End Stage Renal Disease ESRD Health And Social Care Essay

End Stage Renal Disease ( ESRD ) is defined as an irreversible nephritic failure which needs to have nephritic replacing therapy ( RRT ) or undergo long term dialysis [ 1 ] . There are three types of nephritic failure replacing therapy which are hemodialysis ( HD ) , peritoneal dialysis ( PD ) and nephritic graft. In Malaysia, Continuous Ambulatory Peritoneal dialysis ( CAPD ) patients are increasing from 1525 patients in twelvemonth 1999 to 1744 patients in December 2008, an addition of 12 % [ 2 ] . Malnutrition is really common in end phase nephritic disease patients on care dialysis [ 2 ] . In Malaysia, national information showed that merely 13 % of CAPD patients are good nourished where serum albumen is above 4.0 g/dL [ 3 ] . Majority of patients ( 87 % ) undergoing CAPD are malnourished. Protein energy malnutrition ( PEM ) is one of the most prevailing complications looking in patients undergoing dialysis and it is associated to high morbidity and mortality [ 4,5 ] . Malnutrition is an of import factor associated with increasing hazard of mortality in Chronic Kidney Disease ( CKD ) patients. Hence, it is of import to measure the nutrition position of patients. Screening for malnutrition is an of import constituent of dietary pattern and improves the ability to prioritize intercession to those most at hazard [ 6 ] . Early acknowledgment and intervention can give better outcome [ 7 ] . Nutrition showing is a executable option for placing patients at hazard of PEM [ 4 ] . Screening tools are largely designed for general intents every bit good as for specific topics as aged, institutionalised person and hospitalized patients [ 4 ] . There are several showing tools available for CAPD patients. These are Malnutrition-inflammation mark ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and capable planetary appraisal ( SGA ) . Among them, none was antecedently studied for usage in Malayan chronic kidney disease patients on dialysis. The dietitian plays an indispensable function in nutritionary showing. In Malaysia, entree to dietitian is limited in most dialysis Centres. Hence, nurses will play an indispensable function to place the malnourished patients. On the other manus, a comprehensive nutritionary appraisal is time-consuming and requires both subjective and nonsubjective opinions from the tester. Therefore, important preparation is necessary to guarantee consistent consequences among assorted testers and periods of appraisal. Therefore, there is a demand for a simplified nutritionary showing tool which can be used by dieticians or nurses that can be performed easy.1.1 Objective1.1.1 Main ObjectiveTo place a simplified nutritionary showing tool which compares good with the Malnutrition Inflammation Score ( MIS ) , Subjective Global Assessment ( SGA ) and with assorted single nutritionary steps for Continuous Ambulatory Peritoneal dialysis ( CAPD ) .1.1.2 Specific aimTo depict the human ecology, anthropometr y, biochemical analysis features and dietetic form of CAPD patients. To depict the per centum of malnourished patients harmonizing to BMI, serum albumen, MSGA, and MIS. To formalize the usage of MIS and mSGA in CAPD patients against anthropometric ( BMI, Triceps Skinfold, computed Mid Arm Muscle Circumference ) and biochemical ( serum albumen ) appraisals ; To compare the usage of simplified tools: NRS, MUST, MST and GNRI showing tools in CAPD patients.Chapter 2: Literature Reappraisal2.1 Overview of kidney mapKidney maps to modulate organic structure homeostasis system [ 8 ] . Kidney plays a critical function in keeping circulatory and organ system functional homeostasis. Other than that, kidney is the site of synthesis of some endocrines and an of import catabolic site for several polypeptide endocrines. ( Table 2.1 ) Table 2.1: Components of kidney map Elimination of metabolic waste merchandises ( urea, creatinine, uric acid ) Elimination and detoxification of drugs and toxins Care of volume and ionic composing of organic structure fluids Acid-base ordinance Regulation of systemic blood force per unit area Production of erythropoietin Control of mineral metamorphosis through endocrinal synthesis ( 1,25-dihydroxycholecalciferol and 24,25-dihydroxycholecalciferol ) Degradation and katabolism of peptide endocrines ( insulin, glucagon, parathyroid endocrine endocrines ) and low-molecular-weight proteins ( ?2-microglobulin and light ironss ) Regulation of metabolic procedures ( gluconeogenesis, lipid metamorphosis ) Beginning: Mitch ( 2009 ) [ 8 ]2.2 Causes of kidney failureThere are two types of kidney failure which are acute kidney failure and chronic kidney failure. Acute nephritic failure is defined as sudden decrease of glomerular filtration rate ( GFR ) or loss of kidney map which is reversible [ 9 ] . Table 2.2 shown causes of acute kidney failure. Chronic kidney failure is defined as structural or functional abnormalcies of the kidney for more than 3 months [ 10 ] . It is an irreversible advancement of kidney harm. The causes of chronic kidney failure are shown in Table 2.2. Table 2.2: Causes of kidney failureAcute Renal FailureChronic Renal FailureAcute cannular mortification ( Trauma ) Nephrotoxicity ( antibiotics and drugs ) Infection Urinary piece of land obstructor Acute glomerulonephritis Diabetess Mellitus Uncontrolled high blood force per unit area Familial disease of kidney Obstructive Uropathy Inflammation or infection of kidney Beginning: KDOQI, 20012.3 Nephritic failure and dialysisGlomerular filtration rates ( GFR ) is an first-class step of filtrating capacity of the kidneys. GFR have been used to quantify the degree of kidney map [ 10 ] . There are 5 phases of GFR degree from phase 1-normal, to present 5-severe. A lessening in GFR precedes kidney failure in all signifier of progressive kidney disease [ 10 ] . In phase 5, where GFR is less than 15 ml/min, it is considered as terminal phase nephritic failure ( ESRD ) . Phase of chronic kidney disease was shown in Table 2.3. Table 2.3: Phases of chronic kidney disease Phase GFR Description 1 90-130 ml/min Kidney harm with normal or higher GFR 2 60-89 ml/min Mild lessening in kidney map 3 30-59 ml/min Moderate lessening in kidney map 4 15-29 ml/min Severe lessening in kidney map 5 Less than 15 ml/min End phase nephritic failure Beginning: KDOQI There are three types of intervention for nephritic failure which are kidney organ transplant, hemodialysis ( HD ) and peritoneal dialysis ( PD ) [ 9 ] . Peritoneal dialysis can foster split into three methods, including uninterrupted ambulatory peritoneal dialysis ( CAPD ) , automated peritoneal dialysis ( APD ) and combination of CAPD and APD [ 9 ] .2.4 CAPD processIn Continuous Ambulatory Peritoneal Dialysis ( CAPD ) , semi permeable membrane of the peritoneum is used as the filtration membrane [ 9 ] . A catheter is surgically implanted in the venters and into peritoneal pit. In CAPD, the dialysate is left in the peritoneum and exchanged manually [ 9 ] . A dialysate battalion is connected to the catheter while another tubing is connected to an empty battalion outside to have the waste fluid merchandises. A high-dextrose concentration dialysate is instilled into the peritoneum by the catheter. The dialysate diffusion carries waste merchandises from the blood through the peritoneal membrane and into the dialysate [ 9 ] . The waste merchandises and dialysate work interdependently via osmosis to transport out the waste merchandises. The waste fluid merchandises are withdrawn and discarded. Exchanges of dialysate are done for four to five times a twenty-four hours [ 9 ] . There are different concentrations and volumes of dialysate used which depend on the patient ‘s status.2.5 Nutrition demands for CAPD patientsIn peritoneal dialysis, Calories absorbed from glucose in the dialysis fluid are included in the computation of dietetic energy consumption. Approximately, 90 % of glucose is absorbed during dwells over 8 hours a twenty-four hours and 70 % is absorbed during short dwell [ 11 ] . Therefore, the sum of saccharide absorbed should be calculated to forestall overconsumption of ene rgy particularly for diabetes patient. From KDOQI 2000, the energy demand for chronic peritoneal dialysis patients who less than 60 old ages of age is 35 Kcal/kg organic structure weight per twenty-four hours [ 2 ] . For those who above 60 old ages of age, 30 to 35 kcal/body weight per twenty-four hours is recommended due to more sedentary life style [ 2 ] . Protein need in peritoneal dialysis patient is higher than hemodialysis patient. Peritoneal protein losingss average approximately 5 to 15 g/24 hours [ 2 ] . Generally, dietetic protein demand is to keep positive N balance and prevent malnutrition. Dietary protein more than 1.2 g/kg BW/day associated with impersonal or positive N balance [ 12,13 ] . KDOQI 2000 suggest that 1.3 g/kg BW/day protein for peritoneal dialysis patient and at least 50 % of protein should be from high biological value ( HBV ) [ 2 ] . Continuous Ambulatory Peritoneal Dialysis ( CAPD ) patients have higher cholesterin, triglyceride, LDL and lipoprotein degree [ 14 ] . The abnormalcy of lipid profile for CAPD patients is due to loss of protein from dialysis fluids and soaking up of glucose from dialysis fluid [ 14 ] . Therefore, 25 to 35 % of fat from entire Calories is recommended for CAPD patients [ 15 ] . Calcium and P are mineral demand in our organic structure to keep bone wellness. Conversion of vitamin D from inactive signifier to active signifier is impaired due to kidney failure [ 16 ] . When vitamin D lack develops, it may take to faulty enteric soaking up of Ca. In contrast, phosphorus elimination becomes restricted because of reduced cannular map. Therefore, dietetic phosphate limitation is necessary. Harmonizing to KDOQI guideline, 800-1000mg phosphate per twenty-four hours is recommended [ 2 ] . Furthermore, add-on of unwritten phosphate binder is besides needed to command serum phosphate degree [ 16 ] . The grade of Na sensitiveness is increasing exponentially with declined kidney map [ 17 ] . Nevertheless, sodium limitation can assist to command blood force per unit area. Excessive Na consumption may do thirst and increase fluid gained which in bend cause oedema [ 9 ] . Malaysia Medical Nutrition Therapy ( MNT ) guideline recommends 1500mg of salt intake per twenty-four hours and no add-on salt in cookery. Suggested unstable consumption is up to 1500ml per twenty-four hours [ 15 ] . CAPD patients may be hypokalaemic due to potassium loss during dialysis procedure. Therefore, potassium limitation is non necessary for CAPD patients. Persons with CAPD peculiarly have vitamin lack [ 18 ] . Hence, vitamin addendum is recommended for CAPD patients. Table 2.4 shows the recommended alimentary consumption for CAPD patients. Table 2.4: Recommended foods intake for CAPD patientsFoodRecommendationKilogram calories 35 kcal/kg BW/day for & A ; lt ; 60 old ages old 30-35 kcal/kg BW/day for & A ; gt ; 60 old ages old Protein 1.3 g/kg BW/day, 50 % HBV Carbohydrate 50-60 % of energy consumption Fat 25-35 % of energy consumption Sodium 1500 mg/ twenty-four hours Potassium 3-4g adjust to serum degree Fluid Up to 1500 ml/day Phosphate 800-1000 mg/day Calcium Calcium from diet and phosphate binder non transcend 2000 mg/day Vitamin B: Thaimine Vitamin b2 Vitamin b6 Vitamin bc Addendum to run into recommended day-to-day consumption Vitamin C Supplement up to 60-100 mg/day Beginning: Malaysia Medical Nutrition Therapy guideline, 20052.6 Malnutrition among CAPD patients2.6.1 DefinitionLack of protein and energy consumption or both is mentioning as protein-energy malnutrition ( PEM ) [ 19 ] . PEM is a status ensuing from long-run unequal consumption of energy and protein which can take to blowing of organic structure tissues and increased susceptibleness to infection [ 19 ] . PEM is strongly linked to malnutrition and mortality rate in person who undergoes care dialysis [ 2 ] . CAPD patients are more prone to malnutrition compared to HD patients. In CAPD, protein lost during dialysis procedure will ensue in protein lack and cause malnutrition [ 2 ] .2.6.2 PrevalenceBy the terminal of twelvemonth 2008, there are 3836 patients who are new to dialysis out of entire 19000 patients. The entire dialysis prevalence rate in December 2008 is 680 [ 3 ] . Patients who undergo CAPD are increasing twelvemonth by twelvemonth. Chronic kidney disease patients who underg o CAPD were 1744 patients out of entire 19221 patients in December 2008. The gender distribution is male ( 55 % ) and female ( 45 % ) from a entire 18856 patients [ 3 ] . The primary cause of nephritic disease is diabetes mellitus ( 55 % ) followed by high blood pressure ( 7 % ) from entire 3836 new dialysis patients on twelvemonth 2008 [ 3 ] . Protein-energy malnutrition ( PEM ) is really common among patients with advanced chronic nephritic failure ( CRF ) and those undergoing care dialysis ( MD ) therapies worldwide [ 2 ] . K/DOQI guideline proposed that, both work forces and adult females patients undergoing maintenance dialysis to accomplish BMI of at least about 23.6 kg/m2 and 24.0 kg/m2, severally. There are 14 % of CAPD patients who are scraggy ( BMI & A ; lt ; 18.5 kg/m2 ) . In Malaysia, malnutrition among dialysis patients is of great concern as it remains to be one of the strongest forecasters of morbidity and mortality [ 2 ] . There are 87 % of CAPD patients have serum albumin degree ( & A ; lt ; 4.0g/dL ) which assigned as malnourished [ 3 ] . Table 2.5 shows the categorization of serum albumen degrees. Table 2.5: Categorization of serum albumens degreeStatusSerum albumin degreeWell nourished 4.0 g/dL Mild undernourished 3.5 – & A ; lt ; 4.0 g/dL Moderate undernourished 3.0 – & A ; lt ; 3.5 g/dL Severe undernourished & A ; lt ; 3.0 g/dL Beginning: KDOQI, 20002.7 Factors doing malnutrition among CAPD patientsThere are multiple factors that cause malnutrition in these patients [ 2,20 ] . They are chiefly categorised into three causes: unequal dietetic consumption, disease conditions and intervention or dialytic factors. Inadequate dietetic consumption will take to malnutrition among dialysis patients. Altered gustatory sensation esthesiss caused by unequal dosage of dialysis, emotional hurt, anorexia and unpalatable prescribed diets ensuing in patients ‘ hapless unwritten consumption, and later impair their nutritionary position [ 20 ] . Disease status is besides a factor causes malnutrition in dialysis patients. Uremia is the most of import subscriber to inadequate nutrition in CAPD patients. As the Glomerular Filtration Rate ( GFR ) declines, azotemic toxins accumulate, taking to sickness and diminished appetite. Patients on dialysis have exposed to chronic inflammatory province will increase hypercatabolism and loss of thin organic structure mass when there is negative nitrogen balance [ 2 ] . Inflammation caused by infection, periodontic disease and familial factor will besides take to hapless nutrition intake [ 20 ] . Ascitess patient is at higher hazard of PEM. Ascites is another disease status doing protein loss more than 30g per twenty-four hours particularly after peritoneal dialysis induction. However, the sum of protein loss will decrease over clip [ 20 ] . In dialysis intervention, unequal dialysis might bring on anorexia and decreased gustatory sensation sharp-sightedness [ 20 ] . In add-on, dialysis promotes blowing by taking foods such as aminic acids, peptides, protein, glucose, water-soluble vitamins, and other bioactive compounds, and promotes protein katabolism, due to bioincompatibility [ 2 ] . In CAPD patients, redness of catheter site, bioincompatibility of dialysis solution will impact the nutrition position [ 20 ] . Besides, dialysis therapy may besides take to peritonitis. Transportation of K and azotemic toxin down a concentration in peritoneal capillaries will do protein loss. Furthermore, peritoneal inflammation will do ‘leaky ‘ in peritoneal capillaries and prolong peritoneal redness ensuing in release of cytokine and protein loss, which in bend influence patient ‘s nutrition position. Intra-peritoneal force per unit area is another factor impacting dietetic consumption. An addition in intra-abdominal force per unit area will take to symptoms of decrease in dietetic consumption and early repletion by delayed gastric emptying [ 20,21 ] . The most holds in stomachic voidance happened in those with smaller organic structure surface country [ 22 ] . Gastric emptying clip is associated with adequateness of foods ingestion. Last but non least, psychological factor will besides impact patient ‘s nutrition position. Psychological load causes loss of appetency in CKD patients, ensuing in a diminution of nutritionary position [ 20 ] .2.8 Nutrition Screening2.8.1 Purpose of testingHigh prevalence of CAPD patients with hapless nutritionary position is associated with inauspicious results [ 20 ] . Early sensing of malnutrition patient can diminish the hazard of inauspicious result of hapless nutrition. Therefore, it is critical that a validated and accurate tool used to place those malnutrition patients. Nutritional appraisal acts as an indispensable and introductory clinical process in nutritionary direction [ 4 ] . K/DOQI 2000 recommends nutrition appraisal should be performed routinely with combined method such as anthropometric measurings, organic structure composings measurings, biochemical measurings, dietetic appraisals and subjective appraisals [ 2 ] . However, most of these processs are time-consuming and cumbersome, even when a adept dietician is involved [ 4 ] . Therefore, a simplified and user friendly testing tool is needed for others wellness professional to observe malnutrition among the patients.2.8.2 Introduction of showing toolsThere are entire 6 showing tools will be used in this survey: Malnutrition-inflammation mark ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and modified subjective planetary appraisal ( MSGA ) . The SGA and MIS tools are the gilded criterion showing tools which have proven in many surveies [ 2,23 ] . However, MSGA is used in this survey alternatively of SGA. MSGA is more nonsubjective, easy and practical that utilizing quantitative marking system if compared to SGA which is utilizing semi-quantitative marking system [ 24 ] . Whereas, MIS is validated and proven by Kalantar-Zadeh et. Al ( 2001 ) as a dependable tools to place malnutrition patient particularly in inflammatory province [ 23 ] . A survey by Yamada K. ( 2008 ) obtained the mark from several testing tools such as NRS, MUST, MST, GNRI and Mini nutritionary Assessment-Short Form ( MNA-SF ) and comparing the MIS testing tool as the mention criterion. Among the five showing tools, consequences shown GNRI was the most accurate showing in placing hemodialysis patient at nutritionary hazard. However, this survey did non included CAPD patients [ 4 ] . MSGA is a modified quantitative subjective planetary appraisal which modified utilizing the constituents of conventional SGA by Kalantar-Zadeh and co-workers, 1999. MSGA is a to the full quantitative hiting system with mark from 1 ( normal ) to 5 ( really severe ) . MSGA consists of seven variables including weight alteration, dietetic consumption, GI symptoms, functional capacity, comorbidity, hypodermic fat and marks of musculus cachexia. This survey had shown a relationship between malnutrition mark and the combination of MAMC, BMI, serum albumen and TIBC. MSGA is an nonsubjective, dependable and easy tools which can execute in proceedingss compare to SGA. However, the survey did non include any CAPD patients [ 24 ] . Malnutrition-inflammation mark ( MIS ) was another testing tool developed by Kalantar-Zadeh and co-workers in twelvemonth 2001. It is a utile tool to mensurate nutrition and redness on care hemodialysis ( MHD ) patients. This tools was developed utilizing seven constituents in SGA and added three new elements which are body aggregate index, serum albumen degree and total-iron binding capacity with mark 7 ( normal ) to 35 ( terrible malnourished ) . Kalantar-Zadeh and co-workers proved it is a good tool in foretelling mortality every bit good as nutrition, redness and anaemia in MHD patients. [ 23 ] Nutrition hazard showing ( NRS ) is developed by Kondrup and co-workers in old ages 2002. This tool was designed to steps current possible undernutrition and disease badness patients in order to measure whether tools was capable to separate patients with a positive clinical result from those who non profit from nutrition support. The consequence proved this screening tool is able to separate positive consequence and those who are likely to profit from nutrition support. It scored 0 ( absent ) to 3 ( terrible ) . [ 25 ] Malnutrition Universal Screening Tool ( MUST ) was designed to observe protein-energy malnutrition and the hazard of developing malnutrition in grownup patients. There are three independent standards use in this tool which is BMI, weight loss mark and acute disease consequence mark which mark from 0 to 2. The entire tonss is added and delegate into one out of three classs including 0 ( low hazard ) , 1 ( medium hazard ) and & A ; gt ; 2 ( high hazard ) . Stratton and co-workers concluded that MUST was a speedy and easy performed tool. [ 26 ] Malnutrition Screening tool ( MST ) was developed to observe hospitalized grownup ague patients at hazard of malnutrition by Ferguson and co-workers. It consisted of two inquiries sing appetency and recent unwilled weight loss. The information showed a relationship between patients who are high hazard of malnutrition harmonizing to MST with low average value of nonsubjective nutrition parametric quantities and longer length of infirmary staying. Ferguson and co-workers proposed MST as a simple, speedy, validated and dependable tool to observe malnutrition. [ 27 ] Geriatric Nutrition Risk Index ( GNRI ) was developed by Bouillanne and co-workers in twelvemonth 2005. GNRI was used to observe patients at hazard of malnutrition and related to mortality and morbidity. Nutrition position indexs including albumen, weight and WLo was used to cipher GNRI mark. It had four classs of nutrition related hazard which are no hazard, low hazard, moderate hazard and major hazard categorized by utilizing GNRI mark. This survey showed a strong relationship between albumen and GNRI. It is a simple showing tool for foretelling mortality and morbidity hazard particularly in hospitalized aged patients. [ 28 ]Chapter 3: Materials and Methods3.1 Study designThis research was a cross-sectional survey which done amongst 50 CAPD patients in Hospital Kuala Lumpur ( HKL ) . The research has been approved by the IMU Joint commission Research and Ethics. This research was to place a suited simplified testing tool to observe malnourished patients on CAPD. Six available showi ng tools were tested on patients ‘ nutritionary position. The diagram shows the flow of the survey.3.2 Sample sizeParticipants were chosen by utilizing convenient trying method at the Nephrology unit in Hospital Kuala Lumpur ( HKL ) . The sample size computation was based on the prevalence of malnutrition CAPD patients as reported in National Renal Registry, 2006. ( Z ) 2 P ( 1-p ) e2 Sample size computation, Ns = = ( 1.96 ) 2 ( 0.87 ) ( 1-0.87 ) ( 0.10 ) 2 = 43.4 50 patients Where Z = Z0.95 = 1.96 is read from a standard normal distribution tabular array. Where P = Prevalence of malnutrition CAPD patients = 0.87 ( 87 % ) Where E = Estimated trying mistake = 10 % Therefore, 50 patients were recruited for this survey.3.3 Capable choiceThe inclusion standard of this survey were participants recruited must be above 18 old ages old and undergoes at least 6 months of care dialysis. Participants who admitted in wad or hospitalized were categorized into exclusion standards.3.4 Sampling methodParticipants recruited by utilizing convenient trying method. There were in entire 50 participants in this survey. Participants available at the CAPD unit at informations aggregation period were approached and invited to fall in the survey.3.5 Methodology3.5.1 Questionnaire designThe questionnaire consisted of 8 sectors to obtain information on participants ‘ personal inside informations, socioeconomic background, medical history, drug profile, CAPD prescription, appetite, lifestyle history and dietetic informations. Information was obtained through interview. This is shown in appendix 1. A ) Personal inside informations This subdivision covered inquiries on personal information of the participant ‘s name, gender, age, day of the month of birth, ethnicity, matrimonial position, instruction degree and employment. B ) Medical history Information on cause of kidney failure, intervention history ( continuance, history of kidney graft and parathyroid secretory organ remotion ) and co-morbidities of the participant is obtained. C ) Drug profile This subdivision covered informations on the medicine prescription and besides information of multiple addendum taken and traditional medical specialty. D ) CAPD prescription Information was obtained on figure of exchanges done in one twenty-four hours and the concentration, type and volume of dialysate usage per exchange. Tocopherol ) Appetite Participant ‘s current appetency was questioned by utilizing a graduated table of ranking which included good, just, hapless and really hapless. F ) Physical activity The frequence of exercising and the grounds for non exerting were asked. G ) Dietary Data Food readying, eating wonts and any allergic reaction of nutrients were specified in this portion. H ) Hospitalization Subject ‘s hospitalization ground and surgery history was asked. 3.5.2 Anthropometric informations ( Appendix 3 )3.5.2.1 Height and weightParticipant ‘s tallness and weight was obtained from the medical record. Three measurings of participant ‘s station dialysis weight were recorded at first hebdomad for 3 old months from December 2010 to February 2011. The 3-month weight informations provides the information of topic ‘s weight position ( weight addition or weight loss ) for testing tool constituent. Body Mass Index ( BMI ) will be calculated from topic ‘s tallness and weight, utilizing the undermentioned expression: BMI = Body weight ( kilogram ) / Height2 ( M2 ) *KDOQI 2000 recommended that the BMI of care dialysis patient to be at least 24-28 kg/m2. Table 3.1: Categorization of BMI cut off point for grownupCategorizationBMI ( kg / M2 )Underweight & A ; lt ; 18.50 Normal 18.50 – 24.99 Corpulence 25.00 Corpulent 30.00 Beginning: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.3.5.2.2 Mid arm perimeter ( MAC )Mid arm perimeter was performed with mensurating tape ( preciseness  ± 0.1 centimeter ) . Landmarking was done on the center of acromiale and radiale. Cross manus technique was used to mensurate the perimeter.3.5.2.3 Tricep skinfold ( TSF )Triceps skinfold was performed with Harpenden Skinfold Caliper ( John Bull, British Indicators Ltd. England ; preciseness  ± 0.1 centimeter ) . Landmarking was carried out prior to skinfold measuring.3.5.2.4 Mid arm musculus perimeter ( cAMA )Mid arm musculus perimeter is a computation derived from mid arm perimeter ( MAC ) and Tricep skinfold ( TSF ) : MAMC ( centimeter ) = MAC ( centimeter ) – [ ? – TSF ( centimeter ) ] Calculate mid arm musculus country ( cAMA ) provides a more accurate appraisal of musculus mass by gauging bone-free arm musculus country, corrected with gender differences. Calculate mid arm musculus country, cAMA = [ ( MAC ( centimeter ) – ? – TSF ( centimeter ) ) 2 ] / 4 ? – 10.0 ( work forces ) = [ ( MAC ( centimeter ) – ? – TSF ( centimeter ) ) 2 ] / 4 ? – 6.5 ( adult females ) Table 3.2: Cut off point of arm musculus perimeter ( AMA )PercentileClass 5th Wasted & A ; gt ; 5th but ? 15th Below norm & A ; gt ; 15th but ? 85th Average & A ; gt ; 85th but ? 95th Above norm & A ; gt ; 95th High musculus Beginning: Frisancho AR. 1990. Anthropometric criterion of the appraisal for growing and nutritionary position. 3.5.3 Biochemical informations ( Appendix 4 ) Serum albumen, serum beta globulin, serum Total Fe binding capacity ( TIBC ) , serum cholesterin, serum creatinine, Kt/V and serum carbamide were obtained from participant ‘s latest blood trial consequence. Table 3.3: Cut off point biochemical value Biochemical constituents Normal scope Serum albumen & A ; gt ; 4.0 g/dl Serum Tranferrin Serum TIBC Serum Cholesterol Serum Creatinine Serum Urea Kt/V & A ; gt ; 1.7 3.5.4 24 hours dietetic callback ( Appendix 5 ) Dietary consumption was obtained utilizing 24 hours dietetic callback. Participant ‘s dietetic consumption of 1 weekday and 1 weekend were recorded. Dietary appraisal tools ( bowls, spoon, matchbox and cup ) were shown to the topic at the first interview subdivision. The subsequent information aggregation was done through phone call. Food functioning size recorded was converted to unit gm and analysed via Nutrient composing of Malayan Food ( Tee E Siong, 1997 ) and Nutritionist Pro. Programme.3.6 Screening toolA sum of 6 showing tools were used in this survey.3.6.1 Modified Subjective planetary appraisal ( MSGA )This tool was designed by Kalantar-Zadeh group in twelvemonth 1999. This testing tool was developed by utilizing the constituent of conventional SGA and consists of seven variables: weight alteration, dietetic consumption, GI symptoms, functional capacity, co-morbidity, hypodermic fat and marks of musculus cachexia. Each constituent was scope from 1 ( normal ) to 5 ( te rrible ) . The entire mark used to find the nutrition position of the patient.3.6.2 Malnutrition-inflammation mark ( MIS )MIS was developed by Kalantar-Zadeh et. Al 2001 based on 7 constituents of SGA method and 3 extra constituents of BMI, serum albumen and serum TIBC. The medical history buttockss weight loss during the predating 6 months, dietetic consumption, GI symptoms, functional capacity ( nutritionary related functional damage ) , and co-morbidity including figure of old ages in Dialysis ; while physical scrutiny assesses loss of hypodermic fat and musculus cachexia. Each constituent was scored from 0 to 3, the entire mark of all 10 constituents ranged from 0 to 30 ( higher figure indicates more terrible ) .3.6.3 Nutrition hazard showing ( NRS )Nutrition hazard showing ( NRS ) was developed by Kondrup and co-workers in old ages 2002. The concluding tonss were categorized into absent, mild, moderate or terrible malnourished with a entire mark 0-6. It contain of two testing c onstituents, initial and concluding showing. There were four variables included in initial screening- BMI, recent weight loss, alterations in nutrient consumption and wellness status. In concluding showing, two chief constituents were tested by each hiting 0 ( absent ) to 3 ( terrible ) . The entire mark was added and one extra mark for participant above 70 old ages old.3.6.4 Malnutrition Universal testing tool ( MUST )MUST was developed for multidisciplinary usage by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition. MUST consists of 3 independent constituents which are current weight position measured by BMI ( mark: 0 to -2 ) , unwilled weight loss ( mark: 0 to -2 ) , and acute disease consequence bring forthing no nutritionary consumption for & A ; gt ; 5d ( mark: 0 or 2 ) . The amount of these 3 tonss was calculated.3.6.5 Malnutrition testing tool ( MST )The MST was developed by Ferguson et. Al 1999 had been used for acute infirmary patients ; it incorporates 3 constituents which are weight loss ( mark: 0 or 2 ) , sum of weight lost ( mark: 1-4 ) , and hapless nutrient consumption or hapless appetency ( mark: 0 or 1 ) . The entire mark was calculated for each patient.3.6.6 Geriatric nutrition hazard index ( GNRI )The GNRI was developed by modifying the nutritionary hazard index ( NRI ) for aged patients. This index was calculated from the serum albumen and organic structure weight by utilizing the undermentioned equation: GNRI = [ 1.489 – albumen ( g/dL ) ] + 41.7 – ( organic structure wt/ideal organic structure wt ) ]3.7 Statistical AnalysisAll the information was analysed by utilizing Statistic Merchandises and Services Solution, SPSS ver. 18.0. Each variable is presented as the mean  ± Standard Deviation ( SD ) . Descriptive frequence trial was used to prove the distribution of the variables among gender. T-test was besides used to show the correlativity between the variables. P & A ; lt ; 0.05 was considered as statistically important. Sensitivity, specificity, positive prognostic value ( PPV ) and negative prognostic value ( NPV ) were used between testing tools and nonsubjective variables. Crosstab was used to transport out the sensitiveness and specificity trial. Formula of computation: Sensitivity = true positives/ ( true positives + false negatives ) Specificity = true negatives/ ( true negatives + false positives ) Positive prognostic value ( PPV ) = true trial positives/all trial positives Negative prognostic value ( NPV ) = true trial negatives/all trial negatives