1. Reggie J. Divina, M.D. (1) 2. Fe S. Felicilda, M.D., DPBCN (1,2) 3. Rufino E. Chan, M.D. (1) 4. Luisito O. Llido, M.D.

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1 82 TITLE: Nutritional status of hemodialysis patients in the Philippines: a cross sectional survey in four out- patient dialysis centers Submitted: January 10, 2010 Posted: August 30, 2010 AUTHOR(S) 1. Reggie J. Divina, M.D. (1) 2. Fe S. Felicilda, M.D., DPBCN (1,2) 3. Rufino E. Chan, M.D. (1) 4. Luisito O. Llido, M.D., DPBCN (1,2) INSTITUTION(S) WHERE STUDY WAS DONE: 1. Department of Medicine, Amang Rodriguez Medical Center, Sumulong Highway, Marikina City, Metro Manila, Philippines 2. Clinical Nutrition Services, St. Luke s Medical Center, E. Rodriguez Sr. Ave. Quezon City, Metro Manila, Philippines MAILING ADDRESS: 1. Clinical Nutrition Services, St. Luke s Medical Center, 279 E. Rodriguez Sr. Ave., Quezon City, Metro Manila, Philippines 2. address: llido2001@gmail.com ABSTRACT OBJECTIVE: To determine the prevalence of malnutrition among chronic hemodialysis patients and determine the association between degree of malnutrition with frequency and duration of dialysis treatment. METHODOLOGY: Design: cross sectional survey; Setting: 4 dialysis centers in Metro Manila; Patients: 111 adult patients (male to female ratio: 1.09 to 1) with end stage renal disease (ESRD) on long term hemodialysis (HD); Intervention: hemodialysis, nutritional assessment; Statistical analysis: T- test, chi- square, correlation and regression analysis. Main outcome measure: nutritional status using body mass index and subjective global assessment (SGA), serum albumin, frequency and duration of hemodialysis treatment RESULT: Mean age is 50 years (range: 20 to 86 years); the mean duration of dialysis is 3 years (range: 0.25 to 17 years); most of the patients (76.6%) were on dialysis twice a

2 83 week. Prevalence of malnutrition was 75% (83/111) and of these 56.8% (63/111) were severely malnourished; of the severely malnourished patients, 44% (28/63) had chronic glomerulonephritis, 41% (26/63) had diabetic nephropathy, and 6% (4/63) had hypertensive nephropathy. Decreased frequency of dialysis resulted to increase in severe malnutrition (SGA C ), Odd s Ratio 95% C.I.=0.024 to 0.955, p =0.04; no difference was seen between duration of dialysis and severe malnutrition. CONCLUSION: There is a high prevalence of malnutrition among chronic ESRD patients on hemodialysis and the severity of malnutrition increases with decrease in frequency of dialysis. Keywords: severe malnutrition; end stage renal disease; hemodialysis; Philippines INTRODUCTION Chronic Kidney Disease (CKD) is a serious condition associated with premature mortality, decreased quality of life and increased health care expenditure (1,2). The number of patients with CKD is growing worldwide. In the United States, the prevalence of CKD is 16.8% based on the National Health and Nutrition Survey (NHANES) data, higher when compared to the report (14.5%) (3). In the Philippines, there is an increasing trend in the number of patients with CKD. The 2001 report of the Philippine Renal Disease Registry (PRDR) showed 4,363 CKD patients on dialysis treatment which increased to 5,070 in 2003 with the majority of them (83%) on hemodialysis (4). At present there are 210 hemodialysis centers in the Philippines (4). In CKD, protein energy malnutrition may develop during the course of the disease and is associated with adverse outcomes (1). It is estimated that 50-70% of patients on maintenance dialysis suffer from protein energy malnutrition (1,5). It is important to monitor the nutritional status of patients on hemodialysis, since malnutrition is a significant predictor of risk for morbidity and mortality (1,3). At present, there are no available local studies on the nutritional status of CKD patients in the Philippines, thus this study was done with the following objectives: a) To show the profile of patients in selected hemodialysis centers in metro- Manila, Philippines, b) To determine the prevalence of malnutrition in this group of patients, and c) to determine the association between malnutrition and the duration and frequency of dialysis treatment. METHODOLOGY Patients from four (4) dialysis centers in Metro Manila, Philippines were enrolled in the study. These centers were the following: Amang Rodriguez Medical Center (ARMC)

3 84 dialysis unit, Salve Regina Hospital Renal Center, and Philippine Kidney Dialysis Foundation (Tomas Morato and Roces branches). Consent from the hospital administrators to conduct the study was obtained and all Chronic Kidney Disease (CKD) patients undergoing hemodialysis with ages 18 years old and above were included. Excluded were patients on hemodialysis for acute renal failure and those with unstable hemodynamic status. Informed consents from all participating patients were secured. The following data were collected: age, sex, diagnosis and/or etiology of End Stage Renal Disease (ESRD), frequency of dialysis (once, twice, or three times a week), and the duration of dialysis treatment (the number of years on dialysis). Nutritional status was determined using both Body Mass Index (BMI) and Subjective Global Assessment (SGA)(6-8). For BMI, normal nutrition status is and any value outside this range is categorized as malnutrition, underweight or overweight- obese. For the SGA score, category A and B corresponds to normal nutritional status, while category C was considered severe malnutrition status. The height and post dialysis weight as well as the latest serum albumin level (within the last 4 weeks) were obtained from the patient s medical record. For statistical analysis, differences were determined using T- Test for normally distributed data and chi- square for non- normally distributed data. Relationships and association were analyzed using correlation and regression analysis. Significance was pegged at < 0.05 (9). The NCSS 2004/PASS 2002 software was used in the statistical analysis of the data ( 2004 Jerry Hintze, McGraw- Hill Companies). RESULTS Patient Profile (Tables 1 and 2): There were 111 patients enrolled in the study with a male to female ratio of 1.09:1). The mean age is 50 years (range: 20 to 86 years old); the mean duration of dialysis is 3 years (range: 0.25 to 17 years). Most of the patients (76.6%) were on dialysis twice a week. The three most common etiologies of CKD in this study were: chronic glomerulonephritis (46/111 or 41.4%), diabetic nephropathy (42/111 or 37.8%), and hypertensive nephropathy (16/111 or 14.4%). The mean duration of disease and dialysis period for chronic glomerulonephritis is 4 years, for diabetic nephropathy: 2.4 years, and hypertensive nephropathy: 2.8 years.

4 85 Prevalence of Malnutrition (Table 1,2,3): The SGA showed the prevalence of malnutrition to be 75% (83/111) and of these 56.8% (63/111) were severely malnourished. Of the severely malnourished patients, 44% (28/63) were in the Chronic Glomerulonephritis group, 41% (26/63) were in the Diabetic Nephropathy group, and 6% (4/63) were in the Hypertensive Nephropathy group. The BMI nutritional status classification showed 25% (28/111) were malnourished- underweight, 15% (20/111) were overweight, and 3% (3/111) were obese. Weight loss was present in 29% (32/111) and hypoalbuminemia in 17% (16/111) of these patients.

5 86 Relationship between malnutrition and the frequency and duration of hemodialysis (Tables 3 and 4): The frequency of dialysis showed significant association with severe malnutrition (SGA C ) where a decrease in the frequency of dialysis treatment resulted to increase in severe malnutrition. No significant association was noted with frequency of dialysis to BMI, weight loss, and serum albumin. The study also did not show significant association between the duration of dialysis and all nutrition related variables measured in this study. DISCUSSION This study showed that the prevalence of malnutrition in hemodialysis patients in this part of the Philippines is high at 75%, which is similar to reported rates from other studies (71% [8] to 90% [10]). However the presence of severe malnutrition in more than half of the patient population (56.8%) was higher compared to some reports (10), which point to the need for identifying the factors that would lead to severe malnutrition. The BMI was checked to determine the presence of obesity in this group of patients (BMI >30) and it was only 3% in the overall population. This study therefore, gave the following implications regarding chronic hemodialysis patients: a) a high percentage of severe malnutrition with expected higher incidence of morbidity and mortality, b) the need for more intensive nutrition management, and c)

6 87 the need for close monitoring of patient status and response to nutrition care as the process of long term hemodialysis progressed. The weight loss in this population was low with 29% of patients showing significant weight loss and in contrast, 96% had normal serum albumin (>33.4 gm/l), which are features of chronic malnutrition. This may be due to most patients having severe malnourished status at the beginning of dialysis treatment, which was not adequately corrected during the succeeding periods of maintenance HD therapy. The higher percentage of patients having normal serum albumin are indications of firstly, long term inadequate nutrient intake and secondly, the effect of HD in reducing factors that suppress albumin synthesis in the liver like the cytokines, thus keeping the albumin levels within the normal range (11,12). The duration of dialysis treatment did not show significant correlation with the development of malnutrition. It was the frequency of dialysis that showed significant association with the development of malnutrition, most especially severe malnutrition (SGA C ). When it was done on a once a week schedule the odds of severe malnutrition occurring rose significantly (p = 0.04). This explained the findings of lesser weight loss and normal albumin levels in the group of patients having more frequent dialysis e.g. two to three times a week (101/111 or 91%). This was also proof for the need of sustaining the frequency of dialysis to a minimum of twice a week in order to avoid the complication of worsening malnutrition in this group of patients. Frequency of dialysis did not show any significant relationship with serum albumin changes although some reports infer to this effect (Owen et al) (13). The main concern raised then would be how to improve the nutritional status and lessen the severe malnutrition in this group of patients. Two main factors have been pointed as the underlying causes of malnutrition: low nutrient intake (especially protein) and the inflammatory state due to the renal disease (Locatelli et al) (14). This study showed that increasing the frequency of dialysis per week would improve the microcirculatory environment (lesser inflammatory factors) and cause better delivery and utilization of nutrients. The unanswered question was regarding the quantity of nutrient intake: would an increase lessen the prevalence of severe malnutrition? The high percentage of severely malnourished patients points to this need together with the inclusion of a strict nutrient intake auditing system (e.g. calorie and protein counts). Increasing the nutrient dose is given in the NKF- DOQI clinical practice guidelines for nutrition in chronic renal failure guidelines 15 and 17 (15).

7 88 CONCLUSION There is a high prevalence of malnutrition among hemodialysis patients in this part of the Philippines. Malnutrition increases in severity as the frequency of dialysis decreases. REFERENCES 1. Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergstrom J. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant 2000; 15: Kalantar- Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis 2003; 42: CDC. MMWR. March 2, (08); Danguilan R. ESRD Registry, Philippine Society of Nephrology. Updated Dec 3, NKF- K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 2000; 35 [Suppl 2]: S1- S Norman K, Schütz T, Kemps M, Josef Lübke H, Lochs H, Pirlich M. The Subjective Global Assessment reliably identifies malnutrition- related muscle dysfunction. Clin Nutr Feb: 24 (1): Tapiawala S, Vora H, Patel Z, Badve S, Shah B. Subjective global assessment of the nutritional status of patients with chronic renal insufficiency and end stage renal disease. J Assoc Physicians India 2006; 54: Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, Sehgal AR, Kalantar- Zadeh K. Multicenter study of the validity and reliability of subjective global assessment in the hemodialysis population. J. Renal Nutri 2007: 17 (5): Dawson B, Trapp RG. Basic and clinical biostatistics, 3rd ed. Lange Medical Books/McGraw- Hill; Faintuch J, Morais AA, Silva MA, Vidigal EJ, Costa RA, Lyrio DC, Trindade CR, Karoline KP. Nutritional profile and inflammatory status of hemodialysis patients. Ren Fail 2006; 28 (4): Giordano M, De Feo P, Lucidi P, et al. Increased albumin and fibrinogen synthesis in hemodialysis patients with normal nutritional status. J Am Soc Nephrol 2001; 12: Kaizu Y, Kimura M, Yoneyama T, Miyaji K, Hibi I, Kumagai H. Interleukin- 6 may mediate malnutrition in chronic hemodialysis patients. Am J Kidney Dis 1998; 31: Owen WF, Chertow GM, Lazarus JM, and Lowrie EG. Dose of hemodialysis and

8 89 survival: differences by race and sex. JAMA 1998; 280 (20): Locatelli F, Fouque D, Heimburger O, et al. Nutritional status in dialysis patients: a European consensus. Nephro Dial Transplant 2002; 17: NKF- K/DOQI clinical practice guidelines and clinical practice recommendations, 2006 updates. m (accessed February 1, 2009).