Associations Between the Prognostic Nutritional Index and Morbidity/Mortality During Intestinal Resection in Patients with Ulcerative Colitis

Nutritional Status and Nutritional Support in Patients with Gastrointestinal Diseases

Gastrointestinal diseases include a wide spectrum of functional and structural disorders of the alimentary system, involving hepatic, bile duct, and pancreatic diseases [...].

The Prognostic Nutritional Index is a Predictive Marker for Postoperative Complications in Patients with Late-Onset Ulcerative Colitis

PURPOSE

The number of patients with late-onset ulcerative colitis (UC) requiring surgery has increased in recent years. The risk of postoperative complications is higher in the elderly, so preoperative assessment is important. We aimed to explore the performance of preoperative assessment of nutritional markers for predicting postoperative complications in patients with late-onset UC.

METHODS

We retrospectively analysed 140 medically refractory UC patients who underwent surgery. The association between age at UC onset and risk of postoperative complications was explored using a fractional polynomial model. Uni- and multi-variate logistic regression analyses were performed to identify nutritional markers associated with postoperative complications.

RESULTS

The polynomial model showed patients with UC onset after 50 years of age had an increased risk of postoperative complications. Late-onset (LO) UC, an onset occurring after 50 years old, was associated with a higher risk of incisional surgical site infection (SSI) and intra-abdominal abscess than early-onset (EO) UC. Compared with the EO group, the LO group had fewer nutritional markers that were significantly associated with postoperative complications. The prognostic nutritional index (PNI) was calculated using the albumin level and the total lymphocyte count, and it was the only index that was significant in the LO group (odds ratio 0.872 95% CI 0.77-0.99, P = 0.03).

CONCLUSIONS

It was more difficult to use nutritional status to predict the risk of postoperative complications in patients with late-onset UC than in patients with early-onset ulcerative colitis. PNI may be a useful nutritional marker for patients with both late- and early-onset UC.

Association between the Prognostic Nutritional Index and Chronic Microvascular Complications in Patients with Type 2 Diabetes Mellitus

The prognostic nutritional index (PNI) is associated with inflammatory conditions. Since type 2 diabetes mellitus (T2DM) and its microvascular complications produce a significant inflammatory burden, we aimed to compare the PNI levels of the subjects with T2DM to those of healthy individuals. Furthermore, we aimed to compare the PNI levels of the diabetic subjects, with and without microvascular complications. The study cohort consisted of T2DM patients and healthy volunteers. The general characteristics, laboratory data, and PNI of the T2DM and control groups were compared. We further compared the PNI levels of the diabetic patients, with and without diabetic microvascular complications. The PNI levels of the T2DM patients and the control group were 51.6 (30.1-73.8)% and 64.8 (49.4-76)%, respectively (p < 0.001). Subgroup analyses revealed that the PNI was lower in the diabetic subjects with diabetic microvascular complications than in the diabetic patients without microvascular complications (p < 0.001), in patients with diabetic nephropathy compared to those without nephropathy (p < 0.001), in patients with diabetic retinopathy compared to those without retinopathy (p < 0.001), and in patients with diabetic neuropathy compared to those without neuropathy (p < 0.001). In conclusion, we assert that assessing the PNI may yield additional diagnostic value in regards to the timely determination of diabetic microvascular complications.

Nutritional Status and Its Detection in Patients with Inflammatory Bowel Diseases

Malnutrition is an important issue in patients with inflammatory bowel diseases (IBDs) including Crohn's disease (CD) and ulcerative colitis (UC). It is caused by altered digestion and absorption within the small bowel, inadequate food intake, and drug-nutrient interactions in patients. Malnutrition is an essential problem because it is related to an increased risk of infections and poor prognosis in patients. It is known that malnutrition is also related to an increased risk of postsurgery complications in IBD patients. Basic nutritional screening involves anthropometric parameters with body mass index (BMI) and others (fat mass, waist-to-hip ratio, muscle strength), medical history concerning weight loss, and biochemical parameters (including the Prognostic Nutritional Index). Besides standard nutritional screening tools, including the Subjective Global Assessment (SGA), Nutritional Risk Score 2002 (NRS 2002), and Malnutrition Universal Screening Tool (MUST), specific nutritional screening tools are used in IBD patients, such as the Saskatchewan Inflammatory Bowel Disease-Nutrition Risk Tool (SaskIBD-NR Tool and IBD-specific Nutritional Screening Tool). There is a higher risk of nutrient deficiencies (including iron, zinc, magnesium) and vitamin deficiencies (including folic acid, vitamin B12 and D) in IBD patients. Therefore, regular evaluation of nutritional status is important in IBD patients because many of them are undernourished. An association between plasma ghrelin and leptin and nutritional status in IBD patients has been observed. According to some authors, anti-tumor necrosis factor (anti-TNFα) therapy (infliximab) can improve nutritional status in IBD patients. On the other hand, improvement in nutritional status may increase the response rate to infliximab therapy in CD patients. Optimization of nutritional parameters is necessary to improve results of conservative and surgical treatment and to prevent postoperative complications in patients with IBDs. This review presents basic nutritional screening tools, anthropometric and laboratory parameters, dietary risk factors for IBDs, common nutrient deficiencies, associations between anti-TNFα therapy and nutritional status, selected features regarding the influence of nutritional status, and surgical outcome in IBD patients.

Clinical results following colonic resection for ulcerative colitis in elderly individuals (elderly-onset vs. nonelderly onset)

BACKGROUND

The incidence of ulcerative colitis (UC) is increasing, but there are few reports comparing elderly UC patients undergoing colectomy for elderly-onset UC (EO) and nonelderly-onset UC (NEO). The aim of this study was to analyze the differences between EO and NEO patients who underwent UC-related surgery.

METHODS

We identified 1973 patients with UC who underwent colectomy at Hyogo College of Medicine between January 1, 1984, and December 31, 2018. Only patients aged 65 years old and older who underwent colectomy were enrolled in this study (n = 221, 11.2%), and their clinical records were retrospectively reviewed. Patients were divided into two groups according to their age at disease onset: those with onset at younger than 60 years old (NEO) and at 60 years old or older (EO).

RESULTS

In the 221 UC patients who underwent colectomy at 65 years old or older, there were 155 cases of EO and 66 cases of NEO. The main surgical indication in NEO patients was colitis-associated cancer/dysplasia (32/66, 47%). In contrast, refractory to medical treatment was the leading cause of surgery in EO patients (80/155, 52%). The distributions of surgical indications were different between the two groups (p < 0.01). The preoperative daily dose of steroids was significantly higher in the EO group than in the NEOgroup (0 mg vs. 10 mg, p < 0.01). The rates of immunosuppressant, infliximab (IFX) and adalimumab use did not differ significantly between the groups. Significantly more patients underwent emergency surgery in the EO group than in the NEO group (14% vs. 35%, p < 0.01). The proportions of patients with postoperative morbidity (Clavien-Dindo grade III or higher) were 17.4% (27/155) in the EO group and 13.6% (9/66) in the NEO group. There was no significant difference between the two groups (p = 0.48). The prognosis of the EO patients who underwent UC-related emergency surgery was worse than that of the NEO patients (p < 0.01). In the EO group, 8 (14.8%) of 54 patients died within 30 postoperative days, while there were no deaths in the NEO group.

CONCLUSION

Among elderly UC patients undergoing UC-related surgery, EO patients undergoing emergency surgery had very poor outcomes, and the mortality rate was 14.8%. In such cases, it is important for physicians and surgeons to begin communication at an early stage so that the optimal surgical timeframe is not missed.

Associations between systemic inflammation and intestinal permeability with Onodera's prognostic nutritional index in critically ill patients

Background

Malnutrition is a serious condition in critically ill patients. The aim of this study is to evaluate the relationships between the Onodera’s prognostic nutritional index (OPNI) and intestinal permeability and between OPNI and systemic inflammation in critically ill patients.

Methods

This was a cross-sectional study conducted in the general intensive care unit (ICU) of a university-affiliated hospital. A total of 162 patients admitted between May 2018 and December 2019, was included in the study. The OPNI was calculated at admission and categorized as ≤40 or >40. We assessed plasma endotoxin and zonulin concentrations as markers of intestinal permeability as well as serum interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) as markers of systemic inflammation upon admission under stringent conditions. The relationships between these markers and OPNI were assessed after adjusting for potential confounders through estimation of a binary logistic regression model.

Results

Median (interquartile range) hs-CRP, IL-6 zonulin, and endotoxin were significantly greater in the low OPNI subgroup than in the high OPNI subgroup (all P<0.05). Multivariate analyses showed significant association between serum IL-6 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.64–0.96), serum hs-CRP (OR, 0.77; 95% CI, 0.53–0.92), plasma endotoxin (OR, 0.81; 95% CI, 0.72–0.93), and plasma zonulin (OR, 0.83; 95% CI, 0.75–0.98) levels with OPNI in the overall population.

Conclusions

Our results provide evidence that higher plasma endotoxin, zonulin, IL-6, and hs-CRP levels are associated with progressively lower OPNI in mixed ICU populations, particularly in surgical ICU patients.

Clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis and pancreatic pseudocyst, and the effects on IL-6 and CRP

The study aimed to investigate the clinical efficacy of duodenoscopy combined with laparoscopy in the treatment of patients with severe acute pancreatitis (SAP) and pancreatic pseudocyst (PP), and its effects on serum inflammatory factors. Altogether 94 patients complicated with SAP and PP who were admitted to Weifang People's Hospital (Weifang, China) from September 2015 to December 2018 were included. Based on the different operation methods, 49 patients who underwent traditional laparotomy under laparoscopic surgery were included in group A, and 45 patients who underwent duodenoscopy and laparoscopy under duodenoscope to treat the drainage of nipple and pancreatic pseudocysts were included in group B. The expression levels of related serum indexes and serum stress indexes before and at 48 h after surgery, the postoperative nausea, vomiting and abdominal pain scores, as well as the clinical efficacy, perioperative related indexes, recovery and complications were compared between the two groups. The prognostic factors in both groups were assessed via Logistic univariate and multivariate analyses. C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-β (IL-β), endotoxin and nuclear factor κB (NF-κB) were significantly lower in group B than those in group A (P<0.001). Upregulating cortisol and norepinephrine in group B was lower than that in group A (P<0.001). The total effective rate in group B was higher than that in group A (P<0.05). The perioperative related indexes, recovery, and postoperative complications in group B were better than those in group A (P<0.05). Scores of abdominal pain, nausea and vomiting in group B were markedly lower than those in group A (P<0.001). Multivariate Logistic regression analysis showed that CRP, TNF-α, IL-6, IL-β and surgical methods were independent risk factors for the prognosis of patients with SAP and PP. In conclusion, the combined treatment with duodenoscopy and laparoscopic surgery has little inflammatory and stress reaction, and it is highly safe, worthy to be popularized.

The advanced lung cancer inflammation index predicts outcomes in patients with Crohn's disease after surgical resection

AIM

Precise biomarkers for predicting prognosis could help to identify high-risk Crohn's disease (CD) patients to facilitate better follow-up during the postoperative course. In this study, the primary aim is the identification of the most reliable nutrition marker that predicts surgical relapse in CD patients.

METHOD

We first evaluated the predictive value of various nutrition markers for postoperative surgical relapse in CD patients and identified the advanced lung cancer inflammation index (ALI) as a promising biomarker. Then, we assessed the clinical significance of preoperative ALI in CD patients using two cohorts.

RESULTS

Preoperative ALI showed the highest correlation with reoperation rate compared with other nutritional parameters in CD patients receiving surgical resection (sensitivity 53%, specificity 86%, area under the curve 0.71). Lower levels of preoperative ALI were significantly correlated with the presence of perianal disease. A lower level of preoperative ALI was an independent prognostic factor for reoperation rate after an intestinal resection (hazard ratio 3.37, 95% CI 1.38-10.12, P = 0.006), and the prognostic impact of preoperative ALI was successfully validated in an independent cohort using the same cut-off value.

CONCLUSION

Preoperative ALI might be useful for postoperative management of CD patients.

The prognostic nutritional index might predict clinical outcomes in patients with idiopathic dilated cardiomyopathy

BACKGROUND AND AIMS

The prognostic nutritional index (PNI) had been associated with adverse outcomes in numerous clinical conditions. However, its influence on idiopathic dilated cardiomyopathy (DCM) was not determined. This aim of this study was to determine the predictive ability of PNI in patients with idiopathic DCM.

METHODS AND RESULTS

A total of 1021 consecutive patients with idiopathic DCM were retrospectively included and divided into three groups based on admission PNI tertiles: <41.7 (n = 339), 41.7-47.3 (n = 342), >47.3 (n = 340). The association of PNI with in-hospital major adverse clinical events (MACEs) and death during follow-up was evaluated. In-hospital mortality (2.9% vs. 1.5% vs. 0.0%, respectively; p = 0.006) and MACEs (13.6% vs. 6.7% vs. 3.5%, respectively; p < 0.001) decreased from the lowest to the highest PNI tertile. The optimal cut-off value of PNI to predict in-hospital MACEs was 44.0 (area under the curve: 0.689; 95% confidence interval [CI]: 0.626-0.753; p < 0.001). Multivariate analysis showed that a PNI≤44.0 was an independent risk factor of in-hospital MACEs (odd ratio: 2.86; 95% CI: 1.64-4.98; p < 0.001) and all-cause mortality at a median follow-up of 27 months (hazard ratio: 1.67; 95% CI: 1.11-2.49; p = 0.013). In addition, patients with a PNI≤44.0 had a lower cumulative survival rate during follow-up (log-rank: 35.62; p < 0.001).

CONCLUSION

The PNI was an independent risk factor for in-hospital MACEs and all-cause mortality at a median follow-up of 27 months in patients with idiopathic DCM; hence, it may be considered a tool for risk assessment.

The Impact of Prognostic Nutritional Index on Coronary Flow Reserve in Patients with Inflammatory Bowel Disease

Objective

The recurring inflammation of mucosal layer of intestines is known as inflammatory bowel disease (IBD), which can be accompanied by nutritional deficiencies. The association between inflammation and coronary artery disease has been established. Coronary flow reserve (CFR), which is an established method to evaluate combined microvascular and epicardial flow of coronary arteries, can be assessed by using transthoracic echocardiography. The aim of this study was to evaluate the association of Prognostic Nutritional Index (PNI) with CFR in IBD patients.

Method

This prospective study included 101 patients with IBD. These patients were compared to control group (n=32). PNI was calculated by using serum albumin level and lymphocyte count. CFR was assessed by using Doppler echocardiography.

Results

Multivariate regression analysis indicated that the presence of IBD, age (>40 years) and decreased PNI (<53.8) independently predict impairment of CFR. The area under the curve (AUC) was 75.1% (95% CI:0.664-0.838), and PNI levels were significant predictor of low CFR (p<0.001).

Conclusion

This study showed that PNI, which is calculated using the serum level of albumin and lymphocyte count, is a strong predictor of decreased CFR in IBD patients in remission. Our findings support previous studies showing the relationship between PNI and coronary artery disease. This immunonutritional index has only two components and is easy to calculate, and inexpensive.

Bioimpedance phase angle is associated with serum transthyretin but not with prognostic inflammatory and nutritional index during follow-up of women submitted to bariatric surgery

BACKGROUND & AIMS

Phase angle (PhA) has been used as a prognostic indicator in several clinical situations. However, the use of PhA as a prognostic tool in bariatric patients is less known. The aim of this study was to evaluate PhA as a prognostic index and its correlation with the prognostic inflammatory and nutritional index (PINI) during follow-up of women subjected to bariatric surgery.

METHODS

Twenty female volunteers were studied. Body weight, body mass index (BMI), PhA, and biochemical components of PINI [serum C-reactive protein, alpha-1-acid glycoprotein, albumin, and transthyretin (TTR) concentrations] were evaluated at three time points: before (T0) and approximately 2-3 (T1) and 6 (T2) months after surgery. One-way repeated measures ANOVA or the Friedman test with Tukey's post hoc test was used depending on data normality. The associations between PhA and the other parameters were evaluated using Spearman's (nonparametric data) or Pearson's (parametric data) correlation coefficient.

RESULTS

Phase angle reduction was accompanied by a significant decrease in body weight and BMI at T1 (P < 0.05), but not at T2 (P > 0.05). PINI indicated low-risk complications during the preoperative period and no risk during the postoperative period (T1 and T2). No significant correlation was observed between PhA and PINI (P > 0.05). Regarding its association with the biochemical components of PINI, lower PhA values were significantly correlated with lower serum TTR concentrations (r = 0.633, P < 0.001).

CONCLUSIONS

Phase angle was not associated with PINI, although lower values were correlated with lower serum TTR, suggesting that PhA reduction is associated with an increased nutritional risk.

The prognostic nutritional index for postoperative infectious complication in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis following subtotal colectomy

Objectives: Restorative proctocolectomy and ileal pouch-anal anastomosis is frequently performed in patients with ulcerative colitis and factors suspected of increasing the risk of postoperative infectious complications. Using a three-stage approach may result in improvement in overall outcomes, because this leads to improvement in nutritional status and reduction of immunosuppressive doses. However, the influence of preoperative nutritional status on postoperative infectious complications after this procedure has not been examined. The aim of this study was to clarify the potential associations between nutritional status and postoperative infectious complications in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis. Methods: The records of 110 patients who had undergone proctectomy with ileal pouch-anal anastomosis from January 2000 to March 2018 in Mie University and met the eligibility criteria were reviewed and possible associations between postoperative infectious complications and clinical factors were assessed. Results: Of the remaining 110 patients, 18 (16.4%) had developed postoperative infectious complications. Multivariate analysis revealed that operative bleeding ≥270 g and prognostic nutritional index <47 were significant predictors of postoperative infectious complications (P = 0.033, 0.0076, respectively). Various variables associated with immunosuppressives before ileal pouch-anal anastomosis were not associated with postoperative infectious complications. Conclusions: Our findings suggest that immunosuppressives have no association with postoperative infectious complications, whereas a poor prognostic nutritional index may be a significant predictor of postoperative infectious complications in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis.

Associations between multiple immunosuppressive treatments before surgery and surgical morbidity in patients with ulcerative colitis during the era of biologics

PURPOSE

It is unclear whether immunomodulators or biologics, with the exception of corticosteroids, can be risk factors for postoperative infectious complications of ulcerative colitis (UC). Moreover, many immunosuppressive therapies including some biologics are used mainly to treat UC, and many patients are on multi-agent immunosuppressive therapy at the time of surgery. Therefore, we evaluated the influence of pre-operative multiple immunosuppressive agents on the occurrence of surgical site infection (SSI) in UC during the era of biologics.

METHODS

We reviewed surveillance data from 301 patients who underwent surgery between January 2015 and April 2018. The incidences of SSI and possible risk factors among patients receiving different immunosuppressive therapies were compared and analyzed.

RESULTS

The incidence of incisional SSI was 6.6%, and that of organ/space SSI was 7.0%. Doses of corticosteroids were significantly decreased because of the recent shift toward the use of biologics. The types and numbers of immunosuppressive agents did not significantly correlate with each incidence. Age ≥ 65 years (odds ratio (OR) 3.0), total prednisolone dose ≥ 9000 mg (OR 2.7), and perioperative blood transfusion (OR 3.6) were shown to be independent risk factors for incisional SSI, whereas duration of surgery ≥ 252 min (OR 3.8), urgent/emergent surgery (OR 2.9), and perioperative blood transfusion (OR 2.6) were identified as independent risk factors for organ/space SSI.

CONCLUSIONS

Although no correlation between pre-operative immunosuppressive therapies, except for corticosteroids, was found, selection bias may have occurred due to treatment before surgery. However, biologics, calcineurin inhibitors, and thiopurines did not affect surgical morbidity in UC.