Prevalence and consequences of nutritional depletion in lung transplant candidates

Global Leadership Initiative on Malnutrition-Diagnosed Malnutrition in Lung Transplant Candidates

BACKGROUND AND AIMS

Malnutrition in lung transplantation (LT) candidates increases postoperative morbidity and mortality. Early diagnosis of malnutrition could attenuate adverse prognostic factors. This study aimed to assess the prevalence of nutritional risk and malnutrition using GLIM criteria in LT candidates and clinically characterize those with malnutrition.

METHODS

A prospective longitudinal study was conducted from 2000 to 2020 of LT candidates who underwent complete nutritional assessment (nutritional screening, anthropometry, bioelectrical impedance, blood laboratory tests and malnutrition diagnosis using GLIM criteria).

RESULTS

Obstructive diseases (45.6%), interstitial diseases (36.6%) and cystic fibrosis/non-cystic fibrosis bronchiectasis (15.4%) were the main conditions assessed for LT. Of the 1060 candidates evaluated, 10.6% were underweight according to BMI, 29% were at risk of malnutrition and 47% were diagnosed with malnutrition using GLIM criteria. Reduced muscle mass was the most frequent GLIM phenotypic criterion. Malnutrition was more prevalent in patients with cystic fibrosis/non-cystic fibrosis bronchiectasis (84.5%) and obstructive (45.4%) and interstitial (31.3%) diseases. GLIM criteria detected some degree of malnutrition in all diseases requiring LT and identified patients with higher CRP levels and worse respiratory function, anthropometric measurements and visceral protein and lipid profiles.

CONCLUSIONS

LT candidates present a high prevalence of malnutrition using the GLIM algorithm. GLIM criteria detected malnutrition in all diseases requiring LT and defined patients with worse clinical-analytical profiles.

Rectus Femoris Cross-Sectional Area and Phase Angle asPredictors of 12-Month Mortality in Idiopathic Pulmonary Fibrosis Patients

BACKGROUND

The value of the phase angle (PhA), measured via bioelectrical impedance analysis (BIA), could be considered a good marker of the cell mass and the cell damage of a patient; however, there are new techniques, such as muscle ultrasonography, that allow the quantity and quality of muscle to be assessed in a minimally invasive way. The aim of this study is to determine the prognostic value of morphofunctional techniques in the prognosis of mortality in patients with idiopathic pulmonary fibrosis (IPF).

METHODS

This multicenter, cross-sectional study included 86 patients with idiopathic pulmonary fibrosis with a mean age of 71 years, 82.7% of whom were male. The nutritional risk of the patients was assessed by means of questionnaires, such as the Subjective Global Assessment (SGA), and non-invasive functional techniques, including BIA, nutritional ultrasound, and hand grip strength (HGS). Statistical analysis of the sample was performed using JAMOVI version 2.3.22.

RESULTS

Correlations were made between the RF-CSA techniques with PhA (r = 0.48, p < 0.001), BCM (r = 0.70, p < 0.001), SMI (r = 0.64, p < 0.001), and HGS (r = 0.54, p < 0.001). The cut-off points for 12-month mortality were PhA = 4.5° (AUC = 0.722, sensitivity of 72.7% and specificity of 66.6%), BCM = 28.8 kg (AUC = 0.609, sensitivity of 32.4% and specificity of 100.0%), RF-CSA = 3.00 cm2 (AUC = 0.857, sensitivity of 64.4% and specificity of 100.0%), 6MMW = 420 m (AUC = 0.830, sensitivity of 63.27% and specificity of 100.0%), and TUG = 7.2 s (AUC = 0.771, sensitivity of 100.0% and specificity of 56.67%). In addition, a multivariate analysis was performed with RF-CSA, HR = 8.11 (1.39-47.16, p = 0.020), and PhA of 6.35 (1.29-31.15, p = 0.023), taking into account age, sex, and BMI to determine mortality. Finally, a Kaplan-Meier survival analysis was conducted with low or normal values for classical parameters (GAP and T6MM) and new parameters (PhA, BCM, RF-CSA, and TUG).

CONCLUSION

RF-CSA and PhA were shown to be good prognostic markers of 12-month mortality and could, therefore, be useful screening tools to complement the nutritional assessment of IPF patients.

Estimation of 24-hour urinary creatinine excretion from patient variables: A novel approach to identify patients with low muscle mass and malnutrition and relationship to outcomes

BACKGROUND

Low muscle mass has been correlated with adverse outcomes in patients who are critically ill. Methods to identify low muscularity such as computed tomography scans or bioelectrical impedance analyses are impractical for admission screening. Urinary creatinine excretion (UCE) and creatinine height index (CHI) are associated with muscularity and outcomes but require a 24-h urine collection. The estimation of UCE from patient variables avoids the need for a 24-h urine collection and may be clinically useful.

METHODS

Variables of age, height, weight, sex, plasma creatinine, blood urea nitrogen (BUN), glucose, sodium, potassium, chloride, and carbon dioxide from a deidentified data set of 967 patients who had UCE measured were used to develop models to predict UCE. The model identified with the best predictive ability was validated and then retrospectively applied to a separate sample of 120 veterans who were critically ill to examine if UCE and CHI predicted malnutrition or were associated with outcomes.

RESULTS

A model was identified that included variables of plasma creatinine, BUN, age, and weight and was found to be highly correlated, moderately predictive of UCE, and statistically significant. Patients with model-estimated CHI  ≤  60% had significantly lower body weight, body mass index, plasma creatinine, and sera albumin and prealbumin levels; were 8.0 times more likely to be diagnosed with malnutrition; and were 2.6 times more likely to be readmitted in 6 months.

CONCLUSION

A model that predicts UCE offers a novel method to identify patients with low muscularity and malnutrition on admission without the use of invasive tests.

Nutritional Risk of Candidates for Simultaneous Pancreatic-Kidney Transplantation-A Narrative Review

INTRODUCTION

Not much is known about the significance of nutritional status and support in transplant surgery, least of all in simultaneous pancreatic and kidney transplantation. Malnutrition in the context of simultaneous pancreatic-kidney transplantation seems to be complex and a still poorly investigated problem. Since SPKTX is highly qualified and also has a small volume procedure, it is difficult to obtain data from large cohorts of patients. The aim of this article is to gather existing evidence and information about the subject, as well as to elicit some questions and goals for the future.

METHODS

We searched through the Pub-Med database using the keywords "pancreas and kidney transplantation" combined with "nutritional risk", "nutritional status", "malnutrition", "nutritional intervention", and "frailty", finding a total of 4103 matching results. We then narrowed it down to articles written in English with the full text available. We also researched through the references of articles most accurately matching our researched terms.

RESULTS

There are numerous tools that have been investigated for the screening of malnutrition, such as the NRI index, PNI index, NLR, SGA scale, and NRS-2002 scale, each of which proved to be of some use in predicting patient outcomes in different surgical settings. Since all of them differed in components and assessed parameters and, in the absence of more sensitive or infallible indicators, the most reasonable approach seems to evaluate them jointly.

CONCLUSION

It is important to underline the necessity of nutritional screening and the subsequent introduction of adequate therapy while awaiting transplantation in an attempt to improve results. Considering the complexity of surgical procedures and the severity of underlying diseases with their intense metabolic components, the patient's nutritional status seems to significantly influence results. Consequently, nutritional risk assessments should be a part of the routine care of patients qualified for transplantation.

Application of creatinine height index in patients with trauma for the evaluation of psoas muscle mass: A clinical validation study

BACKGROUND

The creatinine height index (CHI) is an estimate of lean body mass. We hypothesize that a modified CHI estimate using serum creatinine (sCr) levels in patients with normal renal function when performed soon after injury would reflect preinjury protein nutrition status.

METHODS

The urine CHI (uCHI) was calculated using the 24-h urine sample. The serum-derived estimated CHI (sCHI) was calculated using the sCr on admission. Correlation between abdominal computed tomography images at specific lumbar vertebral levels and total body fat and muscle content was used for comparison as an independent measurement of nutrition status unlikely to be substantially altered by trauma.

RESULTS

A total of 45 patients were enrolled, all with a significant injury burden (median injury severity score [ISS] = 25; interquartile range, 17-35). The calculated sCHI on admission was 71.0% (SD = 26.9%) and likely underestimates the CHI when compared with uCHI (mean = 112.5%, SD = 32.6%). Stratifying by degree of stress demonstrated that in a group of 23 moderately and severely stressed patients, uCHI (mean = 112.7%, SD = 5.7%) and sCHI (mean = 60.8%, SD = 1.9%) were significantly different and without correlation (r = -0.26, P = 0.91). In patients without stress, there was a significant negative correlation between sCHI and psoas muscle area (r = -0.869, P = 0.03), and in patients with severe stress there was a significant positive correlation between uCHI and psoas muscle area (r = 0.733, P = 0.016).

CONCLUSION

The CHI calculated from the initial sCr is not an appropriate estimate of uCHI in critically ill trauma patients and is not a valid measure of psoas muscle mass in this setting.

Lung transplantation outcomes in underweight recipients: A single center experience

Background

Current guidelines recommend a body mass index (BMI) of 16 kg/m² as the minimum threshold for lung transplantation, despite mixed evidence on outcomes in underweight patients. The current study aimed to describe survival outcomes of underweight patients who underwent lung transplantation at a single center.

Methods

This retrospective observational study included adult lung transplant recipients who underwent transplantation for the first time between March 2010 and March 2022 at King Faisal Specialist Hospital and Research Center and excluded patients with obesity. We defined an underweight status as a BMI <17 kg/m².

Results

Forty-eight of the 202 lung transplant recipients were underweight at the time of surgery. The underweight patients had similar lengths of hospital (p = 0.53) and intensive care unit (p = 0.81) stays compared to other patients. Thirty-three percent of underweight patients had died within 5-year follow-up, compared to 34% of patients who were not underweight. There was no significant difference in mortality risk between underweight patients and patients with normal BMIs in our multivariable Cox regression model (adjusted HR 1.57, 95%CI: 0.77-3.20, p = 0.21). Exploratory analyses revealed that a pre-transplant BMI <13 kg/m² was associated with a trend towards increased 5-year mortality (adjusted HR 4.00, 95%CI: 0.87-18.35, p = 0.07).

Conclusions

Our findings suggest that patients with BMIs of 13-17 kg/m² may be candidates for lung transplantation. Large multi-center cohort studies are needed to confirm the lower BMI limit for safely transplanting patients.

Low body mass index as a barrier to lung transplant in cystic fibrosis

RATIONALE

Low body mass index (BMI) may influence lung transplant decisions for patients with advanced cystic fibrosis (CF) lung disease.

OBJECTIVE

Determine whether patients with advanced CF lung disease and BMI ≤17 kg/m2 are less likely to be listed for lung transplant or have a higher risk of death without listing compared to those with higher BMI.

METHODS

Using merged United Network for Organ Sharing and CF Foundation Patient Registries, we identified adults with onset of advanced lung disease (FEV1 ≤ 40% predicted) between May-2005 and December-2016. We analyzed survival using competing risks regression with cause-specific risks of listing for lung transplant and death without listing. BMI ≤ 17 kg/m2 was our predictor.

MEASUREMENTS AND MAIN RESULTS

Among 5,121 CF patients with advanced lung disease, 23% were listed for lung transplant (n = 1,201), 23% died without listing (n = 1,190), and 44% were alive without listing (n = 2,730) as of December-2016. Patients with BMI ≤ 17 kg/m2 were less likely to be listed for transplant (HR 0.69; 95% CI 0.57, 0.83) and more likely to die without listing (HR 1.63; 95% CI 1.41, 1.88). We identified important regional variations in the likelihood of referral and listing, based on BMI.

CONCLUSIONS

Patients with advanced CF lung disease and BMI ≤ 17 kg/m2 are less likely to be listed for lung transplant and have a higher risk of dying without listing, compared to those with higher BMI. Regional differences suggest access to transplant for malnourished CF patients may be limited by location.

Radiological and Physiological Predictors of IPF Mortality

Background and Objectives: Idiopathic pulmonary fibrosis (IPF) has a variable clinical course, which ranges from being asymptomatic to progressive respiratory failure. The purpose of this study was to evaluate the novel clinical parameters of IPF patients who receive an anti-fibrotic agent. Materials and Methods: From January 2011 to January 2021, we identified 39 IPF patients at Okinawa Chubu Hospital. Clinical information was obtained, such as laboratory data, pulmonary function test (PFT) results, and chest images, including of soft tissue thickness and the high-resolution computed tomography (HRCT) pattern at diagnosis. Results: The mean age was 72.9 ± 7.0 (53–85); 27 patients were men and 12 were women. The mean body mass index was 25.1 ± 3.9 (17.3–35). Twenty-four were active smokers and the median number of packs per year was 20. Regarding laboratory findings, mean white blood cell (WBC), lactate dehydrogenase (LDH), and Krebs Von den Lungen-6 (KL-6) values were 7816 ± 1859, 248 ± 47, and 1615 ± 1503, respectively. In PFT, the mean percent predicted FVC, percent predicted total lung capacity, percent predicted functional residual capacity (FRC), and percent predicted diffusion capacity of the lung for carbon monoxide (DLco) were 66.8 ± 14.9%, 71.8 ± 13.7%, 65 ± 39.6%, and 64.6 ± 27.9%, respectively. In chest radiological findings, soft tissue thickness at the right 9th rib was 26.4 ± 8.8 mm. Regarding chest HRCT patterns, 15 showed the definite usual interstitial pneumonia (UIP) pattern, 16 showed the probable UIP pattern, and eight showed the indeterminate for UIP pattern. In the treatment, 24 patients received pirfenidone and 15 patients took nintedanib. The mean observation period was 38.6 ± 30.6 months and 24 patients died. The median survival time was 32.4 months (0.9–142.5). Multivariate analysis adjusted for age showed that both soft tissue thickness [Hazard ratio (HR): 0.912, 95% confidence interval (CI): 0.859–0.979, p-value: 0.009] and percent FRC [HR: 0.980, 95% CI: 0.967–0.992, p-value: 0.002] were robust predictors of IPF mortality. Conclusions: In IPF patients treated with anti-fibrotic agents, both soft tissue thickness at the right 9th rib shown on the chest radiograph and %FRC can be novel predictors of IPF mortality.

Relationship between body composition, exercise capacity and health-related quality of life in idiopathic pulmonary fibrosis

INTRODUCTION

Bioelectrical impedance analysis (BIA) can be used to estimate Fat-Free Mass Index (FFMI). However, the use of directly measured BIA variables, such as phase angle (PhA), has gained attention. The frequency of low FFMI and PhA and its associations with exercise capacity and health-related quality of life (HRQL) in patients with idiopathic pulmonary fibrosis (IPF) have been scarcely studied.

OBJECTIVES

To investigate the frequency of low FFMI and PhA and their associations with exercise capacity and HRQL in patients with IPF.

METHODS

Patients underwent assessment of lung function, body composition, exercise capacity by the 6 min walk distance (6MWD), and HRQL by the Medical Outcomes Study Short-Form 36-item Questionnaire (SF-36). Patients were classified as presenting normal or low PhA or FFMI, accordingly to the 10th percentiles of age-sex-body mass index (BMI)-specific reference values.

RESULTS

98 patients (84 males, age: 68±8 years, forced vital capacity: 64%±18%predicted) were included. 24 patients presented low PhA. They were characterised by worse lung function, exercise capacity and HRQL compared with patients with normal PhA. 10 patients presented low FFMI, but despite differences in body composition, no differences were found between these patients and patients with normal FFMI. In a single regression analysis, age, lung function and body composition variables (except FFMI) were related to 6MWD and SF-36 Physical Summary Score (R²=0.06-0.36, p<0.05). None of the variables were related to SF-36 Mental Summary Score.

CONCLUSION

One-fourth of the patients with IPF with normal to obese BMI present abnormally low PhA. Patients classified as low PhA presented worse lung function, exercise capacity and HRQL.

Frailty and aging-associated syndromes in lung transplant candidates and recipients

Many lung transplant candidates and recipients are older and frailer compared to previous eras. Older patients are at increased risk for pre- and posttransplant mortality, but this risk is not explained by numerical age alone. This manuscript represents the product of the American Society of Transplantation (AST) conference on frailty. Experts in the field reviewed the latest published research on assessment of elderly and frail lung transplant candidates. Physical frailty, often defined as slowness, weakness, low physical activity, shrinking, and exhaustion, and frailty evaluation is an important tool for evaluation of age-associated dysfunction. Another approach is assessment by cumulative deficits, and both types of frailty are common in lung transplant candidates. Frailty is associated with death or delisting before transplant, and may be associated with posttransplant mortality. Sarcopenia, cognitive dysfunction, depression, and nutrition are other important components for patient evaluation. Aging-associated inflammation, telomere dysfunction, and adaptive immune system senescence may also contribute to frailty. Developing tools for frailty assessment and interventions holds promise for improving patient outcomes before and after lung transplantation.

A GLIMmer of insight into lung transplant nutrition: Enhanced detection of malnutrition in lung transplant patients using the GLIM criteria

BACKGROUND & AIMS

The Global Leadership Initiative on Malnutrition (GLIM) is a novel framework for diagnosing malnutrition and requires evaluation in wide-ranging clinical settings. This study aimed to assess the prevalence of malnutrition and its phenotypic characteristics among lung transplantation (LTx) candidates comparing GLIM to International Classification of Diseases, 10th Revision (ICD-10) criteria.

METHODS

A retrospective analysis was conducted of all adult patients assessed for LTx in a one-year period. Phenotypic criteria included body mass index (BMI), unintentional loss of weight (LOW) over a 12-month period and fat-free mass index (FFMI) using bioelectrical impedance analysis (BIA). Systemic inflammation associated with severe end-stage lung disease met GLIM's etiological criterion. Diagnosis of malnutrition, and its severity, were classified according to each of GLIM and ICD-10.

RESULTS

Of 130 patients, 112 (86%) had all data to classify malnutrition. Malnutrition prevalence according to GLIM was 59%, which was markedly greater than using ICD-10 criteria (26%). Half of the LTx patients were moderately malnourished using GLIM, compared to 19% using ICD-10. A similar proportion were severely malnourished using GLIM (9%) and ICD-10 (7%). Fat-free mass (FFM) depletion (47% of all patients) was a major contributor to GLIM-malnutrition. Over 60% of LTx patients with GLIM-malnutrition were not detected as malnourished using ICD-10 criteria.

CONCLUSION

Malnutrition diagnosis using GLIM was higher than using ICD-10 in LTx patients, primarily attributable to the incorporation of quantitative evaluation of FFM depletion. This highlights the utility of the GLIM framework and the importance of including body composition in malnutrition assessment.

Nutritional status and quality of life in interstitial lung disease: a prospective cohort study

Background

Malnutrition and altered body composition are well-documented in chronic pulmonary diseases; however, investigation of nutritional status in interstitial lung disease (ILD) is limited. This study aimed to describe the nutritional status of ILD patients within three diagnostic groups and explore the relationship between nutritional status and quality of life (QoL).

Methods

Consecutive patients attending an ILD clinic within a tertiary referral hospital in Sydney, Australia were studied. Weight, body-mass-index, anthropometrics, handgrip strength (HGS), subjective global assessment and QoL questionnaires (EQ-5D-5L and King’s-Brief Interstitial-Lung-Disease ‘K-BILD’) were collected. Associations between nutritional status and QoL were analysed.

Results

Ninety participants were recruited and categorised: (1) Idiopathic Pulmonary Fibrosis (IPF) (2) Connective-Tissue Disease associated-ILD (CTD-ILD) or (3) Other (non-IPF/non-CTD ILD). Median age was 66.5 (18) years. Four-percent of patients were underweight and 50% were overweight or obese. Median HGS was 71%-(25.3) of predicted and was correlated to all measures of QoL including EQ-5D health-state index (r = 0.376, p < 0.0001), patient-reported EQ-5D-5L Visual Analogue Score (r = 0.367, p < 0.0001) and K-BILD total score (r = 0.346, p = 0.001). Twenty-three percent of the variance in K-BILD total score (F = 12.888, p < 0.0001) was explained by HGS (ß = 0.273, p = 0.006) and forced vital capacity % predicted (ß = 0.331, p = 0.001).

Conclusions

Although a small number of ILD patients were malnourished, a large proportion of the cohort were overweight or obese. Handgrip strength was compromised and correlated to QoL. Future research with a larger cohort is required to explore the role of HGS as a predictor of QoL.

Malnutrition according to GLIM criteria in stable renal transplant recipients: Reduced muscle mass as predominant phenotypic criterion

BACKGROUND & AIMS

Malnutrition has a negative impact on quality of life and survival in renal transplant recipients (RTR). Therefore, malnutrition detection is important in RTR, but this may be hampered by concomitant presence of weight gain and overweight. Recently, the Global Leadership Initiative on Malnutrition (GLIM) developed a set of diagnostic criteria for malnutrition. We aimed to assess the prevalence of malnutrition according to the GLIM criteria and the distribution of phenotypic criteria in RTR. Additionally, we examined the potential value of 24-h urinary creatinine excretion rate (CER) as alternative measure for the criterion reduced muscle mass.

METHODS

We used data from stable outpatient RTR included in the TransplantLines Cohort and Biobank Study (NCT02811835). Presence of weight loss and reduced intake or assimilation were derived from Patient-Generated Subjective Global Assessment (PG-SGA) item scores. Reduced muscle mass was assessed by multi-frequency bio-electrical impedance analysis (MF-BIA) and defined as an appendicular skeletal muscle mass index (ASMI) < 7 kg/m² for men and <5.5 kg/m² for women, and in additional analysis defined as creatinine-height index (CHI, based on 24 h urine CER) < 80%. Inflammation was present if C-reactive protein (CRP) was >5 mg/L. Malnutrition was defined as presence of at least one phenotypic (weight loss and/or low BMI and/or reduced muscle mass) and one etiologic criterion (reduced intake/assimilation and/or disease burden/inflammation).

RESULTS

We included 599 RTR (55 ± 13 years old, 62% male, BMI 27.2 ± 4.7 kg/m²) at a median of 3.1 years after transplantation. According to GLIM criteria, 14% was malnourished, of which 91% met the phenotypic criterion for reduced muscle mass. Similar results were found by using CHI as measure for muscle mass (13% malnutrition of which 79% with reduced muscle mass).

CONCLUSIONS

Malnutrition is present in one in 7 stable RTR, with reduced muscle mass as the predominant phenotypic criterion. Assessment of nutritional status, most importantly muscle status, is warranted in routine care, to prevent malnutrition in RTR from remaining undetected and untreated. The diagnostic value of 24-h urinary CER in this regard requires further investigation.

Underweight Patients With Cystic Fibrosis Have Acceptable Survival Following Lung Transplantation: A United Network for Organ Sharing Registry Study

BACKGROUND

Reduced BMI is an absolute contraindication for lung transplantation (LTx) at most centers in the United States. The objective of this study was to quantify post-LTx survival of moderate to severely underweight patients with cystic fibrosis (CF) (BMI < 17 kg/m²) in the United States relative to normal-weight recipients with CF and other frequently transplanted patient cohorts.

METHODS

Using United Network for Organ Sharing Registry data (undergoing transplant from June 2005-November 2015), Kaplan-Meier estimates of median posttransplant survival were calculated for all patients with CF, COPD, and idiopathic pulmonary fibrosis (IPF), as well as low and normal weight CF subgroups. Cox regression modeling stratified according to transplant center assessed risk of posttransplant mortality in recipients with CF and a BMI < 17 kg/m² compared with recipients with COPD (reference).

RESULTS

Median posttransplant survival (95% CI) for CF, COPD, and IPF was 7.9 (7.2-8.6), 5.9 (5.6-6.2), and 5.5 (5.2-5.8) years, respectively. Although an absolute decrease was noted in posttransplant survival for recipients with CF and a BMI < 17 kg/m², compared with those with CF and a BMI ≥ 17 kg/m² (7.0 years [4.5-7.9] vs 8.2 years [7.3-9.0]), Cox modeling found no increased mortality risk (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .38). There was no difference in posttransplant mortality between patients with CF and a BMI < 17 kg/m² and recipients with COPD and all BMIs (adjusted hazard ratio, 1.04; 95% CI, 0.86-1.25; P = .71).

CONCLUSIONS

Transplant recipients with CF and a BMI < 17 kg/m² had posttransplant survival rates comparable to those of other groups frequently undergoing transplantation. BMI < 17 kg/m² as a single risk factor in the CF population should not be treated as an absolute contraindication to LTx.

Optimizing Nutrition Assessment to Create Better Outcomes in Lung Transplant Recipients: A Review of Current Practices

Lung transplantation offers patients with end-stage lung disease an opportunity for a better quality of life, but with limited organ availability it is paramount that selected patients have the best opportunity for successful outcomes. Nutrition plays a central role in post-surgical outcomes and, historically, body mass index (BMI) has been used as the de facto method of assessing a lung transplant candidate’s nutritional status. Here, we review the historical origins of BMI in lung transplantation, summarize the current BMI literature, and review studies of alternative/complementary body composition assessment tools, including lean psoas area, creatinine-height index, leptin, and dual x-ray absorptiometry. These body composition measures quantify lean body mass versus fat mass and may provide a more comprehensive analysis of a patient’s nutritional state than BMI alone.

The Impact of Waiting List BMI Changes on the Short-term Outcomes of Lung Transplantation

BACKGROUND

Obesity and underweight are associated with a higher postlung transplantation (LTx) mortality. This study aims to assess the impact of the changes in body mass index (BMI) during the waiting period for LTx on early postoperative outcomes.

METHODS

Medical records of 502 consecutive cases of LTx performed at our institution between 1999 and 2015 were reviewed. Patients were stratified per change in BMI category between pre-LTx assessment (candidate BMI) and transplant BMI as follows: A-candidate BMI, less than 18.5 or 18.5 to 29.9 and transplant BMI, less than 18.5; B-candidate BMI, less than 18.5 and transplant BMI, 18.5 to 29.9; C-candidate BMI, 18.5 to 29.9 and transplant BMI, 18.5 to 29.9; D-candidate BMI, 30 or greater and transplant BMI, 18.5 to 29.9; and E-candidate BMI, 30 or greater or 18.5 to 29.9 and transplant BMI, 30 or greater. Our primary outcome was in-hospital mortality and secondary outcomes were length of mechanical ventilation, intensive care unit length of stay (LOS), hospital LOS and postoperative complications.

RESULTS

BMI variation during the waiting time was common, as 1/3 of patients experienced a change in BMI category. Length of mechanical ventilation (21 days vs 9 days; P = 0.018), intensive care unit LOS (26 days vs 15 days; P = 0.035), and rates of surgical complications (76% vs 44%; P = 0.018) were significantly worse in patients of group E versus group D. Obese candidates who failed to decrease BMI less than 30 by transplant exhibited an increased risk of postoperative mortality (odds ratio, 2.62; 95% confidence interval, 1.01-6.48) compared with patients in group C. Pre-LTx BMI evolution had no impact on postoperative morbidity and mortality in underweight patients.

CONCLUSIONS

Our results suggest that obese candidates with an unfavorable pretransplant BMI evolution are at greater risk of worse post-LTx outcomes.

Nutritional status and muscle dysfunction in chronic respiratory diseases: stable phase versus acute exacerbations

Nutritional abnormalities are frequent in different chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis (CF), interstitial fibrosis and lung cancer, having important clinical consequences. However, nutritional abnormalities often remained underdiagnosed due to the relative lack of awareness of health professionals. Therefore, systematic anthropometry or even better, assessment of body composition, should be performed in all patients with chronic respiratory conditions, especially following exacerbation periods when malnutrition becomes more accentuated. Nutritional abnormalities very often include the loss of muscle mass, which is an important factor for the occurrence of muscle dysfunction. The latter can be easily detected with the specific assessment of muscle strength and endurance, and also negatively influences patients' quality of life and prognosis. Both nutritional abnormalities and muscle dysfunction result from the interaction of several factors, including tobacco smoking, low physical activity-sedentarism, systemic inflammation and the imbalance between energy supply and requirements, which essentially lead to a negative balance between protein breakdown and synthesis. Therapeutic approaches include improvements in lifestyle, nutritional supplementation and training. Anabolic drugs may be administered in some cases.

Monitoring Nutrition in Critical Illness: What Can We Use?

BACKGROUND

Nutrition monitoring in the context of critical care presents unique challenges. Traditionally used anthropometric and biochemical markers may be difficult to obtain or confounded by factors such as fluid status and the inflammatory response. A previous survey identified 15 parameters in common use, all of which have confounding influences during critical illness.

MATERIALS AND METHODS

A literature search was conducted to assess current use of commonly used nutrition-monitoring parameters and to explore other possible methods that might be more useful. More than 1000 journal articles were reviewed to identify indicators of nutrition status or nutrition progress that have been used in ICU studies. The most recent 200 articles were examined to quantify the number of occurrences for each indicator. Each parameter was rated for availability and feasibility in the ICU.

RESULTS

There were 53 parameters found, including the 15 already identified as commonly used; 27 were used in ≥3 recent studies. Less-well-established nutrition indicators with potential for use in the ICU (moderate or high feasibility and availability) included ultrasound measurement of arm or leg muscle thickness, fatigue scoring with the Chalder scale, urinary creatinine assay, and serum insulin-like growth factor 1 level. None of these was among the commonly used indicators in recent studies.

CONCLUSION

This study identifies commonly used nutrition-monitoring parameters and discusses their feasibility and availability in the critical care setting. Further investigation of nutrition indicators in ICU is needed, ideally as part of a randomized trial to reduce the effect of the many possible confounding factors.

Current Nutrition Practices in Adult Lung Transplantation

Nutrition therapy is vital to the overall management of lung transplant recipients. The objective of this review is to outline the current applications of pre- and posttransplant nutrition management of the adult lung transplant recipient. Pretransplant nutrition therapy decisions are based on cause of end-stage lung disease, transplant indications, and pretransplant nutritional status. Maintaining adequate nutrient stores is the major goal of nutrition therapy for patients awaiting transplantation. In the posttransplant course, several gastrointestinal (GI) complications such as gastroesophageal reflux, gastroparesis, and distal intestinal obstruction syndrome complicate nutritional recovery. Long-term nutrition therapy for lung transplant recipients is aimed at management of common comorbid conditions such as obesity, diabetes mellitus, hypertension, osteoporosis, and hyperlipidemia. Lung transplantation outcomes are steadily improving; however, much has yet to be explored to improve the nutrition management of these patients in both the pre- and posttransplantation course.

Home Monitoring for Lung Transplant Candidates

Home monitoring by lung transplant recipients has been effective for early detection of clinical problems. This study used an electronic diary for home monitoring by lung transplant candidates to improve communication between candidates and the transplant team. Candidates were randomized into control (52 subjects following standard telephone reporting procedures) and intervention (67 subjects using an electronic diary to record and transmit a range of health-related measures) groups. Outcome measures were monitoring adherence and level of communication (for monitor acceptability and utilization), hospital length of stay after transplantation and survival at 4 months (for clinical effectiveness). Subjects used the diary without difficulty and with good adherence. Subjects and coordinator contacts were similar between groups; intervention group subjects were positive regarding contact based on diary use. There were no significant differences in clinical outcomes between groups. Changing diary questions might improve the effectiveness of electronic monitoring for lung transplant candidates.

Nutrition Management of Cystic Fibrosis in the 21st Century

Despite significant advancements made in life expectancy over the past century, cystic fibrosis remains a life-threatening genetic disease that affects the gastrointestinal tract, and it has significant impact on the nutrition status of those with the disease. Nutrition management includes a high-calorie/high-fat diet, pancreatic enzyme replacement therapy, vitamin and mineral replacement, and enteral support as needed. As patients are living longer, clinicians may encounter patients with cystic fibrosis in obstetrician offices, endocrine clinics, or hospital settings, owing to lung transplantation or for treatment for distal intestinal obstruction syndrome.

Lung transplantation as rescue therapy in patients too sick to be discharged from acute care

BACKGROUND

There is an increasing demand for lung transplantation in patients in advanced respiratory failure. Although many of these patients do not require mechanical ventilation or extracorporeal membrane oxygenation, an increasing number are critically ill. In this single-center study, we have analyzed our experience with lung transplantation in subjects who were inpatients at the time of their transplant and not expected to survive to discharge.

METHODS

Between July 2006 and March 2012, we performed 274 bilateral sequential lung transplants and 34 single-lung transplants. Twenty-six patients who were inpatients at the time of their transplant, and were not expected to survive to hospital discharge, formed the inpatient group in this retrospective review. The remaining 281 outpatient lung transplant patients formed the comparison group.

RESULTS

The inpatient group spent significantly fewer days on the waiting list compared to the outpatient group. Postoperative survival was significantly poorer in the inpatient group compared to the outpatient group (P = .001), and this was most noticeable in the first 90 days. There was no significant difference in survival between the inpatient transplant cohort and a historically comparable wait list cohort (P = .614).

CONCLUSION

Lung transplantation in critically ill inpatients, although associated with a survival advantage compared to not transplanting them, does give poorer survival results compared to postoperative survival in outpatient patients.

Survival of patients with chronic respiratory failure on long-term oxygen therapy and or non-invasive ventilation at home

BACKGROUND & AIMS

Chronic respiratory failure (CRF) is the common fate of respiratory diseases where systemic effects contribute to outcomes. In a prospective cohort of home-treated patients with CRF, we looked for predictors of long-term survival including respiratory, nutritional and inflammatory dimensions.

METHODS

637 stable outpatients with CRF, 397 men, 68 ± 11 years, on long-term oxygen therapy and/or non-invasive ventilation from 21 chest clinics were enrolled and followed over 53 ± 31 months. CRF resulted from Chronic Obstructive Pulmonary Disease (COPD) in 48.5%, restrictive disorders 32%, mixed (obstructive and restrictive patterns) respiratory failure 13.5%, bronchiectasis 6%. Demographic characteristics, smoking habits, underlying respiratory diseases, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), arterial blood gases, 6-min walking distance (6MWD), hemoglobin, body mass index (BMI), serum albumin, transthyretin, C-reactive protein (CRP), history of respiratory assistance, antibiotic and oral corticosteroid use during the previous year were recorded.

RESULTS

322 deaths occurred during the follow-up. One-, five- and 8-year actuarial survival was 89%, 56% and 47%. By Cox univariate analysis, age, respiratory disease, PaO2, PaCO2, FEV1/FVC, BMI, 6MWD, activity score, type and length of home respiratory assistance, smoking habits, oral corticosteroid and antibiotic uses, albumin, transthyretin, hemoglobin and CRP levels were associated with survival. Multivariate analysis identified eight independent markers of survival: age, FEV1/FVC, PaO2, PaCO2, 6MWD, BMI, serum transthyretin, CRP ≥ 5 mg/l.

CONCLUSIONS

In CRF, whatever the underlying diseases, besides the levels of obstructive ventilatory defect and gas exchange failure, 6MWD, BMI, serum transthyretin and CRP ≥ 5 mg/l predicted long-term survival identifying potential targets for nutritional rehabilitation.

Heart-lung transplantation: pediatric indications and outcomes

As indications for heart-lung transplant (HLT) have changed to some degree in the past 30 years, this treatment is being used less frequently in children due to more advanced care of severe heart and lung disease. This is fortunate as the outcomes for HLT are poor compared to other solid organ transplants and this is mainly due to the poorer outcome of the lung graft.

Practical guidelines: lung transplantation in patients with cystic fibrosis

There are no European recommendations on issues specifically related to lung transplantation (LTX) in cystic fibrosis (CF). The main goal of this paper is to provide CF care team members with clinically relevant CF-specific information on all aspects of LTX, highlighting areas of consensus and controversy throughout Europe. Bilateral lung transplantation has been shown to be an important therapeutic option for end-stage CF pulmonary disease. Transplant function and patient survival after transplantation are better than in most other indications for this procedure. Attention though has to be paid to pretransplant morbidity, time for referral, evaluation, indication, and contraindication in children and in adults. This review makes extensive use of specific evidence in the field of lung transplantation in CF patients and addresses all issues of practical importance. The requirements of pre-, peri-, and postoperative management are discussed in detail including bridging to transplant and postoperative complications, immune suppression, chronic allograft dysfunction, infection, and malignancies being the most important. Among the contributors to this guiding information are 19 members of the ECORN-CF project and other experts. The document is endorsed by the European Cystic Fibrosis Society and sponsored by the Christiane Herzog Foundation.

Lung transplantation in patients with cystic fibrosis: special focus to infection and comorbidities

Despite advances in medical care, patients with cystic fibrosis still face limited life expectancy. The most common cause of death remains respiratory failure. End-stage cystic fibrosis can be treated with lung transplantation and is the third most common reason for which the procedure is performed. Outcomes for cystic fibrosis are better than most other lung diseases, but remain limited (5-year survival 60%). For patients with advanced disease lung transplantation appears to improve survival. Outcomes for patients with Burkholderia cepacia remain poor, although they are better for patients with certain genomovars. Controversy exists about Mycobacterium abscessus infection and appropriateness for transplant. More information is also becoming available for comorbidities, including diabetes and pulmonary hypertension among others. Extra-corporeal membrane oxygenation is used more frequently for end-stage disease as a bridge to lung transplantation and will likely be used more in the future.

Energy expenditure and nutritional status in pediatric patients before and after lung transplantation

Resting energy expenditure and nutritional status in pediatric patients was determined before and then 1 and 2 years after lung transplantation. Mean resting energy expenditure was increased (132%) before transplantation and declined (112%) after transplantation. Body mass index and weight z-scores improved posttransplantation, but nutritional measurements remained below normal population values.

Impact of nutritional state on lung transplant outcomes

BACKGROUND

When high-risk lung transplant candidates are evaluated, nutritional state is often neglected. We evaluated the prevalence of markers reflecting pre-transplant malnutrition and their association with post-operative complications and death.

METHODS

From January 2005 to July 2010, 453 patients underwent primary lung transplantation at our institution. Pre-operative nutrition-related variables, including body mass index and weight/height ratio, reflecting cachexia, and albumin, total protein, immunoglobulins, and absolute lymphocyte count were considered in identifying risk factors for time-related major post-operative complications (renal failure requiring dialysis, respiratory failure requiring tracheostomy), pulmonary or bloodstream infections, and death.

RESULTS

Forty-eight patients had BMI <18.5 kg/m(2), 41 had a weight/height ratio ≤ 0.3, 102 had albumin <3.5 g/dl, 110 had total protein <6 g/dl, and 112 had an absolute lymphocyte count <1,000/μl, indicative of a malnourished state. At 6 months, 30% had experienced pulmonary infection, with lower total serum protein concentration an important risk (p = 0.02). One-year actuarial mortality was 15%; risk factors included lower serum albumin (p = 0.004), particularly when <3 g/dl. In contrast, variables reflecting nutritional state were not statistically significantly correlated with dialysis, respiratory failure requiring tracheostomy, or bloodstream infections.

CONCLUSION

Although malnutrition is uncommon in lung transplant patients, those at extremes of low serum albumin and total protein have worse survival and increased risk of post-operative infection. Strategies to improve nutrition of these high-risk candidates awaiting lung transplantation should be developed.

Maintenance of nutritional status in patients with cystic fibrosis: new and emerging therapies

Poor clinical outcomes in cystic fibrosis are often associated with undernutrition. Normal growth and development should be achieved in cystic fibrosis, and nutritional counseling is paramount at all ages. Prevention and early detection of growth failure is the key to successful nutritional intervention. The advance in nutritional management is certainly one factor that has contributed to the improved survival in recent decades. This review outlines the major nutritional parameters in the management of the patient with cystic fibrosis, including recent advances in pancreatic enzyme replacement therapy and fat-soluble vitamin therapy. There are sections on complicated clinical situations which directly affect nutrition, for example, before and after lung transplantation, cystic fibrosis-related diabetes, and bone health.

Long-term impact of liver transplantation on respiratory function and nutritional status in children and adults with cystic fibrosis

Early liver transplant (LT) has been advocated for patients with cystic fibrosis liver disease (CFLD) and evidence of deterioration in nutritional state and respiratory function to prevent further decline. However, the impact of single LT on long-term respiratory function and nutritional status has not been adequately addressed. We performed a retrospective analysis of the outcomes of 40 (21 adult/19 pediatric) patients with CFLD transplanted between 1987 and 2009 with median follow-up of 47.8 months (range 4-180). One and five-year actuarial survival rates were 85%/64% for adult and 90%/85% for pediatric LT cohorts, respectively. Lung function remained stable until 4 years (FEV(1) % predicted; pretransplant 48.4% vs. 45.9%, 4 years posttransplant) but declined by 5 years (42.4%). Up to 4 years posttransplant mean annual decline in FEV(1) % was lower (0.74%; p = 0.04) compared with the predicted 3% annual decline in CF patients with comorbidity including diabetes. Number of courses of intravenous antibiotics was reduced following LT, from 3.9/year pretransplant to 1.1/year, 5 years posttransplant. Body mass index was preserved posttransplant; 18.0 kg/m(2) (range 15-24.3) pretransplant versus 19.6 kg/m(2) (range 16.4-22.7) 5 years posttransplant. In conclusion, LT is an effective treatment for selected patients with cirrhosis due to CFLD, stabilizing aspects of long-term lung function and preserving nutritional status.

Body composition: why, when and for who?

Body composition reflects nutritional intakes, losses and needs over time. Undernutrition, i.e. fat-free mass (FFM) loss, is associated with decreased survival, worse clinical outcome and quality of life, as well as increased therapy toxicity in cancer patients. In numerous clinical situations, such as sarcopenic obesity and chronic diseases, the measurement of body composition with available methods, such as dual-X ray absorptiometry, computerized tomography and bioelectrical impedance analysis, quantifies the loss of FFM, whereas body weight loss and body mass index only inconstantly reflect FFM loss. The measurement of body composition allows documenting the efficiency of nutrition support, tailoring the choice of disease-specific and nutritional therapies and evaluating their efficacy and putative toxicity. Easy-to-use body composition methods integrated to the routine of care allow sequential measurements for an initial nutritional assessment and objective patients follow-up. By allowing an earlier and objective management of undernutrition, body composition assessment could contribute to reduce undernutrition-induced morbidity, worsening of quality of life, and global health care costs by a timely nutrition intervention.

Changes in nutritional status in ICU patients receiving enteral tube feeding: a prospective descriptive study

OBJECTIVES

This study aimed to assess the changes in nutritional status in Korean ICU patients receiving enteral feeding, and to understand the contribution of baseline nutritional status and energy intake to nutritional changes during the ICU stay.

METHODS

This was a prospective study of nutritional changes in 48 ICU patients receiving enteral feeding for 7 days. The Subjective Global Assessment scale was used upon admission. In addition, anthropometric measures (triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference, body mass index and percent ideal body weight) and biochemical measures (albumin, prealbumin, transferrin, haemoglobin and total lymphocyte count) were evaluated twice, upon admission and 7 days after admission.

RESULTS

Seventy-five percent of ICU patients were severely malnourished at admission. Although the nutritional status worsened in both the patients with suspected malnourishment and the patients with severe malnutrition at admission, the nutritional status worsened significantly more in the patients with severe malnutrition than in the patients with suspected malnourishment. Moreover, a number of nutritional measures significantly decreased more in underfed patients than in adequately fed patients. The most significant predicting factor for underfeeding was under-prescription.

CONCLUSION

The ICU patients in our study were severely malnourished at admission, and their nutritional status worsened during their ICU stay even though enteral nutritional support was provided. The changes in nutritional status during the ICU stay were related to the patients' baseline nutritional status and underfeeding during their ICU stay. This study highlights an urgent need to provide adequate nutritional support for ICU patients.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60–80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

Impact of nutritional status on body functioning in chronic obstructive pulmonary disease and how to intervene

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease is the fifth leading cause of mortality in the world. This study reviews diet as a risk or protective factor for chronic obstructive pulmonary disease, mechanisms of malnutrition, undernutrition consequences on body functioning and how to modulate nutritional status of patients with chronic obstructive pulmonary disease.

RECENT FINDINGS

Different dietary factors (dietary pattern, foods, nutrients) have been associated with chronic obstructive pulmonary disease and the course of the disease. Mechanical disadvantage, energy imbalance, disuse muscle atrophy, hypoxemia, systemic inflammation and oxidative stress have been reported to cause systemic consequences such as cachexia and compromise whole body functioning. Nutritional intervention makes it possible to modify the natural course of the disease provided that it is included in respiratory rehabilitation combining bronchodilators optimization, infection control, exercise and, in some patients, correction of hypogonadism.

SUMMARY

Diet, as a modifiable risk factor, appears more as an option to prevent and modify the course of chronic obstructive pulmonary disease. Reduction of mechanical disadvantage, physical training and anabolic agents should be used conjointly with oral nutrition supplements to overcome undernutrition and might change the prognosis of the disease in some cases. Major research challenges address the role of systemic inflammation and the best interventions for controlling it besides smoking cessation.