Q J Med 2002; 95: 811-820
© 2002 Association of Physicians
Nutrition, adequacy of dialysis, and clinical outcome in Indo-Asian and White European patients on peritoneal dialysis
From the Renal Services, University Hospitals Coventry and Warwickshire, Walsgrave Hospital, Coventry, UK
Received 8 March 2002 Accepted for publication 10 September 2002.
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Background: There is a high incidence of end-stage renal disease in Asians originating from the Indian subcontinent living in the UK. Research to date has focused on the cause of renal disease in Indo-Asians, and their outcome on peritoneal dialysis (PD) is less well studied.
Aim: To determine whether nutrition, adequacy of dialysis, and outcome of Indo-Asian patients on PD were similar to those of White European patients.
Design: Prospective longitudinal observational study over 2 years.
Methods: We enrolled 35 Indo-Asians and 35 White Europeans on peritoneal dialysis, closely matched for age, gender, diabetes and duration of renal replacement therapy. At enrolment (>3 months on PD), demographic data was recorded. From enrolment, and at 6-month intervals, dialysis adequacy, nutritional status, hospitalizations, PD infections, and treatment modality changes were recorded.
Results: Dietary protein intake, which was significantly worse in Indo-Asians (particularly vegetarians), declined in all patients over time, along with other measures of nutritional status. Adequacy of dialysis, peritoneal characteristics, and PD infections were similar in Indo-Asian and White patients. Technique failure, and death rate were similar in both groups, but the transplant rate was lower in Indo-Asians.
Discussion: Interventions are needed to improve nutritional status in these patients, particularly the Indo-Asian patients. The long-term impact of worse social deprivation and lower transplant rates in Indo-Asians needs to be investigated further.
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Introduction |
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There is a high incidence of end-stage renal disease (ESRD) in Asians originating from the Indian subcontinent living in the UK, compared to White Europeans.1 Indo-Asian and Afro-Caribbean patients have a three-fold to four-fold higher acceptance rate onto renal replacement therapy, compared to White patients.2 Diabetic nephropathy, and idiopathic interstitial nephritis contribute significantly to this higher incidence of ESRD in Indo-Asians.1,3,4
There are various Asian communities in the UK (e.g. Pakistani, Gujarati, Muslim, Indian Sikh, etc.), which differ in terms of environmental factors such as diet, language, religion, and lifestyle, as well as genetic composition. Although it is difficult to define ethnic status, it can be a useful research variable, and is an important factor which needs to be considered when providing health care. Many of the areas of ethnic health that have been focused on, such as heart disease, diabetes, and mental health, have been identified by the Government as target areas for improvement. UK Indo-Asians have a higher incidence of coronary heart disease, and type 2 diabetes compared to White Europeans. There is evidence that UK Indo-Asians with diabetes have a worse understanding of their condition compared to White patients, and one of the factors contributing to inadequate compliance is a lack of culturally appropriate patient information.2
In the US, where African-Americans and Hispanics are the fastest growing ethnic groups with ESRD, some research has been carried out examining the experience and outcome of ethnic minorities on renal replacement therapy.6–9 Certain measures of dialysis adequacy, blood pressure, and serum biochemistry were worse in ethnic minority patients; however, survival was as good or better compared to White Americans.6–9 In a recent North American study, ‘Asian’ ethnicity (not defined) was associated with lower serum albumin, muscle and fat stores compared to non-Asians.10 Malnutrition has been cited as a possible contributory factor towards a poor prognosis in ESRD patients, and any suggestion of worse nutrition in Asians needs to be explored further.11 Studies have also shown that Asian ethnicity is associated with high peritoneal transport status.12,13 As high transport characteristics are linked to worse treatment outcomes, any ethnic difference in transport status needs to be examined further.14
The number of Indo-Asians in the UK requiring treatment for ESRD is expected to increase in the coming years as the Indo-Asian population ages. In some districts with large ethnic populations, the number of people on renal replacement therapy is over 700 per million population, compared to the UK average of 354 per million.2 In view of the increasing number of Indo-Asians with ESRD, and the lack of research on the experience and outcome of Indo-Asians in this country on RRT, ethnicity was considered when planning a longitudinal peritoneal dialysis (PD) study. The aim of the study was to determine if nutrition, adequacy of dialysis, and outcome of Indo-Asians on PD were similar to those of White European patients.
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Methods |
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The study was done at Coventry Renal Unit, between December 1996 and November1999. The protocol was approved by the local research and ethics committee. All adult Indo-Asians (from the Indian subcontinent/East Africa) (Indo-Asian) who were on peritoneal dialysis (PD) for >3 months enrolled in the study, and were studied prospectively for a 2-year period (n=35). White European (White) PD patients (n=35) most closely matched for age, gender and diabetes were also enrolled. Patients were excluded if (i) they were unable to give informed consent, (ii) were due to have a living related kidney transplant in the following 6 months, or (iii) had been on PD for less than 3 months. Enrolment to the study was delayed by 4 weeks if the patient had a peritonitis, and/or following discharge from hospital for an emergency admission. The target urea clearance (Kt/V) was 2.0 and target creatinine clearance (Crcl) 60 l/1.73 m2/wk for all peritoneal dialysis patients at our centre. Patients who failed to achieve the set target, or refused to alter their prescription were not obliged to transfer to haemodialysis. At our centre, the mean number of people on peritoneal dialysis was 115, and 165 were on hospital haemodialysis for the duration of the study. In general, patients who presented with chronic renal failure selected their treatment modality, and the percentage of Indo-Asians, and of diabetics, on each treatment modality was similar.
Data collected on enrolment
Demographic details were recorded for age, gender, ESRD diagnosis, months renal replacement treatment, ethnicity, comorbidity and social deprivation. Comorbidity was scored using the accepted method of Davies15 Social deprivation was calculated using Townsend scoring,16 which is explained in the Methods section of a previous paper.17
Data collected on enrolment and at 6-month intervals
Adequacy of dialysis was calculated from 24-h dialysate, and urine collections. Peritoneal creatinine clearance (pCrcl) was corrected to a body surface area of 1.73 m2. Renal creatinine clearance (rCrcl), was calculated from the mean of creatinine and urea clearance18 corrected to a body surface area of 1.73 m2. Urea clearance was expressed as Kt/V using the Watson formula for body water.19 Peritoneal membrane transport was calculated from a 4-h peritoneal equilibration test (PET),20 and dialysate prescriptions were recorded. Total protein loss per day was calculated from 24-h urine and dialysate collections. Protein intake per day was calculated from the mean daily protein intake (g/day) recorded by patients at home in a 3-day food diary. The target protein intake for our renal patients was >1.2 g/kg/day. Estimated dietary protein intake was also calculated using 24-h urine and dialysate collections, expressed as g protein nitrogen appearance per day (PNA), and also normalized to patient body weight (nPNA). Bergstrom's formula was used to calculate PNA.21 A score of nutritional status was calculated using Subjective Global Assessment (SGA).22 SGA is based on a medical history of weight changes, appetite and gastrointestinal symptoms, and a physical examination of body fat and muscles. In this study, the more recently modified and validated seven-point SGA scale was used.23 An SGA score of 6–7 indicates well-nourished, 3–5 mildly to moderately malnourished, and 1–2 severely malnourished. Patient's weight, triceps skinfold thickness (TSF), and mid-arm circumference (MAC), were measured. Mid-arm muscle circumference (MAMC) was calculated from the TSF and MAC measures.24 Serum albumin was measured using the bromocresol purple method (reference range 34–48 g/l), and serum prealbumin (reference range 0.18–0.45 g/l) using a Bayer Advia 1650 Analyser. Non-fasting cholesterol, urea, electrolytes, and blood count were measured. Glycated haemoglobin (reference range 3.6–6.8) results were calibrated to DCCT/UKPDS standards.
Information was recorded on hospital admissions, and infections were recorded from the date of enrolment in the study. Peritonitis (PS) was diagnosed on white blood cell count of >100 in the dialysis effluent, with or without a positive culture.25 An exit site infection (ESI) was defined as exudate and redness around the exit site, with or without positive culture.26
Statistical analysis
Values are expressed as means±SD. Paired-samples t test was used for comparisons of the Indo-Asian vs. White patients at enrolment (Tables 1
–4). The non-parametric Mann-Whitney U test was used for subsequent analysis of group differences (Table 5), when patients were lost from the Indo-Asian and White groups to haemodialysis, transplant and death. A 
2 test was used when comparing group differences in peritoneal transport status (Table 4). All univariate analyses were tested using Pearson's correlation coefficient, and multiple (backward stepwise) regression analyses were used to test the degree of association between variables. Variations in results over-time were measured by ANOVA (Figure 1, Table 5). The 5% significance level was used for all statistical tests. Analyses were performed using SPSS for Windows 9.0, and Microsoft Excel Analyse-it Statistics Add-in (University of Leeds, UK).
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Results |
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Patient characteristics and clinical results on enrolment
Patient demographic and clinical characteristics on enrolment are shown in Table 1
. The White diabetic patients were all insulin-dependent diabetics, whereas the Indo-Asian diabetic patients were predominantly non-insulin-dependent. Indo-Asian patients were significantly more socially deprived compared to the White patients. Several anthropometric and nutritional characteristics were similar in Indo-Asian and White patients. However, as shown in Table 2, protein intake was significantly worse in Indo-Asians. SGA scores of nutrition showed a high level of mild-to-moderate malnutrition in all patients. The most significant difference in serum biochemical results between the groups on enrolment was the lower measures of phosphate, urea, and creatinine in the Indo-Asian group (Table 3). Mean serum cholesterol, and C-reactive protein were raised in both Asian and White patients. The glycated haemoglobin results were above the normal reference range in both groups, suggesting poor diabetic control. Peritoneal dialysis prescriptions/characteristics, and adequacy results on enrolment are shown in Table 4.
Patient characteristics and clinical results in Indo-Asian subgroups
The Indo-Asians in the study were mainly from the Punjab region (49%), and East Africa (mainly Kenya) (26%), with a small number originating from Gujarat, Pakistan, and Bangladesh. The most prevalent religion was Sikh (51%), followed by Hindus (29%), and Muslims (20%). There was no significant difference between nutritional measures or adequacy of peritoneal dialysis between the Asian subgroups on enrolment. Muslim patients were more socially deprived than Sikh (p=0.001) or Hindu (p=0.01) patients.
Vegetarian status and clinical results
Six of the study patients (all Indo-Asian) were vegetarians (3 Hindu, 3 Sikh). Protein intake and serum pre-albumin were significantly lower in vegetarians compared to non-vegetarians. However, if vegetarians were excluded from analysis of measures of adequacy and nutrition, all significant differences between Indo-Asian and White patients shown in Tables 2–4 remained.
Adequacy of dialysis over time
In the 35 patients who remained on PD at 2 years, as residual renal function declined over time, total creatinine clearance (Crcl), and urea clearance (Kt/V) declined in both Indo-Asians and Whites. Figure 1 shows how peritoneal creatinine clearance (pCrcl) increased significantly in both groups (Indo-Asian p=0.006; White, p=0.009), as a result of increasing dialysate volume used per day (Table 5). Dialysate used per day was significantly greater in the White patients. Two White patients commenced automated peritoneal dialysis (APD) and two started a fifth exchange at night using an automated machine. One Indo-Asian patient commenced APD.
Nutritional/anthropometric results over time
Dietary protein intake calculated by nPNA, which was significantly worse in Indo-Asians on enrolment, remained significantly worse (p=0.04) in 26 Indo-Asians compared to 23 Whites, on dialysis at 1 year post enrolment. In the 35 patients who remained on PD for 2 years, the nPNA remained worse in Indo-Asians compared to Whites at each of the 6-month assessments in the patients studied for 2 years as shown in Table 5. Serum albumin remained similar in Indo-Asian and White patients from enrolment to 24 months, declining from 31 g/l to 29 in Indo-Asians, and from 32 g/l to 30 in White patients. SGA worsened slightly in both patient groups. During the first 12 months of the study, weight and BMI increased significantly in both groups, but this trend was no longer evident at 24 months. There were no other significant changes in anthropometric measures over the first 12 months of the study. In the 35 patients who remained on PD, mid-arm circumference measurements decreased in Indo-Asian and White patients between enrolment and 24 months, and this reached significance in the Indo-Asian patients (p=0.028). By 24 months, triceps skinfold measurements had also declined in all patients (Indo-Asian p=0.07; White p=0.01).
Hospital admissions
Fifty-four (77%) patients had one or more hospital admission from enrolment until exiting the study or completion at 2 years. There were 42 admissions in the Indo-Asian patients, and 42 in the White patients. Hospital admissions classified according to cause and ethnicity are shown in Figure 2. On multivariate analysis, increased social deprivation (Townsend score) was the only variable independently associated with an increased number of hospital admissions (p=0.024). Hospital admissions with fluid overload were significantly associated with increased social deprivation (p=0.008). Longer hospital admissions were independently associated with increased patient age (p=0.04), and lower serum albumin (p=0.02), but not with social deprivation on multivariate analysis.
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Peritoneal dialysis-related infections
The peritonitis (PS) rate was 1 episode in 18 patient months, and the exit site infection (ESI) rate was 1 in 11 patient months. Half of the patients did not have a PS during the study time, and 44% did not have an ESI. There was no significant difference between ESI and PS rates between Indo-Asians and Whites, or between diabetics and non-diabetics. The number of hospital admissions with PS was higher in Indo-Asians, but this was not statistically significant.
Treatment modality outcome over time
At 2 years post enrolment, 35/70 (50%) study patients remained on PD. Fourteen patients (20%) had transferred to haemodialysis (HD), nine patients (13%) had had a renal transplant (TXP), 11 (16%) had died, and one had transferred to another Unit. The mean months on PD for these patients on enrolment was 20±17 (3–66). Treatment outcome at 2 years, classified by ethnicity, is shown in Figure 3. The number of diabetic patients who remained on PD, transferred to HDX or died was similar for Indo-Asians and Whites. The main cause of transfer to HD was catheter removal for repeat peritonitis or fungal infection (n=8, 57%).
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Discussion |
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This is the first prospective longitudinal study, comparing adequacy of dialysis, nutrition and outcome in Indo-Asian and White peritoneal dialysis patients in the UK. All of our Indo-Asian PD population enrolled in this study, along with 35 closely matched White controls. On enrolment, adequacy of dialysis, as measured by total creatinine clearance (Crcl) and total urea clearance (Kt/V), was similar in Indo-Asians and Whites. During the course of the study, as renal function declined, total Crcl declined in both patient groups, as shown in Figure 1
. The dialysate volume used per day was increased over time, leading to a significant improvement in peritoneal creatinine clearance. The litres of dialysate used per day was lower in Indo-Asians compared to Whites, even after adjusting for patient body surface area (significantly lower from 12 to 24 months). Although the volume of dialysate used per day increased significantly in both groups, the biggest increase was seen in the White group, who had more patients transfer to automated dialysis (APD) or use of a fifth exchange device. Although these data might suggest reduced access to APD for Indo-Asians, further follow-up does not support this. In autumn 2001, an audit showed that 35% of Indo-Asians on our PD program were on APD, 26% of Whites were on APD, and 10% of Whites were using a fifth exchange device. The number of Indo-Asian patients with high/high average peritoneal transport characteristics on enrolment was higher than that found in the White patient group using an abbreviated PET,20 but this difference was not statistically significant.
High peritoneal transport status, which is associated with increased protein losses and fluid overload has been linked with worse outcomes on PD.14,27–30 Studies of peritoneal transport characteristics carried out in India have shown that Indian patients have a high proportion of high-high average transporters.12,13 A higher prevalence of high-high average transporters has also been found in Chinese and Mexican populations.31,32 In our study, there was no significant difference between transport status in diabetics and non-diabetics who were on PD for a mean of 18 months on enrolment. This lack of a significant difference between transport status in diabetics and non-diabetics was also found in other studies,31–33 in contrast with some reports.14,34,35 Serum glucose levels and glycated haemoglobin levels were similar in Indo-Asian and White diabetic patients.
It is well documented that protein malnutrition is common amongst dialysis patients, and many patients are malnourished on commencing dialysis.36–39 Several factors are thought to contribute to this high incidence of malnutrition on PD, such as inadequate dialysis to correct acidosis, high peritoneal protein losses, loss of appetite caused by presence of PD fluid in the abdomen and glucose absorption.36–38 Analysis of protein intake on enrolment using 3-day food diary records, and protein nitrogen appearance (PNA) calculated from urine and dialysate collection showed that Indo-Asians had significantly worse protein intakes than Whites. Protein intake was calculated from the food diaries by hand, and calorie intake was not assessed in this study. A second analysis of the protein intake data excluding the six vegetarians in the study, who were all Indo-Asian, still showed significantly worse protein intake in Indo-Asians. Analysis of the Indo-Asian subgroups in our study (Sikh, Hindu, Muslim) found that protein intake was similar in Sikhs and Hindus and highest in Muslims, but differences were not significant. Although all of our Indo-Asian patients on PD enrolled in the study, the sample was too small to draw meaningful conclusions on the reasons for the differences in nPNA between the groups over time.
Several studies highlight the adverse impact of malnutrition on morbidity and mortality in ESRD patients.11,15,39–41 The precise impact of malnutrition on morbidity and mortality in renal patients with inflammation remains unclear. Serum albumin and prealbumin results were not significantly different in Indo-Asians and Whites. Serum albumin and prealbumin are sometimes criticized as nutritional markers, as they are influenced by inflammation.37 A separate analysis of the data excluding all patients with a raised C-reactive protein level (>6) again showed no significant difference between Indo-Asians and Whites.
Anthropometric assessment (TSF, MAC and MAMC) results on enrolment were similar in Indo-Asian and White patients. Because fat distribution can differ in Indo-Asians and Whites,42 analysis of changes within each group over time was considered a more important factor for examination than analysis of difference between the two groups using anthropometric standards such as NHANES tables.43 Over the 2-year study period, TSF measures of subcutaneous fat declined in all patients (overall p=0.009; White p=0.01; Indo-Asian p=0.07). MAC measures also declined over time, significantly so in Indo-Asian patients (p=0.02). MAMC measures declined in all patients, but this did not reach significance. A study comparing Asian and non-Asian dialysis patients in North America found a significantly lower albumin level and MAMC in Asians.10 The US Asian population comprises a mixture of ethnic groups, and the study did not state the mix. In many renal units serial anthropometric assessments are not performed, as there are several potential causes of error.44 In our study, all the anthropometric measures were carried out by one person, thereby eliminating one of the main criticisms associated with this method of nutritional assessment.
The third method of nutritional assessment used in our study was Subjective Global Assessment (SGA).22 Mild-to-moderate malnutrition was found in 65% of patients using the newer modified SGA scoring system, which may be more sensitive to picking up mild malnutrition.23 SGA scoring showed a similar rate of decline in nutritional status over time in Indo-Asians and Whites.
Hospital admission rates are frequently used as an outcome measure in studies examining treatment of people with chronic diseases. Hospital admission rates during the 2-year study period were identical in both Indo-Asians and Whites. The admission rate did not differ significantly between the groups, after adjustments were made for the number of days that patients were enrolled in the study. A greater number of Indo-Asian patients were admitted with fluid overload and peritonitis compared to the White patients, although this did not reach statistical significance. Admissions with fluid overload were independently associated with social deprivation. Indo-Asian patients were significantly more socially deprived than White patients, as measured by the Townsend score (p=0.0003).16 On multivariate analysis, social deprivation was associated with the overall number of hospital admissions patients had in the 2-year study period (p=0.024), and in particular admissions with fluid overload (p=0.008). Other studies in cardiac and pulmonary disease have shown that social deprivation is an important predictor of hospital admission rates, independent of other factors such as disease severity.45–47 Increased morbidity from disease conditions such as diabetic eye disease and chronic respiratory conditions are also associated with social deprivation.48 An inverse association has been found between social deprivation and onset of type 2 diabetes, suggesting that exposure to lifestyle factors implicated in type 2 diabetes is more common in deprived areas.49 At present, there is no general population data available on deprivation scores in Coventry. Analysis of the Indo-Asian subgroups in our study (Sikh, Hindu, Muslim) found the worst deprivation in Muslims (p=0.006). Our previous work has highlighted aspects of quality of life (QoL) which were worse in Indo-Asians on dialysis and following renal transplant compared to Whites.17 The earlier work, which included 40 PD patients, found that QoL was not associated with measures of treatment adequacy, but was associated with social deprivation, which was worse in Indo-Asians. Lifestyle and cultural factors are important determinants of food intake, as well as level of education about diet and fluid balance in ESRD. In this study, social deprivation was not associated with nutritional status or measures of protein intake. The impact of worse social deprivation on intermediate and long term outcomes in dialysis patients needs to be investigated further.
At the end of the 2-year study period, 50% of the patients enrolled in the study remained on PD (21 Indo-Asian, 14 White). Analysis of modality outcome data showed that the number of patients who transferred to haemodialysis and the reasons for transfer were similar in Indo-Asians and Whites. The number of patients in each group who died was also similar, as was the cause of death. During the study period, eight White patients had a kidney transplant (5 cadaveric) compared to one Indo-Asian patient (cadaveric). Previous research carried out on our Unit has shown that the rate of organ donation is considerably lower in the Indo-Asian population than in the White population, and that Indo-Asians (commonly blood groups B and AB) wait longer for a kidney transplant.50 Recent research on our Unit has suggested that Indo-Asians could benefit from a blood-group-compatible cadaveric kidney allocation system.51
In summary, this study found protein intake was significantly lower in Indo-Asians on peritoneal dialysis compared to White Europeans, and the rate of decline in certain serial anthropometric measures was worse in Indo-Asians. However, these differences in nutritional and anthropometric measures do not appear to be related to outcomes in this study, which is somewhat limited by the sample size. There was no significant difference in dialysis adequacy, peritoneal characteristics, PD infection rates or technique failure in Indo-Asians compared to Whites. Although social deprivation, which was worse in Indo-Asians, was associated with increased hospital admissions, it was not associated with measures of adequacy of dialysis or nutritional status.
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Acknowledgments |
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The researchers would like to thank Baxter Healthcare, who funded the research nurse post.
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Address correspondence to Dr A. Bakewell, Renal Services, University Hospitals Coventry and Warwickshire, Walsgrave Hospital, Clifford Bridge Road, Coventry CV2 2DX. e-mail: Anne.Bakewell{at}wh-tr.wmids.nhs.uk
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