Malnutrition in Haemodialysis – is there a link with haemoglobin?

L Wells, R Wolfenden, S Jorgensen, D Richardson, C Jones

York Hospital

Problem: Anaemia is an almost universal complication of ESRF. The UK Renal Association guidelines recommend that renal units achieve a specific haemoglobin outcome in patients treated by haemodialysis (HD) and renal units are audited against this in the Renal Registry report. The MDT can influence a number of factors that determine haemoglobin outcome, predominantly EPO dose and availability of adequate iron stores. Malnutrition is also common in this patient group. Manipulation of nutritional state is less straightforward than altering EPO and iron doses.

Purpose: As part of our routine nutrition assessment audit we wished to examine whether or not malnutrition was related to haemoglobin in our haemodialysis population.

Design: Anaemia management in our HD unit is determined by a computer algorithm that gives a fixed haemoglobin outcome. This is the ideal situation in which to examine factors that influence haemoglobin. All patients have an annual nutrition assessment, including 3 day food intake, subjective global assessment (SGA) on a 3‑ and 7‑point scale (SGA), triceps skinfold thickness, mid arm muscle circumference (MAMC), dry weight, BMI, relevant biochemistry and a composite nutritional score (comprising both subjective and objective measurements).

Findings: 104 patients had a full nutritional assessment completed. Data was compared to recognised nutritional standards and correlations between markers of malnutrition were sought. Patients who were malnourished, as shown by SGA score of B vs A on a 3‑point scale, had a lower mean haemoglobin (10.9 ± 2.0 vs 12.0 ± 1.7; p=0.02). In univariate analysis, haemoglobin was negatively correlated with C‑reactive protein and positively correlated with 7‑point SGA (higher score = better nutritional state), dietary protein and calorie intake, and serum albumin. CRP did not correlate with any nutritional parameter. In a multivariate analysis CRP and composite nutritional score were independently associated with haemoglobin.

Conclusion: These results indicate that patients who are malnourished have a significantly worse haemoglobin outcome. This is independent of elevated inflammatory markers.

Relevance: Detailed assessment and management of poor nutrition is an important part of anaemia management.