SGA Score Research Articles

NUTRITIONAL CHARACTERISTICS AND DIETARY INTAKE OF PATIENTS ATTENDING THE PRE-DIALYSIS ASSESSMENT CLINIC

Poor nutrition status at the start of dialysis is associated with morbidity and mortality. Timely management of patients with ESKD pre-dialysis including providing nutrition intervention is important. The aim of this study was to describe the baseline nutritional status and dietary intake of patients attending the pre-dialysis assessment clinic. Of the 210 patient assessed, 60.5% were male; mean age was 65.7±13.6 years and mean GFR was 17.0±4.2 ml/min. 17.1% were underweight (BMI<23 kg/m2) while 62.5% were overweight or obese (BMI>26 kg/m2). 39.5% were rated as malnourished (SGA score B&C) and 18.5% were overweight/obese and malnourished. 26.7% had MAMC 10% less than 50th percentile of the standard. Mean energy and protein intakes were 23.4±6.9 kcal/kg IBW/d and 1.16±0.43 g/kg IBW/d with 65.5% and 15.6% did not meet the recommended intake of energy and protein respectively. 48% of patients experienced symptoms (e.g. poor appetite and nausea) affecting dietary intake while 15.7% of patients self-imposed dietary restriction inappropriately due to misconception of nutrition requirements in ESKD. 41.4% and 85.2% did not consume adequate fruit and vegetables of 2 and 5 serves per day respectively based on the Australian Guide to Healthy Eating. Nutrient intake (prevalence %) below the Recommended Daily Intake (DRI) levels were: VitB1 (36.5%), VitB2 (43.5%), Niacin (3.9%), VitC (202%), VitE (41.0%), folate (83.2%), VitA (50.5%), Mg (94.5%), Fe (36.1%), Zn (70.8%) and dietary fibre (83.3%). In conclusion, patients attended the current pre-dialysis assessment clinic presented with parameters indicative of poor nutritional health. This clinic may provide an opportunity to optimise nutritional status of ESKD patients before dialysis is required.

Self-Reported Appetite and Intake Adequacy In Patients With Non-dialysis Chronic Kidney Disease

Subjective assessment of appetite using the Appetite and Diet Assessment Tool (ADAT) with 5-point Likert scales, (1) very good, (2) good, (3) fair, (4) poor and (5) very poor has been useful in screening patients for suboptimal intake and predicting hospitalization rate in patients on maintenance dialysis. The purpose of this study was to examine the relationships of self-reported appetite score and the estimated energy and protein intakes in a cohort of ESKD patients attending the pre-dialysis assessment clinic. As part of the routine assessment, patients were asked to rate their appetite using the ADAT; their dietary intake was assessed by the renal dietitian using a structured diet history method and computer software analysis. Of the 205 patient assessed, 60.5% were male; mean age was 65.7±13.6 years and mean GFR was 17.0±4.2 ml/min. 39.5% were rated as malnourished (SGA score B&C). 69.8% of patients rated their appetite as (1) very good or (2) good, whereas 30.2% rated their appetite as (3) fair or (4) poor or (5) very poor. Intakes of >25 kcal/kg IBW/d and >0.75 g/Kg IBW/d were considered adequate for energy and protein respectively. The mean ±SD of energy and protein intakes rated by the appetite score are as follow:Appetite score1+2 (Good)3+4+5(Reduced)P valueEnergy kcal/kgIBW/d24.4±6.720.7±6.6< 0.0001Protein g/kgIBW/d1.21±0.421.00±0.43< 0.004 The positive predictive value (95%CI) of appetite rating for energy and protein were 0.37 (0.32–0.41) and 0.90 (0.86–0.93) respectively. In conclusion, while self-reported appetite scores were useful in ranking energy and protein intakes, subjective reporting of good appetite was associated with adequate protein but not energy intake. Report of a good appetite does not always mean adequate intake in non-dialysis ESKD patients with high symptom burden.

NUTRITIONAL ASSESSMENT OF CAPD PATIENTS

Appearance and progressive development of malnutrition significantly influence the efficacy and treatment outcome in chronic renal failure (CRF) patients receiving continuous ambulatory peritoneal dialysis (CAPD) therapy. The aim of the present investigation was estimation of incidence and risk factors of the malnutrition development in CRF patients treated with CAPD. Nutritional status was studied in 244 PD patients (97 women, 146 men; age 59.58±16.55 years) being under CAPD during 1-104 (median 30) months. Anthropometric (body mass index, dermato-fatty fold over 3-headed muscle, Subjective Global Assessment SGA, normalized protein catabolic rate nPCR) and biochemical indices (hemoglobin Hb, serum albumin SALB, serum pre-albumin Spre-ALB, serum cholesterol SChol) were used for nutritional status estimation. The overall mean body mass index was 28.18±47.11. The mean level of hemoglobin was 101.30±23.81 g/L, Scr was 857.28±336.17 umol/L, KT/V was 2.25±0.73. The overall mean SALB was 30.67±5.58 g/L, 74.2% patients on low SALB (SALB <35 g/L). The mean level of Spre-ALB was 331.63±91.43 mg/L, 35.66% patients on low Spre-ALB (Spre-ALB <300 mg/L). The mean level of PCR was 0.93±0.24 g/kg.d, 59.01% patients on low level PCR (PCR <1 g/kg.d). The mean dermato-fatty fold over 3-headed muscle was 13.42 mm. 25% patients had a SGA score of 1-4(malnutrition range). The prevalence of malnutrition was 18.03%. The main cause (44.6%) of death is infection in our study, and the majority of these patients were complicated with different level of malnutrition. In conclusion, the results indicate that malnutrition is quite common and plays an important role in mortality in CAPD patients independent of dialysis efficacy and prevention or treatment of malnutrition by suitable means is necessary to improve clinical outcomes in CAPD patients.

Malnutrition (Subjective Global Assessment) Scores and Serum Albumin Levels, but not Body Mass Index Values, at Initiation of Dialysis are Independent Predictors of Mortality: A 10-Year Clinical Cohort Study

To examine the associations between demographic, clinical, lifestyle, and nutritional parameters at the start of dialysis and mortality, including the combined effects on nutritional parameters, which were seldom investigated in the literature. Ten-year retrospective clinical cohort study. Dialysis unit of a metropolitan tertiary teaching hospital in Sydney, Australia. Incident dialysis patients (n = 167; hemodialysis, 57.5%; male, 61.7%; age, 65.3 ± 13.6 years; diabetic, 24.5%) who commenced on a planned dialysis program. Associations were examined between all-cause mortality and baseline demographics, including age and gender; clinical and lifestyle characteristics, including glomerular filtration rate, smoking habits, presence of comorbidities (e.g., coronary artery disease, diabetes mellitus, and peripheral vascular disease); and nutritional parameters, including body mass index (BMI), serum albumin (s-albumin) levels, and subjective global assessment score (SGA). Associations with combination values for malnutrition, s-albumin (<3.3 vs. ≥3.3 g/dL), and BMI (<26 vs. ≥26 kg/m(2)) were also examined. Median survival was 54.2 months (interquartile range, 23 to 83), and 52.1% of patients were malnourished (SGA score B and C) at the start of dialysis. Advanced age (classified as >65 years, P < .0001), presence of peripheral vascular disease (P < .0001), reduced s-albumin levels (P = .01), and malnutrition scores (P = .02) independently predicted mortality. Being overweight and obese (BMI: ≥26 kg/m(2)) did not show any advantage on survival (P = .73). Being malnourished and overweight (or obese) was associated with a 3-fold increase in mortality risk (adjusted hazard ratio [HR], 2.96; 95% confidence interval [CI], 1.12 to 7.33; P = .02) compared with being well nourished with a BMI <26 kg/m(2) (referent). Compared with being well nourished (SGA = A), being malnourished with normal or low s-albumin was associated with higher risk (HR, 2.06; 95% CI, 1.06 to 4.00; P = .03 and HR, 2.86; 95% CI, 1.65 to 4.94; P < .0001, respectively). There was no statistical difference between mortality risks through any combination of s-albuminand BMI values (P = .54). Malnutrition and reduced s-albumin levels were found to be independent predictors of mortality, whereas being overweight and obese did not show protective effects.

Nutritional status evaluation and survival in haemodialysis patients in one centre from Romania

Protein-energy wasting is a common complication and an important predictive factor for mortality in chronic dialysis patients. Therefore, nutritional status needs to be regularly assessed in these patients, by using several methods, and, if malnutrition is present, its possible causes should be thoroughly searched for and properly treated. In 149 prevalent haemodialysis patients (82 men, mean age 53.9 +/- 13.7 years), we evaluated the nutritional status by anthropometrics [post-dialysis height (H), body weight (BW), body mass index (BMI), mid-arm circumference (MAC), tricipital skin-fold thickness (TST), mid-arm muscle circumference (MAMC), corrected mid-arm muscle area (cMAMA) and three-category subjective global assessment score (SGA)], biochemical tests [protein equivalent of nitrogen appearance (nPNA), and pre-dialysis serum albumin, creatinine, total cholesterol, bicarbonate and haemoglobin (Hb) levels] and bioelectrical impedance analysis (BIA) to estimate body composition [percent body fat (%BF), fat-free mass (%FFM), body cell mass (%BCM), extracellular mass (%ECM) and the phase angle (PhA)]. Age was found to be positively correlated with BMI (P = 0.001), and inversely correlated with %BCM (P = 0.013). Patients with A-category SGA were significantly younger (50.1 versus 63.7 years) than those with B-category SGA. Patients with diabetes had lower %BCM (32.9 versus 35.9%; P = 0.035) and PhA (5.5 versus 6.9 degrees ; P = 0.0007) than those without diabetes. The presence of heart failure was associated with significantly reduced nPNA (1.17 versus 1.34 g/kg day; P = 0.014), MAMC (22.0 versus 23.6 cm(2); P = 0.041), %BCM (33.0 versus 36.1; P = 0.021), PhA (5.8 versus 7.0 degrees ; P = 0.031), serum albumin (39.7 versus 42.4 g/l; P = 0.013) and serum creatinine (8.1 versus 9.4 mg/dl; P = 0.010), and with a higher percent of B-category SGA (47.8% versus 22.6%; P = 0.019). Eleven deaths (7.4%) occurred during the follow-up period. Among general factors, age >or= 55, the presence of diabetes, and dialysis vintage <2 years were associated with significantly reduced survival. Among nutritional factors, B-category SGA, nPNA <1.2 g/kg day, %BF <15% and PhA <6 degrees significantly predicted mortality in both Kaplan-Meier and Cox analyses. The most important risk factor appeared to be nPNA; for every 0.1 g/kg day increase in nPNA, death risk decreased by 15%. In our haemodialysis patients, advancing age, diabetes and heart failure were associated with worse nutritional status, as estimated by anthropometry, biochemical markers and BIA. Age >or=55 years, the presence of diabetes, nPNA <1.2 g/kg day, lower SGA score, %BF <15% and PhA <6 degrees were associated with significantly increased death risk.

Decline in SGA Score, Hospitalization, & Death in New Start Hemodialysis Patients

Decline in SGA Score, Hospitalization, & Death in New Start Hemodialysis Patients

Elevated acylcarnitine (AC) concentrations are associated with lower physical composite scores (PCS) in hemodialysis (HD) patients

The physical composite score of the SF36 is a measure of an individual’s perceived physical functioning. Acylcarnitine intermediates are a reflection of mitochondrial metabolism. The purpose of this study was to determine whether HD patients with high AC concentrations had lower physical functioning as measured by the SF36. This is a secondary analysis of baseline data from a clinical trial conducted in HD patients with PSC of less than 35, a free carnitine of less than 40mmol/L, and received HD 3 time a week. The AC was measured from plasma at baseline using HPLC/MS/MS; SF36 was conducted within 2 weeks of the plasma collection. SPSS vs 14.0 was used to analyze the data and significance was defined as p<0.05. 40% of the sample (n=38) were female, 88% were Caucasian, and 42% had diabetes. The mean age, albumin, mid-arm muscle circumference and PSC were 71+12years, 3.8+0.3mg/dL, 26.1+5.0cm, and 28.5+7.6, respectively. PCS was correlated with the following AC concentrations: octanoyl (r=−0.5), lauroyl (r=−0.5), trans-2-dodecenoyl (r=−0.4), myristoyl (r=−0.4), palmitoyl (r=−0.6), and plamitoleoyl (r=−0.5), respectively. No differences were found between gender, etiology, ethnic group or SGA score in the correlated intermediates. These results indicate that as AC concentrations increase perceived physical functioning decreases in hemodialysis patients.

Nutritional and inflammatory status influence darbepoetin dose in pre-dialysis elderly patients

Anaemia is a common finding in elderly patients particularly in those with chronic kidney disease. Effective correction of anaemia improves survival and quality of life. The association between anaemia and a poor nutritional status as well as the presence of inflammation has already been documented. The aim of our study was to assess the impact of the nutritional and inflammatory status on darbepoetin dose requirements of elderly patients followed in a "Chronic Kidney Disease" outpatient clinic. We included 71 elderly patients (age>or=65 years) in a "Chronic Kidney Disease" outpatient clinic. Creatinine Clearance (CrCl) was estimated according to the Cockroft-Gault equation. Nutritional status was evaluated by biochemical and anthropometric parameters. Tumour Necrosis Factor-alpha (TNF-alpha), Interleukin-6 (IL-6) and high sensitivity C-reactive protein (hs-CRP) were used as biomarkers of inflammation. Our patients (56% males) with a mean age of 76.2+/-6.6 years were followed for 33.1+/-43.6 months. Mean eCrCl was 13.5+/-7.2 ml/mn/1.73 m2. All patients were under supplemental iron therapy and 74.7% needed darbepoietin (0.762+/-0.6 (microg/kg/week) to correct anaemia. Among the several variables regressed on darbepoietin dose, in a multiple regression model, only Hb, IL-6 and TNF-alpha levels and SGA score predicted the need for higher doses of darbepoietin. (r=0.677; r2=0.459). In Conclusion, in our pre-dialysis elderly patients, markers of a poor nutritional status (SGA and albumin) and inflammation (IL-6 and TNF-alpha) independently predicted the use of higher doses of darbepoietin to correct anaemia.

Relation between number of prescribed medication and outcome in peritoneal dialysis patients

Many patients with end-stage renal disease need to take a large number of medications. In the present study, we studied the magnitude of problem and explored the relationship between the number of prescribed medications and the clinical outcome of a large cohort of prevalent peritoneal dialysis (PD) patients. We studied the medication list of 266 prevalent PD patients. Dialysis adequacy, residual renal function and nutritional assessment were also performed. The patients were followed for 33.7 +/- 20.7 months. On average, each patient required 4.7 +/- 1.8 type of medications or 10.0 +/- 4.9 tablets per day. 40 patients (15.0%) needed at least 7 types of medication; 33 patients (12.4%) had to take more than 15 tablets each day. There is a significant but weak correlation between the number of types of medication and the Charlson's comorbidity score (r = 0.252, p < 0.001). Despite the large number of medication prescribed, the blood pressure control, serum cholesterol level, and the use of aspirin after atherosclerotic disease remained suboptimal in many patients. By multivariate analysis, independent factors for patient survival were Charlson's comorbidity score, number of types of medication, duration of dialysis, overall SGA score, and mean arterial blood pressure. Each additional type of medication conferred 20% increase in risk of death (95% CI, 1.6-41.7%, p = 0.032), and the effect is independent on the Charlson's comorbidity score. The actual number of pills taken by a patient did not influence survival in this model. Our results indicate that the number of prescribed medications is related to the clinical outcome of PD patients. The number of prescribed medication may reflect the severity of uremic complications and comorbid diseases not reflected by the Charlson's comorbidity score. Nevertheless, dialysis physicians should carefully balance the clinical need of treating multiple medical conditions with the potential problems of a complicated therapeutic regimen.

Assessment of nutritional status in CAPD patients: serum albumin is not a useful measure.

In CAPD patients serum albumin is frequently used as an index of nutritional status, although it is recognized that hypoalbuminaemia may be caused by many factors. We have further examined the relationship between serum albumin and nutrition. Nutritional status was assessed by biochemistry, anthropometry, mid-arm muscle circumference, muscle strength (hand grip and back), and lean body mass (from anthropometry, creatinine kinetics and bioimpedance) in a group of 76 stable CAPD patients. Correlations between biochemical and nutritional parameters were sought and data were compared between patient groups defined by serum albumin (> or = 37 vs < 37 g/l on two occasions 2 months apart) and separately according to subjective global assessment score (normal nutrition, A vs mild to moderate, B, and severe, C, malnutrition). In patients with a low SGA score, actual body weight, body mass index, mid-arm muscle circumference, lean body mass, subscapular skinfold thickness, hand grip strength (males and females) and iliac and triceps skinfold thicknesses and back strength (females only) were all significantly less than in patients with a normal SGA score. In contrast, none of these variables differed in either gender when patients were compared according to serum albumin. Serum albumin was correlated with serum creatinine (r = 0.45, P = 0.01), daily urine protein excretion (r = -0.42, P = 0.02) and uncorrected weekly creatinine clearance (r = -0.39) in females, but not with any index of body composition in either gender. Whilst SGA identified a patient group with significantly abnormal body mass, muscle mass and muscle strength, serum albumin did not. Serum albumin is not a useful marker of malnutrition in stable patients on CAPD.