Protein-energy malnutrition (PEM) is a risk factor for morbidity and mortality in persons receiving maintenance hemodialysis (MHD). The prevalence of PEM varies from 18% to 75%, using either single or combined measures of protein-energy nutritional status. Various factors contribute to the development of PEM, including disturbances in protein-energy metabolism, reduced dietary energy and protein intakes, and amino acid losses. Comorbid medical conditions such as diabetes, cardiovascular disease, and chronic inflammation may also contribute to PEM. Clinical, anthropometric, and biochemical measures have been used to assess nutritional status in patients receiving MHD.
Low or declining nutrition indicators in MHD patients have been associated with poor clinical outcome (that is, increased morbidity). Documenting the characteristics of patients receiving dialysis with low or declining nutrition indicators will alert practitioners to provide interventions that may lead to actions that lower the risk of adverse health outcomes. Therefore, the purpose of this analysis was to compare the demographic and clinical characteristics of patients receiving MHD who are at different levels of nutritional risk, and to document the relationship between the level of nutritional risk and morbidity.
This analysis, a retrospective, longitudinal medical chart review, included 537 adult men and women who received MHD at the Beth Israel Medical Center Dialysis Treatment Center in New York City for 5 years. All subjects were followed until a censored event (that is, time of death, kidney transplantation, transfer to another dialysis facility, withdrawal from dialysis, or to the end of the study period). Subjects were stratified according to their number of nutritional risk factors: zero to one=low risk, two to three=moderate risk, four to six=high risk.
Compared with the high-risk group, the majority of subjects in the low-risk group were younger, male, and did not have diabetes; fewer had two or more comorbidities. The high-risk group had 75% more hospitalizations and spent 195% more days in the hospital than the low-risk group. In this analysis, 70% of the study cohort had multiple nutritional risk factors. This finding was also associated with an increased frequency and duration of hospitalizations and higher hospitalization rates. The groups with multiple risk factors (that is, moderate and high risk) also experienced more frequent and longer hospital admissions than subjects in the low-risk group.
Subjects in the low-risk group appeared to have a better nutritional status than those in the moderate-risk and high-risk groups. They had significantly higher mean levels of SA1b, SCr, serum total cholesterol, nPNA, and higher mean BMI, and had a more positive change in body weight than subjects in the moderate-risk and high-risk groups. Striking differences were also observed between the groups and morbidity. A lower mean frequency and duration of hospitalizations were observed in the low-risk group compared with the moderate-risk and high-risk groups. Overall, the nutrition indicators were significantly lower in the high-risk group compared with the low-risk and moderate-risk groups and in subgroup analyses.
A definite trend of higher hospitalization rates was observed with increasing level of nutrition risk (from low risk to moderate risk to high risk) in the univariate analysis, which seems to indicate that morbid events occurred more frequently in patients with multiple nutritional risk factors. In light of this finding, it seems prudent to monitor closely and to intervene with appropriate interventions in those patients with low or declining nutritional risk factors.
Accordingly, patients with low levels of SA1b, SCr, serum total cholesterol, nPNA, and BMI, and those with weight loss, should be considered at nutritional risk and be treated with aggressive nutrition counseling and interventions, although there are no conclusive data on effective treatment regimens for PEM in the dialysis population. Evidence is sparse, showing that improvement in protein-energy nutritional status or in measures of nutritional status will reduce morbidity rates in patients receiving MHD. Further research is needed to determine whether interventions that maintain or improve the level of the nutrition indicators will reduce subsequent morbidity and, hence, improve health outcomes for patients receiving MHD.
J. Burrowes, S. Dalton, J. Backstrand, N. Levin. Patients receiving maintenance hemodialysis with low vs high levels of nutritional risk have decreased morbidity. JADA; 105(4):563-572 (April 2005) [Correspondence to: Jerrilynn D. Burrowes, PhD, RD, Department of Nutrition, C.W. Post Campus of Long Island University, 720 Northern Blvd, Brooksville, NY 11548. E-mail: jerrilynn.burrowes@liu.edu]
COPYRIGHT 2005 Frost & Sullivan
COPYRIGHT 2005 Gale Group
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