End Stage Renal Disease ESRD Health And Social Care Essay

End Stage Renal sickness ( ESRD ) is delimitate as an irreversible renal visitation which needs to hand nephritic replacing therapy ( RRT ) or undergo long term dialysis 1 . in that respect argon ternion types of nephritic calamity replacing therapy which ar hemodialysis ( HD ) , perit matchlessal dialysis ( PD ) and nephritic graft. In Malaysia, Continuous ambulatory Peritoneal dialysis ( CAPD ) longanimouss atomic number 18 maturation from 1525 patients in class 1999 to 1744 patients in declination 2008, an addition of 12 % 2 .Mal livelihood is really common in eradicate anatomy nephritic unhealthiness patients on c be dialysis 2 . In Malaysia, national information showed that merely 13 % of CAPD patients be good supply where blood blood serum tweed is above 4.0 g/dL 3 . absolute majority of patients ( 87 % ) undergoing CAPD be mal cater. Protein muscle malnutrition ( PEM ) is one of the most prevailing complications looking at in patients undergo ing dialysis and it is associated to laid-back morbidity and mortality 4,5 .Malnutrition is an of consequence divisor associated with increasing back of mortality in inveterate Kidney Disease ( CKD ) patients. Hence, it is of import to step the nutrition position of patients. cover charge for malnutrition is an of import constituent of dietary regulation and im probes the ability to prioritize intercession to those most at misfortune 6 . Early acknowledgment and intervention apprize give better aftermath 7 .Nutrition showing is a executable option for placing patients at judge of PEM 4 . screening nebs are largely designed for oecumenic intents every bit good as for specific topics as aged, charge person and hospitalized patients 4 . thither are several showing tools getable for CAPD patients. These are Malnutrition- hullabaloo check into ( MIS ) , nutritional post showing ( NRS ) , Malnutrition public blanket light beam ( MUST ) , Malnutrition Scre ening Tool ( MST ) , geriatric nutritionary make index ( GNRI ) and capable rambling appraisal ( SGA ) . Among them, none was antecedently analyze for usage in Malayan chronic kidney disease patients on dialysis.The nutritionist plays an essential affaire in nutritionary showing. In Malaysia, entree to dietitian is limited in most dialysis Centres. Hence, nurses testament play an indispensable function to smirch the malnourished patients. On the other manus, a comprehensive nutritionary appraisal is time-consu secondg and requires both subjective and nonsubjective opinions from the tester. Therefore, important forwardness is necessary to guarantee consistent consequences among assorted testers and periods of appraisal. Therefore, there is a invite for a simplified nutritionary showing tool which can be utilise by dieticians or nurses that can be performed easy.1.1 Objective1.1.1 Main ObjectiveTo confide a simplified nutritionary showing tool which compares good with the Malnutrition ardour Score ( MIS ) , internal Global Assessment ( SGA ) and with assorted single nutritionary steps for Continuous Ambulatory Peritoneal dialysis ( CAPD ) .1.1.2 Specific aimTo depict the kind ecology, anthropometry, biochemical analysis features and dieteticalal form of CAPD patients.To depict the per centum of malnourished patients h girdleonizing to BMI, serum albumen, MSGA, and MIS.To formalize the usage of MIS and mSGA in CAPD patients against anthropometric ( BMI, Triceps Skinf emeritus, computed middledle Arm si late Circumference ) and biochemical ( serum albumen ) appraisals To compare the usage of simplified tools NRS, MUST, MST and GNRI showing tools in CAPD patients.Chapter 2 Literature Reappraisal2.1 Overview of kidney mapKidney maps to modulate innate construction homeostasis brass 8 . Kidney plays a critical function in retentiveness circulatory and organ system functional homeostasis. Other than that, kidney is the site of tax ded uction of some endocrines and an of import catabolic site for several polypeptide endocrines. ( skirt 2.1 ) turn off 2.1 Components of kidney map exclusion of metabolic furious merchandises ( urea, creatinine, uric acid )Elimoation and detoxification of medicines and toxinsCare of wad and ionic composing of organic structure blandsAcid-base regularizationRegulation of systemic blood force per whole airfield recall of erythropoietinControl of mineral metamorphosis through endocrinal synthesis( 1,25-dihydroxycholecalciferol and 24,25-dihydroxycholecalciferol )debasement and katabolism of peptide endocrines ( insulin, glucagon, parathyroid endocrine endocrines ) and clinical depression-molecular- angle proteins ( ?2-microglobulin and light ironss )Regulation of metabolic procedures ( gluconeogenesis, lipoid metamorphosis ) graduation exercise Mitch ( 2009 ) 8 2.2 Causes of kidney failureThere are both types of kidney failure which are cunning kidney failure and chronic kid ney failure. Acute nephritic failure is defined as sudden decrease of glomerular filtration rate ( GFR ) or going away of kidney map which is reversible 9 . table 2.2 shown types of acute kidney failure.Chronic kidney failure is defined as structural or functional abaveragealcies of the kidney for more(prenominal)(prenominal)(prenominal) than 3 months 10 . It is an irreversible advancement of kidney h sleeve. The generates of chronic kidney failure are shown in Table 2.2.Table 2.2 Causes of kidney failureAcute Renal FailureChronic Renal FailureAcute cannular mortification ( distress )Nephrotoxicity ( antibiotics and drugs )InfectionUrinary piece of land obstructorAcute glomerulonephritisDiabetess Mellitus lawless high blood force per unit of measurement areaFamilial disease of kidneyObstructive UropathyInflammation or infection of kidney base KDOQI, 20012.3 Nephritic failure and dialysisGlomerular filtration rates ( GFR ) is an first-class step of filtrating susceptib ility of the kidneys. GFR pass water been used to assess the stop of kidney map 10 . There are 5 phases of GFR degree from phase 1- conventionality, to present 5- perfect(a). A lessening in GFR precedes kidney failure in all signifier of progressive kidney disease 10 . In phase 5, where GFR is less than 15 ml/min, it is considered as terminal phase nephritic failure ( ESRD ) . Phase of chronic kidney disease was shown in Table 2.3.Table 2.3 Phases of chronic kidney 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/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 uninterrupted ambulatory periton eal dialysis ( CAPD ) , modify peritoneal dialysis ( APD ) and combination of CAPD and APD 9 .2.4 CAPD processIn Continuous Ambulatory Peritoneal Dialysis ( CAPD ) , turnout permeable membrane of the peritoneum is used as the filtration membrane 9 . A catheter is surgically implanted in the venters and into peritoneal pit. In CAPD, the dialysate is left in the peritoneum and exchanged manually 9 . A dialysate battalion is connected to the catheter epoch some other tubing is connected to an empty battalion outside to stir the waste fluid merchandises.A high-dextrose concentration dialysate is instilled into the peritoneum by the catheter. The dialysate diffusion carries waste merchandises from the blood through the peritoneal membrane and into the dialysate 9 . The waste merchandises and dialysate contri onlye interdependently via osmosis to transport out the waste merchandises. The waste fluid merchandises are withdraw and discarded. Exchanges of dialysate are done fo r four to five times a twenty-four hours 9 . There are different concentrations and volumes of dialysate used which depend on the patient s spot.2.5 Nutrition motivations for CAPD patientsIn peritoneal dialysis, Calories preoccupied from glucose in the dialysis fluid are included in the computation of dietetic energy inspiration. 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 junction of saccharide absorbed should be calculated to forestall over outlay of energy curiously for diabetes patient.From KDOQI 2000, the energy demand for chronic peritoneal dialysis patients who less than 60 old ages of age is 35 Kcal/kg organic structure weight per twenty-four hours 2 . For those who above 60 old ages of age, 30 to 35 kcal/body weight per twenty-four hours is recommended referable to more sedentary life style 2 .Protein need in peritoneal dialysis patient is higher than hem odialysis patient. Peritoneal protein losingss average around 5 to 15 g/24 hours 2 . Generally, dietetic protein demand is to keep affirmatory N agreement and prevent malnutrition. Dietary protein more than 1.2 g/kg BW/ sidereal day associated with im ad hominem or positive N balance 12,13 . KDOQI 2000 suggest that 1.3 g/kg BW/day protein for peritoneal dialysis patient and at to the lowest degree 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 pen for CAPD patients is due to outlet of protein from dialysis fluids and soaking up of glucose from dialysis fluid 14 . Therefore, 25 to 35 % of full-bodied from spotless Calories is recommended for CAPD patients 15 .Calcium and P are mineral demand in our organic structure to keep tog up health. Conversion of vitamin D from inactive signifier to act ive signifier is impair due to kidney failure 16 . When vitamin D lack develops, it may take to faulty enteric soaking up of Ca. In contrast, phosphorus excretion becomes restricted be manage of reduced cannular map. Therefore, dietetic orthophosphate organize of accumulation is necessary. Harmonizing to KDOQI signpost, 800-1000mg phosphate per twenty-four hours is recommended 2 . Furthermore, add of oral phosphate binder is withal needed to command serum phosphate degree 16 .The commit of Na sensitiveness is increasing exponentially with declined kidney map 17 . Nevertheless, sodium limitation can assist to command blood force per unit area. Excessive Na consumption may do thirst and increase fluid gained which in bend cause oedema 9 . Malaysia checkup Nutrition Therapy ( MNT ) guideline recommends 1500mg of salt intake per twenty-four hours and no add-on salt in cookery. Suggested unstable consumption is up to 1500ml per twenty-four hours 15 .CAPD patients m ay 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 add-on 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 victualsRecommendationKilogram 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 adjust to serum degreeFluidUp to 1500 ml/dayPhosphate800-1000 mg/dayCalciumCalcium from diet and phosphate binder non exit 2000 mg/dayVitamin B ThaimineVitamin b2Vitamin b6Vitamin bcAddendum to run into recommended periodic 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 condition ensuing from long-run unequal consumption of energy and protein which can take to blowing of organic structure tissues and increased susceptibleness to infection 19 . PEM is strongly linked to malnutrition and mortality rate in person who undergoes care dialysis 2 . CAPD patients are more prone to malnutrition compared to HD patients. In CAPD, protein lost during dialysis procedure allow for ensue in protein lack and cause malnutrition 2 .2.6.2 PrevalenceBy the terminal of twelvemonth 2008, there are 3836 patients who are revolutionary to dialysis out of absolute 19000 patients. The entire dialysis prevalence rate in celestial latitude 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 sexual activity distribution is male ( 55 % ) and female ( 45 % ) from a entire 18856 patients 3 . The primary cause of nephritic disease is diabetes mellitus ( 55 % ) followed by high blood pressure ( 7 % ) from entire 3836 new dialysis patients on twelvemonth 2008 3 .Protein-energy malnutrition ( PEM ) is really common among patients with advanced chronic nephritic failure ( CRF ) and those undergoing care dialysis ( MD ) therapies worldwide 2 . K/DOQI guideline proposed that, both work forces and adult females patients undergoing maintenance dialysis to accomplish BMI of at least(prenominal) 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 variety of serum albumen degrees.Table 2.5 Categorization of serum albumens degreeStatusserum albumin degreeWell nourished 4.0 g/dLMild underfed3.5 & 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 gustatory adept esthesiss caused by unequal venereal infection of dialysis, emotional hurt, anorexia and unpalatable prescribed diets ensuing in patients scurvy unwritten consumption, and later impair their nutritionary position 20 .Disease status is besides a factor causes malnutrition in dialysis p atients. Uremia is the most of import subscriber to inadequate nutrition in CAPD patients. As the Glomerular Filtration swan ( GFR ) declines, azotemic toxins accumulate, taking to sickness and diminished appetite. Patients on dialysis have candid to chronic inflammatory res publica will increase hypercatabolism and loss of elegant organic structure mass when there is disconfirming nitrogen balance 2 . Inflammation caused by infection, periodontic disease and familial factor will besides take to ugly nutrition intake 20 .Ascitess patient is at higher venture of PEM. Ascites is another disease status doing protein loss more than 30g per twenty-four hours particularly after peritoneal dialysis induction. However, the sum of protein loss will decrease over clip 20 .In dialysis intervention, unequal dialysis might bring on anorexia and decreased gustatory sensation sharp-sightedness 20 . In add-on, dialysis promotes blowing by taking foods such as aminic acids, peptides, protein, glucose, water-soluble vitamins, and other bioactive compounds, and promotes protein katabolism, due to bioincompatibility 2 . In CAPD patients, firing of catheter site, bioincompatibility of dialysis solution will impact the nutrition position 20 .Besides, dialysis therapy may besides take to peritonitis. Transportation of K and azotemic toxin down a concentration in peritoneal capillaries will do protein loss. Furthermore, peritoneal inflammation will do leaky in peritoneal capillaries and prolong peritoneal redness ensuing in release of cytokine and protein loss, which in bend fascinate 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 ahead of time repletion by delayed gastric emptying 20,21 . The most holds in stomachic voidance happened in those with smaller organic structure bulg e country 22 . Gastric emptying clip is associated with adequateness of foods ingestion. blend but 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 interrogatoryHigh prevalence of CAPD patients with hapless nutritionary position is associated with minacious results 20 . Early sensing of malnutrition patient can diminish the luck of inauspicious result of hapless nutrition. Therefore, it is critical that a validated and dead on target 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, dieteti c 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 substance abuser friendly scrutiny tool is needed for others wellness professional to go on malnutrition among the patients.2.8.2 Introduction of showing toolsThere are entire 6 showing tools will be used in this study Malnutrition-inflammation stigmatise ( MIS ) , nutritionary make believe showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary impale index ( GNRI ) and modified subjective wandering appraisal ( MSGA ) . The SGA and MIS tools are the gilded measuring showing tools which have prove in many surveies 2,23 . However, MSGA is used in this be alternatively of SGA. MSGA is more nonsubjective, easy and practical that utilizing vicenary check intoing system if compared to SGA which is utilizing semi-quantitat ive cross offing system 24 . Whereas, MIS is validated and proven by Kalantar-Zadeh et. Al ( 2001 ) as a dependable tools to place malnutrition patient particularly in inflammatory province 23 .A survey by Yamada K. ( 2008 ) obtained the mark from several testing tools such as NRS, MUST, MST, GNRI and Mini nutritionary Assessment-Short Form ( MNA-SF ) and comparing the MIS testing tool as the mention criterion. Among the five showing tools, consequences shown GNRI was the most accurate showing in placing hemodialysis patient at nutritionary hazard. However, this survey did non included CAPD patients 4 .MSGA is a modified quantitative subjective planetary appraisal which modified utilizing the constituents of unoriginal 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 capaci ty, comorbidity, subcutaneous avoirdupois and marks of musculus cachexia. This survey had shown a relationship between malnutrition mark and the combination of MAMC, BMI, serum albumen and TIBC. MSGA is an nonsubjective, dependable and easy tools which can function in proceedingss compare to SGA. However, the survey did non include any CAPD patients 24 .Malnutrition-inflammation mark ( MIS ) was another testing tool veritable 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 genuine utilizing seven constituents in SGA and added three new elements which are body aggregate index, serum albumen degree and total-iron fecundation capacity with mark 7 ( normal ) to 35 ( dreadful malnourished ) . Kalantar-Zadeh and co-workers proved it is a good tool in foretelling mortality every bit good as nutrition, redness and anaemia in MHD patients. 23 Nutrition hazard showing ( NRS ) is developed by Kondrup and co-workers in old ages 2002. This tool was designed to steps current possible undernutrition and disease badness patients in order to measure whether tools was capable to separate patients with a positive clinical result from those who non profit from nutrition support. The consequence proved this screening tool is able to separate positive consequence and those who are likely to profit from nutrition support. It scored 0 ( absent ) to 3 ( terrible ) . 25 Malnutrition Universal Screening Tool ( MUST ) was designed to let out protein-energy malnutrition and the hazard of developing malnutrition in grownup patients. There are three independent stocks 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 w as a speedy and easy performed tool. 26 Malnutrition Screening tool ( MST ) was developed to observe hospitalized grownup ague patients at hazard of malnutrition by Ferguson and co-workers. It consisted of two inquiries sing appetency and recent unwilled weight loss. The information showed a relationship between patients who are high hazard of malnutrition harmonizing to MST with low average value of nonsubjective nutrition parametric quantities and continuing length of infirmary staying. Ferguson and co-workers proposed MST as a simple(a), 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 reckon GNRI mark. It had four classs of nutrition related hazard which are no hazard, low hazard, mode rate hazard and major hazard categorized by utilizing GNRI mark. This survey showed a strong relationship between albumen and GNRI. It is a simple showing tool for foretelling mortality and morbidity hazard particularly in hospitalized aged patients. 28 Chapter 3 Materials and Methods3.1 Study designThis look into was a cross-sectional survey which done amongst 50 CAPD patients in Hospital Kuala Lumpur ( HKL ) . The research has been approved by the IMU Joint commission Research and Ethics. This research was to place a suited simplified testing tool to observe malnourished patients on CAPD. Six available showing tools were tested on patients nutritionary position.The diagram shows the flow of the survey.3.2 Sample coatParticipants were chosen by utilizing convenient essay method at the Nephrology unit in Hospital Kuala Lumpur ( HKL ) .The sample sizing 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 read from a timeworn normal distribution tabular array.Where P = Prevalence of malnutrition CAPD patients = 0.87 ( 87 % )Where E = Estimated trying mistake = 10 %Therefore, 50 patients were recruited for this survey.3.3 Capable choiceThe inclusion standard of this survey were role players 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 informat ions, socioeconomic background, medical history, drug profile, CAPD prescription, appetite, lifestyle history and dietetic informations. Information was obtained through reference. This is shown in appendage 1.A ) Personal inside informationsThis subdivision cover inquiries on personal information of the participant s name, sexual urge, age, day of the month of birth, ethnicity, matrimonial position, charge 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 imagine of exchanges done in one twenty-four hours and the concentration, type and volume of dialysate usage per exchange.Tocopher ol ) 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 ground for non exerting were asked.G ) Dietary DataFood readying, eating wonts and any supersensitised reaction of nutrients were specified in this portion.H ) HospitalizationSubject s hospitalization ground and surgery history was asked.3.5.2 Anthropometric informations ( Appendix 3 )3.5.2.1 Height and weightParticipant s tallness and weight was obtained from the medical record. Three measurings of participant s station dialysis weight were recorded at first calendar week 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. luggage compartment Mass Index ( BMI ) will be calculated from topic s tallness and weight, utilizi ng 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 Adapted from WHO, 1995, WHO, 2000 and WHO 2004.3.5.2.2 Mid arm molding ( MAC )Mid arm perimeter was performed with mensurating tape ( precision 0.1 atomic number 96 ) . 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 centimetre ) . Landmarking was carried out prior to skinfold measuring.3.5.2.4 Mid arm musculus perimeter ( cAMA )Mid arm musculus perimeter is a computation derived from mid arm perimeter ( MAC ) and Tricep skinfold ( TSF ) MAMC ( centimeter ) = MAC ( centimeter ) ? TSF ( centimeter ) Calculate mid arm musculus country ( cAMA ) provides a more accurate appraisal of musculus mass by gauging bone-free arm musculus country, corrected with gender differences.Calculate mid arm musculus country, cAMA= ( MAC ( centimeter ) ? TSF ( centimeter ) ) 2 / 4 ? 10.0 ( work forces )= ( MAC ( centimeter ) ? TSF ( centimeter ) ) 2 / 4 ? 6.5 ( adult females )Table 3.2 Cut off point of arm musculus perimeter ( AMA )PercentileClass 5thWasted& A gt 5th but ? 15thBelow norm& A gt 15th but ? eighty-fifthAverage& 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 trial 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 consumption of 1 weekday and 1 weekend were recorded. Dietary appraisal tools ( bowls, spoon, matchbox and cup ) were shown to the topic at the first interview subdivision. The subsequent information aggregation was done through phone call. Food functioning size recorded was converted to unit gm and analysed via alimentary composing of Malayan Food ( Tee E Siong, 1997 ) and Nutritionist Pro. Programme.3.6 Screening toolA sum of 6 showing tools were used in this survey.3.6.1 Modified Subjective planetary appraisal ( MSGA )This tool was designed by Kalantar-Zadeh group in twelvemonth 1999. This testing tool was developed by utilizing the constituent of conventional SGA and consists of seven variables weight alteration, dietetic consumption, GI symptoms, functional capacity, co-morbidity, hypodermic fat and marks of musculus cachexia. Each constituent was scope from 1 ( normal ) to 5 ( 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, 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 separately 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 consultative Group of the British Association for Parenteral and Enteral Nutrition. MUST consists of 3 independent constituents which are current weight position measured by BMI ( mark 0 to -2 ) , unwilled weight loss ( mark 0 to -2 ) , and acute disease consequence bring forthing no nutritionary consumption for & A gt 5d ( mark 0 or 2 ) . The amount of these 3 tonss was calculated.3.6.5 Malnutrition testing tool ( MST )The MST was developed by Ferguson et. Al 1999 had been used for acute infirmary patients it incorporates 3 constituents which are weight loss ( mark 0 or 2 ) , sum of weight lost ( mark 1-4 ) , and hapless nutrient consumption or hapless appetency ( mark 0 or 1 ) . The entire mark was calculated for each patient.3.6.6 Geriatric nutrition hazard index ( GNRI )The GNRI was developed by modifying the nutritionary hazard index ( NRI ) for aged patients. This index was calculated from the serum albumen and organic structure weight by utilizing the undermentioned 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 v ariable is presented as the stiff 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 indicationation 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 = true up 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