Effect of nutritional counseling in the form of individualized meal

plan on serum albumin level among Hemodialysis patients

Author:Suheir Abdallah Khalil,Ph.D

Consultant Clinical Nutrition, Acting Chief- Clinical Nutrition Department
King Faisal Specialist Hospital & Research Center Jeddah, KSA

Co. Author:Prof. Yousif Babiker Yousif

Professor of Clinical Nutrition, Ahfad University for Women, Khartoum/Sudan
 Global Facts: About Kidney Disease

• CKD is a worldwide public health problem.

• 10% of the population worldwide is affected by CKD, and millions
die each year.
• According to the Global Burden of Disease study, CKD was ranked
27th in the list of causes of total number of deaths worldwide in
1990, but rose to 18th in 2010.
• In 2013, nearly one million people died from CKD . it is a 135%
increase from the number of CKD -related deaths in 1990
• Among the major non-communicable killers (nearly 70 % of all
deaths globally), one of the lesser-recognized but increasingly
significant causes of death is CKD
Stages of CKD
 ESRD

United States: The number of patients diagnosed with

ESRD is increasing by 5% each year. After one year of
treatment, those on dialysis have a 20-25% mortality
rate, with a 5-year survival rate of 35%.

Worldwide: The numbers are staggering. Estimates are

that 2 million people worldwide suffer from ESRD, and
the number of patients diagnosed with the disease
continues to increase at a rate of 5-7% per year

Source
U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of End-Stage Renal Disease in the United States,
National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014.
 Complications of ESRD on Dialysis

Hypoalbuminemia
Hyperphosphatemia
Hyperkalemia
Fluid Overload

Nutrition in HD is very important in decreasing complications &

improving quality life of patients.

Hypoalbuminemia is a serious problem with kidney disease pt

 Hypoalbuminemia

Non-nutritional
factors
Infection
Nutritional factors
Inflammation
Poor energy &
Co-morbidities protein intake
Fluid overload Anabolic &
Inadequate dialysis catabolic stage
Blood loss
Metabolic acidosis

Hypoalbuminemia is a medical condition where levels of albumin in blood serum

are ↓ & Treatment focus on its underlying cause
• Some studies (Beddhu 2002, Panichi 2006)
describe hypoalbuminemia in HD patients as a
strong indicator for mortality & morbidity.
• As a result of malnutrition, albumin synthesis
decreases and develops hypoalbuminemia.
Assessment of Nutrition status with ESRD on HD

As Assessment of the nutrition status is an integral part of the

nutrition management. Several parameters should be evaluated
together including:

▪ Weight loss Several

history biochemical
markers
▪Dietary protein & Of these, serum
energy intakes (serum albumin,
albumin has so far
prealbumin, &
▪Subcutaneous fat been the most
transferrin)
& muscle mass commonly used
have been used to
▪ BMI
evaluate visceral
▪ SGA protein stores.
 Serum Albumin
• one measure of total body protein, both muscle & visceral
which is the most frequently used marker of protein status and
is the standard recommended by KDOQI to be used in assessing
the nutritional status among CKD.
• A strong marker for the evaluation of malnutrition (estimated
prevalence of 10-70%) and Hypoalbuminemia among HD
patients
• A decreased albumin results in an increased in morbidity &
mortality. Which has been shown for ESRD patients whose
albumin is below 4.0 g/dL, and result in an excess risk of death.
• Serum albumin level at dialysis initiation is an
independent risk factor for mortality
• Serum albumin ≥ 4.0 g/dL at initiation of dialysis is
associated with reduced mortality risk.
• Only 11% of new dialysis patients had serum albumin
≥ 4.0 g/dL
• There are 0.2-0.5 g/kg or 10-14 g/day of protein, amino acids (aa) and peptide
losses with the dialysis fluid during HD
• pt do not consistently take the recommended amounts of energy and protein
for ESRD patients on HD (which lead to hypoalbuminemia). In research, it is
emphasized that the inadequate protein intake increases mortality
• The lost in amino acids needs to be replaced to avoid negative nitrogen
balance.
• According to "KDOQI)" and studies by other investigators, dietary protein
should be adjusted at least 1.2 g/kg/day in HD patients.
• According to ESPEN, adjusted diet protein should be consumed as 1.1-1.2
g/kg/d and should be high in the biological value (of animal origin) of 50 %
protein in HD patients.

Low quality
High quality

• Animal protein • plant, protein

• comes from milk, meats, • comes from vegetables,
chicken, fish, and eggs breads, and cereals
• and contains all the needed • and is lacking in some of the
ingredients for tissue growth. ingredients tissues need to
grow.
•They are in need of individualized meal plans but they rarely
consult a dietitian.
• A special diet is needed for ESRD patients on HD.
• Recommended daily nutrients intake for an adult on HD are

Recommended daily nutrients intake for an adult on HD

Nutrients Recommendation

Calorie 30-35 (30>60yr,35<60yr) kcal/kg/day

Protein 1.2 gm/kg/day

Phosphorus 17 mg/kg/day

Potassium 40 mg/kg/day

Fluids urine output + 500-750 ml/day

• Individual Diet must be followed up closely by renal dietitians

renal dietitian will

figure out the needs
to include a mixture of
50% both. 50%

10-14 g free amino acids lost per treatment during dialysis

 This was an intervention study
to evaluate the effect of
nutritional counseling in the
The purpose of the study form of individualized meal
plan on serum albumin level
among HD patients.
 The study was conducted
on MHD patients
Methods: attending one of the
biggest HD Center in
Khartoum.
 Inclusion Criteria
• ESRD patients on regular HD (2-3
times weekly)
• Patient, who dialyzed for at least 3
months, dialyzed 4 hours per session
• Both sexes ˃18 years of age
• Consent given for participation in
the study
• Absence of active underlying disease
• Absence of active infection (free
from infections and inflammations)
• No requirement for hospitalization
during the month preceding the
study
Exclusion Criteria
• Patients younger than 18 years of
age
• Having infections or inflammations,
• having any underlying disease
• on hospitalization during the
month preceding the study
• Not on regular HD receiving HD
more or less than 2-3 times per
week.
• Refuse to sign Consent form
• 134 adult patients (males & females) were divided into a test
group (n=77) and a control group (n=57).
• The test group after nutritional counseling, consumed
individualized diets for a period of 6 months that provided
adequate amounts of energy and protein according to the
recommendations of the National Kidney Foundation while
the control group continued consuming their usual diets.
• Serum albumin was determined at baseline and every 2
months.
• Data were analyzed using SPSS.
Nutritional status differences of the study patients according to changes in serum
albumin in both groups.(n=134)

baseline
2 mo
4 mo
6 mo
 Result & Discussion:

• In this study, baseline serum

albumin levels were similar in
both groups
• values obtained were below the
4.0 g/dl recommended by
NKF/DOQI for adults on HD
• which reflects the high incidence
of hypoalbuminia among both
groups.
 Result & Discussion:
• After 6 months serum albumin
levels increased in the test group
but not in the control one; the
difference was highly significant
within the test group (P=0.000)
and between the test and
control groups (P=0.000).
• This is explained by the higher
intake of energy and protein by
the test group which showed
gradual increases in the albumin
level during the intervention
period.
 Conclusion:

• The study demonstrated that effective nutritional counseling

rendered to MHD patients in the form of individualized meal
plans that provided adequate energy & protein was effective in
the control and improvement of serum albumin level among
these patients.
• Therefore, nutritional counseling by qualified dietitians should be
mandatory in renal units as part of the medical therapy
management to reduce the incidence of hypoalbminemia among
HD patients.
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 rawansahr@hotmail.com
King Faisal Specialist Hospital & Research Center Jeddah, KSA