Clinical Medicine Insights Received 15 Feb 2022 | Revised 18 Feb 2022 | Accepted 23 Feb 2022 | Published Online 26 Feb 2022 DOI: https://doi.org/10.52845/CMI/2022-3-1-4 CMI 03 (01), 268−277 (2022) ISSN (O) 2694-4626 RESEARCH ARTICLE Study of the nutritional status of end-stage renal disease patients on maintenance hemodialysis in Hawary Kidney center and nephrology unit at Benghazi Medical Center Safia S. Elramli 1Assistant Professor, Nutrition department, faculty of Public Health, University of Benghazi) Afaf Omer Sati, Ebtesam Mostafa , Norhan Elhassi( Public Health Students Abstract Background: Malnutrition, which is a powerful predictor of morbidity and mortality, is common in patients undergoing hemodialysis. There-fore, adequate nutrition is very important for such patients. Nutritional management in hemodialysis patients is a very important factor for prognosis , a better overall outcome and quality of life. Objectives: The current study mainly aimed to determine the nutritional status and prevalence of malnutrition and to investigate the relationship between nutritional markers, anthropometric parameters such as body mass index (BMI), and routine laboratory parameters with SGA in patients undergoing hemodialysis. Patients and Methods: A cross-sectional study was carried out on HD patients in Hawari Nephro Center and Nephro Unit of Beng-hazi Medical Center from December 2019 to January 2020. A total of 155 HD patients were recruited for this study and assessed for nutritional status include both Male and females aged 18 years and over with regular hemodialysis. Outcome measures: Measurements included questionnaire that elicited information on social demographic characteristics, Patient’s medical history , and duration of hemodialysis. Anthropometry, biochemical parameters were measured. Seven- Point Subjective Global Assessment (7-point SGA) was used to assess the nutritional state of HD patients. Biochemical tests were obtained during the study period from medical files of the studied patients. Data were analyzed using descriptive statistics. The Chi-Square test was applied to examine the study data. Results: Data shows that 58% of HDP were well-nourished while the remaining 39%, 3%had mild-to-severe malnutrition. Regarding the prevalence of malnutrition in both gender, males group was mor preva-lent of malnourished than female group. SGA score results indicated some significant correlations with patient’s post dialysis BMI and albu- min ,however, there was a negative correlation between demographic characteristics as gender, income, education level, comorbid disease , clinical variable such as duration and frequency of HD and some biochemical tests as electrolytes, phosphorous ,hemoglobin, cholesterolwith SGA scores. In addition, results show that insignificant correlation between nutrients intake, meals pattern of HD patients with SGA. Conclusions: Observations of nutritional status are necessary to maintain the health status of dialysis patients. Every strategy should be used to avoid complications of hemodialysis manifested in uremic state including anorexia, nausea, vomiting leading to malnutrition, fluid and electrolyte imbalance leading to volume overload, hyperkalemia, metabolic acidosis, and hyperphosphatemia, as well as abnormalities related to hormonal or systemic dysfunction such as hypertension, anemia, hyperlipidemia, and bone disease, Timely diagnosis of protein- energy-wasting (PEW) is important for early initiation of nutritional intervention and treatment. In addition, education plans should be prepared to mediate the nutrient intakes and identify the patient's difficulties and provide practical help. Keywords: Renal dialysis, Nutritional status, Hemodialysis, Malnutrition MANUSCRIPT CENTRAL used to avoid complications of hemodialysis manifested in uremic state including anorexia, nausea, vomiting leading to malnutrition, fluid and electrolyte imbalance leading to volume overload, hyperkalemia, metabolic acidosis, and hyperphosphatemia, as well as abnormalities related to hormonal or systemic dysfunction such as hypertension, anemia, hyperlipidemia, and bone disease, Timely diagnosis of protein- energy-wasting (PEW) is important for early initiation of nutritional intervention and treatment. In addition, education plans should be prepared to mediate the nutrient intakes and identify the patient’s difficulties and provide practical help. Keywords: Renal dialysis, Nutritional status, Hemodialysis, Malnutri- tion Copyright : © 2022 The Authors. Published by Publisher. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/). CMI 03 (01), 268−277 268 https://doi.org/10.52845/CMI/2022-3-1-4 https://creativecommons.org/licenses/by-nc-nd/4.0/ 1 INTRODUCTION One expanding global public health challenge is chronic kidney disease (CKD) , which is manifested by an irreversible deteriora- tion of kidney function that may eventually lead to end-stage renal disease (ESRD) and require renal replacement therapy such as renal transplantation or hemodialysis (HD) [1]. The main aim of HD is to rebalance the intracellular and extracellular fluid vol- ume that is a characteristic function of normal kid- neys. This is performed by transporting solutes (i.e. urea) from the blood to the dialysate and by trans- porting solutes (i.e. bicarbonate) from the dialysate to the blood [1]. kidney dysfunction is associated with defects in acid excretion, systemic inflammation, end-organ hormone resistance and uremic toxin accumulation. These abnormalities can further worsen kidney func- tion, creating a vicious circle, adversely affect pa- tients’ outcome[2]. 2 CAUSES OF NUTRITIONAL DISORDER IN HD 2.1 Inadequate food intake In dialysis patients, the decrease in food intake is a major cause of PEW and mortality [3]. Multi- ple factors have been implicated .Major causes of feeding restriction are comorbidities mainly cardio- vascular disease and history of volume overload , hospitalizations, depression, low social status, di- etary restrictions , multiple medical treatments, and accumulation of uremic toxic molecule[3] 2.2 Abnormal nutrient metabolism Energymetabolism:Most studies on resting energy expenditure (REE) measurements in HD and PD pa- tients reported REE values similar to that of controls [4]. In two studies, REE was found to be increased [3], and in one study in malnourished HD patients, REE was found to be decreased [4]. Regarding the determinants of REE, it was shown that severe hy- perparathyroidism , elevated serum CRP and serum IL-6 were associated with increased REE. Amino acid and protein metabolism: In HD pa- tients, plasma concentrations of amino acids( AAs) are characterized by a relative decrease in plasma serine and essential AAs except methionine, and an increase in citrulline and aspartate . Tyrosine and histidine are considered as essential AAs in renal failure [5]. These disturbances of plasma AAs during chronic kidney disease ( CKD) have been attributed to the abnormal handling of AAs not only in the kidneys but also in the hepatosplanchnic area[5]. Protein-energy malnutrition is a common problem among patients on hemodialysis (HD). Malnutrition can occur in up to 40% of the patients with renal failure and is associated with increased mortality and morbidity. Therefore, management of the nutri- tional aspects of patients with chronic kidney disease (CKD) presents a number of challenges [6]. In hemodialysis patients (HDP), it is important to perform an early diagnosis of malnutrition (MN) and inflammation, which are represented by protein- energy wasting (PEW) as they are significant pre- dictors of mortality , using the best clinically avail- able tools to create specific nutritional strategies that can predict outcomes, evaluate therapeutic re- sponses, and avoid severe nutritional deterioration [7]. This adds to the importance and significance of the presence of nutrition specialists in HD center for early detection of malnutrition and strategies to be implemented to prevent further deterioration [8]. The pathogenesis of malnutrition in dialysis pa- tients The causes of both malnutrition and inflammation are numerous in chronic renal injury ( CRI )patients with elevated serum levels of C-reactive protein( CRP) and pro-inflammatory cytokines. Patients may not ingest sufficient amounts of food because of loss of appetite. Anorexia can be caused by factors such as the retention of uraemic toxins and chronic metabolic acidosis, which, moreover, is an important Supplementary information The online version of this article (10.52845/CMI/2022-3-1-4) contains supplementary material, which is available to autho- rized users. CMI 03 (01), 268−277 MANUSCRIPT CENTRAL 268 MANUSCRIPT CENTRAL SAFIA S. ELRAMLI catabolic factor [9]. In this regard, inadequacy of dialysis treatment may be an important cause of mal- nutrition. Renal replacement therapy per se causes a loss of nutrients. During a hemodialysis (HD) session, a considerable quantity of amino acids may be lost (4–9 g in the fasting state and 8–12 g post- prandially). In contrast, protein losses are negligible, unless multiple re-use of dialysis filters is practiced. HD can cause a loss of vitamins, particularly water- soluble vitamins. Endocrine and metabolic distur- bances of uremia, in particular insulin resistance, can reduce protein anabolism and favor catabolism. The role of psychological factors (depression) and socio- economic factors (loneliness, invalidity, poverty) should never be neglected, considering that at present the majority of the dialysis population is composed of elderly patients [9]. Acute concurrent illnesses can also contribute to malnutrition. Finally, inadequate dietary prescription, due to the traditional physi- cian’s preference of prescribing nutritional restric- tion rather than providing nutritional counselling, can further worsen malnutrition [9].The pathogen- esis of chronic systemic inflammation in dialysis patients, which is associated with hyper catabolism and bodywasting, is complex and not yet fully under- stood. Other non-dialysis related causes of elevated CRP include co-morbid conditions, e.g. chronic heart failure with edema and the atherosclerotic process [10]. Moreover, various chronic infections, such as Chlamydia pneumoniae and dental or gingival in- fections may also contribute [10]. Furthermore, it has been suggested that factors related to the dial- ysis procedure itself may contribute to maintaining chronic systemic inflammation. In order to prevent and treat malnutrition in dialysis patients, it is im- portant to assess appropriately the nutritional status and to identify patients at risk [10]. Methods to assess nutritional status in dialysis patients There is a single best nutritional marker in patients with CRI, but that several nutritional markers should be evaluated together. The assessment of nutritional status should be based on a combination of clin- ical parameters with biophysical and biochemical parameters[11]. Malnourished dialysis patients often have protein energy malnutrition with a reduction of both fat mass (FM) and lean body mass (LBM). Therefore, clinical assessment of subcutaneous FM and muscle mass and a history of weight loss are important parts of routine nutritional assessment. Percentage of standard weight and body mass index (BMI) are also important and easy to measure, al- though BMI is more useful for assessment of obesity than of malnutrition.Most dialysis patients with mal- nutrition also have co-morbid diseases, in particular cardiovascular disease and inflammation, and the assessment of co-morbid conditions is an important part of the nutritional assessment of dialysis patients [11]. Laboratory parameters used in clinical routine, such as proteins, serum levels of C-reactive protein (CRP) and lipid profile may be influenced in HD patients by the inflammatory condition [11]. Fur- thermore, it should be noted that other parameters, such as serum cholesterol concentration, experience a reverse epidemiology in patients onHD. However, both serum prealbumin levels in early stages of mal- nutrition and those of albumin (much later) are good nutritional markers [12]. During recent years, sub- jective global assessment of nutritional status (SGA) has been used increasingly to assess nutritional status in many studies of dialysis patients (mainly cross- sectional studies) and in patients with CRI at start of dialysis therapy [13]. SGA correlates well with other nutritional markers in patients with CRI .Fur- thermore, it has a high predictive value for mortality in these patient groups . However, one potential problem with SGA is its subjective nature, which may reduce its reproducibility, thus small differences in SGA score must be interpreted with great caution [13]. 3 AIM AND OBJECTIVES The aim of this study was to study the prevalence of malnutrition among hemodialysis patients. Objectives 1.To determine the prevalence of nutritional disor- ders (malnutrition, anemia, hypernatremia, hyper- kalemia, and hyperphosphatemia) 2.To show the association between nutritional status and regular hemodialysis in both gender MANUSCRIPT CENTRAL CMI 03 (01), 268−277 (2022) 269 3.To identify the effects of demographic character- istics, chronic disease of HD patients on nutritional status 34To find out wither the frequency and duration of dialysis session per week are effect on nutritional status of HD patients 5.To determine whether nutritional status decline over time in patients receiving dialysis 4 METHODOLOGY Design: It was cross-sectional study random sample con- ducted at Nephrology unit of BenghaziMedical Cen- tre and Hawari Nephrology Center – Libya, to deter- mine the nutritional status of end-stage renal disease patients on maintenance hemodialysis aged from 18 to 83 years old. The access to this study was ob- tained following ethical approval after consultation with and permission of local medical research ethics committee, senior management, and site managers at Benghazi Medical Centre and Howari Nephrology Center. Total sample was 155 patients includes both Male and females aged 18 years and over with regu- lar hemodialysis . Criteria for inclusion the study The target of study consisted of patients with ESRF with maintenance hemodialysis both male and fe- male with Libyan nationality. All enrolled patients should have completed a minimum of three months duration on HD Exclusion criteria: Patients had acute renal failure on hemodialysis , any patient with chronic renal failure or end stage renal failure did not start of hemodialysis , as well as pa- tients on temporary hemodialysis due to other cause than renal failure. 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 Patients from other nationality other than Libyan nationality or patients younger than 18 years old were excluded. Procedure and materials:The study will be carried out over 2 months period from December 2019 to January 2020 and included 155 patients with a mean age of 47.8 ; there were 92(59.4%) males and 63(40.6%) females . The researcher will seek approval to conduct the study and to discuss access with site mangers. Re- searchers should be set to meet with participants to discuss the study, obtaining an informed consent, measurements, and data collections. Researchers were set to meet with participants, the study was ex- plained, and an informed consent obtained. A com- plete social and medical history , including details of the patient’s diet using 24 hours recall method and food frequency questionnaire , physical exam- ination, and recording of the dry body weight was performed to calculate BMI . Biochemical tests were obtained during the study period from medical files of the studied patients. The baseline laboratory tests included serum hemoglobin ,serum albumin, [total cholesterol, serum creatinine, CRP, serum potassium ,sodium, calcium and phosphorus, and serum urea nitrogen. Assessment of nutritional status As no single measure predicts overall nutritional sta- tus in patients with HD, amultidimensional approach has been proposed to include measurement of body composition, dietary intake, biochemical measures and muscle strength . However, this is clearly not practical for all patients in routine clinical practice and therefore the use of nutritional screening tools, such as Subjective Global Assessment (SGA) which incorporates important measures such as body mass index should be applied to the general HD patients to identify patients at risk of malnutrition. Selected patients should then undergo more detailed assess- ment, including dietary intake, anthropometric eval- uation and measurement of laboratory investigation. Serum albumin level and body mass index (BMI) were the most predictive parameters of malnutrition [14]. However, the nutritional status of patients was assessed by extensive anthropometric measurements .Whereas the biochemical markers of nutrition such as serum albumin, S. creatinine, CRP ,S. cholesterol was unavailable for most patients as well as the detection of malnutrition can be problematic in HD CMI 03 (01), 268−277 (2022) MANUSCRIPT CENTRAL 270 MANUSCRIPT CENTRAL SAFIA S. ELRAMLI patients as the body weight is influenced by fluid status and biochemical markers such as albumin, CRP and haemoglobin are affected by the disease process. In clinical practice, Therefore review of the patients albumin level, and body weight include recent changes and their dietary intake is approve helpful [14]. 5 RESULT The aim of this study was to assessment the nutri- tional status and prevalence of malnutrition among hemodialysis patients in Howari Nephrology Center and Nephrology Unit of BMC Hospital in Benghazi. 1.DESCRIPTION OF STUDY PARTICIPAM- NTS The background characteristics of the participants are summarized in Table (4.1.and 4.2) A total of 155 HD patients in this study were re- cruited for the study, the age ranges was between (18-83 years), the mean age was 47.48 , included 92 males and 63 females Table (4.1)distribution of age 2. Demographic characteristicand clinical infor- mation of the studied patients All participants enrolment in this study were on regular dialysis. approximately 23.9% did not earn an income (either unemployed or a housewife), and Most patients (29% )had a monthly income of 500- 1000dinner ,while only 7% had income ,1500 dinner as shows in table(4.3) Regarding the patient’s educational level, approximately 54.2% ,whereas 45.2% were illiterates as demonstrated in table(4.3) clinical information of the studied patients is presented in table(4,3) . most (56.8%) of studied HD patients reported that they have been do surgeries ,however, about 43,2% they do not. Table (4,3) demonstrated that the highest percent of participants were have family history for chronic disease which was 60% ,while only 40% did not found history of chronic disease. and approximately 72% of the studied patients reported did not having family history of renal disease , only 27.3 confirmed with family history of renal disease. Comorbid conditions in the study patients were mainly hypertension (HTN)94 (60.6%) followed by diabetes mellitus (DM) 23(14.8%). A bout 23 (14.8% ) of the patients had both DM and HTN. Overall, 13(8.4%)of HD patients did not have any comorbid condition. Table(4,3) Demographic characteristic and clinical information of participants MANUSCRIPT CENTRAL CMI 03 (01), 268−277 (2022) 271 Table(4.2) distribution of gender Subjective Global Assessment (SGA) score that was originally developed to assess post-operative nutri- tional state and is one of the methods suggested to assess nutritional status in HD patients. The SGA was suggested by the National Kidney Foundation and has undergone several modifications . The SGA comprises of five criteria, and includes medical his- tory, physical examination, subcutaneous fat, muscle wasting and fluid retention. A score A indicated well nourished , score B mildly to moderately malnour- ished ,score C severely malnourished . The nutritional status of the patients indicated that (58%) were well-nourished while the remaining (39%, 3%) had mild-to-severe malnutrition [Figure 4,1] below. (figure 4.1) Prevalence of malnutrition among HD patients 6.2 Body mass index in the study pa ents Regarding the patient’s post dialysis BMI 43.3% were had normal BMI , 28.4% were overweight ,while 16.1%,7.1%,1.9% were grad1,2,and 3 obese respectively . however, 4.5% appeared to be under weight . The figure (4.2)shows all previously men- tioned. CMI 03 (01), 268−277 (2022) MANUSCRIPT CENTRAL 272 6 ASSESSMENT OF NUTRITIONAL STATUS OF HD. PATIENTS 6.1 Prevalence of malnutri on using Subjec ve Global Assessment MANUSCRIPT CENTRAL SAFIA S. ELRAMLI Figure (4.2)Post- dialysis BMI of study patients 6.3 BMI and SGA score Based on the results (table4.4 ) there was showed the post dialysis BMI had a highly significant associa- tion with SGA scores { P-value 0.29}. Table (4,4) correlation between post-dialysis BMI and SGA 3.4. frequency of dialysis : Based on the results (ta- ble 4,14)there was no association between frequency of dialysis and SGA (P value-0.578). 6.4 laboratory inves ga on Result revealed that hemoglobin level regarding both sex , the mean level of HBG among male group was 9.9ml/dl as well as the minimum level was 5.4ml/dl while the maximum level was 16.8ml/dl. About female group the mean HBG level was 9.5 while the maximum and minimum HBG level was 13.3 ml/dl and 9.5 respectively. Table (4,6) Hemoglobin level among gender Table(4,7) laboratory result among both sex Regarding biochemical indexes of nutritional status the table below(4,7) shows that the maximum and minimum level of serum cholesterol among male group was 198 ml/dl and 160ml/dl, whereas the maximum and minimum level among female group was 254ml/dl and 170 respectively We noted that all patients in our sample had hyperc- holesterolemia compared with normal level ,whereas urine albumin was high at maximum level in both groups. High loss of albumin in urine is marker of malnutrition. Table(4,7) serum cholesterol-albumin in both sex MANUSCRIPT CENTRAL CMI 03 (01), 268−277 (2022) 273 Correlation between SGA score and biochemical tests Correlational analysis was carried out between SGA scores and laboratory results correlation (Table4,8) No significant correlation was found between SGA score and potassium level (P = 0.889), sodium level (P = 0.400), hemoglobin (P = 0.706),cholesterol level(p=0.764) and phosphate level (P = 0.562). However, significant positive correlation was found between SGA core and albumin level (P = 0.031). Table(4,8) Correlation between SGA and biochemi- cal test 6.5 Associa on between nutrient intake and SGA Table 4.9 below shows the association between nutri- ents intake among HD patients and SGA parameters, based on result was showed a negative correlation , the correlation between SGA scores and protein (p =0.652),calorie (p=0.998),CHO(p=0.575),and fat(p=0.932). Table (4,9) ): Association between SGA scores and daily nutrient intake 7 DISCUSSION In this study, we aimed to estimate the nutritional status of a sample of HD patients and potential significant predictors of nutritional status among the studied patients. Nutritional status is an important predictor of outcome in ESRD patients on main- tenance HD. Assessment of the nutritional status needs a systematic nutritional evaluation based on anthropometric, laboratory, and clinical parameters from which a malnutrition score can be calculated. With regard to association between BMI and SGA score our result illustrated that 43.3% HD patients post dialysis BMI were had normal and most of them were well-nourished, while patients with un- derweight were severely malnourished. In addition, the result demonstrated that there was showed post dialysis BMI had a highly significant association with SGA scores with P-value 0.29. Similarly, study done by Ekramzade et al. reported that HDPwithMN had a lower BMI than well-nourished patients [15]. CMI 03 (01), 268−277 (2022) MANUSCRIPT CENTRAL 274 MANUSCRIPT CENTRAL SAFIA S. ELRAMLI Another study was done by . Mohammed (2014) convinced that post dialysis BMI had high significant association with SGA [16] On the other hand, our results disagreed with the study of Ghali and Malik,[17 ] there was no significant effect of post dialysis BMI and SGA . About frequency of dialysis , In present study most of participants in our sample were dialysis for 3 times a week was well nourished while the rest of them were mildly malnourished and five patients had sever malnourished among those patients also the result showed that frequency of hemodialysis non-significant correlation with SGA. However, study was done by Bohé and Rennie (2006) [18]provided a significant analysis and discussion on the subject and reported that patients receiving dialysis three times a week lost 2 kg of lean body mass in a year [18]. Some other studies also found severity of malnourished increased with increased dialysis frequency [19]. As demonstrated in our result, the correlation between SGA scores and laboratory results were No significant was found with potassium level (P = 0.889), sodium level (P = 0.400), hemoglobin (P = 0.706),cholesterol level(p=0.764) and phosphate level (P = 0.562). However, significant positive correlation was found between SGA core and albumin level. In contrast other study by Stosovic etal (2011) have previously found that SGA score was significantly correlated with Hb level but not with albumin level or any other biochemical indicator[20]. The evident poor intake of high quality protein also reported in present study. In this study we also found that the association between nutrients intake among HD patients and SGA parameters was a negative correlation. The correlation between SGA scores and protein (p =0.652),calorie. (p=0.998),CHO(p=0.575),and fat(p=0.932). poor protein and energy intake, comorbidities and inflammation were the predictors of MN in descending order of importance [21]. Morais et al. performed a prospective study to investigate the association between nutritional status and food intake in HDP and the authors reported that nutrients intakes had a significant correlation with subjective global assessment, which was different to our findings reported here [22]. Study was done by Therrien etal (2015) [23] were analyzed nutrient intake of the subjects and found out that calorie and protein intakes were insufficient compared to the dietary intakes recommended for dialysis patients. 8 CONCLUSIONS We conclude that the majority of our dialysis pa- tients were well nourished, and followed by mildly malnourished. Poor dietary knowledge and practices were encountered among these patients with poor biochemical parameters among the majority of them. this study showed the majority of patients reported a lower than recommended energy and protein intake The SGA score results indicated that MN was mod- erately prevalent among patients undergoing HD. These results show some significant correlations be- tween the nutritional status and patient characteris- tics (i.e. post dialysis BMI and biochemical tests as albumin ) , However , our result shows that HDP had un-significant relation between demographic char- acteristics , clinical variable and some biochemical tests such as gender, income, education level, co- morbid disease , and frequency of HD , electrolytes, phosphorous ,hemoglobin, cholesterol with SGA scores. We also found that a negative correlation between nutrients intake among HD patients with SGA parameters. Therefore, these findings should increase the awareness of healthcare providers for interventions to enhance the nutritional status for HDP, especially those who are elderly, have multiple comorbid diseases, , have a long dialysis vintage or live alone. 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J Ren Nutr. 2015;25:329–338 CMI 03 (01), 268−277 (2022) MANUSCRIPT CENTRAL 276 MANUSCRIPT CENTRAL SAFIA S. ELRAMLI How to cite this article: S.S.E. Study of the nutritional status of end-stage renal dis- ease patients on maintenance hemodialysis in Hawary Kidney center and nephrology unit at Benghazi Medical Center . Clinical Medicine Insights. 2022;268−277. https://doi.or g/10.52845/CMI/2022-3-1-4 MANUSCRIPT CENTRAL CMI 03 (01), 268−277 (2022) 277 Introduction Causes of nutritional disorder in HD Inadequate food intake Abnormal nutrient metabolism Aim and objectives Methodology Result Assessment of nutritional status of HD. patients Prevalence of malnutrition using Subjective Global Assessment Body mass index in the study patients BMI and SGA score laboratory investigation Association between nutrient intake and SGA Discussion Conclusions References