Malnutrition in dialysis patients following COVID

By : Mme DORSON Sandy, Infirmière référente nutrition CHPM

Malnutrition in haemodialysis patients

Malnutrition is a common problem in patients suffering from end-stage chronic renal failure treated by haemodialysis. The current rate of malnutrition during dialysis remains high at 30%, as evidenced in a recent French study of a cohort of over 7,000 haemodialysis patients.

Furthermore, malnutrition is an independent risk factor for increased morbidity and mortality, regardless of the underlying medical conditions, even in overweight or obese people (HAS Recommendation: diagnosis of malnutrition in people aged 70 and over).

During dialysis, catabolism is a significant factor for the patient. Preventing malnutrition is therefore part of the overall management of haemodialysis patients, and personalised measures should be offered to patients who are malnourished or at risk of malnutrition. The DHOS circular dated 29 March 2002 on food and nutrition in health establishments recommends that CLANs (Food and Nutrition Liaison Committees) be set up in all health establishments.

The COLENDIA study found that "a protein-enriched snack given to malnourished or non-malnourished patients during haemodialysis significantly increased serum albumin concentration", a simple and effective measure. In addition to the nutritional value of the snack during the session, we can also highlight that this is a key moment for patients during the session. Meals are not only a source of pleasure through taste; it's also a time that provides social gratification through interacting with others. It's a time when illness isn't a factor, a happy moment with the carers that differs from treatment time, which is associated with constraint, pain and often anguish.

Suspending snacks during the COVID-19 pandemic

The first lockdown in France began in March 2020. The CHPM introduced an immediate ban on snacks to prevent the spread of the virus.

Periods when snacks are suspended:

- 24 March to 13 July 2020

- 2 November 2020 to June 2021

- 7 December 2021 to 13 March 2022

For three long periods, the patients no longer received snacks during their sessions, and the quality of their protein intake was significantly affected (drop in nPCR), leading to fragility and malnutrition in some patients.

The nPCR (normalised protein catabolic rate) or standardised protein catabolic rate, measures the protein (or protide) intake of a patient between two dialysis sessions.

The figures:

the CHPM has seen a clear drop in the average rate of nPCR

In correlation with our study, a study published on 5/09/2022 involving 121 patients showed that "the withdrawal of intra-dialytic snacks during the COVID-19 pandemic worsened the nutritional parameters of chronic haemodialysis patients".

Actions taken by CLAN to combat malnutrition

The Food and Nutrition Liaison Committee, which has been active within the CHPM since 2015, quickly recognised the nutritional impact of the COVID-19 crisis on most patients’ risk of malnutrition .

Further to cutting out snacks, we have seen a reduction in weight gain among our elderly patients. Several factors are at play: patients are often isolated, no longer receiving visits from their families, and have difficulty going shopping.

In response, CLAN has developed a number of initiatives to encourage people to eat more:

- Allowing malnourished patients to take their oral nutritional supplements (ONS) by passing the straw under the mask during the session

- Giving ONCs to patients to take home with them after their session

- Personalised video and telephone consultations with a dietician and doctor

Conclusion

Snacking appears to be a key part of the dialysis session: a treatment imperative aimed at combating malnutrition, which is an independent factor in mortality, and a social imperative aimed at maintaining social links and patient/carer and patient/patient interaction. CLAN plays a particularly important role in preventing malnutrition and shouldn't hesitate to set up initiatives for patients, families (workshops, events) and care staff (training, events).