Introduction
Worldwide, the total number of patients beginning dialysis who are above 65-75 is still rising. According to a recent ERA-EDTA registry report, the growth of dialysis is primarily due to a higher incidence of renal replacement therapy in patients over 75 years of age.1, 2 Dialysis could be a greater burden for elderly patients compared to the younger population. Its impact on life expectancy, practical state and quality of life may be different in the former group. The early mortality rate among all dialysis patients is the highest within 3 months of initiating dialysis, especially with elderly patients who already have a higher early mortality rate than others.3 Geriatric syndromes such as aging, frailty, functional impairment and cognitive impairment play a crucial role in the prognosis of elderly hemodialysis patients.4, 5, 6 Therefore, it might be logical to conclude that a greater frequency of adequate dialysis could likely lower the mortality rate of geriatric patients.
Materials and Methods
Sampling method
Probability sampling method is used in this study, the sample size included are 54 geriatric hemodialysis patients.
Exclusion criteria
In this study patient on Peritoneal dialysis, Pediatric dialysis are excluded from the study.
Data collection
Demographic data of the subjects, specifically age, sex, diagnosis, frequency and duration of dialysis, were collected from their respective medical record. Anthropometric measurements (height, weight, etc) of the subjects were recorded using appropriate instruments and techniques.
Blood parameters
Blood samples were collected, processed and assayed and the results were tabulated. all procedures were carried out according to the manufacturers' instructions:
Hemoglobin (Oxyhemoglobin method)
Albumin (Bromocresol green method)
Urea (Urease, UV method)
Creatinine(Chromatography method)
Cholesterol (Cholesterol oxidase, Esterase, peroxidase method)
Total protein (Biuret method)
Sodium & potassium (ISE Indirect)
Calcium (Arsenazo III)
Kt/V (Dialyzer clearance of urea)
Kt/V was calculated using the following formula
Kt/V = - ln (R-0.008 x t) + (4-3.5 x R) x UF/W
ln - natural logarithm
R – post dialysis Serum urea nitrogen
t – session time length (in hours)
UF – volume of fluid removal during dialysis(l)
V – the volume of post- dialysis urea distribution(l)
Geriatric nutritional risk index determination process
Demographic factors (gender and age)
Anthropometric characteristics such as height, weight and body mass index (BMI),
Complete medical history including previous alcohol and tobacco use and other co-morbidities was obtained. Test results (e.g., albumin, creatinine) were collected from individual medical records upon admission according to pre-specified definitions.
Body mass index was computed as body weight divided by height squared (kg/m2).
The estimated glomerular filtration rate (eGFR) was calculated by the chronic kidney disease epidemiology collaboration formula and a physical examination was performed to determine the Wagner grade of the foot lesion.
Follow-up data were obtained from medical records or through telephone interviews.
GNRI was estimated using the following information: serum albumin level, ideal body weight, present body weight in kg and individually measured height in cm.
GNRI = [1489 × albumin (g/L)] + [41.7 × (weight/WLo)]
Where WLo indicates ideal weight
Wlo is calculated using the following formula, where H indicates height,
Men: WLo = H - 100 - [(H - 150)/4]
Women: H - 100 - [(H - 150)/2.5]
Statistical analysis
Mean, Basic anthropometric, frequency distribution and percentages were utilized to interpret the subjects' body composition, demographic and anthropometric data.
Correlation Analysis: Statistical significance was evaluated by employing the Pearson correlation coefficient and the chi-square test.
Results
Demographic information and biochemical parameters
Age: The study population comprised of 54 geriatric dialysis patients in the 60-85 age group. The age-wise distribution is shown in (Figure 1).
Height: The patients’ height (in cm) ranged between 110 – 185cm. (Figure 2)
Biochemical parameters: Several clinical/biochemical parameters were assessed and the results are shown in (Table 1). The ean ± SD and the minimum/maximum levels observed for each assay in the study population are tabulated.
Table 1
Biochemical parameters
Comorbid causes of end-stage kidney disease
Figure 3 chart shows the distribution of co-morbidities amongst the study population. A majority (57%) of the patients had both diabetes mellitus (DM) and hypertension (HT) as co-morbid conditions while 17% had only HT and 9% only DM. Multiple combinations of the co-morbidities were also present in a small but significant percentage of the patient population.
Vascular access for haemodialysis
Of the 54 patients included in this investigation, 24% of patients presented with temporary vascular access in the form of either an internal jugular vein catheter, subclavian catheter or femoral catheter while 76% of the patients had permanent vascular access called Arteriovenous fistula as depicted in (Figure 4).
Frequency of dialysis
Figure 5 shows the dialysis frequency among the patients investigated. 40% of the patients underwent twice-weekly dialysis whereas 60% had access to thrice-weekly dialysis procedures.
Geriatric nutritional risk index
Among the 54 patients studied, 12% of patients were identified as high risk on the GNRI, 9% as moderate risk while 22% were low risk on the GNRI. The remaining 57% of patients were deemed to be without any risk (Figure 6).
Body mass index
43% of the total study population was calculated to be within the normal BMI range 18.5-24.9). 33% fell in the overweight range (25-29.9) and 11% were characterized as being obese (>30)13% of the study population was found to be underweight (<18.5). The data is shown in (Figure 7).
Classification of the respondents based on levels of risk and frequency
The participants in the study were classified based on levels of risk and frequency of dialysis. Accordingly, as shown in (Table 2), 6 of them were placed in a high-risk group, 12 of them in a low-risk group whereas 31 patients were identified as without any risk.
Discussion
The present study focuses on geriatric surveillance of patients undergoing maintenance hemodialysis. Geriatric patients have more risk of mortality and morbidity compared with normal patients because of age, nutritional deficiency, cardiovascular problems, depression, etc., which correlates with Steven R.Gambert et al.2 This study included 54 geriatric patients undergoing maintenance hemodialysis. The demographic patient data were gathered. Anthropometric assessment among the subjects was measured using appropriate instruments and recorded. Kt/V dialyzer clearance of urea is calculated by using Kt/V formula Daugirdas et al., 20157 the evaluation of the suitability of intermittent hemodialysis is conventionally based upon urea kinetic methods for calculation of single pool Kt/V with 1.2 accepted as minimum adequate clearance for weekly thrice hemodialysis.
This study showed that low body weight and hypo-albuminemia could reflect malnutritional and that lower BMI could also be an important index of protein-energy wasting. BMI was related to mortality in patient on hemodialysis.8 Kobayashi et al., 2015 also proved that there was substantial correlation between the GNRI and mortality in patient on hemodialysis.9 Berger et al., 2016 article discussed with particular emphasis on the outcome of fraility and functional status, choice of dialysis and frequency of dialysis will improve the standard of living in geriatric patients which was correlated with this study.
An another study Tsai et al.,201610 stated that an important predictor of death for senior hemodialysis patients was the low geriatric nutritional risk index and may be adopted to improve assessment of the malnutrition-inflammation status which was completely correlated with our study.
In this investigation, GNRI demonstrated a stronger predictive value for diagnosing and categorizing nutritional status and nutritional-related problems in hospitalized older patients which correlated with Abd-El-Gawad et al.,2014 research.11 In another study Anand S. M. Kurella Tamura et al.,2010 stated the application of HD to support the elderly has expanded along with improvements in life expectancy that corresponded to this inquiry. Elderly people receiving dialysis had a decreased survival rate12 Goncalves. J.G et al.,2021 correlates with this investigation.
Panichi et al.,201413 stated that low GNRI is a powerful predictor of overall mortality in HD patients and is linked to malnutrition. Locatelli Francesco et al.,200514 mentioned The use of Daily HD has great promise for enhancing dialysis results and quality of life, while its effect on patient mortality has not yet been conclusively demonstrated which was distinctive with this study.15
Tuğcu M et al.,2018 revealed In the group of elderly hemodialysis patients, comorbidities and poor performance level of dialysis had reduced the survival time that slightly analog with this research.
The proportion of all patients in normal nutritional status was 57.4% and the rate of malnutrition and / or severe risk of nutrition was 11%. From the above crosstabs between BMI, GNRI and Dialysis frequency concluded that the frequency of dialysis and GNRI were significantly correlated.
The patients undergoing weekly thrice dialysis have better adequacy and lower risk of GNRI, compared to twice-weekly dialysis.
Conclusion
In our study, based on the geriatric nutrition risk index, the geriatric patients with critical risk of nutrition were 11% and average risk of nutrition was 9.3% and 22.2% of patients with mild risk of nutrition. Patients who received thrice weekly dialysis have higher adequacy and a lower risk of GNRI than twice-weekly dialysis.
Hence, a higher frequency of dialysis improves the quality of life and lowers the GNRI risk in dialysis patients.