Risk factors affecting nutritional status of dialysis patients: a quality improvement project

People with chronic kidney disease on dialysis are at very high risk for protein energy malnutrition (PEM). It is well documented that malnourished patients have increased frequency of hospital admissions, longer hospital stays, lower quality of life, and increased risk of death. Serum albumin level is a valid measure for nutritional status of PEM. Clinical practice guidelines for nutrition, established by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI), recommend that patients on dialysis achieve an albumin of 3.7 g/dL (BCP) to ensure optimal nutrition and decrease risks of PEM. At Mercy Dialysis Center, it was determined that only 6% (n=97) of patients at Mercy Dialysis Center met this recommended albumin level. This led to an extensive continuous quality improvement project to improve these results. The nephrologist, nurse practitioner, dietitian, social worker, nurses, and dialysis technicians all contributed to this team project.

Eleven risk factors for low serum albumin levels were identified. All patients at Mercy Dialysis Center were assessed for each risk factor. Interventions were implemented to reduce these risks. Serum albumin levels were tracked at the beginning of our study, at six months, and at one year on all patients.

At the end of the study, 36% of the patients met the KDOQI recommendations for serum albumin levels (compared to only 6% prior to the project), and albumin levels overall improved. The risk factors that affected our patients the most included: dentition, infections or sepsis, multiple medications, and pain. It was determined that these, and all other risk factors had an impact on the nutritional status of our patients and need to be addressed on a regular basis.