End Stage Renal Disease ESRD Health And Social Care Essay

End Stage Renal distemper ( ESRD ) is defined as an permanent nephritic failure which take aways to gestate nephritic replacing therapy ( RRT ) or undergo long term dialysis 1 . There ar ternion roles of nephritic failure replacing therapy which ar haemodialysis ( HD ) , perit adeptal dialysis ( PD ) and nephritic bribery. In Malaysia, Continuous Ambulatory Peritoneal dialysis ( CAPD ) patients be increasing from 1525 patients in year 1999 to 1744 patients in declination 2008, an accession of 12 % 2 .Mal eatable is really common in end phase nephritic disease patients on c argon dialysis 2 . In Malaysia, national learning showed that hardly 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 almost 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 venture of mortality in Chronic Kidney Disease ( CKD ) patients. Hence, it is of import to cadence the nutrition smudge of patients. Screening for malnutrition is an of import constituent of dietary pattern and improves the ability to prioritize intercession to those most at circumstances 6 . Early acknowledgment and intervention chamberpot give better outcome 7 .Nutrition showing is a executable option for placing patients at hazard of PEM 4 . Screening animals 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 immortalize ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( essential ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and capa ble 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 give play an indispensable function to place the malnourished patients. On the other manus, a comprehensive nutritionary appraisal is time-consuming and requires both congenital and clinical opinions from the tester. Therefore, important preparation is necessary to guarantee consistent upshots among assorted testers and periods of appraisal. Therefore, there is a regard for a simplified nutritionary showing tool which tail assembly be utilise by dieticians or nurses that basin be performed easy.1.1 Objective1.1.1 Main ObjectiveTo place a simplified nutritionary showing tool which compares good with the Malnutrition fervor Score ( MIS ) , Subjective Global Assessment ( SGA ) and wit h assorted single nutritionary steps for Continuous Ambulatory Peritoneal dialysis ( CAPD ) .1.1.2 Specific aimTo depict the human ecology, anthropometry, biochemical analysis features and dietetical form of CAPD patients.To depict the per centum of malnourished patients h beef uponizing to BMI, serum albumen, MSGA, and MIS.To formalize the usage of MIS and mSGA in CAPD patients against anthropometric ( BMI, Triceps Skinf doddering, 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 representKidney maps to modulate constituent(a) structure homeostasis system 8 . Kidney plays a critical function in keeping circulatory and organ system useable homeostasis. Other than that, kidney is the land site of discount of some endocrines and an of import catabolic site for several polypeptide endocrines. ( remit 2.1 )Table 2.1 Components of kidney mapElimination of metabolic excess merchandises ( urea, creatinine, uric acid )Elimination and detoxification of drugs and toxinsCare of volume and ionic composing of thoroughgoing structure fluidsAcid-base ordinanceRegulation of systemic blood force per unit areaProduction of erythropoietinControl 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 rev ersible 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 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 )InfectionUrinary enchantment of land obstructorAcute glomerulonephritisDiabetess MellitusUncontrolled high blood force per unit areaFamilial disease of kidneyObstructive UropathyInflammation or transmitting of kidneyBeginning KDOQI, 20012.3 Nephritic failure and dialysisGlomerular filtration rates ( GFR ) is an first-class step of filtrating capacity of the kidneys. GFR establish 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 decrease in GFR precedes kidne y 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 diseasePhaseGFRDescription190-130 ml/minKidney harm with normal or higher GFR260-89 ml/min bats lessening in kidney map330-59 ml/minModerate lessening in kidney map415-29 ml/minSevere lessening in kidney map5Less than 15 ml/minEnd phase nephritic failureBeginning KDOQIThere 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 ceaseless 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 tissue layer 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 attached to the catheter plot of ground another tubing is connected to an empty battalion outside to have the waste fluid merchandises.A high-dextrose dumbness 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 through 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 include 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 energy especially 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 constituent(a) 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 ascribable 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 incontrovertible 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 foster ( 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 soak up of glucose from dialysis fluid 14 . Therefore, 25 to 35 % of blubber 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 neglect 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 restriction is necessary. Harmonizing to KDOQI guidepost, 800-1000mg phosphate per twenty-four hours is recommended 2 . Furthermore, add-on of unwritten phosphate binder is in addition required to command serum phosphate degree 16 .The target of Na sensitiveness is increasing exponentially with declined kidney map 17 . Nevertheless, sodium limitation can assist to command blood force per unit area. profuse Na consumption may do thirst and increase fluid gained which in bend cause oedema 9 . Malaysia medical checkup Nutrition Therapy ( MNT ) guideline recommends 1500mg of salt inspiration 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 patie nts. Table 2.4 shows the recommended alimentary consumption for CAPD patients.Table 2.4 Recommended foods intake for CAPD patientsFoodRecommendationKilogram 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 sic to serum degreeFluidUp to 1500 ml/dayPhosphate800-1000 mg/dayCalciumCalcium from diet and phosphate binder non r all(prenominal) 2000 mg/dayVitamin B ThaimineVitamin b2Vitamin b6Vitamin bcAddendum 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 poor consumption of energy and protein wh ich 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 garbled during dialysis procedure will ensue in protein lack and cause malnutrition 2 .2.6.2 PrevalenceBy the terminal of class 2008, there are 3836 patients who are new to dialysis out of entire 19000 patients. The entire dialysis preponderance 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 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 p atients 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 categorisation of serum albumens degreeStatus blood serum albumin degreeWell nourished 4.0 g/dLMild undernourished3.5 & A lt 4.0 g/dLModerate undernourished3.0 & A lt 3.5 g/dLSevere undernourished& A lt 3.0 g/dLBeginning 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 gustative sensation esthesiss caused by unequal dose of dialysis, emotional hurt, anorexia and unpalatable prescribed diets ensuing in patients distressing unwritten consumption, and later impair their nutritionary position 20 .Disease status is likewise 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, victorious to sickness and diminished appetite. Patients on dialysis have exposed to chronic inflammatory province will increase hypercatabolism and loss of thin organic structure press when there is negative nitrogen balance 2 . Inflammation caused by infection, periodontic disease and familial factor will besides take to slimy 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 later on peritoneal dialysis induction. However, the sum of protein loss will decrease over magazine 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, fervor of catheter site, bioincompatibility of dialysis solution will impact the nutrition position 20 .Besides, dialy sis 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 stomachal 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 craving in CKD patients, ensuing in a diminution of nutritionary pos ition 20 .2.8 Nutrition Screening2.8.1 Purpose of examenHigh 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 key out malnutrition among the patient s.2.8.2 Introduction of showing toolsThere are entire 6 showing tools will be used in this survey Malnutrition-inflammation immortalize ( 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 just 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 Asse ssment-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 heftiness cachexia. This survey had shown a blood 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 p atients 24 .Malnutrition-inflammation mark ( MIS ) was another testing tool certain 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 abl e 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 info 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 unbiased, 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 categorise 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 suit simplified testing tool to observe malnourished patients on CAPD. Six available showing tools were tested on patients nutritionary position.The diagram shows the flow of the survey.3.2 attempt 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 )e2Sample size computation,Ns == ( 1.96 ) 2 ( 0.87 ) ( 1-0.87 )( 0.10 ) 2= 43.4 50 patientsWhere Z = Z0.95 = 1.96 is ask 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 b ody 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 report, drug profile, CAPD prescription, appetite, lifestyle business relationship and dietetic informations. Information was obtained through interview. This is shown in appendix 1.A ) Personal inside informationsThis subdivision covered inquiries on personal information of the participant s name, gender, age, day of the m onth 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-morbidities of the participant is obtained.C ) Drug profileThis subdivision covered informations on the medicine 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 ) Physical activityThe frequence of exercising and the grounds for non exerting were asked.G ) Dietary DataFood readying, eating wonts and any allergic reception of nutrients were specified in this portion.H ) HospitalizationSubject s hospitalization ground and surgery history was asked.3.5.2 anthropometrical 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 concourse Index ( BMI ) will be calculated from topic s tallness 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 24.99Corpulence 25.00Corpulent 30.00Beginning qualified from WHO, 1995, WHO, 2000 an d 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 proficiency 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 squeeze off point of arm musculus perimeter ( AMA )PercentileClass 5thWasted& A gt 5th but ? fifteenthBelow norm& A gt 15th but ? 85thAverage& A gt 85th but ? 95thAbove norm& A gt 95thHigh musculusBeginning 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 visitation consequence.Table 3.3 Cut off point biochemical valueBiochemical constituentsNormal scopeSerum 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 consum ption 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 congregation 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 ( terrible ) . The entire mark used to find the nutrition position of the patient.3.6.2 Malnutrition-in flammation 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 constituents, 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 ( mar k 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 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 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 computationSensitivity = truthful positives/ ( true positives + false negatives )Specificity = true negatives/ ( true negatives + false positives )Positive prognostic value ( PPV ) = true trial positives/all trial positivesNegative prognostic value ( NPV ) = true trial negatives/all trial negatives