Objectives: Nutritional status is a vital predictor of survival in chronic hemodialysis patients. Protein-energy wasting and micronutrient deficiencies are associated with increased morbidity and mortality. In this study, we evaluated the prevalence of malnutrition and seasonal nutritional fluctuations among patients who were receiving hemodialysis in the Azerbaijan Republic.
Materials and Methods: We conducted a retrospective analysis of 126 patients undergoing chronic hemodialysis in 2024. Assessments included serum biochemical markers (albumin, hemoglobin, ferritin, vitamin D), body mass index, and dietary records.
Results: Among 126 patients, hypoalbuminemia was observed in 49 patients (39%) and 55 patients (44%) presented with body mass index <20 kg/m². Micronutrient deficiencies were frequent, with iron deficiency in 45 patients (36%) and vitamin D deficiency in 60 patients (48%). Seasonal variations significantly affected protein and caloric intake (P < .⁰⁵).
Conclusions: Malnutrition is a significant burden in Azerbaijani hemodialysis units. Implementation of regular monitoring and individualized dietary counseling is essential to optimize patient outcomes.

Key words : Azerbaijan, Hemodialysis, Malnutrition, Protein-energy wasting, Vitamin D

Introduction
The survival and quality of life of patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis are closely linked to their nutritional status. Protein energy wasting (PEW), characterized by a decline in body protein and fat stores, is a common complication in this population.^1,2 Factors contributing to PEW include systemic inflammation, uremic toxins, nutrient loss during dialysis, and overly restrictive renal diets.^3,4 Nutritional assessment tools and clinical scoring systems are widely used to identify early malnutrition, sarcopenia, and functional decline in hemodialysis populations.^5,6 In the Azerbaijan Republic, the number of patients receiving renal replacement therapy has grown steadily. Despite widespread technical access to dialysis, systematic data on nutritional health remain limited. Malnutrition is often part of the “malnutrition-inflammation complex syndrome,” which significantly increases cardiovascular mortality.^7,8 Understanding regional nutritional patterns and seasonal influences is crucial for developing national clinical guidelines.^5,9,10 Clinical practice recommendations emphasize adequate protein intake, personalized dietary strategies, and structured nutritional monitoring in patients with chronic kidney disease.⁶ In this study, we conducted a retrospective analysis of the nutritional status of patients undergoing hemodialysis in Azerbaijan during 2024.

Materials and Methods

Study design and population
This retrospective multicenter study included 126 chronic hemodialysis patients treated in multiple centers across Azerbaijan throughout 2024. Inclusion criteria were age ≥18 years and a dialysis vintage of at least 3 months. Patients with active malignancy or acute infections were excluded to minimize the impact of nonnutritional inflammation on serum albumin levels.

Nutritional assessment with biochemical markers
We recorded the monthly averages of patient serum albumin, hemoglobin, and ferritin levels and the quarterly levels of serum 25-hydroxyvitamin D.

Anthropometry
Post-dialysis dry weight was used to calculate BMI body mass index (BMI; calculated as weight in kilograms divided by height in meters squared). Mid-arm circumference was used to assess muscle mass depletion.^11,12 Sarcopenia-related muscle loss was interpreted according to contemporary clinical definitions.¹³

Dietary analysis
We analyzed the 24-hour dietary recall records and food diaries to evaluate caloric and protein intake.^11,12

Statistical analyses
We used SPSS version 26 to analyze data. We expressed continuous as mean ± SD. We used t tests to make comparisons between groups (based on dialysis vintage and seasonal variation). P < .⁰⁵ was considered statistically significant.

Results

Patient characteristics and protein energy wasting
Among the 126 included patients, mean age was 54.2 ± 12.8 years. The analysis revealed a substantial burden of malnutrition. Hypoalbuminemia (<3.5 g/dL) was present in 49 patients (39%) and 55 patients (44%) had a BMI <20, indicating a high risk for PEW (Table 1).

Micronutrient deficiencies and seasonal impact
Vitamin D deficiency was the most common micronutrient deficit, shown in patients 60 (48%). Iron deficiency occurred in 45 patients (36%) (Table 1). Seasonal variations significantly affected caloric and protein intake, which decreased significantly by approximately 12% during winter months compared with summer months (P < .⁰⁵).

Dialysis vintage
Patients with a dialysis vintage >5 years exhibited more pronounced nutritional deficits, including lower serum albumin (3.1 ± 0.4 g/dL) and higher rates of anemia compared with those recently initiated on hemodialysis therapy (P = .⁰¹²).¹⁴

Discussion
Our findings confirmed that malnutrition is a pervasive issue in Azerbaijani hemodialysis units. The 39% prevalence of hypoalbuminemia is a strong predictor of poor clinical outcomes, as low albumin is associated with increased hospitalization and mortality. The high rate of low BMI (44%) was particularly concerning, as higher BMI in dialysis patients may serve as a protective factor (the so-called “obesity paradox”).⁸ The prevalence of vitamin D deficiency (48%) suggests that current supplementation strategies in Azerbaijan may be insufficient, potentially exacerbating bone-mineral disorders.^10,15 Seasonal fluctuations in intake indicate that dietary counseling must be tailored to regional food availability and cultural habits, particularly during winter months. Previous studies have also demonstrated associations between nutritional status, quality of life, sarcopenia, and long-term clinical outcomes in patients on hemodialysis.^13,16

Conclusions
Malnutrition and micronutrient deficiencies remain important challenges in Azerbaijan. Regular nutritional screening, the involvement of renal dietitians, individualized supplementation strategies, and continuous patient education are essential to improve long-term prognosis, treatment response, and quality of life among patients on hemodialysis.