Most studies reporting on nutritional assessments in dialysis patients come from economically developed countries [15]. We therefore report on adult patients dialysing at the largest tertiary hospital in the country and the only public hospital with a specialised renal unit in the country. Almost 75% of patients had reduced dietary protein intake, when compared to that advised by clinical guideline committees [3, 19]. The prevalence of malnutrition was 43.8% using the 7-point SGA assessment [19], and malnutrition was independently associated with lower serum albumin, creatinine, MUAC, BCM and unemployment. The prevalence of PEW and sarcopenia were lower, being 20.4% and 4.1%, respectively and 19.6% classified as frail using the CFS [11, 15, 22]. The 7-point SGA includes assessment of weight change, dietary intake, gastrointestinal symptoms, functional ability, co-existing co-morbidity, and physical examination. Whereas there was fair agreement between SGA and frailty, there was only slight agreement with PEW and no agreement with sarcopenia. As our patient cohort was younger and had fewer co-morbidities than those typically dialysing in economically advanced countries, this may have impacted on SGA scores. In addition, we used the cut-offs from European and North American clinical guidelines to screen for sarcopenia, and these may not be appropriate in a sub-Saharan African population, and may account for the poor association between SGA and sarcopenia.

Compared to other studies, the reported prevalence of malnutrition in our study was lower than that reported in other studies [15]. One study from Egypt reported a much higher prevalence of 85% [23], and one from Nigeria 55% [24]. The difference in prevalence between these studies published almost 10 years ago, could reflect differences in terms of access to dialysis, as patients may have to pay in full or part for dialysis treatments in developing countries, so having less than thrice weekly sessions and re-using low-flux dialyzers, along with differences in comorbidities, dialysis vintage, let alone dietary habits [25], whereas all the patients we report were in receipt of what would now be considered standard of care with thrice weekly 4-hour dialysis sessions.

Failure to achieve adequate clearance of uraemic toxins has been reported to increase the risk of PEW [26]. All our patients dialysed for 4 h thrice weekly, even so only 55% achieved a sessional KT/Vurea target of ≥1.4, and there was no associated between sessional Kt/Vurea and SGA scores, which supports a previous report from Iran which also reported no association between dialysis session urea clearance and nutritional status [27].

Serum albumin can be lowered by inflammation, PEW and so not just a marker of malnutrition, and the mean serum albumin was below the ISRNM advisory target level of 38 g/L in our patient cohort [28]. However, whether our patients were classified as malnourished by SGA criteria, or those with PEW, then all had a low serum albumin [15, 19]. Those classified as frail had a mean lower albumin than those who were not frail though the result was not significant [11]. The number of patients who were classified as sarcopenic was low (n = 4), therefore, due to this no further analysis was done.

Similarly, serum creatinine was lower in our patients who were malnourished, which is in keeping with reports from Turkey [29], demonstrating the association between lower serum creatinine in dialysis patients and reduced muscle mass and malnutrition. For both frailty and PEW, patients who were malnourished had lower values compared to those who were not malnourished. For frailty, the result was not statistically significant, but for PEW, there were significant differences.

However, another observational study from Iran found no association between serum creatinine and malnutrition [30]. Although this study did show a significant difference in the prevalence of malnutrition between male and female patients, with greater moderate malnutrition observed with male patients, which have biased the study results. Creatinine is generated from muscle creatine, so more physically active patients will generate more creatinine. In our study patients who were employed were less likely to be malnourished, and this is in keeping with other reports of physical activity linked to employment, and reduced prevalence of PEW, sarcopenia, and frailty [9]. Our malnourished patients had lower body cell mass and more importantly lower lean tissue when indexed for height, in keeping with less muscle mass. Similarly, the MUAC was lower in our malnourished patients, and as there was no difference in fat mass indexed for height, this would again suggest lower upper arm muscle mass in the malnourished patients.

Creatinine is also affected by diet, in particular dietary meat protein intake. We found that the median nPNA value was well below the 2020 Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition recommended dietary protein intake 1.0–1.2 g/kg/day [3], and almost three-quarters (74%) of the patients had low protein intake (nPNA < 0.8 g/kg/day) which could be affected by diet patterns. The primary staple food is a starch-based food (maize) and as most individuals, especially those from poorer households predominantly only eat maize with only very little meat, this could explain the lower nPNA reported in our study [31]. Although there was no significant difference in the dietary protein intake in those who were malnourished and not malnourished, this may have been confounded by all patients being given a meal when they attended for their dialysis session. As such most dietary restrictions and recommendations for dialysis patients developed for economically advanced countries [1, 3], may be inappropriate for patients living in sub-Saharan Africa. Therefore, it is important that dietary recommendations should be appropriate for the dialysis population, considering geopolitical, religious, and other factors, including ethnicity. Whereas in economically developed countries emphasis on protein and phosphate restriction may be appropriate [3, 4], in resource-limited settings in developing countries more attention is required to provide dietary advice to ensure adequate nutrition. Our unemployed patients were more likely to be malnourished, and economic factors, such as the lack of financial resource to purchase essential foods may have played a role in the development of malnutrition. In our study, a higher proportion of individuals who were unemployed had low nPNA, though when compared to those who were employed, the result was not statistically significant.

We have reported the first study to assess nutritional status and diet among CKD patients in the country. As with any observational study, there are a number of limitations to consider. Firstly this was a cross sectional study so we cannot comment on whether patients nutritional status changed over time. Secondly it was conducted at the only public run haemodialysis centre, and there are now private dialysis centres opening. Thirdly the staple diet is maize, and although maize is widely eaten in many African countries, other countries may have different dietary patterns. As with any observational study our findings should be interpreted with caution, as we can only report factors associated with malnourishment, but not apportion causality.