(A) Patient’s related medical history
|
1- Change in end dialysis dry weight history:
|
0
|
1
|
2
|
3
|
No decrease in dry weight or weight loss <0.5 kg
|
Minor weight loss (≥0.5 kg but <1 kg)
|
Weight loss more than 1 kg but <5 %
|
Weight loss >5 %
|
2- Dietary intake:
|
0
|
1
|
2
|
3
|
Good appetite and no deterioration of the dietary intake pattern
|
Somewhat sub-optimal solid diet intake
|
Moderate overall decrease to full liquid diet
|
Hypo-caloric liquid to starvation
|
3- Gastrointestinal (GI) symptoms:
|
0
|
1
|
2
|
3
|
No symptoms with good appetite
|
Mild symptoms, poor appetite or nauseated occasionally
|
Occasional vomiting or moderate GI symptoms
|
Frequent diarrhea or vomiting or severe anorexia
|
4- Functional capacity (nutritionally related functional impairment):
|
0
|
1
|
2
|
3
|
Normal to improved functional capacity, feeling fine
|
Occasional difficulty with baseline ambulation, or feeling tired frequently
|
Difficulty with otherwise independent activities (e.g., going to the bathroom)
|
Bed/chair-ridden, or little to no physical activity
|
5- Comorbidity including number of years on dialysis:
|
0
|
1
|
2
|
3
|
On dialysis less than 1 year and healthy otherwise
|
Dialyzed for 1–4 years, or mild comorbidity (excluding MCCa)
|
Dialyzed >4 years, or moderate comorbidity (including one MCCa)
|
Any severe, multiple comorbidity (2 or more MCCa)
|
(B) Physical exam (according to SGA criteria):
|
6- Decrease fat stores or loss of subcutaneous fat (below eyes, triceps, biceps, chest):
|
0
|
1
|
2
|
3
|
Normal (no change)
|
Mild
|
Moderate
|
Severe
|
7- Signs of muscle wasting (temple, clavicle, scapula, ribs, quadriceps, knee, interosseous):
|
0
|
1
|
2
|
3
|
Normal (no change)
|
Mild
|
Moderate
|
Severe
|
(C) Body mass index:
|
8- Body mass index: BMI = Wt (kg)/Ht2 (m)
|
0
|
1
|
2
|
3
|
BMI ≥20 kg/m2
|
BMI 18–19.99 kg/m2
|
BMI 16–17.99 kg/m2
|
BMI <16 kg/m2
|
(D) Laboratory parameters:
|
9- Serum albumin:
|
0
|
1
|
2
|
3
|
Albumin ≥4.0 g/dL
|
Albumin 3.5–3.9 g/dL
|
Albumin 3.0–3.4 g/dL
|
Albumin <3.0 g/dL
|
10- Serum TIBC (total iron-binding capacity): ♣
|
0
|
1
|
2
|
3
|
TIBC ≥250 mg/dL
|
TIBC 200–249 mg/dL
|
TIBC 150–199 mg/dL
|
TIBC <150 mg/dL
|
Total score = sum of above 10 components (0–30)
|