HUE UNIVERSITY
UNIVERSITY OF MEDICINE AND PHARMACY
VO THANH HUNG
STUDY ON MALNUTRITION STATUS AND SERUM LEPTIN
LEVELS IN END-STAGE RENAL DISEASE PATIENT IS ON
MAINTENANCE HEMODIALYSIS AND OUTPATIENTS
CONTINUOUS PERITONEAL DIALYSIS
Specialized: INTERNAL MEDICAL
Code: 9 72 01 07
SUMMARY THESIS OF MEDICAL DOCTOR
HUE - 2020
The study was completed at:
College of Medicine and Pharmacy, Hue University
Science instructor:
Assoc. Prof, PhD HOANG BUI BAO
University of Medicine and Pharmacy, Hue University
Reviewer 1: Assoc. Prof, PhD VU DINH HUNG
Binh Duong Medic General Hospital
Reviewer 2: Assoc. Prof, PhD HA HOANG KIEM
Military Hospital, Viet Nam Military Medical University
Reviewer 3: Assoc. Prof, PhD DINH THI KIM DUNG
Hanoi Medical University
The thesis will be defended in front of the doctoral evaluation council
at Hue University
Meeting at:……………………………………………………………
At: ......... time ........ date ......... month 2020.
The dissertation could be found in:
- National Library of Vietnam
- Learning Resource Center – Hue University
- Library of Hue University of Medicine and Pharmacy
1
BACKGROUND
Malnutrition has been identified as one of the most important
problems in patients with Chronic Kidney Disease (CKD) because it
increases the progression of kidney disease on the one hand (reduces
glomerular filtration rate and blood flow to the kidneys) in
combination with inflammation and cardiovascular diseases increases
mortality. In addition, malnutrition damages the function of the
proximal renal tubules, as evidenced by an increase in the excretion
of amino acids and phosphates. Malnutrition is a risk of death risk for
end-stage renal disease due to decreased serum albumin, which
promotes faster progression of renal failure. In France, the study of
Aparicio Michel et al. Showed that in one patient undergoing
hemodialysis treatment, one third of malnourished patients account
for 20% - 36%. Therefore, any treatment strategy that improves
energy consumption and nutritional quality affects the outcome and
quality of life of patients on renal replacement therapy.
Leptin is one of the first discovered adipokin of adipose tissue
and confirms the important role of adipose tissue as an endocrine
organ. Leptin helps to regulate the metabolism in the body by
stimulating energy expenditure, inhibiting ingestion. Leptin normalizes
immune function that is inhibited by malnutrition and leptin
deficiency. Leptin in the blood is excreted mainly by the kidneys.
For these reasons, we conduct a research project: "Study of
malnutrition and serum leptin concentration in patients with chronic
kidney disease on dialysis and continuous outpatient peritoneal
dialysis", in order to the following goals:
1. To investigate of malnutrition by using indicators: SGA_3,
Body Mass Index, serum prealbumin, serum albumin, normalized
protein catabolic rate (nPCR) and serum leptin concentration in
patients with chronic kidney disease are on Hemodialysis and
continuous peritoneal dialysis at Can Tho General Hospital.
2. To find the factor related malnutrition, serum leptin levels
and clinical, subclinical, and all-cause mortality in 12 months in these
two patient groups.
2
Chapter 1: OVERVIEW
1.1. OVERVIEW OF CHRONIC KIDNEY DISEASE
1.1.1. Epidemiology
In the United States, the statistics of the National Health and
Nutrition Examination Survey (NHANES) on the proportion of
patients with Chronic Kidney Disease (CKD) have been increasing
in recent years. CKD for adults accounts for the following years:
from 1999 to 2014 the percentage of CKD increased over time. The
percentage of patients with CKD from phase 1 to stage 5 is as
follows: from 1999-2002, there were 13.9% (12.9-14.8%), 20032006 up to 14.4% (13.1 -15.7%), 2007-2010 had 13.4% (12.6-14.2%)
and 2011-2014 up to 14.8% (13.6-16.0%) had CKD. Increasing CKD
rate, in the US for subjects greater than or equal to 66 years. The
mortality rate for CKD patients aged 66 years or older has decreased
by 31.5% since 2002, from 197 deaths per 1,000 patients per year to
135 deaths in 2014.
1.1.2. Define
Chronic Kidney Disease (CKD) is a structural or functional
kidney damage that persists for more than 3 months, manifested by
albuminuria, or visual abnormalities or impaired renal function
identified through Glomerular filtration rate <60 ml / minute / 1.73 m2.
1.1.3. Staging of Chronic Kidney Disease (CKD).
Over the 12 years since the American Nephrology Association
published guidelines for the diagnosis, classification and strategies for
chronic kidney disease, CKD has been updated several times: 2002,
2009 and now 2012.
Table 1.2. Classification of CKD stage according to American
Nephrology Association 2012.
Glomerular filtration rate
Stage
Description
(mL/min/1.73 m2)
1
≥ 90
Normal or high
2
60 – 89
Mitigation
3a
45 – 59
Mitigation – moderate
3b
30 – 44
Moderate-severe reduction
4
15 – 29
Heavy reduction
5
< 15
End- stage renal disease
3
1.2. NUTRITION IN CHRONIC KIDNEY DISEASE PATIENTS
WHO ARE ON HEMODIALYSIS AND CONTINUOUS
PERITONEAL DIALYSIS PATIENTS
1.2.1. Definition of malnutrition
According to the World Health Organization (WHO),
malnutrition is an imbalance in the supply of nutrients and energy
compared to the body's need for cells to ensure the development of
malnutrition and maintain the operation of their specialized functions.
1.2.3. The causes of malnutrition in patients with chronic kidney
disease who are on hemodialysis and continuous outpatient
peritoneal dialysis
Causes of malnutrition in CKD patients include:
Providing inadequate food intake: caused by anorexia when
serum urea level increases, changes in taste, repetitive disease,
psychological depression due to illness, prescribed diet unappetizing.
Associated pathology: infection, diabetes, cardiovascular
disease, oral problems.
Dialysis process: promotes the elimination of nutrients such
as: (amino acids, peptides, proteins, glucose, water-soluble vitamins
...) and promotes protein catabolism.
Chronic kidney disease causes inflammation and can
promote protein catabolism, anorexia.
1.2.4. Methods of assessing nutritional status
1.2.4.1. Subjective Global Assessment (SGA) (Appendix 1)
In 1986, Destky et al., The study determined the nutritional
status of patients undergoing gastrointestinal surgery and was then
widely applied in the community.
1.2.4.2. Nutrition evaluation method according to Body Mass Index (BMI)
BMI = Current body weight (kg) / Height (m)2.
Currently, the World Health Organization (WHO) recommends
using Body Mass Index (BMI,kg/m2) to evaluate nutrition status
classification. BMI is often used to classify underweight or obesity in
adults. BMI depends on muscle mass, fat mass and the total amount of
water contained in the body. However, for the elderly and best used for
those aged 20 to 65 years old is appropriate.
1.2.4.3. Serum prealbumin role in nutritional evaluation
In 2002, Beck Frederick K. et al., Published the following
criteria to diagnose nutritional risks according to prealbumin: serum
4
prealbumin < 0.5 g/L (<50 mg/L): severe malnutrition; 0.5 g/L ≤
serum prealbumin <1.5 g/L: mild malnutrition; 1,5 g/L ≤ serum
prealbumin ≤ 3.5 g/L: no malnutrition (normal).
1.2.4.4. Serum albumin in the evaluation of nutrition in CKD patients.
The World Health Organization (WHO) defines malnutrition as
an "inadequate nutrient" situation characterized by "deficiency or excess
of protein intake, lack of energy and disorders of micronutrients like
vitamins". This definition implies that protein malnutrition (known as
"malnutrition") will improve when the deficient nutrients are provided
more adequately: albumin serum ≥ 35g/L is classified as not
malnourished; 28g/L < albumin serum <35g/L called mild malnutrition;
albumin serum ≤ 28g/L is called severe malnutrition.
1.2.4.5. Normalized Protein Catabolic Rate (nPCR, g/kg/day)
* The basics of nPCR (Normalized Protein Catabolic Rate)
In 2000, K/DOQI made the following recommendations on
clinical practice issues regarding nutrition for CKD patients as follows:
The protein supply to dialysis patients with CKD is limited to
about 1.2 g/kg body/day.
At least 50% of patients on protein diet should receive
additional bio-protein in the diet in dialysis patients.
See, an increase in mortality has been demonstrated when
nPNA (similar to nPCR) is less than 0.8 or greater than 1.4 g/kg/day,
while nPCR is considered to be the best recorded with the level
between 1.0 - 1.4 g/kg/day.
* Calculation of PCR
PCR is usually calculated in g/kg/day, a parameter called
standardized PCR (nPCR). Rarely, PCR is not normal for weight and
is measured in g/day.
* Hemdialysis patients: Calculation of nPCR (g/kg/day).
nPCR = 0.22 +
0.036× ID rise in BUN × 24
ID interval hrs
Note:
ID rise in BUN: Concentration of urea before filtration of the
first filter minus the amount of urea after filtration of the next filtration.
ID interval (hrs): Time after finishing the first filter to the
beginning of the next filter.
5
Other formula for calculating nPCR from Kt/V:
nPCR = (0.0136 x F) + 0.25
Inside:
F = Kt / V x ([urea before filtration + urea after filtration] ÷ 2)
* For patients with continuous peritoneal dialysis
Formula for calculating PCR:
PCR = 6.25 x (Serum Urea concentration + 1.81 + [0.031x
body weight (kg)])
The final time in this formula reflects the contribution of the
protein metabolism.
Serum Urea concentration = (Vu x Cu) + (Vd + Cd)
In which: V and C are volume and concentration of urea
concentration in urine (u) and (d) filtrate.
1.3. LEPTIN
1.3.1. Origin and structure of leptin serum
Leptin is a cytokin-like hormone discovered in 1994. It is
considered to be the most important invention related to obesity.
Leptin is considered to be one of the main products excreted from fat
cells. The word leptin comes from the Greek word: leptos means
thin. This is a 16 kDa molecular weight polypeptide containing 167
amino acids. Subcutaneous adipose tissue secretes more leptin than
visceral adipose tissue. Small amounts of leptin are also secreted
from stomach tissue, placenta, muscle and brain. The secretion of
leptin is regulated by many factors such as: Glucocorticoid, acute
infection, pre-inflammatory cytokin concentration ...
1.3.2. Leptin regulates body weight
Obesity is characterized by an increase in fatty acid storage
in adipose tissue mass and is closely associated with the development
of insulin resistance in peripheral tissues such as muscle, bone and
liver. In addition to being the largest fuel source in the body, adipose
tissue and macrophages are also the source of several secreted
proteins. Leptin plays an important role in regulating the body's
metabolism by stimulating energy expenditure, inhibiting ingestion.
1.3.3. Leptin effect on the kidneys
The scientists found that leptin was associated with
glomerular filtration rates in humans. When the leptin molecule is
14-16 kilodaltons, it has the ability to filter in the glomeruli. To
assess the role of the kidney in eliminating leptin in the blood, the
6
scientists conducted leptin tests in the aorta and renal veins from
patients with different levels of glomerular filtration. At the same
time, measurement of the difference in renal leptin concentration and
plasma flow rate in the kidney activates kidney function.
1.3.4. Serum leptin in patients with end-stage renal disease (ESRD)
The serum leptin (ng/mL) is excreted primarily by the
kidneys, indicating that serum leptin will be elevated in patients with
end-stage chronic kidney disease. Several studies have found this
correlation. In a study of 37 patients with chronic kidney disease on
dialysis, it was found that pre-dialysis leptin was quadrupled
compared to a group of 331 healthy subjects (37.6 ± 10.6 ng/mL vs
8.25 ± 7.25 ng/mL, with p = 0.01). Body Mass Index (BMI, kg/m2),
positively correlated with serum leptin (1.30 ± 0.32 ng/mL vs 0.29 ±
0.01 ng/mL, with p = 0.005). Another study found similar results,
independent of 141 patients with end-stage chronic kidney disease,
who found average values in both sexes (male, 26.8 ± 5.7 ng/mL and
female, 38.3 ± 5.6 ng/mL) were significantly higher (statistically
significant (with p = 0.001) compared to the normal subjects (male,
11.9 ± 3.1 ng/mL) and female, 21,2 ± 3,0 ng/mL).
1.4. DOMESTIC AND FOREIGN RESEARCH
In 2017, Trang Thi Khanh Ngo, studied the characteristics
and prognostic value of malnutrition - inflammation - atheroma
syndrome in patients with chronic kidney disease (including 174
patients, 57 chronic kidney disease patients without dialysis, 56
outpatient continuous dialysis patients and 61 hemodialysis patients).
This author recorded a malnutrition rate of 36.8%, inflammation
21.3% and atherosclerosis 50.6%.
In 2015, Ponnudhali D, et al., India, studied Protein energy
and nutrition in CKD patients related to leptin and insulin roles.
Group one (n = 45) is a chronic kidney disease without diabetes;
group two (n = 45) healthy people without diabetes and with normal
renal function. The results were as follows: serum leptin (ng/mL) in
group one increased very high by 24.15 ± 17.44 ng/mL compared to
group two 7.5 ± 1.28 ng/mL with significant differences statistics
(with p = 0.0001). It was found that serum leptin and blood insulin
were positively correlated with CKD patients.
7
Chapter 2: SUBJECTS AND METHODS OF RESEARCH
2.1. RESEARCH SUBJECTS
Our study subjects included 259 patients with end-stage renal
disease who were undergoing renal replacement therapy (including 207
hemodialysis patients and 52 continuous peritoneal dialysis patients).
The study period is from June 2015 to June 2016.
Research location: Internal Kidneys, Urology and Dialysis
Department - Can Tho General Hospital.
2.1.1. Criteria for selecting a disease
+ End-stage renal disease
+ Hemodialysis with cycle time of 3 months or more.
+ Continuous peritoneal dialysis patients from 3 months or more.
+ Hemodialysis ensures 12 hours/week and continuous peritoneal
dialysis with 4 filtration times/day (2 liters peritoneal dialysis/1 time).
+ Hemodialysis patients are allowed to use one type of gampro
filter and bicarbonate filter fluid. Outpatient continuous dialysis
patients using Dextrose 1.5% dialysis solution; 2.5% of Baxter.
+ Patients are managed outpatient treatment dialysis combined
medical treatment of anemia, hypertension ... as recommended by the
Vietnam Nephrology Association.
+ Patient agrees to participate in the study.
2.1.2. Standards excluded from study
+ Patients with sepsis must undergo continuous dialysis.
+ Patients with severe coma do not participate in full dialysis
at the department.
+ Patients with stage IV severe heart failure, continuous breathing
difficulties; Large ascites cirrhosis causes persistent breathing ...
+ Patients with late stage cancers.
+ Patients on peritoneal dialysis are peritonitis, unable to
evaluate peritoneal function.
+ Patients do not agree to participate in the study.
2.2. RESEARCH METHODS
2.2.1. Research design
+ Design: cross-sectional description study
+ Sample size: choose a convenient sample size including all
patients undergoing kidney replacement therapy, who have been on
8
dialysis at the Internal Kidneys - Urology and Dialysis Department –
Can Tho General Hospital, eligible for sample selection were
selected for the study (total number of patients eligible for sample
selection was 259 patients).
2.2.2. Steps to proceed
* Exploiting and patient history in the study subjects:
* Clinical examination
+ Body: Circuits, temperature, blood pressure, edema, skin,
mucous membranes ....
+ Measure height, weight, calculate BMI.
+ Nutrition evaluation according to SGA_3 evaluation board.
* Subclinical tests:
+ Hematology.
+ Biochemistry: albumin, protein, prealbumin, urea, cretinin,
blood ion.
+ CRPhs, serum leptin ....
2.2.3. Process of implementing research variables
2.2.3.1. Hemodialysis procedure
* Hemodialysis
+ Using Polyflux 6L filter (Gampro): belongs to the type of fiber
filter, ultrafiltration (hollow-fiber dialyzer, low-flux) with the polyamix
vein membrane with a membrane area of 1.4 m2, Kuf: 8.6ml/mmHg/h.
Reuse the filter according to the regulations of the Ministry
of Health 6 times/fruit and the membrane filtration water system
(RO) is also used according to the standard procedure of the Ministry
of Health of Vietnam specified in Decision No. 2482 / QD-BYT.
April 13, 2018. RO water standards are set by the Ministry of Health
of Vietnam (Appendix 3).
* Continuous outpatient peritoneal dialysis:
The patient was placed on Baxter's gooseneck abdominal
catheter for continuous peritoneal dialysis. Patients are trained to
master self-manipulation following peritoneal dialysis procedures.
9
2.2.3.2. Quantification of serum leptin
- Reaction principle:
Figure 2.1. An illustration of the ELISA principle quantifying
leptin concentration
Normal: Male: 3.84 ± 1.79 ng/mL; Female: 7.36 ± 3.73 ng/mL.
Boden G et al. Suggested the value of serum leptin in patients
with chronic kidney disease with the following three levels: serum
leptin ≤ 3.5 ng/mL: decreased leptin; 3.5
3 months).
- Albuminuria (AER ≥ 30 mg/24 hours,
ACR ≥ 30 mg/g or 3 mg/mmol).
- Unusually urine sediment.
- Electrolyte disorders or other abnormalities
Mark of kidney
due to tubular disease.
damage (≥ 1 mark)
- An abnormal detected by histology.
- Structural abnormalities (morphological)
detected by geometric images
- History of kidney transplant.
Reduced glomerular <60 mL/min/1.73m2 (classified as GFR
filtration rate (GFR) G3a-G5)
11
* Method of implementation and evaluation of nutritional
status by SGA_3.
Patients were asked a questionnaire about their medical
history and then they were clinically examined (Appendix 1).
* Body Mass Index (BMI, kg/m2)
BMI = Current body weight (kg)/Height (m)2
According to the World Health Organization (WHO), the
threshold of adjusting BMI for Asian community is:
Table 2.3. Nutrition evaluation according to BMI.
Malnutrition
Overweight Obesity
Light Heavy
moderately
18.50 - 24.99 16.0 - 18.49 < 16.0 25.0 - 29.99
≥ 30
Normal
WHO
Southeast Asian
Diabetes
18.50 - 22.99 16 - 18.49
Association
< 16.0
≥ 23.0
2.2.5. Data processing methods
Processing data by the method of medical statistics, using
the software program SPSS 18.0, Microsoft Excel 2010, with the
help of computers.
To investigate the correlation coefficient between the
parameters, we calculate the correlation coefficient r with 95%
confidence intervals. The correlation level is calculated as follows:
.│r│ ≥ 0.7: correlated very closely.
. 0.5 ≤ │r│ <0.7: close correlation.
. 0.3 ≤ │r│ <0.5: moderate correlation.
. r <0.3: very little correlation.
. r (+): positive correlation.
. r (-): inversely correlated.
+ Draw correlation diagram automatically on Execl.
2.3. ETHICS IN RESEARCH
In the context of clinical research, medical research and other
sociological studies, the human subject must follow scientific
principles and must be based on laboratory and animal studies
previously fully and simultaneously based on thorough knowledge
from the scientific literature.
We adhere to the basic ethical standards of biomedical research,
ensure the privacy of our subjects and limit the impact of our research on
physical and mental integrity, dignity of the research object.
12
2.4. RESEARCH CHART
13
Chapter 3
RESEARCH RESULTS
3.1. GENERAL CHARACTERISTICS OF STUDY SUBJECTS
Diagram 3.1. Sex
Research subjects
Male (n=135, %)
Famale (n=124, %)
%
n
%
n
Hemodialysis (n=207)
51,2
106
48,8
101
Peritoneal dialysis (n=52)
55,8
29
44,2
23
Two group (n=259)
52,1
135
47,9
124
Comment: The two groups of patients with hemodialysis and
peritoneal dialysis were higher than men but not significantly.
Diagram 3.2. Age
Age (year)
Male (n=135)
Famale (n=124)
Research subjects
Min
Max
±
SD
X
X ± SD Min Max
Hemodialysis (n=207)
48,9 ± 13,7 17,0 84,0 49,6 ± 12,4 21,0 71,0
Peritoneal dialysis (n=52) 46,7 ± 17,4 17,0 81,0 47,8 ± 16,9 17,0 78,0
Two group (n=259)
48,2 ± 14,6 17,0 84,0 49,3 ± 13,3 17,0 78,0
Comment: The average age of the two groups: male (48.2 ±
14.6) and female (49.3 ± 13.3) are almost the same (the lowest is
17 years and the highest is 84 years).
3.2. NUTRITION SITUATION OF RESEARCH SUBJECTS
3.2.1. Nutritional status according to Body Mass Index (BMI,
kg/m2), SGA_3, albumin and prealbumin
Diagram 3.3. Nutrition assessment based on Body Mass Index(BMI)
Overweight
Normal
Malnutrition
BMI ≥ 23 18,5 ≤ BMI < 23
BMI < 18,5
Research subjects
%
n
%
n
%
n
Dialysis (n=207)
27,0 56
51,7
107
21,3
44
Peritoneal dialysis (n=52) 30,8 16
46,1
24
23,1
12
Two group (n=259)
27,8 72
50,6
131
21,6
56
Comment: The two groups of patients with end-stage renal
disease who were on hemodialysis and peritoneal dialysis assessed
nutrition according to BMI, the rate of malnutrition was almost equal.
14
Diagram 3.4. Nutrition evaluation according to SGA_3
SGA_A
SGA_B
SGA_C
Research subjects
%
n
%
n
%
n
Hemodialysis (n=207)
33,3
69
29,5
61
37,2
77
Peritoneal dialysis (n=52)
36,5
19
30,8
16
32,7
17
Two group (n=259)
34,0
88
29,7
77
36,3
94
Comment: Nutrition assessment based on SGA_3 found that the
rate of severe malnutrition of the two group accounted for 36.3%.
Diagram 3.5. Nutrition evaluation according to the serum albumin (g/L).
Albumin ≥ 35 28 < Albumin < 35 Albumin ≤ 28
%
n
%
n
%
n
Hemodialysis (n=207)
85,5
177
9,7
20
4,8
10
Peritoneal dialysis (n=52)
63,5
33
30,8
16
5,8
3
Two group (n=259)
81,1
210
13,9
36
5,0
13
Comment: The rate of malnutrition according to serum albumin
concentration in two groups of slightly malnourished 13.9% and severe
malnutrition 5.0%.
Diagram 3.6. Nutrition evaluation according to the serum prealbumin
Prealbumin 0,5 ≤ Prealbumin Prealbumin
< 0,5
< 1,5
≥1,5
Research subjects
%
n
%
n
%
n
Hemodialysis (n=207)
95,7
198
1,9
4
2,4
5
Peritoneal dialysis (n=52) 80,8
42
19,2
10
0,0
0
Two group (n=259)
92,7
240
5,4
14
1,9
5
Comment: Serum prealbumin concentration in Hemodialysis
patients group was high in serum prealbumin group <0.5 g/L, accounting
for 95.7% of severe malnutrition. All groups of patients with continuous
peritoneal dialysis had serum prealbumin concentration <1.5g/L and none
of the patients had serum prealbumin concentration> 1.5 g/L (0.0%).
3.2.2. Serum leptin (ng/mL) of study subjects
Diagram 3.8. Serum leptin of two study subjects
Leptin ≤ 3,5 3,5 < Leptin < 7,5 Leptin ≥ 7,5
Research subjects
%
n
%
n
%
n
Hemodialysis (n=207)
66,2
137
10,1
21
23,7
49
Peritoneal dialysis (n=52)
44,2
23
19,2
10
36,5
19
Two group (n=259)
61,8
160
12,0
31
26,2
68
Comment: The serum leptin (ng/mL) was as low as 3.5
0,05
Peritoneal dialysis (n=52) 96,2
50
3,8
2
Two group (n=259)
91,5
237
8,5
22
Comment: The mortality rate for Hemodialysis patients
accounted for 9.7% much higher than continuous peritoneal dialysis
after 12 months of follow-up. The mortality rate of the two study
subjects accounted for 8.5% after 12 months of follow-up.
16
Diagram 3.12. Survival and risk of death by BMI after 12 months.
Survival
Mortality
HR
(n=237, %) (n=22, %)
BMI (kg/m2)
p
(KTC 95%)
%
n
%
n
No malnutrition
92,6 187 7,4
15
Mild and moderate 91,8 45
8,2
4
1,06 (0,35-3,20)
0,916
malnutrition
Heavy malnutrition 62,5
5
37,5
3
5,31 (1,54-18,37)
0,008
Total
91,5 237 8,5
22
Comment: Hemodialysis and continuous peritoneal dialysis
patients diagnosed with malnutrition according to BMI (kg/m2),
severe malnutrition has a very high mortality rate of 37.5 % (HR:
5.31 Cl 95%; 1.54-18.37, with p = 0.008).
Diagram 3.13. Survival and risk of death by nPCR after 12 months
Survival
Mortality
HR
(n=22, %)
nPCR (g/kg/day) (n=237, %)
p
(KTC 95%)
%
n
%
n
nPCR < 0,8
61,1
11
38,9
7
23,36(4,48-112,56) 0,001
0,8 ≤ nPCR ≤ 1,2
92,2 103
7,8
2
nPCR > 1,2
90,2 119
9,8
13
5,55(1,25-24,57)
0,024
Total
91,5 237
8,5
22
Comment: Normal cabotalic protein rate (nPCR) is low
(nPCR <0.8) or high (nPCR> 1.2) respectively, 38.89% and 9.85%
are much higher than 0.8 ≤ nPCR ≤ 1.2 (g/kg/day).
Diagram 3.14. Multivariate regression analysis included nPCR,
prealbumin, albumin and proteins associated with mortality for 12 months.
Reliability 95%
Nutrition Index
B
p
RR
Low
High
nPCR (g/kg/day)
-.368
.569
.692
.195
2,453
Prealbumin HT (g/L)
-.980
.412
.375
.036
3,912
Albumin HT (g/L)
.133
.018
.876
.785
.977
Protein HT (g/L)
.049
.196
1,050
.975
1,130
Constant
-.035
.988
.965
Comment: In multivariate regression analysis including
nPCR, serum prealbumin, serum albumin and serum protein, the
serum albumin variable was associated with statistically significant
mortality (with p = 0.018) multivariate rules:
Mortality rate (Y) = 0.133 x albumin HT - 0.035.
17
Chapter 4
DICUSSION
4.1. GENERAL CHARACTERISTICS OF RESEARCH SUBJECTS
4.1.1. Sex
Among 259 patients who shared the study subjects by gender:
male 52.1%, female 47.9%. Patients with chronic kidney disease (CKD)
were on Hemodialysis, male 51.2%, female 48.8% and continuous
peritoneal dialysis, male 55.8%, female 44.2% between two equivalent
study subjects between men and women. Cuong The Phan et al, found
that men 52.4% and women 47.6%. From the above studies, the ratio
between men and women does not have much difference between men
and women. Our results also match those of other studies. This shows
that the rates of end-stage renal disease (ESRD) that can occur for men
as well as for women at home and abroad are almost the same.
4.1.2. Age
The average age of two study subjects man (48.2 ± 14.6)
years and women (49.3 ± 13.3) years. There is not much difference in
age for the two kidney replacement treatments in ESRD patients.
Thanh Van Nguyen et al. Found that the average age was (42.8 ±
13.2) years. ESRD patients were almost the same in each study, with no
significant differences between the authors (the lowest age was 29 years
old and the highest age was 85 years old, the average age was 51 years).
4.2. NUTRITION SITUATION OF RESEARCH SUBJECTS
4.2.1. Evaluate nutrition according to BMI, SGA_3, albumin and
prealbumin
4.2.1.1. Nutrition assessment based on Body Mass Index (BMI,kg/m2)
In our study, for Hemodialysis patients, nutritional evaluation
according to BMI was 27.0% overweight, normal 51.7% and
malnourished 21.3%. For patients with continuous peritoneal dialysis, it
was 30.8%, 46.1% and 23.1%, respectively. It was found that in two
study groups, Hemodialysis and continuous peritoneal dialysis evaluated
nutrition according to BMI almost equal.
In 2016, Mai Tuyet Vuong et al. Found that the average BMI
was 19.7 ± 2.2 kg / m2 and malnutrition 31.8%, normal 61.8% and
overweight and obesity 6, 4%. Compared to the above studies, our rate
of malnutrition among Hemodialysis patients is higher than that of
foreign authors but not much, compared to that of Mai Tuyet Vuong et
al. The rate of malnutrition in our study is lower, we think the dialysis
time in our study is relatively longer and the patients in our study are
mostly poor patients. This is not good, which leads to a higher rate of
malnutrition according to BMI in our study.
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4.2.1.2. Nutrition evaluation according to SGA_3
Our research results, nutrition evaluation based on SGA_3
found in the hemodialysis patients group: 33.33%, 29.47% and 37.20%,
and continuous peritoneal dialysis: 36.54%, 30.77% and 32.69%.
Nutrition rate of SGA_3 determined by SGA_3 method is quite
high in many studies showing the risk of nutrition in patients with ESRD
undergoing kidney replacement is very large. this can be seen through the
research results of the author, Thanh Van Nguyen in patients who have
not received kidney replacement therapy, the rate of nutrition accounts for
71%. In addition, when treated with hemodialysis patients or continuous
peritoneal dialysis, the rate of malnutrition will increase compared to
patients before renal replacement therapy. Because this group of patients
are at high risk of nutritis due to loss of nutrients during hemodialysis or
continuous peritoneal dialysis. In addition, nutrition may be due to
Hemodialysis patients and Continuous peritoneal dialysis, more quickly
than normal protein cabotalic rate and poor economy.
4.2.1.3. Evaluation of nutrition according to serum albumin concentration (g/L)
The percentage of non-nutritional concentrations according
to serum albumin concentration for patients with ESRD who are
outpatient dialysis and peritoneal dialysis is 85.5% and 63.5%. The
number of patients with serum albumin concentration ≥ 35 g/L is
14.5% with nutritional rigs for patients Hemodialysis (in which 28
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