2249
Implementing Subjective Global Assessment in low clearance clinics
Roshni Desai, Jan Flint, Rachel Nandy, Jacqueline Newman, Rebecca Walker:
Renal Therapy Team, Therapy Services, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG.
Problem: Subjective Global Assessment (SGA) is recommended by the National Kidney Foundation (NKF) Kidney /Disease Outcomes and Quality Initiative (K/DOQI) as the gold standard tool to assess malnutrition in patients with Chronic Kidney Disease (CKD). The prevalence and risks associated with malnutrition amongst CKD patients has been extensively investigated using SGA, particularly amongst CKD stage 5b (dialysis) patients. Its use however has been sparsely investigated in the earlier stages of CKD including stage 4. Use of SGA was previously audited within the Trust however not embedded in routine practice.
Purpose:The aim of the study was to implement the validated Subjective Global Assessment tool in order to determine the nutritional status of a sample of the pre-dialysis population and examine the relationship between nutritional status as scored by the SGA and other anthropometric and biochemical parameters.
Method:Over a 4 month period, 3 dietitians were able to complete an SGA with 100consenting patients attending outpatient low clearance clinics. To ensure the inter-rater reliability and consistency of the nutritional classifications, all 3 dietitians watched a training DVD. The 3 point SGA which has two sections (medical and physical) was used as the main criterion for the classification of malnutrition. Participants were verbally consented to have the SGA tool completed as part of their routine dietetic appointment.The SGA scores from both parts of the assessment were then combined to produce anoverall nutritional scores (A: well nourished, B/C:malnourished). Data was also collected on all subjects; BMI (kg/m2), age, ethnicity, serum albumin (g/L) and eGFR (ml/min). All the data collected was analysed using the statistical package SPSS.
Findings:Of the 100 patients, the prevalence of malnutrition (SGA score B/C)was 27% (n=27). 50% (n=50) of the sample size were male, mean age was 67 ± 16.5 years and mean BMI was 28.9 ± 8.2kg/m2. There was no association between SGA scores andeGFR, age or ethnicity. Patients with an SGA score of Cwere more likely to have a BMI <20kg/m2 compared with those with an SGA classification of A(p=0.034).No significant association was found between the SGA classifications and albumin. Of the 27% (n=27) that were classified as malnourished, 48% (n=13) were known to the dietitian.
Conclusion:The incidence of malnutrition as determined by SGA is low within this low clearance population, in line with the findings from a previous departmental audit of a similar sample size and patient demographic. SGA appears to correlate with BMI and appears to be useful tool for identifying malnutrition. As 52% of patients classified as malnourished had not been seen by a dietitian, the multidisciplinary team needs to consider the best way to identify patients at risk of malnutrition within the low clearance population. Conversely 73% were classified as well-nourished (SGA A) with an average BMI in this cohort of 30.5kg/m2. This suggests a weight management focus may be indicated, particularly for those being worked up for renal transplantation. Further anthropometric assessments such as waist circumference or waist height may be useful in these patients due to known unreliability of BMI in CKD patients. This audit indicates that the use of SGA for this population should form part of routine practice.