Original Article

Association between the level of quality of life and nutritional

status in patients undergoing chronic renal hemodialysis

Authors Abstract Introduction

Ana Carolina Bonelá dos
Santos1 Introduction: The chronic kidney dis- Chronic Kidney Disease (CKD) is
Manuela do Carmo ease and undergoing hemodialysis characterized by the slow progressive
Machado1 (HD) cause limitation in patients' life
Luciene Rabelo Pereira1 irreversible loss of exocrine (filtration,
interfering in their life's quality and
Juliana Lemos Pratti the nutritional care is fundamental to reabsorption, and secretion of substances
Abreu2 through the urine) and endocrine function
the disease treatment. Objective: The
Marisa Barbosa Lyra3
objective is the goal is to analyze the (decreased production of erythropoietin
association between quality of life and 1.25-dihydroxycholecalciferol).1
through the instrument (SF-36) with It has been defined as a complex
1
Espírito Santo Catholic
Salesian College. dietary intake, nutritional status in pa- syndrome due to complications ensuing
2
Vila Velha Evangelical tients with chronic kidney disease in
from the loss of renal function, such
Hospital - HEVV. HD through quantitative research and
3
Federal Institute of Espírito transversal. Methods: Realized valua- as anorexia, uremia, loss of the senses
Santo.
tion anthropometric, collection of the of smell and taste (which explains
results of biochemical tests, applica- the high prevalence of malnutrition
tion of the questionnaire SF-36 and in subjects with CKD); hypertension,
dietary anamnesis (food recall of 24h). hypertriglyceridemia, and hyperglycemia
Results: The sample consisted of thir-
(factors related to cardiovascular disease);
ty adult patients with age between 28
increased incidence of bleeding episodes
to 76 years. The disease related with
chronic kidney disease was found more resulting from renal failure; oliguria;
hypertension systemic arterial (53.3%) edema; mental confusion; adnamia;
The average body mass index was asterixis; obnubilation and coma.2
25.04 ± 4.50 kg/m². By fold cutaneous The 2011 Dialysis Census revealed that
arm, 73.3% were in malnutrition. The 91,314 people were undergoing dialysis in
end nutritional diagnosis of malnutri-
Brazil, and that 84.9% of the patients were
tion was 80% among the patients stud-
ied. The time of diagnosis of renal dis- covered by the Brazilian public health care
ease had a mean of 4.84 ± 3.51 years. system (SUS). The Census also found that
By the middle of biochemical tests only the most common etiologies of CKD are
phosphorus creatinine were adequate. systemic hypertension (SH) and diabetes
In the mean the scores of SF-36 the low- mellitus (DM). Therefore, CKD needs to
est value found was limited to physical be considered as a public health issue.3
Submitted on: 01/18/2013. aspects (16.67 ± 29.60) and the largest
Nutrition in kidney care starts with
Approved on: 07/30/2013. for the social aspect (68.17 ± 33.67).
Conclusion: The average energy con- prevention. The body mass index (BMI)
sumption and protein was below the is a strong indicator for CKD that can be
Correspondence to:
Manuela do Carmo Machado. recommended. Got positive correlation modified with diet. Once renal disease sets
Nephrology Service of the Vila of calories, protein, fiber, calcium and in, nutrition also plays a central role in the
Velha Evangelical Hospital.
Rua Bom Jardim, nº 8, Bairro
carbohydrate, with quality of life. It assessment and treatment of the condition.
Industrial. Vila Velha, Espírito was concluded that feeding is associat-
CKD, whether in pre-dialysis or dialysis,
Santo, Brazil. CEP: 29118-713. ed with quality of life of renal patients
E-mail: manuela.nut@gmail. imposes clinical challenges directly linked
com
undergoing hemodialysis.
to the patient’s nutritional status.4
Tel: (27) 9844-7949.
Keywords: chronic, kidney failure, nutri-
DOI: 10.5935/0101-2800.20130047 tional status, quality of life.

279
 Quality of life, food intake, and nutritional status of hemodialysis patients

Malnutrition is caused by uremia, which by its the age of 18 years at the time of the study were
turn occurs consequently to the loss of exocrine excluded. The study was approved by the Research
function, causing a constant inflammatory state that Ethics Committee of the Espírito Santo Catholic
predisposes patients to this condition. Additionally, Salesian College and by the HEVV board.
dietary restrictions, loss of amino acids during dialysis, The population was characterized based on the data
anorexia, infection, gastrointestinal disorders, and collected from medical charts, namely: patient age,
the administration of certain drugs favor the onset of time on hemodialysis, time since diagnosis of kidney
nutritional anomalies.5,6 disease, conditions associated with kidney disease.
Signs of malnutrition are present in 10% to Patient socioeconomic status was assessed
70% of the patients on hemodialysis (HD) and according to the Brazilian Economics Classification
in 18% to 56% of the individuals on continuous Criteria - CCEB (2008) issued by the Brazilian
ambulatory peritoneal dialysis (CAPD). Malnutrition Association of Research Companies (ABEP).9
is a major factor in the morbidity and mortality of
patients on HD.7 Quality of life (QoL) assessment
Although the many technological and therapeutic The validated Brazilian Portuguese version of the
advances in the area of dialysis have helped increase Medical Outcomes Study Short Form 36 (SF-36)
the survival of individuals with CKD, they were not survey was used to assess the health related quality of
enough to allow patients to return to the lives they life (HRQOL) of the subjects enrolled in the study.10
lived before the disease.6 The survey consists of 36 items divided into eight
Patients with CKD experience dramatic changes scales, namely: physical functioning (PF), role-physical
in their lives. Many are the limitations they face, in (RP), bodily pain (BP) general health (GH), vitality
addition to painful hemodialysis sessions, strict diets, (VT), social functioning (SF), role-emotional (RE),
changes in their personal, professional, and social and mental health (MH). Subjects are given scores
lives. Thoughts about death become more frequent, from 0 to 100 in each scale, where zero represents
along with negative perceptions over health care and the worst and 100 the best health status.11 The survey
the hope that a kidney transplant will help improve was applied by one of the authors while the subjects
their lives.7 were on hemodialysis.
This study aims to correlate quality of life with
food intake and nutritional status in a population of Food intake
patients with chronic kidney disease on hemodialysis. Patients were asked to fill 24-hour dietary recall
forms (R24h)12 for three alternate days. One of the
Methods forms was filled on a day in which the patient had
This cross-sectional quantitative study was carried undergone HD and the other two in days without
out at the Nephrology Care Center of the Vila Velha HD - one being a weekend day (WE) and the other a
Evangelical Hospital (HEVV), in the State of Espírito weekday (WD). Subsequently, the data were analyzed
Santo, Brazil. The clinic has been accredited by the on software DietWin Personal (2012). Intake levels of
SUS and currently takes care of 126 patients on HD calories (kcal/kg of body weight/day), carbohydrates
per month. (CHO), protein (PTN/kg of body weight/day), lipids,
Forty-two of the 126 patients were seen in the total cholesterol, fiber, calcium (Ca), phosphorus (P),
night shift, which prevented their inclusion in the potassium (K), and sodium (Na) were assessed in
study. Therefore, a total of 84 patients treated in the study.
the morning and afternoon shifts were invited to The reference values for the analysis of intake of
join the study. The sample was established based on macronutrients and micronutrients were the daily
convenience, and not on a probabilistic approach. All nutritional recommendations for individuals on
patients with CKD on HD seen at our center offered hemodialysis.13
to join the study and were asked to sign an informed It is worth noting that by the time of the study
consent term, in accordance with Resolution 196/96 the patients were not receiving any type of nutritional
from the National Health Council.8 Patients under care or guidance.

280 J Bras Nefrol 2013;35(4):279-288

 Quality of life, food intake, and nutritional status of hemodialysis patients

Anthropometric assessment overweight for values in the 110%-120% range; and

Patient body weight, height, mid-upper arm obese for values greater than 120%.15
circumference (MUAC), and tricipital skinfold The cutoff points used for the BMI, calculated
thickness (TST) were measured. Measurements were as the ratio between the subject’s weight and height
made after HD session by a trained member of the to the square, were the ones described by Riella &
study’s staff. Martins15 for the population with kidney disease,
Patients were weighed with shoes off, wearing light which were then compared to the cutoff points
clothing, on an electronic digital MEA 08140 Plena® proposed by World Health Organization (WHO) for
scale with increments of 100 g and a total capacity of the general population.16
150 kg. The subject’s dry weight was considered, i.e., The following indicators were measured to verify the
the weight after the end of an HD session. presence of malnutrition: %MUAC, %TST, and BMI.
Subject height was measured using a two-meter The MUAC looks into muscle reserves without
vertical tape stadiometer, precise to the nearest a correction for bone tissue; TST is used to assess
0.1 cm, attached to a wall. Arm circumference was subcutaneous fat; and the BMI to evaluate total body
measured with a non-extending measuring tape mass.17 As each parameter assesses different bodily
placed at the midpoint between the acromion and compartments, the same patient can present three
olecranon of the arm without the arteriovenous different diagnoses. Therefore, patients diagnosed as
fistula, with subjects extending their arms along their having a degree of malnutrition in at least one of the
bodies. Measurements were made in centimeters. parameters were considered to be malnourished.
Arm circumference measurements were used to
estimate the mid-upper arm muscle circumference Biochemical parameters
(MUAMC) using the formula developed by Blackburn The levels of the following biochemical indicators
& Thornton:13 MUAMC (cm) = MUAC (cm) - π x were collected: phosphorus, total calcium, creatinine,
[TST (mm) ÷ 10]. Percent MUAC was calculated with parathyroid hormone (PTH), and potassium. Only
the following formula: %MUAC = MUAC/MUAC the tests cited above were mentioned in the patients’
50 x 100.13 The reference value was obtained from the charts. Data from other tests were stored in the
50th percentile, as defined for the general population clinic’s information system, to which we did not
according to Frisancho.14 have access. The reference values used in this stu-
Patients were categorized by percent MUAC as dy were the ones reported by Martins & Riella15, in
follows: severely malnourished for values under 70%; which the levels seen in patients with chronic kidney
moderately malnourished for values ranging between disease were different from those of the general popu-
70% and 80%; mildly malnourished for values in the lation, as specified: phosphorus: 4.5-6.0 mg/dl; total
80%-90% range; properly nourished for values in the calcium: 9.0-11 mg/dl; creatinine: 7-12 mg/dl; PTH:
90%-110% range; and overweight for values greater 100-300 mg/dl; potassium: 3.5-5.5 mg/dl.
than 110%.13 Important biomarkers such as complete blood
A Cescorf® caliper placed on the same spot used to count, urea, and albumin were not considered, as these
measure MUAC, on the posterior part of the arm whe- test results were not released by the clinic for this study.
re the skinfold separated discretely from muscle tissue,
was used to measure TST. Three consecutive measure- Statistical analysis
ments were performed and the mean value in millime- Software program Bioestat 5.0 was used in statistical
ters was considered as the final result. Relative percent analysis. A five-percent significance level was defined.
TST was calculated with formula %TST = TST/TST The correlation coefficient was used to measure the
50 x 100 using the reference value obtained from the degree of correlation between two metric variables.
50th percentile for the normal population14. Patients Spearman’s rank correlation coefficient was used for
were then categorized as severely malnourished when variables not following a normal distribution.
values were under 70%; moderately malnourished
for values ranging between 70% and 80 %; mil- Results
dly malnourished for values in the 80%-90% range;
The sample consisted of 30 individuals, 23 adults
properly nourished for values in the 90%-110% range;
and seven elderly subjects, aged 28-76 years, with a

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 Quality of life, food intake, and nutritional status of hemodialysis patients

mean age of 51.90 ± 14.19 years. The time since the variables, since each variable may yield different
diagnosis of kidney disease ranged from one month to diagnoses for the same patient. The results of patient
17 years (mean of 5.31 ± 4.02). The population was nutritional assessments are shown in Table 1.
homogeneous with respect to gender, as 15 females
and 15 males were enrolled in the study. Patients had Table 1 Nutritional status according to BMI,
been on dialysis for 1-197 months, and a mean of MUAC, and TST
43.37 ± 47.38 months. Variables n %
When level of income was considered, 26 (76.6%) BMI (Riela)
patients were on class C. Data on diseases associated Malnutrition 15 50.0
with CKD are presented in Graph 1. Adequate 11 36.7
Overweight 4 13.3
Graph 1. Results on diseases associated with chronic kidney disease.
SH: Systemic hypertension; DM: Diabetes Mellitus.
BMI (WHO)
Malnutrition 0 0.0
Adequate 17 56.7
Overweight 13 43.3
Categorization according to MUAC
Severe malnutrition 2 6.7
Moderate malnutrition 1 3.3
Mild malnutrition 6 20.0
Adequate/eutrophic 16 53.3
Overweight 5 16.7
Categorization according to TST
Severe malnutrition 19 63.3
Moderate malnutrition 2 6.7
Mild malnutrition 1 3.3
Eutrophic 4 13.3
In the analysis of anthropometric variables, the
Overweight 1 3.3
categorization of patients according to the BMI
Obesity 3 10.0
classification proposed by Riella & Martins15 revealed
that 50% (n = 15) of the subjects had malnutrition, Nutritional diagnosis
36.7% (n = 11) were normally nourished, and Malnutrition 24 80.0
13.3% (n = 4) were overweight. According to the Eutrophic 4 13.3
classification proposed by the WHO,16 none of the Obesity 2 6.7
patients was malnourished, 56.7% (n = 17) were Total 30 100.0
eutrophic, and 43.3% (13) were overweight.
According to the MUAMC, 6.7% (n = 2) of the Biochemical parameters15 revealed that only
subjects had severe malnutrition, 3.3% (n = 1) had 3.3% (n = 1) of the patients had adequate calcium
moderate malnutrition, and 20% (n = 6), had mild serum levels and that 96.7% (n = 29) had calcium
malnutrition, i.e., 30% (9) had some degree of levels below recommended values. When phosphorus
malnutrition. serum levels were considered, 36.7% of the patients
According to the TST, 73.3% (n = 22) of the indi- had adequate levels, 30% had hyperphosphatemia,
viduals were malnourished; of these, 63.3% (n = 19) and 33.3% hypophosphatemia. Creatinine levels
had severe malnutrition, 6.7% (n = 2) had moderate in 53.3% (n = 16) of the population was found to
malnutrition, and 3.3% (n = 1) had mild malnutrition. be adequate, but 30% (n = 9) had levels above
The final nutritional diagnosis established based recommended values. Conversely, PTH levels were
on anthropometric data indicated that 80% (n = 24) elevated in 53.3% (n = 16) of the subjects, adequate
of the included subjects were malnourished. This in 30% (n = 9), and low in 16.7% (n = 5) of the
diagnosis was not reflected on all anthropometric individuals. For potassium levels, 96.7% (n = 29) of
the patients were hyperkalemic.

282 J Bras Nefrol 2013;35(4):279-288

 Quality of life, food intake, and nutritional status of hemodialysis patients

The lowest mean score observed among the Table 5 shows the correlations between HRQOL
SF-36 scales was in the role-physical (RP) scale and Kcal, PTN/kg of body weight/day, and CHO.
(16.67 ± 29.60) and the highest in social functioning Statistically significant (positive) correlations were
(SF) (68.17 ± 33.67), as shown in Table 2. seen between quality of life and the following: KCAL
The mean values found in the analysis of the and physical functioning and bodily pain scales,
24-hour dietary recall forms presented in Table 3 show the strongest of which with physical functioning;
that the subjects’ mean calorie intake (kcal/kg of body CHO and physical functioning and bodily pain
weight/day) was below the recommended levels for scales, the strongest of which with bodily pain;
patients on hemodialysis. As 80% of the patients had PTN/kg of bodyweight/day and physical functioning,
some degree of malnutrition, adequate intake should role-physical, bodily pain, vitality, role-emotional,
be of at least 32 kcal/kg of body weight/day. Protein and mental health scales, the strongest of which with
intake was also lower than recommended. The mean physical functioning.
intake of carbohydrates and lipids was adequate. Correlations were found between HRQOL and
The mean intake of total cholesterol was adequate, fiber and calcium intake. Statistically significant
but the standard deviation revealed that intake correlations were seen between HRQOL and the
values were significantly scattered, thus showing that following: fiber intake and physical functioning,
many patients were having much less or much more bodily pain, and role-emotional scales, the strongest
cholesterol than recommended. of which with bodily pain; calcium intake and
The lower values found for fiber intake in some patients the role-physical scale, phosphorus and physical
speak of how little attention this nutrient has been given. functioning, bodily pain, and role-emotional scales,
The mean intake of calcium was far below adequate levels the strongest of which with bodily pain.
(410.81 ± 265.60 mg). The mean intakes of phosphorus Quality of life and time for which the patient had
(821.93 ± 357.19 mg), potassium (1770.18 ± 609.53 been on dialysis were also tested, but no statistically
mg), and sodium (2470.90 ± 975.06 mg) were within significant correlation was found between these
recommended levels. variables.
Table 4 shows a statistically significant correlation
between HRQOL (physical functioning, bodily pain, Discussion
vitality, and role-emotional scales) and variable values Low socioeconomic status has been implicated as
for Kcal/kg of bodyweight/day (mean 3-day value). All a risk factor for chronic disease.18 In our study,
correlation coefficients were positive, i.e., as the value of 78.3% of the patients had low income levels (classes
variable Kcal/kg/day increases, so do the scores of qua- C and D). Zambonato et al.19 found that 89.6% of
lity of life. The highest correlation coefficient was found CKD patients on dialysis were in classes C, D, and E.
between Kcal/kg/day and the physical functional scale, According to the authors, the association between
showing that higher Kcal/kg/day intake led to better low socioeconomic status and CKD can be attributed
physical functional capacity. There was no significant to factors such as difficulty having access to health
correlation between time on hemodialysis and QoL. care and inadequate management of hypertension
No statistically significant correlations were found and DM. Another factor that may bias the results of
between HRQOL and variables TST, MUAC, and BMI.

Table 2 Overall quality of life

Variables Minimum Maximum Median Mean Standard deviation
Physical functioning 0.00 100.00 55.00 52.83 35.32
Role-physical 0.00 100.00 0.00 16.67 29.60
Bodily pain 0.00 100.00 90.00 67.03 37.75
General health 5.00 94.00 46.00 43.60 23.42
Vitality 10.00 100.00 60.00 57.67 24.49
Social functioning 0.00 100.00 75.00 68.17 33.67
Role-emotional 0.00 100.00 0.00 22.21 36.44
Mental health 20.00 100.00 66.00 67.73 21.88

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 Quality of life, food intake, and nutritional status of hemodialysis patients

Table 3 24-hour dietary recall (three-day mean values)

Variable Minimum Maximum Median Mean Standard deviation
Dry weight (kg) 46.40 110.20 64.50 66.26 12.55
KCAL 787.97 2972.38 1399.20 1445.70 466.21
Kcal/Kg of bodyweight/day 10.59 44.63 22.47 22.70 8.53
CHO (g) 100.58 445.77 197.45 206.36 74.87
PTN/Kg of bodyweight/day 0.30 1.92 0.92 1.02 0.41
PTN (g) 33.11 126.10 62.73 64.38 22.34
LIP (g) 23.22 84.98 40.90 40.61 14.14
Cholesterol (mg) 58.13 673.51 139.90 162.37 112.73
Fiber (g) 8.05 39.09 16.52 18.62 7.22
Ca (mg) 63.91 1258.81 349.80 410.81 265.60
P (mg) 340.89 1769.64 810.39 821.93 357.19
K (mg) 791.10 3447.44 1708.31 1770.18 609.53
Na (mg) 881.48 5721.95 2350.94 2470.90 975.06

Table 4 Correlations between quality of life, KCAL/KG of bodyweight/day and time on dialysis
Kcal/kg of bodyweight/day (3-day mean values) Time on hemodialysis
Quality of life Correlation Correlation
p-value p-value
coefficient coefficient
Physical functioning 0.669* 0.000 -0.283 0.130
Role-physical 0.342 0.064 -0.155 0.415
Bodily pain 0.604* 0.000 -0.103 0.587
General health 0.158 0.404 0.201 0.287
Vitality 0.419* 0.021 -0.180 0.342
Social functioning 0.180 0.340 0.210 0.266
Role-emotional 0.376* 0.040 -0.121 0.524
Mental health 0.288 0.123 -0.072 0.706
* Statistically significant correlation coefficients.

Table 5 Correlations between quality of life and intake of KCAL, CHO, and PTN/KG of bodyweight/day
KCAL Carbohydrates PTN/Kg of bodyweight/day
Quality of life
Coefficient p-value Coefficient p-value Coefficient p-value
Physical functioning 0.568* 0.001 0.444* 0.010 0.610* 0.000
Role-physical 0.279 0.135 0.273 0.144 0.470* 0.009
Bodily pain 0.529* 0.003 0.461* 0.010 0.603* 0.000
General health -0.026 0.890 -0.048 0.802 0.076 0.691
Vitality 0.097 0.012 0.201 0.287 0.492* 0.006
Social functioning 0.949 0.325 -0.162 0.392 0.222 0.239
Role-emotional 0.325 0.080 0.253 0.178 0.439* 0.015
Mental health 0.254 0.176 0.215 0.254 0.419* 0.021
* Statistically significant correlation coefficients.

the study is that the clinic where the study was carried Systemic hypertension and diabetes mellitus
out saw patients from the Brazilian public health care are significant risk factors for the development of
system (SUS) only. According to the 2011 Dialysis CKD.20 In our study, systemic hypertension and
Census, 84.9% of the HD centers provided their diabetes mellitus were the conditions most frequently
services to SUS patients.3 associated with CKD. Similar findings were described

284 J Bras Nefrol 2013;35(4):279-288

 Quality of life, food intake, and nutritional status of hemodialysis patients

in a study done in 2005, in which 42.4% of the quality of life and gender, with the exception of the
subjects were hypertensive, 12.9% had diabetes, and bodily pain domain, male patients had higher scores
19.8% had both hypertension and diabetes.21 in all scales. A multicenter prospective study carried
According to Batista et al.,22 successful clinical out in Canada enrolled 9,423 individuals and found
management of CKD must include the following that males had substantially higher scores than fema-
items: rigorous management of hypertension; glucose les in all scales and components of the SF-36; accor-
control in diabetic patients; correction of proteinuria; ding to the authors, their scores were also higher than
management of anemia; management of calcium and their American counterparts in all SF-36 scales.28
phosphorus levels; management of metabolic acidosis; Biochemical tests usually draw attention to alterations
and prevention of malnutrition. patients are possibly experiencing. PTH values indicate
The analysis of anthropometric data revealed the presence of secondary hyperparathyroidism in
significant discrepancies between the BMI this population. This is a common complication
classifications proposed by Riella & Martins15 and among patients with chronic renal disease induced by
the WHO.16 However, anthropometric measurements hypocalcemia, hyperphosphatemia, calcitriol deficiency
have been found to be highly reproducible and 90% [1.25(OH)2D3] and skeletal resistance to PTH.29
sensitive.13 Bioelectrical impedance tests were used Riella & Martins15 explained that PTH is released in
in overweight and obese dialysis patients to find increased amounts in response to hypocalcemia to correct
reductions in body cell mass and phase angle, which the reduction in calcium serum levels, once PTH acts on
suggested that even when BMI values were above bone, which leads to release of calcium and phosphate.
normal patients could be at risk for malnutrition.23 Biochemical tests also indicate the presence of
The reported prevalence of malnutrition ranged hyperkalemia, which, in severe cases, may trigger
from 6.7% to 73.3% in the different anthropometric fatal arrhythmias. The dietary intake of this mineral
methods used. A study with 58 dialysis patients from should be controlled by managing potassium levels in
northeastern Brazil found, through anthropometric the dialysate and educating patients on which foods
assessment, that 12.1% of the patients were they should cut down and on the proper preparation
malnourished according to the BMI, 84.5% accor- of foods to reduce the intake of potassium.15
ding to TST, and 43% according to the MUAC.24 A The SF-36 elicited the areas in which patients
study conducted in 20 dialysis centers with 574 pa- had impaired performance. The scale with the
tients looked into BMI, arm circumference, TST, and most significant level of involvement was physical
MUAC and noted moderate/severe malnutrition in functioning, followed by role-emotional, and general
51.6% of the male and 46.3% of the female patients.25 health, which had mean scores below 50.
The mean age of the patients in our study was si- Comparing our results with those of other studies
milar to that of Cabral et al.26 The 47 patients seen at conducted in Brazil that used the SF-36 in HD
the Nephrology Service of the University Hospital of patients, we observed that the role-physical scale
Pernambuco enrolled by the authors had a mean age also had the lowest scores.30 The findings reported by
of 50.4 years. To the authors, this sample comprised a Castro et al.31 corroborate our results as the social
relatively young group when compared to cohorts of functioning, bodily pain and mental health scales had
European patients, whose reported mean age ranged the highest scores.
between 58 and 62 years. Cunha et al.32 described higher scores than our
Oliveira et al.24 reported their patients had been study in social functioning. In contrast, the scale
on dialysis for a mean of 4.27 years, whereas the indi- with the lowest score in the aforementioned study
viduals in our study had been on dialysis for a mean was bodily pain - curiously among the scales with the
of 3.61 years. In the United States the risk of death is highest scores in our study.
estimated to increased by 6% for each additional year Coelho et al.33 concluded in their study that patients
in dialysis after adjustments for several covariates. with CKD may show decreased functional performance
However, it is not clear whether the correlation and impairment in physical activities. However, several
between time on dialysis and risk of death is linear.27 studies have shown that physical activity can raise
In terms of HRQOL, although no statistically the level of quality of life, especially when it comes to
significant differences were found in the areas of physical aspects and functional capacity.34

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 Quality of life, food intake, and nutritional status of hemodialysis patients

The analysis of patient 24-hour dietary recall Calorie intake seems to directly impact QoL,
forms revealed that the three-day mean calorie intake according to the data found in this population. Calorie
in Kcal/Kg/day was far below the ideal conditions intake was correlated with the physical functioning,
for individuals as described in our sample. Most vitality, role-physical, and role-emotional scales.
patients had calorie intake deficits in the range of at These scales refer to difficulties in physical capacities
least 10 kcal/kg of body weight/day in relation to the and limitations in the type and amount of activities of
minimum level required for weight repletion, while daily living performed, the level of energy and fatigue,
80% of the patients had some degree of malnutrition. and the psychological well-being of patients.
Energy intake values close to our findings were Protein intake was correlated with more scales of
reported by Martinez et al.35 In contrast, Favalessa HRQOL. Protein intake in hemodialysis patients was
et al.36 described considerably higher mean energy intake found to directly interfere with the capacity patients
values that were closer or reached recommended levels. have of performing daily living activities because of
Mean protein intake was below appropriate levels fatigue or pain.
required for weight repletion. Favalessa et al.36 and
Batista et al.22 reported mean protein intakes below Conclusion
recommended levels, as also seen in our study. Valenzuela Several inadequacies in food intake were found in
et al.5 found high mean protein intake levels, but 47% of this study, indicating that patients do not maintain
their sample also had less protein than recommended. By adequate nutrition, as recommended for their
their turn, Santos et al.4 and Koehnlein et al.37 described underlying disease. The lack of nutritional counseling
adequate mean protein intake levels. may have led to these inadequacies. Food intake was
Phosphorus and potassium intake levels were correlated with quality of life, as the individuals with
within normal range, as also reported by Valenzuela better quality of life were those who had higher levels
et al.,5 Batista et al.22, and Koehnlein et al.37 Favalessa of calorie intake.
et al.36 described mean phosphorus intake below the However, one should be cautious when using
recommended levels, along with adequate levels of this data, because food quality is very important
mean potassium intake. for these patients. And increasing calorie intake in
Calcium intake was below recommended levels, a disorganized manner, without guidance or proper
which can be explained by the fact that calcium-rich recommendation, may adversely affect the patients’
foods are avoided because they are sources of general condition.
phosphorus. A number of studies with patients on It is important to remember that this is a sample
hemodialysis corroborate our findings.26,29,35 in which the majority of the patients was categorized
The mean sodium intake levels reported in our as malnourished. However, at a global level this
study are close to the recommended levels.15 Batista finding may not be consistent with every population
et al.22 reported a similar finding. Vaz38 described and cannot, therefore, be extrapolated to any given
lower sodium intake levels. set of subjects without prior study. Recent studies
The method used to investigate calorie intake, the have shown that there are populations in which a
R24h, has the following strengths: it is affordable, significant portion of the sample is overweight. It is
easy and quick to apply to patients, and allows for important to remember that obesity itself is a risk
quantitative and qualitative assessment of patients’ factor for CKD. Therefore, one must identify the
diets. However, it also has limitations, such as relying limits of increasing or not the calorie intake levels of
on patients’ memories and on estimated food portion the target population.
sizes, which may underestimate or overestimate The diet for CKD patients imposes several
interviewee actual calorie intake levels.39 restrictions, but they can be managed. Therefore, nu-
Cupisti et al.40 carried out a study in Italy with tritional counseling needs to be specific and tailored
CKD patients on HD and observed mean intakes of to patient needs so that they can improve their food
cholesterol within the recommended range, at levels intake levels and quality of life altogether.
close to those found in our study.

286 J Bras Nefrol 2013;35(4):279-288

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