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

Association of Nutritional Risk Index With Infection-Related Hospitalization and Death After Hospitalization in Patients Undergoing Maintenance Hemodialysis

OBJECTIVE

Patients undergoing dialysis frequently experience hospitalization due to cardiovascular disease (CVD) and infection. This population is also at high risk of rehospitalization and subsequent death. In addition to serious outcomes, hospitalization incurs substantial medical cost. Prevention of hospitalization is accordingly an urgent matter. Here, we examined whether nutritional disorder was associated with hospitalization and subsequent death.

METHODS

The study was conducted under a prospective design using data from the Japanese Dialysis Outcomes and Practice Pattern Study. The exposure was the Nutritional Risk Index for Japanese Hemodialysis (NRI-JH), through which patients were divided into low-, medium-, and high-risk groups, with the low-risk group as referent. The primary outcome was CVD-related or infection-related hospitalization. Secondary outcome was all-cause mortality. For exploratory analyses, the associations of baseline or latest NRI-JH just before hospitalization, with death after hospitalizations, were examined.

RESULTS

Of 4021 patients, 566 patients had CVD-related hospitalization and 375 had infection-related hospitalization during a median follow-up of 2.6 years. NRI-JH at baseline was significantly associated with infection-related hospitalization but not with CVD-related hospitalization, in multivariable Cox models (hazard ratio [HR] 1.46, 95% confidential interval [CI]: 1.09 to 1.97, P = .012 for medium-risk vs. low-risk group) (HR 2.46, 95% CI: 1.81 to 3.35, P < .001 for high-risk vs. low-risk group). NRI-JH was also associated with all-cause mortality. In addition, the baseline and latest high-risk NRI-JH groups were significantly associated with death after both CVD-related and infection-related hospitalizations.

CONCLUSIONS

A higher nutritional risk as evaluated by NRI-JH was associated with infection-related hospitalization but not with CVD-related hospitalization. However, NRI-JH was significantly associated with death after both CVD-related and infection-related hospitalizations, suggesting that nutritional risk may be separately involved in hospitalization or subsequent death. NRI-JH may be useful in the planning of individual care to improve outcomes.

Comparison of Mini Nutritional Assessment Tool and Geriatric Nutrition Risk Index in Predicting 12-Y Mortality Among Community-Dwelling Older Persons

BACKGROUND

Malnutrition is a common and dangerous condition in older adults, which has been associated with increased risk of mortality.

OBJECTIVES

This study aimed to evaluate and compare the abilities of Mini Nutritional Assessment short form (MNA-SF), MNA full form (MNA-FF), and geriatric nutritional risk index (GNRI) to predict all-cause and expanded cardiovascular disease (CVD)-related mortality in community-dwelling older adults.

METHODS

This research was an observational cohort study conducted in a community setting, with a 12-y follow-up involving 1001 community-living older adults aged 65 y or older who were enrolled in 2009 and followed up until 2021. Nutritional status assessment was carried out in 2009 using MNA-SF, MNA-FF, and GNRI. Multivariate Cox proportional hazards regression was applied to determine adjusted hazard ratios of mortality with 95% CIs.

RESULTS

A total of 368 deaths (36.76%) and 122 expanded CVD-related deaths (12.19%) were observed after a median follow-up of 12 y. Compared with normal nutritional status, poor nutritional status assessed by the MNA-SF, MNA-FF, and GNRI was found to be associated with an increased all-cause mortality in older persons. MNA-SF and MNA-FF, but not GNRI, were associated with expanded CVD-related mortality. The MNA-FF showed better discriminatory accuracy for all-cause (C-statistics: 0.77; 95% CI: 0.63, 0.79) and expanded CVD-related mortality (C-statistics: 0.79; 95% CI: 0.70, 0.83) than MNA-SF (C-statistics: 0.76; 95% CI: 0.73-0.79; and C-statistics: 0.76; 95% CI: 0.72-0.81, respectively) and GNRI (C-statistics: 0.75; 95% CI: 0.73-0.79; and C-statistics: 0.76; 95% CI: 0.72-0.80, respectively).

CONCLUSIONS

Our findings indicate that MNA-SF, MNA-FF, and GNRI were all independent predictors of all-cause mortality. In particular, the MNA-FF may be the best nutritional assessment tool for predicting all-cause and CVD-related mortality among older persons residing in community, compared with MNA-SF and GNRI.

The impact of malnutrition on the effectiveness of intradialytic exercise in hemodialysis patients: amulticenter cohort study

PURPOSE

Low physical function can be effectively improved via intradialytic exercise. However, the association between the effects of intradialytic exercise on physical function and malnutrition severity has not been studied extensively. This study aimed to investigate the impact of nutritional status severity on physical function in patients undergoing hemodialysis with low physical function to whom intradialytic exercise was prescribed.

METHODS

The participants were patients with decreased mobility [walking speed < 1.0 m/s and/or Short Physical Performance Battery (SPPB) < 12] who had been undergoing hemodialysis thrice a week for 6 months and performing intradialytic exercise program. Patients were divided into groups based on the Geriatric Nutritional Risk Index (GNRI) [Non-malnutrition group (GNRI > 98), Gentle/slim malnutrition group (GNRI ≤ 98, GNRI ≥ 92), Mild malnutrition group (GNRI < 92, GNRI ≥ 82), Severe malnutrition group (GNRI < 82)]. The primary outcomes were Grip strength, isometric knee extension strength (IKES), SPPB, and 10-m walking speed measured at baseline and at 6 months. Statistical analyses were performed using a linear mixed-effects model with the intention-to-treat analysis, including within-group analysis and between-group comparison.

RESULTS

A total of 805 participants were included in the study. Within-group comparisons showed significantly improved IKES, 10-m walking speed, and SPPB improved, except in the Severe malnutrition group. Grip strength significantly improved in the Gentle/slim and mild malnutrition groups. Between-group comparison with controls showed that the improvement in Grip strength was significantly bigger in the Gentle/slim malnutrition group [0.98 (0.15 to 1.82) kg] than in the non-malnutrition group. However, IKES in the Severe malnutrition group [- 5.14 (- 9.18 to - 1.10) %] less significantly improve than that in the non-malnutrition group. No significant differences were found in the other indices.

CONCLUSION

In patients with severe malnutrition, the changes in IKES scores resulting from Intradialytic exercise were significantly smaller than those observed in non-malnourished patients. Therefore, it is necessary to initiate suitable nutritional and exercise therapy based on the severity of malnutrition.

Impact of the geriatric nutritional risk index on long-term outcomes in patients undergoing hemodialysis: a meta-analysis of observational studies

Background

This meta-analysis aimed to synthesize current evidence on the association between the Geriatric Nutritional Risk Index (GNRI) and long-term outcomes in patients undergoing hemodialysis.

Methods

Electronic databases were systematically searched for relevant studies that investigated the association between GNRI and long-term outcomes in hemodialysis patients until November 2023. The primary outcome was the association between the GNRI (i.e., low versus high) and overall mortality risk, while the secondary outcome was the relationship between the GNRI and cardiovascular mortality risk.

Results

Thirty cohort studies involving 55,864 patients were included. A low GNRI was found to be significantly associated with increased overall mortality (hazard ratio [HR]: 2.42, 95% confidence interval [CIs]: 2.10-2.79, p < 0.00001, I2 = 65%). Each unit increase in GNRI corresponded to a 5% reduction in mortality risk (HR: 0.95, 95% CI: 0.93-0.96, p < 0.00001, I2 = 79%). The association remained consistent across Asian (HR = 2.45, 95% CI: 2.08-2.88, p < 0.00001, I2 = 70%) and non-Asian subgroups (HR = 2.3, 95% CI: 1.72-3.06, p < 0.00001, I2 = 23%). Meta-regression analysis of patient age (coefficient: -0.002; p = 0.896), male proportion (coefficient: 0.002; p = 0.875), percentage of diabetes mellitus (coefficient: -0.003; p = 0.605), and follow-up duration (coefficient: -0.003; p = 0.431) revealed that these moderator variables did not significantly influence the association between GNRI and overall mortality risk. Cardiovascular mortality risk also increased with low GNRI (HR, 1.93; 95%CI: 1.51-2.45, p < 0.00001; I2 = 2%). Similarly, an inverse association was observed between the GNRI values and cardiovascular mortality risk (HR, 0.94; 95% CI: 0.91-0.97; p < 0.0001; I2 = 65%) (per unit increase).

Conclusion

The GNRI is a simple nutritional screening tool that can be used to effectively stratify patients undergoing hemodialysis globally. Further studies are warranted to determine whether nutrition optimization based on the GNRI improves long-term outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, CRD42023483729.

Questionnaire survey of the frequency of dietary intake during hemodialysis and the impact of COVID-19 in Japan

BACKGROUND

There have been no coherent reports on the effects of dietary intake during hemodialysis in Japan. Furthermore, few studies have reported the impact of the COVID-19 pandemic on them. This study aimed to investigate dietary intake during hemodialysis and its impact on the spread of COVID-19.

METHODS

This consecutive cross-sectional study included a survey of all hemodialysis facilities in the Niigata Prefecture. The survey form was sent via e-mail or fax.

RESULTS

Fifty four facilities (98%) responded to the 2018 survey. Twenty-eight facilities (52%) provided meals, with 18% of all patients undergoing dialysis and 41% of patients undergoing nocturnal dialysis consuming meals during hemodialysis. In the 2020 survey, the number of facilities decreased to 17 (33%), and the number of all patients undergoing dialysis and nocturnal dialysis consuming meals decreased to 13% and 32%, respectively. In the 2022 survey, the number of facilities decreased to 14 (27%), and the number of all patients undergoing dialysis and nocturnal dialysis decreased to 9% and 19%, respectively.

CONCLUSION

The COVID-19 pandemic has caused a decrease in both facilities serving meals and patients' food consumption during hemodialysis. To prevent the loss of meal opportunities, establishing safe methods for food intake and alternatives in hemodialysis facilities is necessary.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Serum phosphate as an independent factor associated with cholesterol metabolism in patients undergoing hemodialysis: a cross-sectional analysis of the DREAM cohort

Background

Hyperphosphatemia is a risk factor for cardiovascular outcomes in patients with chronic kidney disease. In an experimental model, hyperphosphatemia promotes atherosclerosis by activating sterol regulatory element-binding protein 2 which controls cholesterol homeostasis. In the present study, we hypothesized that serum phosphate level is associated with cholesterol metabolism in patients with kidney failure.

Methods

We conducted a single center cross-sectional study including 492 patients undergoing hemodialysis and 100 healthy controls not on statin or ezetimibe treatment. Serum lathosterol and campesterol levels were measured as a marker of cholesterol synthesis and absorption, respectively. As compared to the control group, the hemodialysis patients had higher median (interquartile range) phosphate [5.8 (5.0 to 6.6) vs. 3.3 (3.0 to 3.6) mg/dL, P &lt; 0.001], lower lathosterol [1.2 (0.8 to 1.7) vs. 2.6 (1.9 to 3.4) µg/mL, P &lt; 0.001] and higher campesterol levels [4.5 (3.6 to 6.0) vs. 4.1 (3.2 to 5.4) µg/mL, P = 0.02]. Serum phosphate correlated positively to campesterol in the control group (Spearman's r = 0.21, P = 0.03) and in the hemodialysis patients (Spearman's r = 0.19, P &lt; 0.001). The positive association between phosphate and campesterol levels in the hemodialysis group remained significant in multivariable-adjusted linear regression analysis. There was no significant association between phosphate and lathosterol in either group.

Conclusions

An independent association was found between phosphate and campesterol levels in patients with kidney failure. This study suggests a novel relationship between phosphate and cholesterol metabolism, both of which could affect cardiovascular outcomes in this population.