van Biesen et al. 2011;
Antlanger et al. 2013; Guo et al. 2013; Kwan et al. 2014).
The use of BCM to assess the hydration status in clinical setting is
practical, safe and with high validity (Dumler & Kilates 2003;
Broers et al. 2014; Fresenius Medical Care 2015). The monitor
measures bio-impedance at 50 frequencies between 5 and
1000 kHz. The measurement is analysed by a bio-impedance
spectroscopy of the body composition from which Extracellular
water (ECW) and Total Body Water are obtained.
The BCM also provides several objective indicators to determine
the patient’s nutritional condition (Dumler & Kilates 2000;
Combe et al. 2001; Rosenberger et al. 2014): The Lean Tissue
Index (LTI) is the quotient from Lean Tissue Mass (LTM) and
height2. LTM ¼ the body massAdipose Tissue Mass (ATM). The
Fat Tissue Index (FTI) is the quotient from ATM and height2.
Together with the LTI information, BCM permits an assessment
of the patient’s nutritional condition.
METHODS
STUDY DESIGN
This was a single centre cross sectional study examining the
prevalence of OH and malnutrition of stable patients on home
dialysis therapy in our centre. The possible risk factors that might
lead to OH and malnutrition were investigated, and the
association between hydration and nutritional status of the
patients on home dialysis were tested.
SETTING AND SUBJECT RECRUITMENT
The study was carried out in a renal centre of a tertiary hospital in
Hong Kong between June and October 2015. The renal centre has
around 400 patients who have received a kidney transplant, 125
patients undergoing PD, 80 patients on in-centre HD and 50
patients on home HD each year. The age range is 20–85 years of age.
INCLUSION CRITERIA OF PATIENTS
All prevalent patients undergoing PD (n ¼ 87) and home HD
(n ¼ 48) who had been stable on dialysis therapy for over one
year in our centre were included.
2 Journal of Renal Care 2018 © 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association
EXCLUSION CRITERIA OF PATIENTS
Patients who had (a) undergone any surgery; (b) history of
inflammatory disease; (c) medical illness that required hospital
admission in the past six months before BCM measurement, or
implanted with (d) a pacemaker, (e) defibrillators, or (f)
amputees, were excluded.
ASSESSMENT TOOL
A Body Composition Monitor (Fresenius Medical Care) was used
to assess the hydration and nutritional status of the patients.
Reference ranges for the expected normo-hydrated tissue
conditions were derived from a reference population of 1000
healthy subjects between 17 and 75 years with a BMI between
18 and 35 kg/m2 (Fresenius Medical Care 2015). The reference
ranges were defined by the 10th and 90th percentiles of the
reference population and were specific to the same age and
gender of the subject with the reference population. In this
study, we defined normohydration as OH within 1.0 to 1.0 l of
the reference range. Below or above the range would be
classified as OH and dehydration, respectively. Malnutrition was
thus defined as an LTI below 10th percentile of the reference
range.
BCM MEASUREMENT
BCM measurement were performed by renal nurses or trained
patient care assistants. They were trained and competent in
using the BCM. A checklist was used to standardise the
procedures including patient’s preparation and electrode
placement of the measurement. As previous studies have
demonstrated, the presence of peritoneal fluid in patients
undergoing PD has insignificant effects on BCM measurement
(Arkouche et al. 1997; Cooper et al. 2000; Biesen et al. 2011;
Parmentier et al. 2013), so the PD fluid was not drained before
BCM measurement was performed, but the body weight of the
patient was corrected for PD fluid volume. For patients on home
HD, the BCM measurement was done on the post-HD treatment
day.
DATA COLLECTION
Relevant clinical and demographic information (age, gender,
body weight, height) were retrieved from the patient’s hospital
record. Social data included mode of living, mode of treatment
support (carer), Comprehensive Social Security Assistance
(CSSA) status were also collected. Clinical information including:
mode of dialysis (MOD), month on home dialysis (MOHD),
serum albumin level (ALB), haemoglobin (Hb) level,

erythropoietin (EPO) treatment data were also collected.
Patients’ co-morbidities including history of diabetes mellitus
(DM), cardiovascular disease (CAVD), cerebral vascular disease
(CEVD), polycystic Kidney disease (PKD), malignancy and
hepatitis status were also collected.
STATISTICAL METHODS
Data on continuous variables were expressed as mean  SD.
Categorical variables were expressed as absolute numbers and
percentages. Chi-square test was used for testing association
between categorical variables and independent-samples t test
was used for testing the difference in means between groups. It
was calculated that 32 samples would be required for the study
if the estimated effect size was 0.5 with degree of freedom
(df) ¼ 1, 80% power at 5% level of significance by Chi-square
test. General linear model (GLM) and logistic regression were
used to determine the risk factors associated with OH and
malnutrition. Significant factors with a p value  0.2 in
univariate analysis were entered into multivariable analysis
models to test for their significance. The multivariable regression
model was built using backward exclusion. Validity of the model
was checked by examining its residuals (GLM) and Hosmer–
Lemeshow goodness of fit test (Logistic regression). Data
analysis was carried out by SPSS for window 21.0. All p-values
were two tailed. p < 0.05 was considered statistically significant.
ETHICAL CONSIDERATIONS
The study was approved by the Research Ethics Committee of
the Queen Elizabeth Hospital, Hong Kong on 25th Febru-
ary 2015 (Ref: KC/KE-15-0021/ER-6). All participants were
required to sign a written consent and they could have
withdrawn from the study at any time. Data were collected
from the patient’s hospital record by designated researchers.
RESULTS
Eighty-eight patients undergoing home dialysis (M/F: 52/36)
with a mean age of 55.64 years were recruited into the study.
Among the 88 patients, 41 patients (46.59%) were undergoing
home PD therapy whereas 47 patients (53.41%) were on home
HD therapy. The mean length of time on dialysis was 36.89
months. Patient demographic and clinical data by different
groups of hydration and nutritional status are shown in Table 1.
Almost one-third (n ¼ 29) of the patients on home dialysis were
in OH status; 20% (n ¼ 18) of the study population had
dehydration whereas 47% (n ¼ 41) had normo-hydration. For
© 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association
HYDRATION AND NUTRITIONAL STATUS IN PATIENTS ON
HOME-DIALYSIS—A SINGLE CENTRE STUDY
nutritional status, 28.41% (n ¼ 25) of the patients had
malnutrition and 71.59% (n ¼ 63) had normal nutrition.
The prevalence of hydration and nutritional status by the mode
of dialysis were shown in Table 2. 46.34% (95% CI for p:
31.08%, 61.61%) of patients on PD (n ¼ 19) and 21.28% (95%
CI for p: 9.58%, 32.98%) of patients on HD (n ¼ 10) were found
to have OH, respectively. On the contrary, 29.79% of patients on
HD (n ¼ 14) suffered from dehydration compared with 9.76% of
patients on PD (n ¼ 4). The mean hydration score (OH) was
þ0.95L  1.43 (95% CI for m: 0.51, 1.39) in PD and
0.33L  1.75 (95% CI for m: 0.83, 0.17) in HD group. A
significant association between the mode of dialysis and
hydration status (p ¼ 0.014) was demonstrated. For nutritional
status, 28.41% of our home dialysis cohort had malnutrition
(34.15% [95% CI for p: 19.63%, 48.66%] PD [n ¼ 14], 23.40%
[95% CI for p: 11.3%, 35.51%] HD [n ¼ 11]). The mean lean
tissue index (LTI) was 13.08  2.83 (95% CI for m: 12.21, 13.95)
and 15.53  3.24 (95% CI for m: 14.60, 16.46) in PD and HD
groups, respectively. No significant association between nutri-
tional status and the mode of dialysis (p ¼ 0.27) but a significant
difference in LTI between PD and HD (p < 0.001) were
demonstrated.
The association between hydration and nutritional status is
shown in Table 3. Forty-eight percent of the malnourished
patients had OH compared with 26.98% of patients with
normal nutritional status (p ¼ 0.08). The mean hydration score
(OH) was 1.16 l in the malnutrition group compared with
0.09 l in the normal nutrition group. There was also a trend
of lowerLTI in the overhydrated patients (m ¼ 13.69) compared
with normally hydrated patients (m ¼ 14.11) and dehydrated
patients (m ¼ 16.13), the difference was statistically significant
between overhydrated and dehydrated patients (p ¼ 0.007),
as well as between the normal and dehydrated patients
(p ¼ 0.04).
The risk factors that have demonstrated an association between
patient characteristic and hydration score (OH) using the general
linear model (GLM) is shown in Table 4. On multivariable GLM
analysis, malnutrition (p ¼ 0.02), reducing haemoglobin level
(p ¼ 0.04), decreasing serum albumin level (p ¼ 0.014) and
CSSA recipient (p ¼ 0.03) were the only identified variables that
had a significant effect on a higher hydration score (OH). Mean
OH score of patients on CSSA and with malnutrition was on
average 0.88 and 0.83 l higher than those not on CSSA and with
Journal of Renal Care 2018 3
 4
Frequency (%) or Mean  SD
Overall Hydration Over-hydration Normal Dehydration Malnutrition Normal
Li et al.

Variable (n ¼ 88) score (n ¼ 29) (n ¼ 41) (n ¼ 18) LTI (n ¼ 25) (n ¼ 63)

Age (year) 55.64  14.51 NA 57.24  16.67 55.12  13.53 54.22  13.46 NA 55.16  15.32 55.83  14.30
Gender
Male 52 (59.09%) 0.31  1.96 21 (40.38%) 19 (36.54%) 12 (23.08%) 15.50  3.28 19 (36.54%) 33 (63.46%)
Female 36 (40.91%) 0.20  1.32 8 (22.22%) 22 (61.11%) 6 (16.67%) 12.77  2.55 6 (16.67%) 30 (83.33%)
BW (kg) 63.14  13.65 NA 63.50  12.41 59.24  12.96 71.46  13.96 NA 63.22  14.62 63.11  13.37

Journal of Renal Care 2018

Height (cm) 164.30  8.83 NA 164.66  8.97 162.82  7.37 167.11  11.16 NA 167.18  9.39 163.16  8.40
BMI (kg/m2) 23.27  4.18 NA 23.40  3.55 22.14  3.77 25.63  5.09 NA 22.50  4.35 23.57  4.10
Living
Family 78 (88.64%) 0.25  1.63 24 (30.77%) 39 (50.00%) 15 (19.23%) 14.40  3.30 20 (25.64%) 58 (74.36%)
Old aged home 4 (4.55%) 1.68  1.82 3 (75.00%) 1 (25.00%) 0 (0.00%) 11.65  1.47 3 (75.00%) 1 (25.00%)
Alone 6 (6.82%) 0.47  2.51 2 (33.33%) 1 (16.67%) 3 (50.00%) 16.00  2.93 2 (33.33%) 4 (66.67%)
Carer
Self-care 71 (80.68%) 0.13  1.77 21 (29.58%) 34 (47.89%) 16 (22.54%) 15.02  3.25 18 (25.35%) 53 (74.65%)
Helper 17 (19.32%) 0.86  1.38 8 (47.06%) 7 (41.18%) 2 (11.76%) 11.75  1.75 7 (41.18%) 10 (58.82%)
MOD
PD 41 (46.59%) 0.95  1.43 19 (46.34%) 18 (43.90%) 4 (9.76%) 13.08  2.83 14 (34.15%) 27 (65.85%)
HD 47 (53.41%) 0.33  1.75 10 (21.28%) 23 (48.94%) 14 (29.79%) 15.53  3.24 11 (23.40%) 36 (76.60%)
MOHD (month) 36.89  26.33 NA 33.97  29.23 38.37  27.40 38.22  18.74 NA 33.76  24.60 38.13  27.07
Hydration (L) 0.27  1.72 NA 2.10  0.83 0.09  0.62 2.27  0.70 NA 1.16  1.81 0.09  1.56
Over-hydration 29 (32.95%) 2.10  0.83 NA NA NA 13.69  2.70 12 (41.38%) 17 (58.62%)
Normal 41 (46.59%) 0.09  0.62 NA NA NA 14.11  3.50 11 (26.83%) 30 (73.17%)
Dehydration 18 (20.45%) 2.27  0.70 NA NA NA 16.13  3.16 2 (11.11%) 16 (88.89%)
LTI 14.39  3.28 NA 13.69  2.70 14.11  3.50 16.13  3.16 NA 12.06  1.99 15.31  3.24
Nutrition
Malnutrition 25 (28.41%) 1.16  1.81 12 (48.00%) 11 (44.00%) 2 (8.00%) 12.06  1.99 NA NA
Normal 63 (71.59%) 0.09  1.56 17 (26.98%) 30 (47.62%) 16 (25.40%) 15.31  3.24 NA NA
FTI 8.68  4.46 NA 8.78  3.72 7.91  3.72 10.24  6.50 NA 9.93  4.76 8.18  4.26
Hb (g/dL) 10.41  1.83 NA 9.72  1.61 10.52  1.74 11.29  2.01 NA 10.66  1.96 10.31  1.78
ALB (g/L) 41.28  6.05 NA 38.76  6.32 41.24  5.17 45.44  5.40 NA 39.36  7.17 42.05  5.42
CSSA
Yes 17 (19.32%) 1.36  1.46 9 (52.94%) 8 (47.06%) 0 (0.00%) 13.65  2.47 9 (52.94%) 8 (47.06%)
No 71 (80.68%) 0.00  1.68 20 (28.17%) 33 (46.48%) 18 (25.35%) 14.56  3.44 16 (22.54%) 55 (77.46%)
EPO
Yes 49 (55.68%) 0.42  1.65 17 (34.69%) 25 (51.02%) 7 (14.29%) 13.77  2.73 15 (30.61%) 34 (69.39%)
No 39 (44.32%) 0.08  1.81 12 (30.77%) 16 (41.03%) 11 (28.21%) 15.16  3.75 10 (25.64%) 29 (74.36%)
DM
Yes 27 (30.68%) 0.71  1.53 14 (51.85%) 10 (37.04%) 3 (11.11%) 13.76  3.15 9 (33.33%) 18 (66.67%)
No 61 (69.32%) 0.07  1.77 15 (24.59%) 31 (50.82%) 15 (24.59%) 14.66  3.32 16 (26.23%) 45 (73.77%)
Table 1: Patient characteristics of different groups of hydration status and nutritional status.
NA: not applicable.

© 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association
 HYDRATION AND NUTRITIONAL STATUS IN PATIENTS ON
HOME-DIALYSIS—A SINGLE CENTRE STUDY

Frequency (%) or Mean  SD Value, p-value

Overall (n ¼ 88) PD1 (n ¼ 41) HD2 (n ¼ 47) Testa,b
Hydration status x2 ¼ 8.59,  p ¼ 0.014a
Over-hydration 29 (32.95%) 19 (46.34%) 10 (21.28%)
Normal 41 (46.59%) 18 (43.90%) 23 (48.94%)
Dehydration 18 (20.45%) 4 (9.76%) 14 (29.79%)
95% CI of proportion (23.13%, 42.78%) (31.08%, 61.61%) (9.58%, 32.98%)

Hydration score (L) 0.27  1.72 0.95  1.43 0.33  1.75 t ¼ 3.72, p < 0.001b
95% CI of mean (0.09, 0.63) (0.51, 1.39) (0.83, 0.17)
Nutritional status x2 ¼ 1.24, p ¼ 0.27a
Malnutrition 25 (28.41%) 14 (34.15%) 11 (23.40%)
Normal 63 (71.59%) 27 (65.85%) 36 (76.60%)
95% CI of proportion (18.99%, 37.83%) (19.63%, 48.66%) (11.30%, 35.51%)
LTI 14.39  3.28 13.08  2.83 15.53  3.24 t ¼ 3.76, p < 0.001b
95% CI of mean (13.70, 15.07) (12.21, 13.95) (14.60, 16.46)
Table 2: The prevalence of over-hydration and malnutrition by the mode of dialysis.
Group 1 (PD); Group 2 (HD). Statistical Significance was considered at p < 0.05 ( p < 0.05,  p < 0.01). aThe difference in proportion between mode of
dialysis (group 1 & 2) was tested by Chi-square test. bThe difference in score between mode of dialysis (group 1 & 2) was tested by Independent-samples t test.

normal nutrition, respectively. There was also a significant
negative relationship between hydration score and serum
albumin and haemoglobin level. When serum albumin and
haemoglobin level increased by 1 unit, the mean hydration score
decreased by 0.10 and 0.18 l, respectively.
The association between patient characteristic and hydration
status using logistic regression was shown in Table 5. On
multivariable logistic regression analysis, male gender
(p ¼ 0.02), reducing haemoglobin level (p ¼ 0.002) and pres-
ence of DM (p ¼ 0.03) were the identified variables that had
significant effect on OH. Patients with diabetes were at 4.73
times higher risk of having OH compared with patients who did
not have diabetes; male patients appeared to have a 4.81 times
increased risk of OH compared with female patients. It was also
found that when the patient’s haemoglobin level increased by
1 g/dl, the risk of OH decreased by half.
The risk factors that have demonstrated an association between
patient characteristic and lean tissue index (LTI) using a general
linear model (GLM) is shown in Table 4. On multivariable GLM
analysis, decreasing BMI (p < 0.001), increasing FTI (p < 0.001)
and decreasing albumin (p < 0.001) were the only identified
variables that had a significant effect on lower LTI. There was a
positive correlation between BMI and LTI, as well as between
albumin and LTI, when BMI and albumin level increased for one
unit, the mean LTI would increase by 1.03 unit and 0.06 unit,
respectively, moreover, there was a negative correlation
between FTI and LTI. When FTI increased for one unit, the
mean LTI decreased by 1.02 unit.
The association between patient characteristic and nutritional
status using logistic regression is shown in Table 5. On
multivariable logistic regression analysis, increasing height
(p ¼ 0.005), on PD treatment (p ¼ 0.04) and rising FTI
(p ¼ 0.03) were the identified variables that had a significant
effect on malnutrition. The odds of malnutrition increased by
10%, and 14% for one unit increased in height and FTI
respectively. Patient undergoing PD had a 3.34 times higher at
risk of having malnutrition than patients on home HD.

Frequency (%) or Mean  SD Value, p-value

Over-hydration 1
(n ¼ 29) Normal 2
(n ¼ 41) Dehydration 3
(n ¼ 18) Testa,b
Nutrition x ¼ 5.10, p ¼ 0.08a
2

Malnutrition 12 (48.00%) 11 (44.00%) 2 (8.00%)

Normal 17 (26.98%) 30 (47.62%) 16 (25.40%)
LTI 13.69  2.70 14.11  3.50 16.13  3.16 t ¼ 0.55, p ¼ 0.59b1; t ¼ 2.82,

p ¼ 0.007b2; t ¼ 2.10,  p ¼ 0.04b3
Table 3: The association between hydration and nutritional statuses.
Group 1 (Over-hydration); Group 2 (Normal); Group 3 (Dehydration). Statistical significance was considered at p < 0.05 ( p < 0.05,  p < 0.01). aThe
difference in proportion between groups of hydration status (group 1, 2 & 3) was tested by Chi-square test. bThe difference in score between the groups
of hydration status (b1: group 1 & 2; b2: group 1 & 3; b3: group 2 & 3) was tested by Independent-samples t test.

© 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association Journal of Renal Care 2018 5
 6
Hydration score LTI
†
Univariate GLM Multivariable GLM Univariate GLM Multivariable GLM†
Li et al.

Beta 95% CI p value Beta 95% CI p value Beta 95% CI p value Beta 95% CI p value

Age NS NS NS 0.08 (0.13, 0.04) <0.001
 
BW 0.03 (0.06, 0.002) 0.03 0.10 (0.06, 0.15) <0.001

Height 0.03 (0.07, 0.01) 0.16 0.14 (0.06, 0.21) <0.001
 
BMI 0.07 (0.16, 0.01) 0.096 0.22 (0.06, 0.38) 0.008 1.03 (0.98, 1.08) <0.001
Gender

Journal of Renal Care 2018


Male NS NS NS 2.73 (1.44, 4.03) <0.001
Female NS NS NS Ref. Ref. Ref.
Carer

Self-care 0.73 (1.65, 0.18) 0.12 3.27 (1.65, 4.90) <0.001
Helper Ref. Ref. Ref. Ref. Ref. Ref.
Living
Family 0.72 (0.72, 2.15) 0.32 1.60 (4.32, 1.13) 0.25

Old aged home 2.14 (0.04, 4.33) 0.06 4.35 (8.50, 0.20) 0.04
Alone Ref. Ref. Ref. Ref. Ref. Ref.
MOD
 
PD 1.28 (0.59, 1.96) <0.001 0.06 (0.87, 0.98) 0.90 2.45 (3.75, 1.15) <0.001 0.11 (0.48, 0.25) 0.54
HD Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Nutrition
 
Malnutrition 1.24 (0.47, 2.01) 0.002 0.83 (0.12, 1.54) 0.02 NA NA NA
Normal Ref. Ref. Ref. Ref. Ref. Ref. NA NA NA
 
Hb 0.22 (0.41, 0.02) 0.03 0.18 (0.35, 0.01) 0.04 NS NS NS
 
FTI NS NS NS 0.29 (0.44, 0.15) <0.001 1.02 (1.06, 0.97) <0.001
   
ALB 0.14 (0.19, 0.08) <0.001 0.10 (0.18, 0.02) 0.014 0.25 (0.15, 0.36) <0.001 0.06 (0.03, 0.09) <0.001
CSSA
 
Yes 1.36 (0.48, 2.24) 0.003 0.88 (0.07, 1.70) 0.03 NS NS NS
No Ref. Ref. Ref. Ref. Ref. Ref. NS NS NS
EPO

Yes NS NS NS 1.39 (2.76, 0.01) 0.048
No NS NS NS Ref. Ref. Ref.
DM
Yes 0.64 (0.15, 1.42) 0.11
No Ref. Ref. Ref.
CAVD
Yes 0.70 (0.06, 1.45) 0.07 1.19 (2.63, 0.25) 0.103
No Ref. Ref. Ref. Ref. Ref. Ref.
CEVD
Yes NS NS NS 1.92 (4.66, 0.83) 0.17
No NS NS NS Ref. Ref. Ref.
Table 4: General linear model (GLM) on factors associated with hydration score and LTI.
Ref.: reference, NA: not applicable, NS: not significant (p value>0.2). Statistical significance was considered at p < 0.05 ( p < 0.05,  p < 0.01).
†All covariates with a p value  0.2 in univariate analysis were entered into multivariable analysis. The multivariable regression model was built using backward exclusion.

© 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association
 HYDRATION AND NUTRITIONAL STATUS IN PATIENTS ON
HOME-DIALYSIS—A SINGLE CENTRE STUDY

Patient with over-hydration Patient with malnutrition

Univariate logistic Multivariable logistic Univariate logistic Multivariable logistic
regression regression† regression regression†
OR 95% CI p value OR 95% CI p value OR 95% CI p value OR 95% CI p value
BW 1.03 (0.99, 1.07) 0.17 NS NS NS

Height NS NS NS 1.06 (0.998, 1.12) 0.06 1.10 (1.03, 1.18) 0.005
BMI 1.10 (0.96, 1.25) 0.16 NS NS NS
Gender
  
Male 3.04 (1.10, 8.43) 0.03 4.81 (1.35, 17.17) 0.02 2.88 (1.02, 8.17) 0.047
Female Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Carer
Self-care NS NS NS 0.49 (0.16, 1.46) 0.199
Helper NS NS NS Ref. Ref. Ref.
MOD

PD 2.43 (0.91, 6.49) 0.08 2.11 (0.66, 6.74) 0.21 1.70 (0.67, 4.32) 0.27 3.34 (1.07, 10.41) 0.04
HD Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
LTI NS NS NS NA NA NA

FTI NS NS NS 1.09 (0.98, 1.21) 0.103 1.14 (1.01, 1.28) 0.03

Hb 0.74 (0.54, 1.02) 0.06 0.51 (0.33, 0.79) 0.002 NS NS NS
ALB 0.92 (0.84, 1.01) 0.08 0.93 (0.85, 1.00) 0.06
CSSA

Yes NS NS NS 3.87 (1.28, 11.65) 0.02
No NS NS NS Ref. Ref. Ref.
DM
 
Yes 2.89 (1.04, 8.02) 0.04 4.73 (1.19, 18.76) 0.03 NS NS NS
No Ref. Ref. Ref. Ref. Ref. Ref. NS NS NS
CAVD
Yes 2.59 (0.96, 6.98) 0.06 NS NS NS
No Ref. Ref. Ref. NS NS NS
CEVD
Yes NS NS NS 5.81 (0.99, 34.05) 0.051
No NS NS NS Ref. Ref. Ref.
PKD
Yes NS NS NS 2.90 (0.76, 11.07) 0.12
No NS NS NS Ref. Ref. Ref.
HepB
Positive NS NS NS 0.22 (0.03, 1.82) 0.16
Negative NS NS NS Ref. Ref. Ref.
Table 5: Logistic regression on factors associated with over-hydration and malnutrition.
Ref.: reference, NA: not applicable, NS: not significant (p value >0.2). Statistical significance was considered at p < 0.05 ( p < 0.05,  p < 0.01).
†All covariates with a p value  0.2 in univariate analysis were entered into multivariable analysis. The multivariable regression model was built using
backward exclusion.

DISCUSSION of the individuals. Other studies also demonstrated that symptoms

As the clearance of toxin and fluid removal are moderately gentle
and continuous in patients on home dialysis therapies, their dietary
and fluid intake are less restricted when compared with patients on
in-centre HD. However, in our cohort, about one-third of our local
patients on home dialysis were found to have OH diagnosed by
BCM, and the prevalence of OH was higher in patients on PD
compared to HD. This finding was consistent with other previous
studies performed in other countries (Plum et al. 2001; Biesen et al.
2013). Clinically, symptoms of OH like oedema and hypertension
may not appear if the fluid gain is less than 2 l (Wabel et al. 2008;
Wizemann et al. 2008) but this is dependent on the cardiac status
might not be apparent despite the presence of OH confirmed by
BCM technique (Katzarski et al. 1996; Kraemer et al. 2006). Hence,
OH status might easily be overlooked clinically in a significant
proportion of patients undergoing home dialysis, Studies have
shown that OH is a strong predictor of mortality which is
independent of cardiac function for patients on peritoneal and HD
treatment (Wizemann et al. 2009; Mihai et al. 2015; Jotterand
et al. 2016). Early detection of OH and prompt interventions might
reduce dialysis complications and improve the patient’s long-term
outcomes (Jotterand et al. 2016). In contrast, normal hydration
status was achieved in 49% of our patients on home HD. A

© 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association Journal of Renal Care 2018 7
 Li et al.
significant proportion of them (29.79%) also had dehydration.
Unrecognised dehydration might increase the risk of intra-dialytic
hypotension leading to myocardial ischemia and myocardial
shunning (Burton et al. 2009).
In our study, gender and DM status were risk factors for the
development of OH. More male patients (40.38%) had OH
compared with females (22.22%) and more patients with DM
(51.85%) had OH compared with patients who did not have DM
(24.59%). These findings echoed with the findings by Ronco
et al. (2015). A more proactive fluid management strategy for
males and also those with diabetes might be warranted.
In our cohort, a significant proportion (28.41%) of patients on
home dialysis were malnourished. It has been reported that
patients having nocturnal home HD might have a good
nutritional status (Sikkes et al. 2009). Contrary to the findings
of Sikkes (2009), however, around 23.40% of our patients on
home HD were found to have malnutrition. In our study, we did
not demonstrate any difference in the prevalence of malnutri-
tion between patients on home HD and home PD. However,
after adjustment of other factors, patients on PD were 3.34
times more at risk of having malnutrition.
Carrero et al. (2013) suggests that it is crucial to identify the
aetiology of PEW for formulating effective preventive and
treatment strategy of malnutrition. Inflammation, dialysis-
associated catabolism, inadequate nutrient intake, loss of
nutrients and water-soluble vitamins during dialysis procedure
have been well documented as risk factors for PEW
(Combarnous et al. 2002; Rocco et al. 2002; Wang et al.
2003). For patients undergoing PD, there is additional protein
and amino acid loss during peritonitis. All these might
contribute to the development of malnutrition in patients
on dialysis treatment. In our study, we found that LTI had a
negative correlation with FTI and increase in FTI was a risk
factor of malnutrition. It has been suggested that there might
be increase in fat mass and weight gain during the first six
months of commencement of PD therapy (Choi et al. 2011).
Patients on PD might gain weight and increase body fat during
dialysis therapy, but however they could have been losing
muscle mass instead. Data on the effect of increase in fat mass
in patient’s outcome have been conflicting (Ikizier 2008; Choi
et al. 2014). Further studies might be required to examine the
impact of fat mass on outcomes in patients undergoing
dialysis.
8 Journal of Renal Care 2018 © 2018 European Dialysis and Transplant Nurses Association/European Renal Care Association
In our study, more patients receiving Comprehensive Social
Security Assistance (CSSA) had malnutrition (52.94% vs.
22.54%) and OH (52.94% vs. 28.17%) compared with non-
CSSA recipients. These patients might represent an under-
privileged group that warrant additional care, so additional
dietetic intervention should be targeted for this group of
patients. However, the underlying cause of OH and malnutrition
might be multifactorial and social factors could be just one of
them. Social factors that might influence hydration and
nutritional status might include lack of financial support for
better nutrient intake, lack of adequate social support and
knowledge of healthy dietary habits. Research concerning the
influence of social aspect on OH and malnutrition in the dialysis
population is limited so warrants further study.
IMPLICATIONS FOR PRACTICE
Our study demonstrated that using clinical assessment alone
to assess dry weight might not be accurate enough. In future,
the use of more objective means for example the bio-
impendence technique might achieve a more accurate dry
weight assessment. A structured nurse-led fluid management
programme providing education, knowledge empowerment
and intensive follow up of dietary and fluid adherence for
patient with OH could play an integral part in fluid
management and this has been shown to improve patient’s
outcome (Wong et al. 2009). Furthermore, the use of non-
glucose based PD solutions such as icodextrin, has been
validated to provide better DM and volume control in patients
with DM receiving PD (Gokal et al. 2002; Babazono et al.
2007). Early adoption of this glucose-sparing strategy might
have additional benefits for patients with diabetes in order to
prevent OH. Patients on PD are found to be more at risk of
having malnutrition; according to a consensus statement by
The International Society of Renal Nutrition and Metabolism
on the prevention and treatment of protein energy wasting
(PEW) in chronic kidney disease (CKD) (Ikizler et al. 2013). A
minimum of three-monthly periodic nutritional screening is
recommended to detect, to treat and to prevent the adverse
consequences of PEW.
LIMITATIONS
This was a single centre cross-sectional study, so findings can
only provide a snapshot of the situation at time of study, so
caution is needed in generalizing the findings. Moreover,
assessment of clinical signs and symptoms for fluid overload
were not performed to support the diagnosis of OH. In addition,

other markers of nutritional assessment for example, serum pre-
albumin concentration, assessment of dietary nutrient intake,
anthropometric measures and subjective global assessment
(SGA) were not collected. In our centre, the adequacy of dialysis
was measured twice a year and the dialysis dose would be
adjusted to meet the target Kt/V according to KDOQI (2006)
guidelines. However, as adequacy of dialysis was not well
defined in home HD population, the dose of dialysis was not
tested for its association with hydration and nutritional status of
patient on home dialysis in this study. We should not undermine
the possibility of the influence of dialysis dose on nutrition and
hydration status of our patients on home dialysis therapy.
CONCLUSION
OH was prevalent in our local patients undergoing home dialysis
treatment in particular the patients receiving PD. Risks factors for
OH included male gender, DM and lower haemoglobin levels.
Patients receiving PD were more at risk of malnutrition than on
those receiving HD. The BCM is an inexpensive tool which
provides objective data to determine the hydration and
nutritional status of the patients on dialysis treatment therapy.
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CONFLICT OF INTEREST
The authors have declared no conflict of interest.
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