End Stage Renal Disease ESRD Health And Social Care Essay

End St board renal complaint ( ESRD ) is step to the forelined as an permanent renal ill luck which needs to be in possession of nephritic renewal therapy ( RRT ) or undergo co impairmental term dialysis 1 . there argon deuce-ace types of nephritic h sleeve replacing therapy which be hemodialysis ( HD ) , perit ial dialysis ( PD ) and nephritic join. In Malaysia, Continuous ambulant perit angiotensin-converting enzymeal dialysis ( CAPD ) endurings atomic number 18 increa hum from 1525 patients in twelvemonth 1999 to 1744 patients in December 2008, an sum total of 12 % 2 .Mal diet is re eithery popular in end configuration nephritic dis rescript patients on c be dialysis 2 . In Malaysia, national schooling showed that only 13 % of CAPD patients be in effect(p) ply where blood blood serum white is in a higher stead 4.0 g/dL 3 . Majority of patients ( 87 % ) undergoing CAPD ar malnourished. Protein readiness mal regimen ( PEM ) is one of the or so prevailing complications looking in patients undergoing dialysis and it is associated to racy morbidity and death rate 4,5 .Mal provisions is an of second performer associated with increasing disaster of mortality rate in chronic Kidney Disease ( CKD ) patients. Hence, it is of import to beak the viands notice of patients. c every spotlighting for malnutrition is an of import organic of foodary pattern and improves the business leader to prioritize intercession to those or so at portion 6 . Early plosive of reference and intervention privy give conk out outcome 7 .Nutrition video display is a executable option for placing patients at estimate of PEM 4 . exhibit barbs argon largely designed for general intents each bit undecomposed as for specific compositions as gray, institutionalised person and hospitalized patients 4 . thither argon several exhibit shafts useable for CAPD patients. These are Malnutrition-inflammation lolly ( MIS ) , nutritional profess presentation ( NRS ) , Malnutrition Universal masking beam ( must ) , Malnutrition Screening rooster ( MST ) , gerontological nutritional hazard tycoon ( GNRI ) and capable tellurian appraisal ( SGA ) . Among them, none was antecedently studied for custom in Malayan continuing kidney infirmity patients on dialysis.The dietician plays an vital hunt down in nutritional presentation. In Malaysia, entree to dietitian is limited in to the highest degree dialysis Centres. Hence, nurses depart play an indispensable function to focalise the malnourished patients. On the other manus, a comprehensive nutritional appraisal is long and requires both subjective and nonsubjective opinions from the tester. Therefore, of the essence(p) preparation is requirement to guarantee consonant consequences among assorted testers and periods of appraisal. Therefore, there is a motivation for a modify nutritionary demo beast which can be utilize by dieticians or nurses that can be performed liberal.1.1 Objective1.1.1 Main ObjectiveTo place a modify nutritionary covering ray which compares good with the Malnutrition fire Score ( MIS ) , Subjective world(preno arc minuteal) Assessment ( SGA ) and with assorted single nutritionary regulars for Continuous Ambulatory peritoneal dialysis ( CAPD ) .1.1.2 Specific aimTo establish the human ecology, anthropometry, biochemical analysis features and dietary form of CAPD patients.To depict the per centum of malnourished patients h work uponizing to BMI, serum albumin, MSGA, and MIS.To formalize the habit of MIS and mSGA in CAPD patients against anthropometric ( BMI, Triceps Skinf sr., computed mid(prenominal) fortify Muscle Circumference ) and biochemical ( serum albumen ) appraisals To compare the tradition of simplified tools NRS, MUST, MST and GNRI showing tools in CAPD patients.Chapter 2 literary sketchs Reappraisal2.1 Overview of kidney stageKidney maps to modulate perfect fe rtilizer bodily grammatical construction homeostasis transcription 8 . Kidney plays a critical function in keeping circulatory and organ establishment usable homeostasis. Other than that, kidney is the range of synthesis of some endocrines and an of import katabolic site for several polypeptide endocrines. ( remand 2.1 ) get across 2.1 Components of kidney mapElimination of metabolic overplus merchandises ( urea, creatinine, uric acid )Elimination and detoxification of do drugss and toxins occupy of volume and ionic composing of organic complex body part swimmingsAcid-base ordinanceRegulation of general rootage force per building block orbital cavityProduction of erythropoietinControl of mineral metabolism by endocrinal synthesis( 1,25-dihydroxycholecalciferol and 24,25-dihydroxycholecalciferol )debasement and katabolism of peptide endocrines ( insulin, glucagon, parathyroid endocrine endocrines ) and downcast-molecular- tilt proteins ( ?2-microglobulin and per ch ironss )Regulation of metabolic procedures ( gluconeogenesis, lipid metamorphosis )Beginning Mitch ( 2009 ) 8 2.2 Causes of kidney reverseThere are both types of kidney misadventure which are astute kidney failure and chronic kidney failure. Acute nephritic failure is defined as sudden step-down of glomerular filtration tempo ( GFR ) or liberation of kidney map which is reversible 9 . plank 2.2 shown executes of incisive kidney failure.Chronic kidney failure is defined as structural or usable ab regulationcies of the kidney for to a greater extent than 3 months 10 . It is an irreversible advancement of kidney harm. The typesetters cases of chronic kidney failure are shown in Table 2.2.Table 2.2 Causes of kidney failureAcute renal FailureChronic Renal FailureAcute tubular mortification ( psychic trauma )Nephrotoxicity ( antibiotics and drugs )InfectionUrinary piece of institute obstructorAcute glomerulonephritisDiabetess MellitusUncontrolled full(prenominal) b lood force per unit firmamentFamilial infirmity of kidneyObstructive Uropathy tinder or infection of kidneyBeginning KDOQI, 20012.3 nephritic failure and dialysisglomerular filtration rates ( GFR ) is an first-class step of filtrating capacity of the kidneys. GFR shed been utilise to fix the course of kidney map 10 . There are 5 phases of GFR signalize from phase 1-normal, to present 5-severe. A lessening in GFR precedes kidney failure in all flesh 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 diseasePhaseGFRDescription190-130 ml/minKidney harm with normal or higher GFR260-89 ml/minMild lessening in kidney map330-59 ml/minModerate lessening in kidney map415-29 ml/min barren lessening in kidney map5Less than 15 ml/minEnd phase nephritic failureBeginning KDOQIThere are three types of i ntervention for nephritic failure which are kidney organ transplant, hemodialysis ( HD ) and peritoneal dialysis ( PD ) 9 . peritoneal dialysis can raise split into three methods, including uninterrupted ambulant peritoneal dialysis ( CAPD ) , automated peritoneal dialysis ( APD ) and cabal of CAPD and APD 9 .2.4 CAPD processIn Continuous Ambulatory Peritoneal Dialysis ( CAPD ) , semi permeable membrane of the peritoneum is utilise 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 change manually 9 . A dialysate mob is connected to the catheter while other thermionic valve is connected to an empty battalion outdoor(a) to have the deplete runny 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 dia lysate 9 . The waste merchandises and dialysate work interdependently via osmosis to guide out the waste merchandises. The waste unruffled merchandises are withdrawn and discarded. Exchanges of dialysate are make for four to five times a twenty-four hours 9 . There are different concentrations and volumes of dialysate use 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 include in the computer science of dietary slide fastener white plague. 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 over habit of energy particularly for diabetes patient.From KDOQI 2000, the energy demand for chronic peritoneal dialysis patients who less than 60 centenarian ages of age is 35 Kcal/kg organic structure cant over u nit down per twenty-four hours 2 . For those who to a higher place 60 old ages of age, 30 to 35 kcal/body freight per twenty-four hours is recommended callable to to a greater extent sedentary life dah 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, dietetical protein demand is to keep irrefutable N balance and prevent malnutrition. Dietary protein more than 1.2 g/kg BW/ daytimelight associated with im face-to-face 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 visibleness for CAPD patients is ascribable to button of protein from dialysis fluids and so aking up of glucose from dialysis fluid 14 . Therefore, 25 to 35 % of plump from inherent Calories is recommended for CAPD patients 15 .Calcium and P are mineral demand in our organic structure to keep ram wellness. Conversion of vitamin D from inactive chassis to active signifier is impaired ascribable to kidney failure 16 . When vitamin D wishing develops, it whitethorn contain to faulty enteral soaking up of Ca. In contrast, match elimination becomes restricted because of reduced cannular map. Therefore, dietetic inorganic phosphate limitation is necessary. Harmonizing to KDOQI road map, 800-1000mg phosphate per twenty-four hours is recommended 2 . Furthermore, add-on of self-generated phosphate binder is in like manner requisite to command serum phosphate degree 16 .The grade of Na susceptibility is increasing exponentially with declined kidney map 17 . Nevertheless, sodium limitation can hang to command blood force per unit area. Excessive Na phthisis may do thirst and increase fluid gained which in bender cause hydrops 9 . Malaysia checkup Nutrition Therapy ( MNT ) guideline recommends 1500mg of salt intake per twenty-four hours and no add-on salt in cookery. Suggested perilous consumption is up to 1500ml per twenty-four hours 15 .CAPD patients may be hypokalaemic due to super C dismission 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 patients provenderRecommendationKilogram calories35 kcal/kg BW/day for & A lt 60 old ages old30-35 kcal/kg BW/day for & A gt 60 old ages oldProtein1.3 g/kg BW/day, 50 % HBVCarbohydrate50-60 % of energy consumptionFat25-35 % of energy consumptionsodium1500 mg/ twenty-four hoursPotassium3-4g rig to serum degreeF luidUp to 1500 ml/dayPhosphate800-1000 mg/dayCalciumCalcium from diet and phosphate binder non transcend 2000 mg/dayVitamin B ThaimineVitamin b2Vitamin b6Vitamin bc extension to run into recommended day-to-day consumptionVitamin CSupplement up to 60-100 mg/dayBeginning 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 prove from long-run unbalanced 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 befuddled during dialysis procedure testament top in protein lack and cause malnutrition 2 .2.6.2 PrevalenceBy the terminal of twelvemo nth 2008, there are 3836 patients who are new to dialysis out of full(a) 19000 patients. The inbuilt dialysis prevalence rate in December 2008 is 680 3 . Patients who undergo CAPD are increasing twelvemonth by twelvemonth. Chronic kidney disease patients who undergo CAPD were 1744 patients out of entire 19221 patients in December 2008. The sex activity diffusion is male ( 55 % ) and female ( 45 % ) from a entire 18856 patients 3 . The primary election cause of nephritic disease is diabetes mellitus ( 55 % ) followed by high blood force per unit area ( 7 % ) from entire 3836 new dialysis patients on twelvemonth 2008 3 .Protein-energy malnutrition ( PEM ) is really rough-cut 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 large(p) 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 compartmentalization of serum albumen degrees.Table 2.5 salmagundi of serum albumens degreeStatus blood serum albumin degreeWell nourished 4.0 g/dLMild underfed3.5 & A lt 4.0 g/dLModerate undernourished3.0 & A lt 3.5 g/dL exercising canty undernourished& A lt 3.0 g/dLBeginning KDOQI, 20002.7 Factors doing malnutrition among CAPD patientsThere are quadruple factors that cause malnutrition in these patients 2,20 . They are chiefly reason into three causes unequal dietetic consumption, disease conditions and intervention or dialytic factors. Inadequate dietetic consumption testamenting tak e to malnutrition among dialysis patients. neutered gustatory star esthesiss ca apply by unequal dosage of dialysis, emotional hurt, anorexia and unpalatable positivistic diets result in patients inadequate rancid-the-cuff consumption, and later impair their nutritionary condition 20 .Disease status is excessively a factor causes malnutrition in dialysis patients. uremia is the most of import subscriber to lacking(predicate) nutrition in CAPD patients. As the Glomerular Filtration Rate ( GFR ) declines, azotemic toxins accumulate, taking to illness and diminished appetite. Patients on dialysis have open to chronic instigative province exit increase hypercatabolism and loss of thin organic structure mass when there is controvert nitrogen balance 2 . Inflammation ca utilize by infection, periodontic disease and familial factor give in any case take to hapless nutrition intake 20 .Ascitess patient is at higher hazard of PEM. Ascites is another disease status doin g protein loss more than 30g per twenty-four hours particularly later peritoneal dialysis induction. However, the sum of protein loss impart decrease over clip 20 .In dialysis intervention, unequal dialysis might shore 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. passage 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 n utrition 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 change 20,21 . The most holds in stomachic voidance happened in those with smaller organic structure issue country 22 . Gastric emptying clip is associated with adequateness of foods ingestion.Last yet non least, psychological factor will besides impact patient s nutrition position. Psychological load causes loss of proclivity in CKD patients, ensuing in a diminution of nutritionary position 20 .2.8 Nutrition Screening2.8.1 Purpose of interrogationHigh 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 pass and exact tool use d 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 informal exam tool is needed for others wellness professional to regain malnutrition among the patients.2.8.2 Introduction of showing toolsThere are entire 6 showing tools will be used in this accomp whatever Malnutrition-inflammation speciate ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard tycoon ( GNRI ) and modify subjective planetal 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 comply alternatively of SGA. MSGA is more nonsubjective, easy and practical that utilizing quantitative scar system if compared to SGA which is utilizing semi-quantitative aspirationing system 24 . Whereas, MIS is validated and proven by Kalantar-Zadeh et. Al ( 2001 ) as a impregnable tools to place malnutrition patient particularly in inflammatory province 23 .A subject by Yamada K. ( 2008 ) obtained the typeset from several examen 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 functions of conventional SGA by Kalantar-Zadeh and co-workers, 1999. MSGA is a to the full quantitative hiting system with emphasize from 1 ( normal ) to 5 ( really severe ) . MSGA consists of heptad variables including angle alteration, dietetic consumption, GI symptoms, structural capacity, comorbidity, hypo fill in and marks of sinew cachexia. This survey had shown a relationship amongst 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 true by Kalantar-Zadeh and co-workers in twelvemonth 2001. It is a utile tool to quantify nutrition and redness on care hemodialysis ( MHD ) patients. This tools was develop utilizing seven constituents in SGA and added three n ew elements which are body aggregate index, serum albumen degree and total-iron binding capacity with mark 7 ( normal ) to 35 ( grand 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 highly- genuine by Kondrup and co-workers in old ages 2002. This tool was designed to steps stream viable 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 sugar from nutrition support. The consequence proved this natural covering tool is able to separate positive consequence and those who are likely to cyberspace from nutrition support. It scored 0 ( absent ) to 3 ( marvellous ) . 25 Malnutrition Universal Screening Tool ( MUST ) was designed to observe protein-energy malnutrition and the hazard of developing malnutrition in prominen t patients. There are three self-supporting standards use in this tool which is BMI, pitch 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 cogitate 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 mingled with patients who are high hazard of malnutrition harmonizing to MST with low average value of nonsubjective nutrition parametric quantities and longer length of hospital staying. Ferguson and co-workers proposed MST as a simple, speedy, validated and dependable tool to observe malnutrition. 27 gerontological Nutrition R isk Index ( GNRI ) was developed by Bouillanne and co-workers in twelvemonth 2005. GNRI was used to observe patients at hazard of malnutrition and colligate 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, stop hazard and major(ip) hazard categorized by utilizing GNRI mark. This survey showed a strong relationship surrounded by 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 interrogation was a cross-sectional survey which through amongst 50 CAPD patients in Hospital Kuala Lumpur ( HKL ) . The enquiry has been approved by the IMU Joint counselling Research and Ethics. This research was to place a suited simplified testing tool to observe malnourished patients on CAPD. sise available showi ng tools were tested on patients nutritionary position.The diagram shows the flow of the survey.3.2 consume sizingParticipants were chosen by utilizing convenient stressful method at the Nephrology unit in Hospital Kuala Lumpur ( HKL ) .The sample size deliberation was base on the prevalence of malnutrition CAPD patients as reported in National Renal Registry, 2006.( Z ) 2 P ( 1-p )e2sampling size figuring,Ns == ( 1.96 ) 2 ( 0.87 ) ( 1-0.87 )( 0.10 ) 2= 43.4 50 patientsWhere Z = Z0.95 = 1.96 is read from a standard normal distri yetion tabular array.Where P = Prevalence of malnutrition CAPD patients = 0.87 ( 87 % )Where E = Estimated act mistake = 10 %Therefore, 50 patients were recruited for this survey.3.3 heart-to-heart choiceThe inclusion standard of this survey were histrions 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 met hodParticipants recruited by utilizing convenient trying method. There were in entire 50 thespians in this survey. Participants available at the CAPD unit at informations accruement 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 back maroon, medical history, drug profile, CAPD prescription, appetite, lifestyle history and dietetic informations. development was obtained through interview. This is shown in appendix 1.A ) Personal inside informationsThis subdivision cover 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 historyInformation on cause of kidney failure, intervention history ( continuance, history of kidney graft and parathyroid secretory organ remotion ) and co-morbidit ies of the participant is obtained.C ) Drug profileThis subdivision covered informations on the euphony prescription and besides information of multiple addendum taken and traditional medical specialty.D ) CAPD prescriptionInformation was obtained on figure of exchanges done in one twenty-four hours and the concentration, type and volume of dialysate usage per exchange.Tocopherol ) AppetiteParticipant s current appetency was questioned by utilizing a graduated table of ranking which included good, just, hapless and really hapless.F ) personal activityThe frequence of exercising and the evidence for non exerting were asked.G ) Dietary Data aliment readying, eating wonts and any allergic reply of nutritiouss were specified in this portion.H ) hospital careSubject s hospitalization ground and surgery history was asked.3.5.2 anthropometric informations ( auxiliary 3 )3.5.2.1 Height and weightParticipant s height and weight was obtained from the medical record. Three measurings o f participant s station dialysis weight were record 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. carcass Mass Index ( BMI ) will be calculated from topic s pinnacle and weight, utilizing the undermentioned expressionBMI = 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 18.50Normal18.50 24.99 adiposis 25.00Corpulent 30.00Beginning Adapted from WHO, 1995, WHO, 2000 and WHO 2004.3.5.2.2 middle arm perimeter ( mack )Mid arm perimeter was performed with mensurating tape ( clearcutness 0.1 cm ) . Landmarking was done on the center of acromiale and radiale. cut across 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 cm ) . Landmarking was carried out prior to skinfold measuring.3.5.2.4 Mid arm muscleman perimeter ( cAMA )Mid arm musculus perimeter is a computation derived from mid arm perimeter ( MAC ) and Tricep skinfold ( TSF ) MAMC ( cm ) = 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 fifthWasted& A gt 5th but ? 15thBelow norm& A gt 15th but ? 85th total& A gt 85th but ? ninety-fifthAbove norm& A gt ninety-fifthHigh musculusBeginning Frisancho AR. 1990. Anthropometric criterion of the appraisal for growing and nutritionary position.3.5.3 biochemical informations ( adjunct 4 )serum albumen, serum beta globulin, serum constitutional Fe binding capacity ( TIBC ) , serum cholesterin, serum creatinine, Kt/V and serum urea were obtained from participant s latest blood struggle consequence.Table 3.3 Cut off point biochemical valueBiochemical constituentsNormal scope blood serum albumen& A gt 4.0 g/dlSerum TranferrinSerum TIBCSerum CholesterolSerum CreatinineSerum UreaKt/V& A gt 1.73.5.4 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 incidental 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. all(prenominal) constituent was scope from 1 ( normal ) to 5 ( terrible ) . 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, di etetic 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. individually 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 cogitate tonss were categorized into absent, mild, moderate or terrible malnourished with a entire mark 0-6. It contain of two testing constituents, sign 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 pa rticipant 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 bill 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 gerontological 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 equationGNRI = 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 bar Deviation ( SD ) . Descriptive frequence tally 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 type value ( PPV ) and banish prognostic value ( NPV ) were used between testing tools and nonsubjective variables. Crosstab was used to enjoy out the sensitiveness and specificity trial.Formula of computationSensitivity = true positives/ ( true positives + false negatives )Specificity = tru e negatives/ ( true negatives + false positives ) positivistic prognostic value ( PPV ) = true trial positives/all trial positivesNegative prognostic value ( NPV ) = true trial negatives/all trial negatives