A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients

Evaluation of malnutrition and inflammation after total parathyroidectomy in patients on maintenance dialysis

PURPOSE

To evaluate the effect of total parathyroidectomy (tPTx) on malnutrition and inflammation in patients on maintenance dialysis (MHD) having secondary hyperparathyroidism (SHPT).

METHODS

Twenty-five patients on MHD having SHPT who were being treated with tPTx were selected, and changes in their general condition (dry body mass), parathyroid hormone (PTH) and calcium levels, nutrition state (hemoglobin, hematocrit, serum albumin, and total iron binding capacity), and inflammatory status [serum C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-α), and the malnutrition-inflammation score (MIS)] were observed at 12, 24, and 36 months postoperatively.

RESULTS

Compared with the preoperative period, the dry body mass increased at 12, 24, and 36 months postoperatively (P < 0.01), hemoglobin, hematocrit, and serum albumin increased significantly (P < 0.01), whereas calcium, phosphorus, and PTH levels decreased significantly (P < 0.01). Serum CRP, IL-6, and TNF-α levels were significantly decreased at 12, 24, and 36 months after surgery (P < 0.01). Furthermore, MIS was reduced as well but to a lesser extent (P < 0.01).

CONCLUSION

tPTx effectively reduced MIS in maintenance dialysis patients, and the alleviated malnutrition and improved inflammatory status may contributed to improving the quality of life of patients on MHD with SHPT.

Association between the geriatric nutritional risk index and the risk of stroke in elderly patients with hypertension: A longitudinal and cohort study

Objective

We aimed to investigate the association between the GNRI and the risk of stroke in elderly patients with hypertension.

Methods

A total of 5312 elderly hypertensive patients free of history of stroke were included. Multivariate Cox models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs) for stroke and its subtypes.

Results

The average time of follow-up was 3.8 years, and the median time was 3.2 years. We identified 640 individuals with stroke, of whom 526 had an ischemic stroke (IS) and 114 had a hemorrhagic stroke (HS). After adjusting for confounding variables, compared with participants in the lowest quartile of the GNRI, those in the third and fourth quartiles were associated with a decreased risk of stroke (adjusted HR 0.72, 95% CI 0.58-0.90, and adjusted HR 0.58, 95% CI 0.46-0.74, respectively, P for trend < 0.001). Similar results were found for IS and HS. Moreover, there were L-shaped associations of GNRI with new-onset HS (P for non-linearity = 0.034). Multiple sensitivity analyses and stratified analyses did not materially change the results.

Conclusions

In summary, we found that a lower GNRI was associated with a higher risk of incident stroke in elderly hypertensive patients. Additional prospective data collection is required to confirm our findings.

The triglyceride-glucose index as a novel marker associated with sarcopenia in non-diabetic patients on maintenance hemodialysis

Objective

Sarcopenia is a common complication in patients with end-stage kidney disease. Insulin resistance is present in non-diabetic patients undergoing maintenance hemodialysis (MHD) and is an important factor leading to sarcopenia. The triglyceride–glucose (TyG) index, a reliable indicator for evaluating insulin resistance, is widely used in clinical practice. The present study investigated the association between the TyG index and sarcopenia in non-diabetic patients undergoing MHD.

Methods

Relevant clinical data of non-diabetic patients undergoing MHD at our center were collected. The TyG index was calculated using the following formula: ln(fasting triglycerides(mg/dL)×fasting blood glucose(mg/dL)/2). Multivariate logistic regression analyses were used to evaluate the associations. The receiver-operating characteristic curve was used to analyze the predictive value of the TyG index in sarcopenia.

Results

Of the 142 patients undergoing MHD who were included, 75 (52.82%) were men, the mean age was 54.05 ± 13.97 years, and 40 (28.17%) patients satisfied the diagnostic criteria for sarcopenia. The TyG index of participants with sarcopenia was higher compared with those without sarcopenia (8.83 ± 0.45 vs. 8.49 ± 0.50, p < 0.001). The prevalence of sarcopenia increased with increasing TyG index tertile (T1, 8.51%; T2, 31.91%; T3, 43.75%; p = 0.001). Logistic regression analysis indicated that the TyG index was an independent risk factor for sarcopenia (odds ratio, 4.21 [95% confidence interval, 1.85–9.59], p = 0.001).

Conclusion

A higher TyG index was associated with an increased risk of sarcopenia in non-diabetic patients undergoing MHD; it may be used as a novel marker to reflect the presence of sarcopenia.

Harmonization and standardization of malnutrition screening for all adults - A systematic review initiated by the Norwegian Directorate of Health

BACKGROUND & AIMS

The Norwegian Directorate of Health has identified a need to harmonize and standardize the malnutrition screening practice in Norwegian hospitals and primary health care settings, in order to provide a seamless communication of malnutrition screening along the patient pathway. Our aim was to perform a systematic review of the validity and reliability of screening tools used to identify risk of malnutrition across health care settings, diagnoses or conditions and adult age groups, as a first step towards a national recommendation of one screening tool.

METHODS

A systematic literature search for articles evaluating validity, agreement, and reliability of malnutrition screening tools, published up to August 2020, was conducted in: MEDLINE, Embase, APA PsycInfo, Cinahl, Cochrane Databases, Web of Science, Epistemonikos, SveMed+, and Norart. The systematic review was registered in PROSPERO (CRD42022300558). For critical appraisal of each included article, the Quality Criteria Checklist by The Academy of Nutrition and Dietetics was used.

RESULTS

The review identified 105 articles that fulfilled the inclusion and exclusion criteria. The most frequently validated tools were Mini Nutritional Assessment short form (MNA), Malnutrition Universal Screening Tool (MUST), Malnutrition Screening Tool (MST), and Nutritional Risk Screening 2002 (NRS-2002). MNA, MST and NRS-2002 displayed overall moderate validity, and MUST low validity. All four tools displayed low agreement. MST and MUST were validated across health care settings and age groups. In general, data on reliability was limited.

CONCLUSIONS

The screening tools MST and NRS-2002 displayed moderate validity for the identification of malnutrition in adults, of which MST is validated across health care settings. In addition, MNA has moderate validity for the identification of malnutrition in adults 65 years or older.

The change in Geriatric Nutritional Risk Index is associated with mortality in patients who start hemodialysis: Korean Renal Data Registry, 2016-2018

Malnutrition is common in patients undergoing hemodialysis (HD) and is associated with mortality. This study aimed to investigate the association between changes in nutrition status measured by the Geriatric Nutritional Risk Index (GNRI) and all-cause mortality in patients who started HD. A nationwide retrospective cohort study was conducted based on the Korean Renal Data System database. Patients who started HD from January 2016 to December 2018, and were eligible for GNRI and GNRI trend were included. GNRI trend was a longitudinal change of GNRI, assessed by random slope in a mixed-effect model. Positive and negative random slopes in each patient were assigned to positive and negative GNRI trends. A total of 2313 patients were included and median follow-up period was 3.1 (2.6-3.7) years. GNRI values decreased over time (estimate - 1.212, 95% confidence interval (CI) - 1.116-0.692) and positive GNRI trend was associated with survival benefit (hazard ratio 0.55, 95% CI 0.36-0.84) after multivariate adjustment. These findings show that serial GNRI assessment, besides GNRI, is a useful prognostic factor for mortality in patients who start HD.

Temporal muscle thickness predicts mortality in prevalent hemodialysis patients

OBJECTIVE

Ultrasonographic temporal muscle thickness measurement has recently emerged as a promising method of nutritional assessment in various conditions; hence, we aimed to determine the relationship between temporal muscle thickness and mortality in prevalent hemodialysis patients.

METHODS

Adult patients who were on a regular in-center hemodialysis program for ≥3 months were included, and patients with severe nonrenal organ failure or any recent significant disease inception were excluded. Baseline demographic; clinical, laboratory, and anthropometric data, including malnutrition inflammation score; and outcomes data were collected using a standardized form.

RESULTS

A total of 60 patients (32 males, diabetes prevalence: 26.6%) who met the eligibility criteria participated in the study, with a mean follow-up of 33.3±11.5 months, a median age of 66.5 (interquartile range 52.7-74) years, time on hemodialysis of 36 months, and a body mass index of 25.9 kg/m². Infections and cardiovascular events were the most common causes of overall mortality that occurred in 41.6% of the patients. Temporal muscle thickness was significantly lower in nonsurvivors (8.8 vs. 10.6 mm, p<0.001). Multivariate Cox regression analysis involving age, albumin, spKt/V, and malnutrition inflammation score revealed that temporal muscle thickness was a significant predictor of mortality (hazard ratio=0.740, p=0.035). Receiver operating characteristic curve analysis has shown 68% of sensitivity and 81.8% of specificity for a cutoff value of 9.4 mm (p<0.001). Temporal muscle thickness was weakly or mildly correlated with hemodialysis vintage, body mass index, albumin, and malnutrition inflammation score and moderately correlated with age (r=-0.536, p<0.001).

CONCLUSION

Ultrasonographic temporal muscle thickness has been found as a significant predictor of mortality in prevalent hemodialysis patients. Temporal muscle thickness could be a novel marker of nutritional status and predictor of mortality; hence, further studies are warranted.

Impact of the Nutrition-Inflammation Status on the Functionality of Patients with Chronic Kidney Disease

Functional capacity of chronic kidney disease (CKD) patients is compromised by their nutrition-inflammation status. We evaluated the functional capacity of advanced chronic kidney disease (ACKD) patients and the influence of the nutrition-inflammation status. In a cross-sectional study, which included ACKD patients from the nephrology department of the Hospital Universitario de la Princesa in Madrid, Spain, we assessed: functional capacity with the Short Physical Performance Battery (SPPB) test, interpreting a result <7 in the test as low functionality; body composition with monofrequency bioimpedance; muscular strength with hand grip strength; nutritional and inflammatory status using biochemical parameters and the Malnutrition Inflammation Scale (MIS). A total of 255 patients with ACKD were evaluated, 65.8% were men, their mean age was 70.65 ± 11.97 years and 70.2% of the patients had an age >65 years. The mean score of SPPB was 8.50 ± 2.81 and 76.4% of the patients presented a score ≥7, with a higher percentage in the group of men. The percentage of patients with limitations increased with age. The patients with SPPB values higher than 7 showed high values of albumin and low soluble C-reactive protein (s-CRP) and MIS. We found better functionality in well-nourished patients. A multivariate logistic regression model established an association of high albumin values with a better functional capacity (OR: 0.245 CI: 0.084−0.714 p < 0.010), while another model showed an association between CRP values and decreased functionality (OR: 1.267 CI: 1.007−1.594 p = 0.044). Conclusion: nutritional status and body composition influence on the functional capacity of patients with ACKD.

Geriatric Nutritional Risk Index and the Prognosis of Patients with Stroke: A Meta-Analysis

Malnutrition evidenced by low geriatric nutritional risk index (GNRI) has been suggested as a potential predictor of poor prognosis of patients with various clinical conditions. We performed a meta-analysis to systematically assess the association between GNRI and the prognosis of patients after stroke. Cohort studies were identified by search of PubMed, Embase, Cochrane's Library and Web of Science databases from inception to March 25, 2022, according to the aim of the meta-analysis. A random-effect model incorporating the potential between-study heterogeneity was used to pool the results. Eight cohort studies with 13573 patients with stroke contributed to the meta-analysis. Pooled results showed that malnutrition as evidenced by low GNRI was independently associated with a higher risk of poor functional outcome [risk ratio (RR): 1.54, 95% confidence interval (CI): 1.19 to 1.98, p<0.001; I2=69%] and an increased incidence of all-cause mortality (RR: 1.82, 95% CI: 1.35 to 2.47, p<0.001; I2=74%). Sensitivity analyses showed consistent results in patients with ischemic stroke, and in prospective cohort studies. Subgroup analyses showed that the associations were not significant for patients with GNRI-defined mild malnutrition (p=0.18 and 0.20 for functional and mortality outcomes, respectively), but significant for patients with moderate-severe malnutrition (both p<0.001). Difference in follow-up durations did not significantly affect the associations (p for subgroup difference=0.75 and 0.70, respectively). In conclusion, a low GNRI is associated with poor functional and survival outcomes in patients after stroke.

Fluid Overload and Tissue Sodium Accumulation as Main Drivers of Protein Energy Malnutrition in Dialysis Patients

Protein energy malnutrition is recognized as a leading cause of morbidity and mortality in dialysis patients. Protein-energy-wasting process is observed in about 45% of the dialysis population using common biomarkers worldwide. Although several factors are implicated in protein energy wasting, inflammation and oxidative stress mechanisms play a central role in this pathogenic process. In this in-depth review, we analyzed the implication of sodium and water accumulation, as well as the role of fluid overload and fluid management, as major contributors to protein-energy-wasting process. Fluid overload and fluid depletion mimic a tide up and down phenomenon that contributes to inducing hypercatabolism and stimulates oxidation phosphorylation mechanisms at the cellular level in particular muscles. This endogenous metabolic water production may contribute to hyponatremia. In addition, salt tissue accumulation likely contributes to hypercatabolic state through locally inflammatory and immune-mediated mechanisms but also contributes to the perturbation of hormone receptors (i.e., insulin or growth hormone resistance). It is time to act more precisely on sodium and fluid imbalance to mitigate both nutritional and cardiovascular risks. Personalized management of sodium and fluid, using available tools including sodium management tool, has the potential to more adequately restore sodium and water homeostasis and to improve nutritional status and outcomes of dialysis patients.

Comparison of three nutritional screening tools for detecting sarcopenia in patients with maintenance hemodialysis

Background

Malnutrition, dynapenia, and sarcopenia are prevalent conditions among patients with maintenance hemodialysis (MHD). They are related to numerous adverse health outcomes. The aim of this study was to compare the effect of three nutritional screening tools on predicting the risk of dynapenia and sarcopenia in patients with MHD.

Methods

From July 2020 to April 2021, a total of 849 patients with MHD were enrolled at seven different healthcare facilities in Shanghai, China in this multi-center cross-sectional study. Geriatric nutritional risk index (GNRI), malnutrition inflammation score (MIS), and creatinine (Cr) index were used for nutritional assessment. The cutoff values of muscle mass and strength to define dynapenia, pre-sarcopenia, and sarcopenia were based on the consensus by the Asia Working Group of Sarcopenia in 2019.

Results

Among 849, almost 60% were malnourished with the majority suffering from dynapenia (27.7%), followed by sarcopenia (22.7%), and pre-sarcopenia (6.2%).The area under the receiver-operating characteristic curve for GNRI was 0.722 [95% confidence interval (CI) = 0.684-0.760] and 0.723 (95% CI = 0.663-0.783) in predicting sarcopenia and pre-sarcopenia. The GNRI [odds ratio (OR) =6.28, 95% CI: 4.05-9.73], MIS (OR =1.91, 95% CI: 1.31-2.78), and the Cr index (OR =2.73, 95% CI: 1.71-4.34) were all significantly associated with the risk of sarcopenia. More importantly, the sarcopenia predictability of the GNRI appears greater than the MIS and Cr index, while MIS was similar to the Cr index. Similarly, the superiority of GNRI prediction was also found in pre-sarcopenia, but not in dynapenia.

Conclusion

All the three nutritional screening tools were significantly associated with an increased risk of sarcopenia. The sarcopenia predictability of the GNRI was greater than the MIS and Cr index.

Validity and Reliability Study of the Turkish Adaptation of Taste and Smell Dysfunction Questionnaire in Hemodialysis Patients

AIM

This study was conducted to assess the validity and reliability of the Turkish adaptation of the Taste and Smell Dysfunction Questionnaire (TSDQ) in hemodialysis patients.

MATERIALS AND METHODS

This study involves 125 hemodialysis patients. Research data were collected using the Descriptive Characteristics Form for Hemodialysis Patients, the TSDQ, and the Questionnaire for the Assessment of Self-Reported Olfactory Functioning and Olfaction-Related Quality of Life. In addition, the questionnaire's language and content validity, construct validity, and reliability were evaluated.

RESULTS

With regard to content validity, a high degree of agreement was determined between expert opinions on the questionnaire items (CGI = 0.96). Exploratory factor analysis revealed that the questionnaire has a two-factor structure explaining 79.33% of the total variance. The confirmatory factor analysis demonstrated that the model is within acceptable fit index limits with factor loads between 0.692 and 0.964. The Cronbach's alpha reliability coefficients of the scale and its two sub-dimensions are 0.928, 0.968, and 0.782, respectively.

CONCLUSION

The TSDQ is a valid and reliable tool for evaluating taste and smell changes in hemodialysis patients.

The Correlation of Interleukin-6, Malnutrition Inflammation Score and Asymmetric Dimethylarginine in Chronic Kidney Disease Patients Undergoing Routine Hemodialysis

Introduction: Chronic kidney disease (CKD) patients undergoing routine hemodialysis (HD) have a high prevalence of protein-energy malnutrition (PEM) and inflammation. The combination of inflammation and PEM is associated with cardiovascular disease and poor outcomes. Interleukin-6 (IL-6) is an inflammatory factor that runs parallel to endothelial damage and is closely related to the nutritional status of CKD HD patients. The tool to assess nutrition status is Malnutrition Inflammation Score (MIS) and to assess endothelial damage is Asymmetric Dimethylarginine (ADMA). It is currently unclear whether there is a correlation between inflammation, malnutrition, and endothelial dysfunction. Therefore the aim of this study is to determine the correlation between IL-6, MIS and ADMA in CKD HD patients.  Methods: A cross-sectional design with analytic observational study was conducted on end stage renal disease patient who undergo routine hemodialysis for at least 2 years with the duration of hemodialysis is 4-5 hours and at least twice per week. IL-6 was examined by kit (ELISA) and ADMA using LC-MS/MS at a certified laboratory in Manado city. History taking and physical examination were used to calculate MIS. Data analysis was done using SPSS version 22. Results: There were 30 participants consisting of 22 men (72%) and 8 women (28%). The median age of the subjects was 56.50 years. There was a statistically significant positive correlation between IL-6 and ADMA (r = 0.440, p = 0.015), MIS and ADMA (r = 0.378, p = 0.039), and IL-6 and MIS (r = 0.682, p = 0.0001). Conclusion: There was a significant correlation between IL-6, MIS and ADMA.

Adherence to the Mediterranean Diet Is Associated with a More Favorable Left Ventricular Geometry in Patients with End-Stage Kidney Disease

Introduction. The aim of the study was to examine the impact of adherence to a Mediterranean-style diet (MD) on left ventricular hypertrophy (LVH) and cardiac geometry in chronic kidney disease patients on dialysis (CKD-5D), given the high prevalence of cardiovascular morbidity in this population. Methods. n = 127 (77 men and 50 women) CKD-5D patients (69 on hemodialysis and 58 on peritoneal dialysis) with a mean age of 62 ± 15 years were studied. An MD adherence score (MDS) (range 0−55, 55 representing maximal adherence) was estimated with a validated method. Echocardiographic LVH was defined by LV mass index (LVMI) > 95 g/m2 in women and >115 g/m2 in men. Based on LVMI and relative wall thickness (RWT), four LV geometric patterns were defined: normal (normal LVMI and RWT), concentric remodeling (normal LVMI and increased RWT > 0.42), eccentric LVH (increased LVMI and normal RWT), and concentric LVH (increased LVMI and RWT). Results. Patients with LVH (n = 81) as compared to patients with no LVH (n = 46) were older in age (66 ± 13 vs. 55 ± 16 years; p < 0.001) had lower MDS (24 ± 2.7 vs. 25 ± 4.3; p < 0.05) and higher malnutrition-inflammation score (5.0 ± 2.7 vs. 3.9 ± 1.9; p < 0.05), body mass index (27.5 ± 4.9 vs. 24.1 ± 3.5 kg/m2; p < 0.001), prevalence of diabetes (79% vs. 20%; p < 0.05), coronary artery disease (78% vs. 20%; p < 0.05) and peripheral vascular disease (78% vs. 20%; p < 0.01). In a multivariate logistic regression analysis adjusted for all factors mentioned above, each 1-point greater MDS was associated with 18% lower odds of having LVH (OR = 0.82, 95% CI: 0.69−0.98; p < 0.05). MDS was inversely related to LVMI (r = −0.273; p = 0.02), and in a multiple linear regression model (where LVMI was analyzed as a continuous variable), MDS emerged as a significant (Β = −2.217; p < 0.01) independent predictor of LVH. Considering LV geometry, there was a progressive decrease in MDS from the normal group (25.0 ± 3.7) to concentric remodeling (25.8 ± 3.0), eccentric (24.0 ± 2.8), and then concentric (23.6 ± 2.7) group (p < 0.05 for the trend). Conclusions. The greater adherence to an MD is associated with lesser LVH, an important cardiovascular disease risk factor; MD preserves normal cardiac geometry and may confer protection against future cardiac dysfunction in dialysis patients.

Nutritional Predictors of Mortality after 10 Years of Follow-Up in Patients with Chronic Kidney Disease at a Multidisciplinary Unit of Advanced Chronic Kidney Disease

Nutritional monitoring in advanced chronic kidney disease (ACKD) units provides personalized care and improves clinical outcomes. This study aimed to identify mortality risk factors in chronic kidney disease (CKD) patients on nutritional follow-up in the multidisciplinary ACKD unit. A retrospective cross-sectional observational study was conducted in 307 CKD patients’ stage 3b, 4−5 followed-up for 10 years. Clinical and nutritional monitoring was performed by malnutrition-inflammation score (MIS), biochemical parameters (s-albumin, s-prealbumin, and serum C-reactive protein (s-CRP), body composition measured by bioelectrical impedance analysis (BIA), anthropometry, and handgrip strength measurements. The sample was classified into non-survivors, survivors, and censored groups. Of the 307 CKD patients, the prevalence of protein-energy wasting (PEW) was 27.0% using MIS > 5 points, s-CRP > 1 mg/dL was 19.20%, and 27.18% died. Survivors had higher significant body cell mass (BCM%) and phase angle (PA). Survival analyses significantly showed that age > 72 years, MIS > 5 points, s-prealbumin ≤ 30 mg/dL, PA ≤ 4°, and gender-adjusted handgrip strength (HGS) were associated with an increased risk of mortality. By univariate and multivariate Cox regression, time on follow-up (HR:0.97), s-prealbumin (HR:0.94), and right handgrip strength (HR:0.96) were independent predictors of mortality risk at 10 years of follow-up in the ACKD unit. Nutritional monitoring in patients with stage 3b, 4−5 CKD helps to identify and treat nutritional risk early and improve adverse mortality prognosis.

Dialysis recovery time: associated factors and its association with quality of life of hemodialysis patients

Introduction

Post-dialysis fatigue is a common and distressing complaint in patients on hemodialysis (HD). The dialysis recovery time (DRT) is a recent and reliable method of Post-dialysis fatigue assessment. We aimed to identify factors affecting the DRT and its relation with HD patients’ quality of life.

Material and methods

This is a cross-sectional study carried out on end-stage renal disease patients on regular HD. All participants underwent detailed history taking and complete physical examination, and data on dialysis and laboratory investigations were also collected. Patients were asked “How long does it take you to recover from a dialysis session?” to calculate the DRT. We used the Malnutrition-Inflammation Score (MIS) and KDQOL-36 questionnaire to assess patients’ nutritional status and quality of life, respectively.

Results

Two hundred and ten patients were screened and 191, with a median age of 47 years, completed the study. Patients had a median DRT of 300 minutes (range: 0.0–2880.0), with 55% of patients reporting a DRT of > 240 minutes and 22.5% of them reporting a DRT of < 30 minutes. Patients had a median MIS score of 7 (range: 0–17). There was a statistically significant negative relation between the DRT and symptom/ problem list (p < 0.001), effects of kidney disease (p < 0.001), burden of kidney disease (p < 0.001), SF-12 physical composite (p = 0.001), and SF-12 mental composite (p < 0.001) of KDQOL. The results of multivariate analyses showed that dialysate Na (p = 0.003), and the number of missed sessions (p < 0.001) were independently correlated with the DRT.

Conclusions

Decreased dialysate Na, and increased number of missed sessions were predictors of prolonged DRT. Patients with prolonged DRT were associated with poorer quality of life. Further randomized clinical trials are needed to assess strategies to minimize the DRT and, perhaps, enhance clinical outcomes.

Trials registration

ClinicalTrials.gov Identifier: NCT04727281. First registration date: 27/01/2021.

Geriatric Nutritional Risk Index as a Prognostic Factor of Patients with Non-Small Cell Lung Cancer: A Meta-Analysis

Geriatric nutritional risk index (GNRI), a newly developed indicator of nutritional status retrieved by serum albumin concentration and ideal body weight, has been suggested as a prognostic factor for various malignancies. The aim of the study was to summarize the prognostic role of GNRI for patients with non-small cell lung cancer (NSCLC) in a meta-analysis. Cohort studies evaluating the relationship between GNRI at baseline and survival OF NSCLC were retrieved by search of PubMed, Embase, and Web of Science databases from inception to January 12, 2022. A conservative random-effect model incorporating the possible influence of between-study heterogeneity was used to pool the results. Eleven cohorts including 2865 patients with NSCLC were included. Compared to those with higher GNRI, NSCLC patients with lower GNRI were associated with poorer overall survival [OS, hazard ratio (HR): 2.39, 95% CI: 1.97-2.91, p<0.001; I2=29%), progression-free survival (HR: 1.94, 95% CI: 1.52-2.47, p<0.001; I2=29%), and cancer-specific survival (HR: 2.59, 95% CI: 1.55-4.35, p<0.001; I2=0%). Subgroup analyses showed that the significant association between lower GNRI and worse OS in patients with NSCLC was not affected by study characteristics including study location, design, cancer stage, treatment, or follow-up durations (p for subgroup effects all<0.001). In conclusion, a lower GNRI in patients with NSCLC may be a predictor of poor survival. Nutritional status indicated by GNRI may be important for the prognostic prediction of patients with NSCLC.

The Relation of Serum Dehydroepiandrosterone Sulfate Level to Protein Energy Wasting in Hemodialysis Patients

Protein-energy wasting (PEW) is a major risk for morbidity and mortality in hemodialysis (HD) patients. The change in the concentration of dehydroepiandrosterone sulfate (DHEA-S) may play a role in PEW. The aim of this work was to study the possible relationship between serum DHEA-S levels and various nutritional and inflammatory parameters in a cohort of HD patients. In total, 78 HD patients (47 males and 31 females) were included in this crosssectional observational study. In addition to taking their history, clinical examinations, and routine laboratory investigations, the nutritional status was assessed, and their serum DHEA-S was measured. Nutritional status was assessed by anthropometric measures, bioelectrical impedance analysis, malnutrition inflammation scores, and subjective global assessments. A diagnosis of malnutrition was made based on the recommendations of the International Society of Renal Nutrition and Metabolism. The relationship between DHEA-S and various nutritional parameters was analyzed. Eighteen patients (23.1%) suffered from PEW. Those with PEW had a longer duration of HD (P = 0.04), and lower serum levels of creatinine (P = 0.003), hemoglobin (P = 0.01), albumin (P <0.0001), cholesterol (P = 0.02), and DHEA-S (P = 0.01). Among the variables, serum DHEA-S levels were significant predictors of PEW in this cohort (odds ratio: 0.976; 95% confidence interval: 0.954-1.0; P = 0.04). PEW is frequently encountered in HD patients. Decreased serum DHEA-S levels were associated with PEW in male HD patients. Further studies are needed to assess the effect of hormone supplementation on this serious disorder in HD patients.

Nutritional and Hydration Status and Adherence to Dietary Recommendations in Dalmatian Dialysis Patients

Protein-energy wasting (PEW) is considered one of the major complications of chronic kidney disease (CKD), particularly in dialysis patients. Insufficient energy and protein intake, together with clinical complications, may contribute to the onset and severity of PEW. Therefore, the aim of the study was to analyze the differences in nutritional and hydration status and dietary intake among Dalmatian dialysis patients. Fifty-five hemodialysis (HD) and twenty peritoneal dialysis (PD) participants were included. For each study participant, data about body composition, anthropometric, laboratory, and clinical parameters were obtained. The Malnutrition Inflammation Score (MIS) and two separate 24-h dietary recalls were used to assess nutritional status and dietary intake. The Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) were calculated to compare actual dietary intake with recommended intake. Additionally, the estimated 10-year survival was calculated using the Charlson Comorbidity Index. The prevalence of malnutrition according to MIS was 47.3% in HD and 45% in PD participants. Significant differences in fat tissue parameters were found between HD and PD participants, whereas significant differences in hydration status and muscle mass parameters were not found. A significant difference in NAR between HD and PD participants was noticed for potassium and phosphorus intake, but not for MAR. MIS correlated negatively with anthropometric parameters, fat mass, visceral fat level and trunk fat mass, and iron and uric acid in HD participants, whereas no significant correlations were found in PD participants. The estimated 10-year survival correlated with several parameters of nutritional status in HD and PD participants, as well as nutrient intake in HD participants. These results indicate a high prevalence of malnutrition and inadequate dietary intake in the Dalmatian dialysis population which, furthermore, highlights the urgent need for individualized and structural nutritional support.

Prevalence of Protein-Energy Wasting in Dialysis Patients Using a Practical Online Tool to Compare with Other Nutritional Scores: Results of the Nutrendial Study

This cross-sectional study aims to explore the prevalence of protein-energy wasting (PEW) in dialysis patients in Catalonia, Spain, using a new and practical online tool which enables rapid calculation and comparison with other nutritional scores. Methods: A web tool (Nutrendial) was created to introduce different variables and automatically calculate PEW, Malnutrition inflammation Score (MIS) and Subjective Global Assessment (SGA) in 1389 patients (88% in haemodialysis (HD)), 12% in peritoneal dialysis (PD) from different regions of Catalonia. Results: A prevalence of 23.3% (26% HD, 10.2% PD) of PEW was found, with a mean MIS score of 6 and SGA score of C in 7% of the patients. ROC analysis showed MIS as the best nutritional score to diagnose PEW (AUC 0.85). Albumin delivered lower diagnostic precision (AUC 0.77) and sensitivity (66%). A cut off point of 7 (86% sensitivity and 75% specificity) for MIS and 3.7 mg/dL for albumin were found to predict the appearance of PEW in this population. SGA B or C showed an 87% sensitivity and 55% specificity to diagnose PEW. Very low nutritional intervention (14%) was recorded with this tool in patients with PEW. Conclusions: This new online tool facilitated the calculation of PEW, enabling different professionals—including nephrologists, dieticians and nurses—to efficiently obtain insights into the nutritional status of the Catalonian dialysis population and implement the required nutritional interventions. MIS is the score with more sensitivity to diagnose PEW.

Predictive Value of HbA1c and Metabolic Syndrome for Renal Outcome in Non-Diabetic CKD Stage 1-4 Patients

Glycated hemoglobin (HbA1c) levels are commonly used to indicate long-term glycemic control. An HbA1c level of 6.5−5.7% is defined as pre-diabetes and is proposed as a criterion for diagnosing metabolic syndrome (MetS). However, HbA1c levels can be affected by chronic kidney disease (CKD). Whether HbA1c is associated with clinical outcomes in nondiabetic CKD patients with or without MetS is still unknown. This study included 1270 nondiabetic CKD stage 1−4 Asian patients, divided by HbA1c and MetS. Through linear regression, HbA1c was positively associated with age, waist circumference, hemoglobin levels, and C-reactive protein and was negatively associated with malnutrition−inflammation. HbA1c levels were 5.5% (0.6%) and 5.7% (0.6%) in non-MetS and MetS, respectively (p < 0.001). In Cox regression, higher-level HbA1c was associated with worse composite renal outcome in MetS patients, but with better renal outcome in non-MetS patients: Hazard ratio (HR) (95% confidence interval [CI]) of HbA1c ≥5.7%, compared with HbA1c <5%, was 2.00 (1.06−3.78) in MetS and 0.25 (0.14−0.45) in non-MetS. An association between HbA1c and all-cause mortality was not found. In conclusion, higher HbA1c levels are associated with worse renal outcomes in nondiabetic CKD stage 1−4 patients modified by the presence of MetS.

Sleep Quality After Intradialytic Oral Nutrition: A New Benefit of This Anabolic Strategy? A Pilot Study

Background

Since disturbances of appetite and sleep are closely related and both affect metabolic disorders, it would be expected that a renal specific oral nutritional supplement (RS-ONS) that covers the energy the patient does not consume on the HD day, could contribute to improve the nutritional status and body composition, as well as sleep quality. There is still scarce information related to this topic.

Aim

To evaluate the effect of the use of intra-dialytic RS-ONS vs. RS-ONS at home on sleep quality, nutritional status, and body composition in patients on HD.

Methods

Adult patients &lt; 65 years, with ≥3 months on HD were invited to participate in an open randomized pilot study (ISRCTN 33897). Patients were randomized to a dialysis-specific high-protein supplement provided during the HD session (Intradialytic oral nutrition [ION]) or at home (control), during non-HD days (thrice weekly, for both) 12 weeks. The primary outcome was sleep quality defined by the Pittsburgh Sleep Quality Index (PSQI) score. Nutritional assessment included Malnutrition Inflammation Score (MIS), bioelectrical impedance analysis, anthropometry, 3-day food records, and routine blood chemistries.

Results

A total of 23 patients completed the study. Age was median 35 (range 24–48 years), 42% were women. At baseline, the PSQI score was median 4 (range 2–7), and MIS showed a median of 6 (range 5–8); there were no baseline differences between groups. After intervention, both groups improved their MIS scores and similarly when we analyzed the whole cohort (pre- vs. post-intervention P &lt; 0.01). Patients in the ION group improved the overall PSQI score to median 3 (2–5), and assessment of sleep duration and sleep disturbances (pre- vs. post-intervention P &lt; 0.05), with a trend toward an effect difference compared to patients consuming the supplement at home (P for treatment-effect across arms 0.07 for PSQI score and 0.05 for sleep latency).

Conclusion

Oral supplementation improved nutritional status in the whole cohort, but only ION improved the PSQI score. More studies are needed to explore the nutritional strategies that influence the relationship between sleep and nutritional status in HD patients.

Screening of malnutrition with malnutrition inflammation score and geriatric nutritional risk index in hemodialysis patients

BACKGROUND AND AIMS

Screening malnutrition, which is the most common complication in hemodialysis patients, is extremely important for these patients. Malnutrition inflammation score (MIS) and geriatric nutritional risk index (GNRI) are malnutrition screening tests used in hemodialysis patients in recent years. The purposes of this study are to evaluate the nutritional status of hemodialysis patients with different screening tests and to determine the cutoff values for this disease-specific MIS and GNRI.

METHODS

The study was conducted with 194 adult patients including 98 males and 96 females whose mean age was 53.1 ± 10.96. Subjective global assessment (SGA) and MIS tests were applied, and the GNRI value was calculated for screening malnutrition. MIS and GNRI cutoff values were obtained by adopting the SGA scores as a standard and drawing a receiver operating characteristic curve. The tatistical Package for the Social Sciences-22.0 package program was used in the analysis.

RESULTS

According to SGA, 70.7% of the patients were nourished, 21.1% were mildly-moderately malnourished, and 8.2% were found to be severely malnourished. The optimal cutoff value predicted for malnutrition was 6.5 points (94.7% sensitivity and 98.5% specificity) for MIS and 86.0 points (64.9% sensitivity and 62.8% specificity) for GNRI. Based on these cutoff values, 28.9% of the patients were determined to be malnourished according to MIS and 45.4% according to GNRI.

CONCLUSION

In conclusion, screening tests are very important in the early identification of malnutrition in hemodialysis patients. This study was conducted to evaluate the malnutrition of hemodialysis patients with different screening tests. At the end of the study, the availability of MIS was found to be high in detecting malnutrition in hemodialysis patients because of its high accuracy and sensitivity of MIS. The cutoff points we identified for both MIS and GNRI are thought to facilitate the determination of malnutrition.

The Association of Controlling Nutritional Status Score and Prognostic Nutritional Index with Cardiovascular Diseases: the Fukuoka Kidney Disease Registry Study

AIM

The Controlling Nutritional Status (CONUT) score and the Prognostic Nutritional Index (PNI) reflect the immunonutritional status of patients. However, the associations of these two indices with cardiovascular disease (CVD) have not been characterized in patients with chronic kidney disease (CKD). Therefore, the current study aimed to determine whether the CONUT score or PNI was associated with prior CVD in patients with CKD.

METHODS

A cross-sectional study of 2,751 patients with CKD who were not on dialysis was performed. The patients were grouped into tertiles (T1-T3) of PNI and placed into three groups following their CONUT score: low- (CONUT score, 0), mild- (CONUT score, 1-2), and moderate-to-high- (CONUT score, ≥ 3) risk groups.

RESULTS

Prior CVD was present in 655 (24%) of the participants. Multivariable logistic regression analyses, with adjustment for potential confounders, showed that high CONUT score was associated with prior CVD than the low score (mild-risk group: odds ratio [OR]=1.35, 95% confidence interval [CI]=1.04-1.76; moderate-to-high-risk group: OR=1.66, 95% CI=1.19-2.30). In addition, the lower PNI tertiles were independently associated with prior CVD compared with T3 of PNI (T1: OR=1.45, 95% CI=1.09-1.92; T2: OR=1.32, 95% CI=1.01-1.72).

CONCLUSIONS

Both CONUT score and PNI were found to be independently associated with prior CVD in patients with CKD in the present cross-sectional study. A longitudinal study is needed to elucidate whether these two indices are associated with subsequent cardiovascular events.

Malnutrition-Inflammation Score: A Valid Tool to Assess Nutritional Status in Patient with End-stage Renal Disease

Nutritional assessment is a basic and necessary process in the nutritional management of dialysis patients. Malnutrition is a prevalent complication in patients on maintenance hemodialysis (HD). The study aimed to evaluate its relationship with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess malnutrition inflammation score (MIS) in HD patients. In this descriptive-analytical study, 153 HD patients were selected with random sampling. All the patients were interviewed and the MIS of the patients was recorded. Evaluate the relationship of malnutrition with the duration of dialysis, demographic and socioeconomic profile of HD patients, and to assess MIS in HD patients. Patients were followed up for 3 months. Data were analyzed with Chi-square and t-tests and Pearson correlation coefficient. A total of 153 patients were studied, 53 (34.64%) patients had good nutritional status and 100 (65.35%) patients had malnutrition. The mean of patients MIS score was 10.71 ± 5.14. Malnutrition rates in males and females were not significantly different. There was a positive and significant relationship between age and MIS score (P = 0.035). There was also a significant correlation between the level of education and MIS score (P = 0.042). The mean dialysis duration was 25.52 ± 2 6.27 months. There was a significant difference in the duration of dialysis in mild to severely malnourished patients (P = 0.002). A significant correlation between MIS score and the serum calcium and serum iron results (r = 0.402). The rise in serum prealbumin level was significantly greater at 3 months. MIS score is the best tool to assess nutritional status in patients with ESRD undergoing HD, because it can recognize various degrees of malnutrition that may remain undetected by a single laboratory assessment. The correlation between MIS score and age and dialysis period was significant.

Unplanned hemodialysis initiation and low geriatric nutritional risk index scores are associated with end-stage renal disease outcomes

Patients with end-stage renal disease (ESRD) have a low nutritional status and a high mortality risk. The geriatric nutritional risk index (GNRI) is a predictive marker of malnutrition. However, the association between unplanned hemodialysis (HD) and GNRI with mortality remains unclear. In total, 162 patients underwent HD at our hospital. They were divided into two groups: those with unplanned initiation with a central venous catheter (CVC; n = 62) and those with planned initiation with prepared vascular access (n = 100). There were no significant differences in sex, age, malignant tumor, hypertension, and vascular disease, while there were significant differences in the times from the first visit to HD initiation (zero vs. six times, p < 0.001) and days between the first visit and HD initiation (5 vs. 175 days, p < 0.001). The CVC insertion group had significantly lower GNRI scores at initiation (85.7 vs. 99.0, p < 0.001). The adjusted hazard ratios were 4.002 and 3.018 for the GNRI scores and frequency, respectively. The 3-year survival rate was significantly lower in the CVC + low GNRI group (p < 0.0001). The GNRI after 1 month was significantly inferior in the CVC insertion group. Inadequate general management due to late referral to the nephrology department is a risk factor for patients with ESRD.

Geriatric Nutritional Risk Index and Survival of Patients With Colorectal Cancer: A Meta-Analysis

Background

Geriatric nutritional risk index (GNRI) is an indicator of nutritional status derived by serum albumin level and ideal body weight, which has been proposed as a predictor of prognosis for elderly population with various clinical conditions. The objective of the meta-analysis was to comprehensively evaluate the association between baseline GNRI and survival of patients with colorectal cancer (CRC).

Methods

Cohort studies were identified by search of PubMed, Embase, and Web of Science databases from inception to January 05, 2022 according to the aim of the meta-analysis. A random-effect model incorporating the potential between-study heterogeneity was adopted to pool the results.

Results

Nine studies including 3658 patients with CRC contributed to the meta-analysis. Results showed that CRC patients with lower GNRI at baseline had worse overall survival (OS, hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.78-3.23, p<0.001; I2 = 60%) and progression-free survival (PFS, HR 1.77, 95% CI 1.38-2.26, p<0.001; I2 = 33%). The results were consistent in sensitivity analyses limited to elderly patients (HR for OS 2.25, p<0.001; HR for PFS 1.65, p=0.003). Subgroup analyses showed consistent results in patents with different cancer stages, and in studies with median follow-up < and ≥ 5 years (p for subgroup effects all < 0.05).

Conclusion

A lower GNRI at baseline may be independent associated with poor survival outcomes of patients with CRC. Evaluating the nutritional status using GNRI may be important for risk stratification of patients with CRC.

In Patients with Chronic Kidney Disease Advanced Glycation End-Products Receptors Isoforms (sRAGE and esRAGE) Are Associated with Malnutrition

Background: in patients with chronic kidney disease (CKD), the inflammatory and pro-oxidant milieu may contribute to malnutrition development. In this study, we investigated the relationship between inflammation, advanced glycation end-products (AGEs), and their receptors (RAGEs) with malnutrition in CKD patients. Methods: we evaluated 117 patients. AGEs were quantified by fluorescence intensity using a fluorescence spectrophotometer, soluble RAGEs isoforms, and inflammatory interleukins by ELISA. Malnutrition was assessed by a malnutrition inflammation score. Results: mean age was 80 ± +11 years, eGFR was 25 ± +11 mL/min/1.73 m2 and BMI was 28 ± 5 Kg/m2. Malnourished individuals were older, had lower estimated protein intake (nPCR 0.65 ± 0.2 vs. 0.8 ± 0.2 vs. 0.8 ± 0.3, p = 0.01), higher C reactive protein (CRP 0.6 ± 1 vs. 0.6 ± 0.7 vs. 0.17 ± 0.13, p = 0.02) and tumor necrosis factor α (TNF α 14.7 ± 8.7 vs. 15.6 ± 8 vs. 11.8 ± 5.8, p = 0.029). Malnourished patients had higher sRAGE (2813 ± 1477 vs. 2158 ± 1236 vs. 2314 ± 1115, p = 0.035) and esRAGE (648 [408–1049] vs. 476 [355–680] vs. 545 [380–730] p = 0.033). In the multivariate analysis, only sRAGE maintained its association with malnutrition (p = 0.02) independently of aging and inflammation. Conclusions: in CKD patients, RAGEs isoforms, but not AGEs, are associated with malnutrition, irrespective of systemic inflammation, aging, and renal function.

Synergistic Effects of the Geriatric Nutritional Risk Index and the Modified Creatinine Index for Predicting Mortality in Patients on Hemodialysis

This study aimed to investigate whether a combined estimation of the geriatric nutritional risk index (GNRI) and the modified creatinine index (mCI) provides synergistic information for mortality in patients treated by chronic hemodialysis. We analyzed 499 patients on hemodialysis for five years. We set each cut-off value as the high (≥92) and low (<92) GNRI groups and the high (≥21 mg/kg/day) and low (<21 mg/kg/day) mCI groups, and divided them into four subgroups: G1, high GNRI + high mCI; G2, high GNRI + low mCI; G3, low GNRI + high mCI; and G4, low GNRI + low mCI. The survival rate was evaluated and time-to-event analysis was performed. All-cause death occurred in 142 (28%) patients. Kaplan−Meier curves showed that G2 and G4 had a significantly worse outcome (p < 0.05) than G1 but not G3. Using the multivariable-adjusted model, only G4 was significantly associated with all-cause mortality compared with G1. Our study suggests that the synergistic effects of the GNRI and the mCI are helpful in predicting all-cause mortality. The combination of these indices may be superior to a single method to distinguish patients who are well or moderately ill from potentially severely ill.

Malnutrition Screening and Assessment

Malnutrition is a serious problem with a negative impact on the quality of life and the evolution of patients, contributing to an increase in morbidity, length of hospital stay, mortality, and health spending. Early identification is fundamental to implement the necessary therapeutic actions, involving adequate nutritional support to prevent or reverse malnutrition. This review presents two complementary methods of fighting malnutrition: nutritional screening and nutritional assessment. Nutritional risk screening is conducted using simple, quick-to-perform tools, and is the first line of action in detecting at-risk patients. It should be implemented systematically and periodically on admission to hospital or residential care, as well as on an outpatient basis for patients with chronic conditions. Once patients with a nutritional risk are detected, they should undergo a more detailed nutritional assessment to identify and quantify the type and degree of malnutrition. This should include health history and clinical examination, dietary history, anthropometric measurements, evaluation of the degree of aggression determined by the disease, functional assessment, and, whenever possible, some method of measuring body composition.

Accuracy of the GLIM criteria for diagnosing malnutrition: A systematic review and meta-analysis

BACKGROUND & AIMS

Although malnutrition remains a global public health concern, and has proved to be a major contributor to death and illness, there has been a foundational lack of a gold standard for diagnostic testing for clinical application. The Global Leadership Initiative on Malnutrition (GLIM) criteria were established to normalize the diagnosis of malnutrition, but their use remains controversial. Therefore, we carried out a meta-analysis based on the published literature to assess the accuracy of the GLIM criteria for diagnosing malnutrition.

METHODS

We utilized publication databases (including CENTRAL, MEDLINE, and EMBASE) to acquire research studies published from the initial use of the GLIM criteria in 2019 until January 22, 2022 that used the criteria to diagnose malnutrition. We conducted this meta-analysis with reference to the recommendations from the PRISMA-DTA statement. We separately calculated the amalgamated sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and AUC with 95%CI for the GLIM criteria. Then, we aggregated and presented the data by drawing forest plots to assess the real accuracy of the criteria. A subgroup analysis was also carried out to identify the potential sources of heterogeneity.

RESULTS

After the initial search of the CENTRAL, EMBASE, and MEDLINE databases, a total of 451 unique studies were identified. Twenty studies met our selection standards and 10,781 total patients were included in the meta-analysis. We noted that 4761 of the 10,781 patients (44.2%) were malnourished. The amalgamated sensitivity of the GLIM criteria was 0.72 (95%CI, 0.64-0.78), the specificity was 0.82 (95%CI, 0.72-0.88), the PLR was 3.9 (95%CI, 2.6-6.1), NLR was 0.35 (95%CI, 0.27-0.44), DOR was 11 (95%CI, 6-20), and AUC was 0.82 (95%CI, 0.79-0.85). Based on the results of a subgroup analysis using the SGA as a reference standard, the GLIM criteria had better diagnostic value (sensitivity, 0.81; specificity, 0.80; DOR, 17; AUC, 0.87).

CONCLUSIONS

The GLIM criteria have high diagnostic accuracy for distinguishing patients with malnutrition, and the GLIM criteria seem to have the potential to be used as a gold standard for diagnosing malnutrition in clinical practice. Moreover, the subgroup analysis showed a better diagnostic value for the GLIM criteria compared to the SGA used as a reference standard. Large-scale diagnostic trials and additional refinements to simplify the criteria are urgently needed to increase the clinical utilization of the GLIM criteria in the future.

Prognostic Value of the Controlling Nutritional Status (CONUT) Score in Patients at Dialysis Initiation

Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD), and affects their prognosis. The Controlling Nutritional Status (CONUT) score is a nutritional screening tool calculated using only blood test data. This study aimed to investigate the prognostic value of CONUT score in patients just initiating dialysis. A total of 311 CKD patients who stably initiated dialysis were enrolled. Only 27 (8.7%) patients were classified as having normal nutritional status. The CONUT score was also independently correlated with elevated C-reactive protein levels (β = 0.485, p < 0.0001). During the median follow-up of 37 months, 100 patients (32.2%) died. The CONUT score was an independent predictor of all-cause mortality (adjusted hazard ratio 1.13, 95% confidence interval 1.04−1.22, p < 0.0024). As model discrimination, the addition of the CONUT score to a prediction model based on established risk factors significantly improved net reclassification improvement (0.285, p = 0.028) and integrated discrimination improvement (0.025, p = 0.023). The CONUT score might be a simplified surrogate marker of the PEW with clinical utility and could predict all-cause mortality, in addition to improving the predictability in CKD patients just initiating dialysis. The CONUT score also could predict infectious-disease mortality.

[Prevalence of malnutrition and absolute and functional iron deficiency anemia in nondialysis-dependent chronic kidney disease and hemodialysis Algerian patients]

In chronic kidney disease, anemia and malnutrition coupled with inflammation as malnutrition-inflammation complex syndrom are common and considered as morbidity-mortality factors. The link between these two factors has been described at length in the literature highlighting an association of malnutrition with iron deficiency considered itself as one of the causes of anemia in chronic kidney disease (non-dialysis and hemodialysis). Our study aims to know the prevalence of these two factors in a population of chronic kidney disease (non-dialysis and hemodialysis) of Algiers and to highlight the possible associations between them.

PATIENTS AND METHODS

This is a multicentre, cross-sectional and descriptive study carried out over a period of 6months (August 2018 to January 2019). Anemia and malnutrition were assessed by various biological and clinical tools such as the malnutrition inflammation score and the International Society of Renal Nutrition and Metabolism criteria. Statistical tests were performed on the R studio software, considering P<0.05 as a statistically significant value.

RESULTS

Two hundred and nine patients on chronic kidney disease were included (90 non dialysis and 119 hemodialysis). The median age was 70 (IQR=16) for non dialysis and 56 (IQR=16.5) for hemodialysis. The prevalence of anemia was 66.66% (n=60) in non dialysis and 70.58% (n=84) in hemodialysis. Absolute iron deficiency anemia was higher in non dialysis (48.33%; n=29) while functional iron deficiency anemia was higher in hemodialysis (34.52%; n=29). The prevalence of malnutrition by malnutrition inflammation score was relatively low. Only functional iron deficiency anemia was associated with malnutrition.

CONCLUSION

The prevalence of anemia was higher in Algerian chronic kidney disease (non-dialysis and hemodialysis) unlike malnutrition which remains associated with functional iron deficiency anemia.

Association between Body Mass Index and Renal Outcomes Modified by Chronic Kidney Disease and Anemia: The Obesity Paradox for Renal Outcomes

Obesity-related nephropathy is associated with renal function progression. However, some studies have associated a high body mass index (BMI) with improved renal outcomes—this is referred to as the obesity paradox for renal outcomes, especially in relation to advanced chronic kidney disease (CKD). Central obesity can explain the obesity paradox in all-cause mortality. However, whether obesity or central obesity is associated with renal outcomes (renal replacement therapy or a 50% decline in the estimated glomerular filtration rate) in patients with advanced CKD remains unclear. Our study included 3605 Asian patients with CKD stages 1−5 divided into six groups according to their BMI (between 15 and 35 kg/m2). Through linear regression, BMI was positively associated with hemoglobin and albumin at CKD stages 4 and 5. In the competing risk Cox regression model, a high BMI (27.5−35 kg/m2) was associated with renal outcomes at CKD stages 1−3, but not stages 4 and 5. A high BMI was associated with renal outcomes in patients with hemoglobin ≥11 g/dL, but not <11 g/dL. A high waist-to-hip ratio was not associated with renal outcomes. We conclude that the CKD stage and anemia may explain the obesity paradox in renal outcomes in patients with CKD.

Nutritional Status Association With Sarcopenia in Patients Undergoing Maintenance Hemodialysis Assessed by Nutritional Risk Index

Background

Malnutrition and sarcopenia are frequently observed in patients undergoing maintenance hemodialysis (MHD). To elucidate whether malnutrition is associated with sarcopenia in those cases, the relationship of nutritional status with sarcopenia was investigated.

Methods

Nutritional status was assessed using a nutritional risk index (NRI) developed for patients undergoing MHD. This retrospective cross-sectional study included 315 MHD patients (199 males, 116 females), who were divided into low-risk (score 0–7) and medium-/high-risk (score 8–13) groups. Sarcopenia and severe sarcopenia, along with low muscle mass, low muscle strength, and low physical performance were defined using the Asian Working Group for Sarcopenia 2019 criteria.

Results

The median NRI score was 5.0, while the prevalence of medium-/high-risk cases among the patients was 31.1%. Additionally, the rates of those with low muscle mass, low muscle strength, and low physical performance were 55.9, 60.6, and 31.4%, respectively, while those of sarcopenia and severe sarcopenia were 44.1 and 20.0%, respectively. Multivariable logistic regression analyses revealed a significant (P < 0.001) association of NRI score with sarcopenia [odds ratio (OR) 1.255, 95% confidence interval (CI) 1.143–1.377] and severe sarcopenia (OR 1.257, 95% CI 1.122–1.407), as well as low muscle mass (OR 1.260, 95% CI 1.157–1.374), low muscle strength (OR 1.310, 95% CI 1.178–1.457), and low physical performance (OR 1.216, 95% CI 1.104–1.339). Furthermore, medium-/high-risk status showed a significant (P < 0.05) association with sarcopenia (OR 2.960, 95% CI 1.623–5.401) and severe sarcopenia (OR 2.241, 95% CI 1.151–4.362), as well as low muscle mass (OR 2.141, 95% CI 1.219–3.760), low muscle strength (OR 7.665, 95% CI 3.438–17.091), and low physical performance (OR 2.570, 95% CI 1.401–4.716).

Conclusions

These results suggest that malnutrition contributes to sarcopenia/severe sarcopenia in MHD patients by reducing muscle mass and strength, and physical performance.

Investigation of the Relationship between Lean Muscle Mass and Erythropoietin Resistance in Maintenance Haemodialysis Patients: A Cross-Sectional Study

Each patient undergoing maintenance haemodialysis (MHD) has a different response to erythropoiesis-stimulating agents (ESAs). Haemodilution due to fluid overload has been shown to contribute to anaemia. Body mass index (BMI) has been shown to influence ESA response in dialysis patients; however, BMI calculation does not distinguish between fat and lean tissue. The association between lean muscle mass and erythropoietin hyporesponsiveness is still not well-known among MHD patients. We designed a cross-sectional study and used bioimpedance spectroscopy (BIS) to analyse the relationship between body composition, haemoglobin level, and erythropoietin resistance index (ERI) in MHD patients. Seventy-seven patients were enrolled in the study group. Compared with patients with haemoglobin ≥ 10 g/dL, those with haemoglobin < 10 g/dL had higher serum ferritin levels, malnutrition−inflammation scores (MIS), relative overhydration, ESA doses, and ERIs. In multivariate logistic regression, higher ferritin levels and MIS were the only predictors of lower haemoglobin levels. The ERI was significantly positively correlated with age, Kt/V, ferritin levels, and MIS and negatively correlated with albumin levels, BMI, and lean tissue index (LTI). Multivariate linear regression analysis revealed that ferritin levels, BMI, and LTI were the most important predictors of ERI. In MHD patients, using BIS to measure body composition can facilitate the development of early interventions that aim to prevent sarcopenia, support ESA responsiveness, and, consequently, improve anaemia management.

The Extracellular Mass to Body Cell Mass Ratio as a Predictor of Mortality Risk in Hemodialysis Patients

The extracellular mass/body cell mass ratio (ECM/BCM ratio) is a novel indicator of nutritional and hydration status in hemodialysis (HD) patients. This study aimed to explore the ECM/BCM ratio as a predictor of mortality risk with nutritional-inflammatory markers in HD patients. A prospective observational study was conducted in 90 HD patients (male: 52.2%; DM: 25.60%). Clinical and biochemical parameters [serum albumin, serum C-reactive protein (s-CRP), interleukine-6 (IL-6)] were analysed and bioelectrical impedance analysis (BIA) was performed. Protein-energy wasting syndrome (PEW) was diagnosed using malnutrition-inflammation score (MIS). Based on BIA-derived measurements, the ECM/BCM ratio with a cut-off point of 1.20 was used as a PEW-fluid overload indicator. Comorbidity by Charlson index and hospital admissions were measured. Out of 90 HD patients followed up for 36 months, 20 patients (22.22%) died. PEW was observed in 24 survivors (34.28%) and all non-survivors. The ECM/BCM ratio was directly correlated with MIS, s-CRP, Charlson index and hospital admissions but was negatively correlated with phase angle and s-albumin (all, p < 0.001). Values of the ECM/BCM ratio ≥ 1.20 were associated with higher probability of all-cause mortality (p = 0.002). The ECM/BCM ratio ≥ 1.20, IL-6 ≥ 3.1 pg/mL, s-CRP and s-albumin ≥ 3.8 g/dL and Charlson index were significantly associated with all-cause mortality risk in multivariate adjusted analysis. This study demonstrates that the ECM/BCM ratio ≥ 1.20 as a nutritional marker and/or fluid overload indicator had a significant prognostic value of death risk in HD patients.

Impact of personalized nutritional intervention on nutritional status and quality of life of maintenance hemodialysis patients with protein energy wasting

BACKGROUND: Protein energy wasting (PEW) is a common multifactorial problem affecting maintenance hemodialysis (MHD) patients. OBJECTIVES: We aimed to explore the impact of personalized nutritional intervention on nutritional status and quality of life (QOL) in MHD patients. METHODS: Interventional study included 18 MHD patients suffering from PEW. They were subjected to personalized nutritional intervention for 6 months according to Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines (2000). QOL was evaluated by using the Kidney Disease Quality of Life (36 KDQOL-36). Nutritional status and QOL of those patients were re-assessed after 6 months and compared to those at the baseline. RESULTS: Fourteen patients completed six months of the study. Following such intervention, half of these patients became no longer suffering from PEW (responder group). Most of the nutritional and QOL data improved in the responder in contrary to the non-responder group of patients. The baseline level of parathyroid hormone (PTH) was significantly higher but physical health was significantly lower in non-responder than responder groups. CONCLUSIONS: Implementation of an internationally acknowledged nutritional program could improve the nutritional status and QOL of MHD patients with PEW. Moreover, PTH level, and physical health of the studied patients could contribute to the positive response to nutritional intervention.

Potential Benefits of Pila ampullacea, Tempeh, Moringa oleifera Leaves as Nutritional Support for Hemodialysis

Background:

Hemodialysis patients can experience problems, including protein-energy malnutrition, infection, disorders of the immune system, and inflammation. One etiology of malnutrition in hemodialysis is inadequate energy and protein intake, making patients need nutritional support, which can be fulfilled by local Indonesian foodstuffs.

Objective:

This paper aimed to review the potential health benefits of snails (Pila ampullacea), tempeh, and Moringa oleifera leaves as nutritional support for hemodialysis patients.

Methods:

In this review, the methodology used was based on comprehensive data searched from PubMed for literature review and technology benchmarking in making nutritional support for hemodialysis patients. An in-depth discussion, including the advantages and drawbacks of each foodstuff, is presented and outlined. Furthermore, key solutions are proposed and presented to overcome hemodialysis issues.

Results:

The mixture of snail, tempeh, and moringa leaves as nutritional support for hemodialysis patients shows a good combination of natural ingredients from animals and plants. The nutritional content of the three mixed ingredients is found to meet the dietary requirements of hemodialysis, which are high protein, calcium and antioxidants, low phosphorus, and a phosphorus-to-protein ratio of <16.

Conclusion:

The combination of snails, tempeh, and moringa leaves provides several potential health benefits in overcoming nutritional problems, decreased immune status, and inflammation of hemodialysis patients.

Protein Energy Wasting in a Cohort of Maintenance Hemodialysis Patients in Dhaka, Bangladesh

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000−40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m2, mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m2), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60−90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.

Diet-Related Inflammation is Associated with Malnutrition-Inflammation Markers in Maintenance Hemodialysis Patients: Results of a Cross-Sectional Study in China Using Dietary Inflammatory Index

Purpose

This cross-sectional study aimed to explore the association between the inflammation potential of the diet and malnutrition-inflammation status in Chinese maintenance hemodialysis (MHD) patients.

Methods

Dietary Inflammatory Index (DII) was computed based on a semi-quantitative food frequency questionnaire. Malnutrition-inflammation status was assessed by six indexes, including C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), hemoglobin (HB), albumin (ALB) and malnutrition-inflammation score (MIS). Multivariable linear regression and logistic regression were employed adjusting for covariables including age, gender, body mass index and dialysis vintage.

Results

A total of 161 Chinese MHD patients with an average age of 60.0 ± 13.6 years were enrolled. The median (IQR) DII score among participants was 0.60 (−0.80, 2.32), revealing a generally pro-inflammatory diet. DII was positively associated with MIS score (β= 0.61, 95% CI: 0.51, 0.69, p < 0.0001) and CRP (β = 0.54, 95% CI: 0.46, 0.63, p < 0.0001). A negative relationship between DII and NLR (β = −0.37, 95% CI: −0.61, −0.13, p = 0.008) was found in the most anti-inflammatory diet. Multivariable logistic regression showed that each unit increase in DII was linked with 3.06 (95% CI: 1.39, 6.69, p = 0.005) times increased odds of MIS.

Conclusion

Diet with a higher DII score may act as a potential trigger contributing to the development of malnutrition-inflammation status. Further studies for verification and for developing strategies to decrease the dietary inflammation burden are warranted.

Clasificación funcional del paciente anciano en hemodiálisis y su influencia en la individualización del tratamiento

Introducción: La edad de los pacientes en hemodiálisis está aumentando, presentando mayor deterioro. Objetivos: Conocer la situación del paciente ancia­no en hemodiálisis categorizando nuestra población. Ana­lizar la relación entre las escalas de funcio­nalidad, desnutrición y comorbilidad. Material y Método: Estudio descriptivo transversal, pacien­tes 75-95 años. Se midieron: a) Comorbilidad-CHARLSON: alta (>6 puntos). b) Nutrición-MISS: extremadamente des­nutrido (<10 puntos.); desnutrición muy severa (>7-10 puntos); moderada-severa (>5-7 puntos); leve-moderada (>2-5 puntos); normonutrido (<2 puntos); c) Dependencia-BAR­THEL, independiente (100 puntos); dependencia leve (91-99 puntos); moderada (61-90 puntos.); severa (21-60 puntos.); total (<20 puntos). d) Fragilidad-FRAIL, no fragilidad (0 puntos); prefrágil (1-2 puntos); frágil (>3 puntos). Resultados: 60 pacientes, 68%(41) hom­bres, edad media 81,85±5,58 años y tiempo HD 49,88±40,29 meses. Etiología más prevalente, diabe­tes mellitus (28%). MIS: 6,01±3,80 puntos. clasificándose 8(13%) normonu­tridos, 24(40%) desnutrición leve-moderada, 10(17%) desnutrición moderada-severa, 13(22%) desnutrición muy severa y 5(8%) extremadamente desnutridos. BARTHEL: 88,16±18,59 puntos, clasificó 32(53%) independientes, 6(10%) dependencia leve, 17(28%) dependencia modera­da, 4(7%) dependencia severa, 1(2%) dependencia total. FRAIL: 1,98±1,32 puntos, clasificó 10(17%) no frágiles, 31(51%) prefrágiles y 19(32%) frágiles. CHARLSON: 10,01±2,20 puntos. Presentando 60(100%) alta comorbilidad. CHARLSON presentó diferencias entre sexo, mayor en hombres (p=0,002). Se encontró alta correlación entre Barthel y Frail (r=0,647,p<0,001), moderada entre MIS y Barthel (r=0,556, p<0,001) y MIS y Frail (r=0,455,p<0,001). Charlson obtuvo peor correlación. Conclusiones: Se evidenció gran deterioro ge­neral del paciente añoso en diálisis, alertando sobre la nece­sidad de realizar tratamientos individualizados enfocados en su recuperación, incluida la propia diálisis.

The impact of nutritional status on health-related quality of life in hemodialysis patients

Malnutrition is frequent in hemodialysis (HD) patients. Nutritional deficiencies may negatively impact quality of life (QOL). This study examines the utility of the Malnutrition-Inflammation Score (MIS) in detecting nutritional risk (NR) and assesses the correlation between nutritional status and QOL in dialysis patients upon starting a nutritional intervention program (NIP). One hundred and twenty patients were included in this cross-sectional study. The MIS was used to detect NR and the Kidney Disease Quality of Life (KDQOL-SF) instrument version 1.2 was used to assess QOL. 62% of patients were found to be at NR (MIS > 5). Nutritional status was significantly correlated with all generic QOL sub-scales. On a multiple linear regression analysis, malnutrition showed the highest level of explanation in the Kidney Disease Summary Component which explained 28.9% of the variance; the Physical Component Summary which explained 33% of the variance; and the Mental Component Summary which explained 21.5% of the variance. Malnutrition was found to be the most significant predictor of impaired scores on the KDQOL-SF. The use of MIS to identify patients at NR and a nutritional assessment to detect malnutrition in its early stages are important given the effects a NIP can have on improving QOL in HD patients.

Standardized Phase Angle for Predicting Nutritional Status of Hemodialysis Patients in the Early Period After Deceased Donor Kidney Transplantation

Background

This study was designed to verify whether early posttransplant standardized phase angle (SPhA) determines nutrition status of hemodialysis patients in regard to different nutritional markers and predicts handgrip strength (HGS) 6 months after kidney transplantation.

Methods

A total of 82 kidney transplant recipients on maintenance hemodialysis treatment entered the study. Nutritional status was evaluated before kidney transplantation, at the hospital discharge date, and 6 months after. We used bioelectrical impedance analysis (BIA), three different malnutrition screening tools, HGS, and anthropometric measurements. Demographic profiles and biochemical nutritional markers were collected. SPhA values, adjusted for age and BMI, were used in our study.

Results

In the early posttransplant period, kidney transplant recipients lost muscle mass, gained fat mass, and developed mostly negative SPhA, accompanied by significantly lower albumin levels. The subjects with lower than median (<-1.46) SPhA_dis [the SPhA (at discharge) adjusted for hospitalization time and the baseline SPhA] displayed lower values of albumin concentration (43.4 vs. 45.1 g/l, p = 0.010), hemoglobin (124 vs. 133 g/l, p = 0.016), GNRI (113 vs. 118, p = 0.041), and HGS (30 vs. 33 kg, p = 0.043). These patients had higher ferritin concentrations (420 vs. 258 mkmol/l, p = 0.026), longer inpatient stays (32 vs. 21 days, p < 0.001), and higher MIS scores (3 vs. 1, p = 0.001).

Conclusion

At the moment of hospital discharge, lower than the median SPhA is related to protein-energy wasting, represented as lower concentrations of nutrition biomarkers and an active inflammatory response. Higher SPhA before kidney transplantation predicts HGS 6 months after kidney transplantation, especially in women.

Benchmarking Diet Quality to Assess Nutritional Risk in Hemodialysis Patients: Applying Adequacy and Moderation Metrics of the Hemodialysis-Healthy Eating Index

OBJECTIVES

This study modified Healthy Eating Index (HEI) based on hemodialysis (HD) specific guidelines and investigated associations between the diet quality (DQ) and nutritional risk in HD patients.

METHODS

The HD-HEI tool adapted the XXX Dietary Guidelines 2010 framework according to HD-specific nutrition guidelines. This HD-HEI was applied to 3-day dietary records of 382 HD patients. Relationships between HD-HEI scores and nutritional parameters were tested by partial correlations. Binary logistic regression models adjusted with confounders were used to determine adjusted odds ratio (_adjOR) with 95% confidence interval (CI) for nutritional risk based on HD-HEI scores categorization.

RESULTS

The total HD-HEI score (51.3 ± 10.2) for this study population was affected by ethnicity (P_trend<0.001) and sex (P=0.003). No patient achieved "good" DQ (score: 81-100), while DQ of 54.5% patients were classified as "needs improvement" (score: 51-80) and remaining as "poor" (score: 0-51). Total HD-HEI scores were positively associated with dietary energy intake (DEI) and dietary protein intakes (DPI), dry weight and handgrip strength, but inversely associated with Dietary Monotony Index (DMI) (all P<0.05). Individually, scores for refined grain, total protein, and animal protein were positively associated with DEI (all P< 0.05), whilst total, animal, fish and vegetable proteins indicated positive associations with DPI (all P< 0.05). Moderating metrics for convenience meals, saturated fats, sodium, and fluid negatively correlated towards DEI with similar trends for DPI excepting convenience meals and fluids. "Poor" DQ was associated with DMI ≥ 29.2 (_adjOR: 18.83, 95% CI: 9.36-37.86, P<0.001), Malnutrition Inflammation Score (MIS) ≥ 5 (_adjOR: 1.78, 95% CI: 1.01-3.15, P=0.045), and Protein Energy Wasting (PEW) (_adjOR: 1.96, 95% CI: 1.14-3.34, P=0.031), but became nullified with covariate adjustments. "Poor" DQ was also associated with low lean tissue mass (< 32.6 kg) in men (_adjOR: 2.38, 95% CI: 1.01-5.58, P=0.046) but not women.

CONCLUSIONS

"Poor" DQ was associated with poor nutritional status in XXX HD patients, who should be targeted for nutritional counselling.

Combined Evaluation of Geriatric Nutritional Risk Index and Modified Creatinine Index for Predicting Mortality in Patients on Hemodialysis

The geriatric nutritional risk index (GNRI) and modified creatinine index (mCI) are surrogate markers of protein-energy wasting in patients receiving hemodialysis. We aimed to examine whether a combined evaluation of these indices improved mortality prediction in this population. We retrospectively investigated 263 hemodialysis patients divided into two groups, using 91.2 and 20.16 mg/kg/day as cut-off values of GNRI and mCI, respectively. The resultant four groups were reshuffled into four subgroups defined using combinations of cut-off values of both indices and were followed up. During the follow-up period (median: 3.1 years), 103 patients died (46/103, cardiovascular causes). Lower GNRI and lower mCI were independently associated with all-cause mortality (adjusted hazard ratio (aHR) 4.96, 95% confidence intervals (CI) 3.10–7.94, and aHR 1.92, 95% CI 1.22–3.02, respectively). The aHR value for the lower GNRI and lower mCI group vs. the higher GNRI and higher mCI group was 7.95 (95% CI 4.38–14.43). Further, the addition of GNRI and mCI to the baseline risk assessment model significantly improved the C-index of all-cause mortality (0.801 to 0.835, p = 0.025). The simultaneous evaluation of GNRI and mCI could be clinically useful to stratify the risk of mortality and to improve the predictability of mortality in patients on hemodialysis.

Nutritional disorder evaluated by geriatric nutritional risk index predicts death after hospitalization for infection in patients undergoing maintenance hemodialysis

OBJECTIVE

Infection is related to higher rate of hospitalization and subsequent death in patients undergoing hemodialysis. Limited data are available about factors associated with death after hospitalization for infection. Nutritional disorder also known as protein-energy wasting is profoundly associated with poor consequences. Geriatric nutritional risk index (GNRI) is a simple but useful nutritional screening tool to predict mortality. We examined whether GNRI could predict hospitalization for infection and subsequent death.

DESIGN AND METHODS

This was a prospective cohort study in hemodialysis patients. The predictor was GNRI. The patients were divided into tertiles of GNRI (T1 to T3), with the highest tertile of T3 as referent. The outcomes of interest were all-cause mortality, hospitalization for infection and subsequent death.

RESULTS

Of 518 patients, 107 patients died (median follow-up period, 5.0 years; interquartile range 3.6-5.0) and 169 patients experienced new hospitalization for infection (median follow-up period, 4.5 years; interquartile range 3.4-5.0) during the follow-up period from December 2004 to December 2009. A lower GNRI was a significant predictor for all-cause mortality in multivariable Cox models (hazard ratio [HR] 2.9, 95% confidential interval [CI] 1.5-5.5, p < 0.001 for T1 vs. T3). However, GNRI was not associated with hospitalization for infection in multivariable Fine-Gray models with death as a competing risk (subdistributional HR 1.5, 95% CI 1.0-2.3, p = 0.056 for T1 vs. T3). After hospitalization for infection, 38 patients died during subsequent 2.5-year follow-up period. GNRI was a significant predictor of death after hospitalization for infection in multivariable Cox models (HR 2.7, 95% CI 1.3-5.6, p = 0.006 for T1 vs. T2+T3).

CONCLUSIONS

A lower GNRI predicted a higher risk of all-cause mortality but not hospitalization for infection. However, a lower GNRI was significantly associated with a higher risk of mortality after hospitalization for infection. These findings suggest that long-term mortality after hospitalization for infection was predicted by nutritional disorder evaluated by GNRI.

Possible Benefits of a Low Protein Diet in Older Patients With CKD at Risk of Malnutrition: A Pilot Randomized Controlled Trial

BACKGROUND

Current guidelines do not clarify whether older patients with advanced chronic kidney disease (CKD) may benefit of low protein (LP) diet if they are at risk of malnutrition. We compared the effects of normocalorie/normoprotein (NP) and normocalorie/LP diet on nutritional status and metabolic complications related to the progression of kidney damage in these patients.

METHODS

This pilot study had an open-label randomized-controlled design (ClinicalTrials.gov Id: NCT05015647). Thirty-five patients were treated for 6 months with two different diets (LP = 17) and (NP = 18). Malnutrition was assessed by the Malnutrition Inflammation Score and International Society of Renal Nutrition and Metabolism criteria. Renal function was assessed by creatinine and cystatin-C-based estimated glomerular filtration rate (eGFR).

RESULTS

At the end of the study, Malnutrition Inflammation Score was improved in both LP and NP groups (respectively: 3 ± 3 vs. 6 ± 1.5, p = 0.020 and 3 ± 2.5 vs. 6 ± 2, p = 0.012), prevalence of protein energy wasting syndrome decreased only in LP. LP group had higher eGFRcys-C (17 ± 6 vs. 12 ± 4 ml/min/1.73 m2; p < 0.05), lower serum urea (105 ± 65 vs. 138 ± 30 mg/dl; p < 0.05) and lower parathormone (68 ± 10 vs. 99 ± 61 ng/L; p < 0.05) than NP. Serum and urinary phosphorous did not change while fibroblast growth factor 23 (FGF23)-intact and FGF23 c-terminal increased in both groups [FGF23-intact in LP: 70 (48; 98) vs. 126 (90; 410) pg/ml, p < 0.01 and in NP: 86 (57; 194) vs. 143 (119; 186) pg/ml, p < 0.01; FGF23 c-terminal in LP: 77 (30.3; 112) vs. 111 (63; 384) RU/ml, p < 0.01 and in NP: 142 (56.6; 175) vs. 157 (76.7; 281) RU/ml, p < 0.01].

CONCLUSIONS

LP diet has a favorable impact on nutritional status as much as NP diet with possible greater benefits on the progression of kidney disease and some of its metabolic complications.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT05015647, identifier: NCT05015647.

Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis

Background:

The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed.

Objective:

To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype.

Design:

Longitudinal cohort study, pre-post design.

Setting:

Multidisciplinary CKD clinics across British Columbia.

Patients:

A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription.

Measurements:

Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR).

Methods:

Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster.

Results:

In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year ( P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period.

Limitations:

Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry.

Conclusions:

Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.

Annual change in the extracellular fluid/intracellular fluid ratio and mortality in patients undergoing maintenance hemodialysis

We aimed to investigate whether annual change in the extracellular fluid to intracellular fluid (ΔECF/ICF) ratio can accurately predict mortality in hemodialysis patients. Totally, 247 hemodialysis patients were divided into two groups according to the median baseline ECF/ICF ratio of 0.563 and ΔECF/ICF ≥ 0% or < 0% during the first year, respectively. Thereafter, they were divided into four groups according to each cutoff point and were followed up for mortality assessment. The ECF/ICF ratio increased from 0.566 ± 0.177 to 0.595 ± 0.202 in the first year (P = 0.0016). During the 3.4-year median follow-up, 93 patients died (42 cardiovascular-specific causes). The baseline ECF/ICF ≥ 0.563 and ΔECF/ICF ≥ 0% were independently associated with all-cause mortality (adjusted hazard ratio [aHR] 4.55, 95% confidence interval [CI] 2.60-7.98 and aHR 8.11, 95% CI 3.47-18.96, respectively). The aHR for ECF/ICF ≥ 0.563 and ΔECF/ICF ≥ 0% vs. ECF/ICF < 0.563 and ΔECF/ICF < 0% was 73.49 (95% CI 9.45-571.69). For model discrimination, adding the ΔECF/ICF (0.859) alone and both the baseline ECF/ICF and ΔECF/ICF (0.903) to the established risk model (0.746) significantly improved the C-index. Similar results were obtained for cardiovascular mortality. In conclusion, the ΔECF/ICF ratio could not only predict all-cause and cardiovascular mortality but also improve predictability of mortality in hemodialysis patients.