[Research Progress in Pathogenesis,Nutrition and Exercise Intervention of Patients With Protein Energy Wasting].

Protein energy wasting(PEW)is common in maintenance hemodialysis(MHD)patients,and it is associated with a variety of adverse clinical outcomes,including weight loss and increased protein catabolism.There are many studies on health interventions for MHD patients through nutrition strategies,exercise patterns and the combination of both.This article reviews the pathogenesis,diagnostic criteria and intervention measures of PEW,aiming to provide a reference for early clinical diagnosis,identification and intervention of PEW.

Deconstructing Disease-Related Malnutrition: A New Assessment Framework for Clinical Practice.

Protein-energy wasting (PEW) is a key cause of functional impairment and poor health outcomes in people with chronic kidney disease. While PEW can be mitigated with nutrition therapy, it is a complex myriad of disorders with numerous interacting etiologies and corresponding presentations, which make it difficult to diagnose and manage in practice. A variety of scoring rubrics have been developed to facilitate malnutrition assessment. Although these tools have greatly benefited the recognition and treatment of PEW, the typical format of grading specified PEW indicators has the potential to overlook or overstate highly relevant individual-specific factors. This review presents a simple framework for malnutrition assessment that can be used to complement and evaluate conventional assessment tools. Unlike standard tools, which are designed to identify and rate malnutrition risk and severity, the malnutrition framework is conceptual model that organizes PEW assessment into three distinct, but interacting facets of PEW risk: nutrient balance, nutrition status, and malnutrition risk. The new framework encourages critical thinking about PEW risk that may help clinicians plan and interpret assessments to efficiently and effectively manage this condition.

A Novel Approach for Managing Protein-Energy Wasting in People With Kidney Failure Undergoing Maintenance Hemodialysis: Rationale and Call for Trials.

Protein-energy wasting (PEW) is a unique presentation of protein-energy malnutrition in people with kidney disease that is characterized by body protein catabolism exceeding anabolism. PEW is especially common in patients undergoing maintenance hemodialysis (HD) treatment. Dietary guidelines for managing PEW in HD patients primarily focus on protein adequacy and typically promote the intake of animal-based protein foods. Although intake of protein and essential amino acids is important for protein synthesis, the emphasis on protein adequacy largely fails to address-and may actually exacerbate-many of the root causes of PEW. This perspective examines the dietary determinants of PEW in people undergoing HD treatment, with an emphasis on upstream disease-related factors that reduce dietary protein utilization and impair dietary intakes. From this, we present a theoretical diet model for managing PEW that includes etiology-based dietary strategies to address barriers to intake and treat disease-related factors, as well as supportive dietary strategies to promote adequate energy and protein intakes. Given the complexity of diet-disease interactions in the pathogenesis of PEW, and its ongoing burden in HD patients, interventional trials are urgently needed to evaluate alternative diet therapy approaches for PEW in this population.

Quality of Life in Patients with Renal Failure Undergoing Hemodialysis.

A good quality of life is one of the many indicators that determine the success of hemodialysis (HD) therapy. Factors that significantly affect the quality of life of patients with renal failure who undergo HD include sociodemographic condition, mental state (depression), severity of kidney disease, accompanying disorders, HD duration, non-adherence towards prescribed medication and nutritional problems. Among said factors, the metabolic and nutritional disorder commonly known as protein energy wasting (PEW), plays an important role in the clinical course of renal failure patients. The aim of nutrition management in patients with renal failure is to slow down the progression of kidney disease, improve quality of life, and reduce cardiovascular morbidity and mortality.

Vitamin D in dysphagic patients who have undergone endoscopic gastrostomy for long-term enteral feeding.

OBJECTIVE: Vitamin D plays a major role in biological processes. Its deficiency is associated with increased morbidity and mortality. Patients who have undergone endoscopic gastrostomy (PEG) present with protein-energy malnutrition, and may be at risk for Vitamin D deficiency, due to their age, less sunlight exposure and lower dietary intake. We aimed to determine the prevalence of hypovitaminosis D in PEG-patients, its change under PEG-feeding, and its relationship with serum proteins and risk factors for Vitamin D deficiency. METHODS: This was a prospective observational study, over 4 weeks, after gastrostomy. Data were collected at the initial PEG procedure (T0), and after 4 weeks (T1). Initial evaluation included age, gender, underlying disorder, NRS-2002, BMI, serum albumin, transferrin and Vitamin D. At T1 we assessed Vit. D, albumin, and transferrin. Vitamin D was performed with Electrochemiluminescence through Elecsys 2010 assay. Patients were fed with blended homemade meals. RESULTS: 200 patients (118 males), 22-92 years of age, were studied. There were initial low values for Vit. D (181), albumin (96), transferrin (121), and BMI (124). A correlation was found between Vit. D and serum albumin (r=0.49, p=0.005) but not with transferrin (r=0.26, p=0.195). At T1 the subgroup who had Vit. D levels assessed (n=48) was part of the initial study group maintained low levels of Vitamin D despite nutritional intervention. CONCLUSION: We recommend systematic Vitamin D supplementation of PEG fed patients using homemade meals or at least screening for hypovitaminosis D as a routine part of their care.

Malnutrition and Perioperative Nutritional Support in Retroperitoneal Sarcoma Patients: Results from a Prospective Study.

INTRODUCTION: Retroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown. MATERIALS AND METHODS: A prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein ß-hydroxy-ß-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient's compliance to preoperative ONS and the physician's compliance to postoperative nutritional targets. RESULTS: PEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04). CONCLUSIONS: Relevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS. TRIAL REGISTRY: ClinicalTrials.gov identifier: NCT03877588.

[Staged approach in the treatment of patients with enterocutaneous fistulae]. / Etapnyi podkhod v lechenii bol'nykh s nesformirovannymi kishechnymi svishchami.

OBJECTIVE: To determine an optimal approach in the treatment of patients with intestinal fistulae. MATERIAL AND METHODS: We have used the above-mentioned algorithm in the treatment of 46 patients. The majority of patients (n=44, 96%) were transferred under supervision of our multidisciplinary team with severe water-electrolyte disturbances and signs of secondary protein-energy malnutrition (PEM) that required complex combined nutritional support. A two-stage approach was applied in all cases. The first one was conservative and included correction and prevention of infectious complications, nutritional and metabolic therapy, local wound treatment, and anatomical assessment of the fistula. The second stage was reconstructive and implied various reconstructive interventions not earlier than 3 months after formation of the fistula. RESULTS: Conservative approach was followed by fistula healing in 6 patients, surgery was required in 25 patients. Complications with subsequent redo surgery occurred in 4 cases. In all cases, favorable outcome was noted. All 25 patients were discharged. Three patients refused reconstructive surgery after development of fistula, they were also discharged. Mortality rate was 26% (n=12). CONCLUSION: A multidisciplinary two-stage approach can significantly improve treatment outcomes in patients with intestinal fistulae.

Cachexia/Protein energy wasting syndrome in CKD: Causation and treatment.

Cachexia is a multifactorial syndrome defined by significant body weight loss, fat and muscle mass reduction, and increased protein catabolism. Protein energy wasting (PEW) is characterized as a syndrome of adverse changes in nutrition and body composition being highly prevalent in patients with CKD, especially in those undergoing dialysis, and it is associated with high morbidity and mortality in this population. Multiple mechanisms are involved in the genesis of these adverse nutritional changes in CKD patients. There is no obvious distinction between PEW and cachexia from a pathophysiologic standpoint and should be considered as part of the spectrum of the same nutritional disorder in CKD with similar management approaches for prevention and treatment based on current understanding. A plethora of factors can affect the nutritional status of CKD patients requiring a combination of therapeutic approaches to prevent or reverse protein and energy depletion. At present, there is no effective pharmacologic intervention that prevents or attenuates muscle atrophy in catabolic conditions like CKD. Prevention and treatment of uremic muscle wasting involve optimal nutritional support, correction of acidosis, and physical exercise. There has been emerging consistent evidence that active treatment, perhaps by combining nutritional interventions and resistance exercise, may be able to improve but not totally reverse or prevent the supervening muscle wasting and weakness. Active research into more direct pharmacological treatment based on basic mechanistic research is much needed for this unmet medical need in patients with CKD.

Effectiveness of Intradialytic Parenteral Nutrition in Treating Protein-Energy Wasting in Hemodialysis: A Rapid Systematic Review.

Intradialytic parenteral nutrition (IDPN) is commonly requested before recommended therapies in malnourished patients on hemodialysis. This review provides updated critical synthesis of the evidence on the use of IDPN in patients on hemodialysis. We searched MEDLINE, CINAHL, and other sources to identify evidence. Two reviewers sequentially selected studies, abstracted data, rated study quality, and synthesized evidence using predefined criteria. IDPN did not improve clinically relevant outcomes compared with dietary counseling or oral supplementation and had varied results compared with usual care in 12 studies. Data are limited on adverse events or cost-effectiveness of IDPN. Important limitations of the evidence, including limited measurement of clinically important outcomes, methodological concerns, and heterogeneity between studies, weaken our confidence in these findings. IDPN may be a reasonable treatment option for patients who fail to respond or cannot receive recommended treatments, but the broad usage of IDPN before recommended treatment options does not appear warranted.

Treatment of malnutrition decreases complication rates and shortens the length of hospital stays in a radiation oncology department.

PURPOSE: The nutritional status of inpatients influences the therapeutic outcome. Malnutrition is a common comorbidity in oncological patients. Both radio- and radiochemotherapy may contribute to the additional deterioration of the nutritional status. The aim of this study was to evaluate the impact of specialized treatment of malnutrition as a clinical routine. METHODS: The nutritional status of inpatients was assessed by the Nutritional risk screening (NRS-2002) on the day of admission to the University Department of Radiation Oncology. In case of significantly elevated NRS-2002 (NRS ≥ 3), a guideline-compliant, individual nutritional treatment was initiated by a specialized nutrition support team. The influence of the nutritional status and nutritional treatment on length of stay and complication rate was assessed. RESULTS: Of 840 included patients, 344 patients (40.95%) were at risk for malnutrition. Malnutrition was a significant, independent risk factor for both prolonged hospital stay, represented by the deviation between the actual length of stay and the DRG-associated mean length of stay (dLOS at risk: 0.88 days, dLOS not at risk: -0.88 days, p = 0.0047), as well as for the occurrence of complications (OR: 1.758 CI: [1.286-2.402], p = 0.0006). In the group of 337 (40.12%) rehospitalized patients the nutritional management was able to assimilate the values of length of stay as well as the complication rates to standard values. CONCLUSIONS: The high risk for malnutrition and the negative consequences for patients and hospitals underline the urgent need for malnutrition screening on admission and treatment of malnutrition. A specialized, interdisciplinary nutrition support team positively influences patient outcome and should be established routinely in all oncological disciplines.

Dietary protein and nutritional supplements in conventional hemodialysis.

Protein energy wasting (PEW) is a condition commonly occurring among patients with ESRD on hemodialysis. PEW is characterized by depletion of protein and energy stores and is caused by multiple factors related to chronic kidney disease, acute and chronic comorbidities and by renal replacement therapy itself. Anorexia is central in the pathogenesis of PEW; it is frequently observed in these patients whose protein and energy intakes are typically lower than guidelines recommendations. If untreated, PEW invariably leads to major complications, and may activate a vicious circle with further worsening of nutritional status. Dietary counseling and nutritional status monitoring play a key role in the prevention and treatment of PEW, since they allow an early identification of high risk patients, as well as the assessment of the response to nutritional intervention. Different nutritional approaches can be implemented following thorough nutritional counseling. These are chosen on the basis of patients' spontaneous dietary intake, severity of PEW and acute comorbidities. Initially, regular encounters with the dietitian allow patients to clarify doubts and strengthen basic concepts on nutrition to improve dietary intake and prevent PEW. When PEW is present or the patient is at high risk, the clinician may opt for the administration of oral intradialytic or daily supplements, aiming at increasing energy and protein intake, while in selected cases intradialytic parenteral nutrition may be used. This review addresses the main issues of nutritional status in ESRD patients on hemodialysis-its evaluation and monitoring, as well as at describing the available nutritional interventions.

A village-matched evaluation of providing a local supplemental food during pregnancy in rural Bangladesh: a preliminary study.

BACKGROUND: Prenatal balanced protein energy supplementation consumed by undernourished women improves mid-upper arm circumference in early infancy. This study aimed to identify whether locally produced maternal food-based supplementation improved anthropometric measures at birth and early infancy. METHODS: A village-matched evaluation, applying principles of a cluster randomised controlled trial, of a locally produced supplemental food to 87 undernourished pregnant women. 12 villages (intervention: n = 8; control: n = 4) in Pirganj sub-district, Rangpur District, northern Bangladesh. Daily supplements were provided. RESULTS: Anthropometric data at birth were available for 77 mother-infant dyads and longer-term infant growth data for 75 infants. Mid-upper arm circumference (MUAC) was significantly larger in infants of mothers in the intervention group compared with the control group at 6 months (p < 0.05). The mean birth weight in babies of supplemented mothers (mean: 2·91 kg; SD: 0·19) was higher than in babies of mothers in the control group (mean: 2·72 kg; SD: 0·13), and these changes persisted until 6 months. Also, the proportion of low birth weight babies in the intervention group was much lower (event rate = 0.04) than in the control group (event rate = 0.16). However, none of these differences were statistically significant (p > 0·05; most likely due to small sample size). The intervention reduced the risk of wasting at 6 months by 63.38% (RRR = 0.6338), and of low birth weight by 88·58% (RRR = 0.8858), with NNT of 2.22 and 6.32, respectively. Only three pregnant women require this intervention in order to prevent wasting at 6 months in one child, and seven need the intervention to prevent low birth weight of one child. CONCLUSIONS: Locally produced food-based balanced protein energy supplementation in undernourished pregnant women in northern Bangladesh resulted in larger MUAC in infants at 6 months. Further research, with larger sample sizes, is required to confirm the role of locally produced supplementation for undernourished pregnant women on weight and linear growth in newborns and infants. TRIAL REGISTRATION: This research was registered with the ISRCTN registry (ISRCTN97447076). This project had human research ethical approval from the James Cook University (Australia) Ethics committee (H4498) and the Bangladesh Medical Research Council (BMRC/NREC/2010-2013/58).

Is it Important to Prevent and Treat Protein-Energy Wasting in Chronic Kidney Disease and Chronic Dialysis Patients?

Protein-energy wasting (PEW), which essentially refers to decreased body protein mass and fuel (energy) reserves, is common in advanced chronic kidney disease (CKD) patients and end-stage kidney disease patients undergoing chronic dialysis. The term PEW is used rather than protein-energy malnutrition because many causes of PEW in CKD and end-stage kidney disease patients does not involve reduced nutrient intake (e.g., catabolic illness, oxidants, biologicals lost in urine and dialysate, acidemia). The prevalence of PEW in CKD increases as glomerular filtration rate declines and is highest in chronic dialysis patients. PEW in CKD is important because it is associated with substantially increased morbidity and mortality and reduced quality of life. Many signs of PEW can be improved with nutritional therapy. It is not known whether amelioration or eradication of PEW by treatment of underlying illnesses, nutritional therapy, and/or other measures will reduce morbidity and mortality or improve quality of life. Clinical trials are indicated to answer these questions.

[Refeeding syndrome in geriatric patients : A frequently overlooked complication]. / Refeeding-Syndrom bei geriatrischen Patienten : Eine oft übersehene Komplikation.

The refeeding syndrome is a life-threatening complication that can occur after initiation of a nutrition therapy in malnourished patients. If the risk factors and pathophysiology are known, the refeeding syndrome can effectively be prevented and treated, if recognized early. A slow increase of food intake and the close monitoring of serum electrolyte levels play an important role. Because the refeeding syndrome is not well known and the symptoms may vary extremely, this complication is poorly recognized, especially against the background of geriatric multimorbidity. This overview is intended to increase the awareness of the refeeding syndrome in the risk group of geriatric patients.

[Percutaneous endoscopic gastrostomy in geriatrics : Indications, technique and complications]. / Die perkutane endoskopische Gastrostomie in der Altersmedizin : Indikationen, Technik und Komplikationen.

The technique of percutaneous endoscopic gastrostomy (PEG) was introduced in 1979 as a semi-invasive approach for children with the need for a gastric fistula in order to avoid an operative intervention. The suture pull-through method was rapidly established and is now omnipresent. Because scientific evidence is broadly missing, there is some uncertainty about the indications in geriatric medicine. Guidelines do not recommend the insertion of a PEG in patients with severe dementia and malnutrition. Tube feeding is mainly recommended as a temporary method for patients who cannot take oral nutrition for more than 3 days or for whom the energy intake for more than 10 days presumably covers less than 50% of their needs, assuming that the overall prognosis is reasonable. Insertion of a PEG is only recommended if artificial nutrition is expected to be necessary for more than 3-4 weeks or if a nasogastric tube is not tolerated.

As we grow old: nutritional considerations for older patients on dialysis.

The number of older people on dialysis is increasing, along with a need to develop specialized health care to manage their needs. Aging-related changes occur in physiological, psychosocial and medical aspects, all of which present nutritional risk factors ranging from a decline in metabolic rate to assistance with feeding-related activities. In dialysis, these are compounded by the metabolic derangements of chronic kidney disease (CKD) and of dialysis treatment per se, leading to possible aggravation of protein-energy wasting syndrome. This review discusses the nutritional derangements of the older patient on dialysis, debates the need for specific renal nutrition guidelines and summarizes potential interventions to meet their nutritional needs. Interdisciplinary collaborations between renal and geriatric clinicians should be encouraged to ensure better quality of life and outcomes for this growing segment of the dialysis population.

Comparison of Subjective Global Assessment and Protein Energy Wasting Score to Nutrition Evaluations Conducted by Registered Dietitian Nutritionists in Identifying Protein Energy Wasting Risk in Maintenance Hemodialysis Patients.

OBJECTIVE: To compare the 7-point subjective global assessment (SGA) and the protein energy wasting (PEW) score with nutrition evaluations conducted by registered dietitian nutritionists in identifying PEW risk in stage 5 chronic kidney disease patients on maintenance hemodialysis. DESIGN AND METHODS: This study is a secondary analysis of a cross-sectional study entitled "Development and Validation of a Predictive energy Equation in Hemodialysis". PEW risk identified by the 7-point SGA and the PEW score was compared against the nutrition evaluations conducted by registered dietitian nutritionists through data examination from the original study (reference standard). SUBJECTS: A total of 133 patients were included for the analysis. MAIN OUTCOME MEASURES: The sensitivity, specificity, positive and negative predictive value (PPV and NPV), positive and negative likelihood ratio (PLR and NLR) of both scoring tools were calculated when compared against the reference standard. RESULTS: The patients were predominately African American (n = 112, 84.2%), non-Hispanic (n = 101, 75.9%), and male (n = 80, 60.2%). Both the 7-point SGA (sensitivity = 78.6%, specificity = 59.1%, PPV = 33.9%, NPV = 91.2%, PLR = 1.9, and NLR = 0.4) and the PEW score (sensitivity = 100%, specificity = 28.6%, PPV = 27.2%, NPV = 100%, PLR = 1.4, and NLR = 0) were more sensitive than specific in identifying PEW risk. The 7-point SGA may miss 21.4% patients having PEW and falsely identify 40.9% of patients who do not have PEW. The PEW score can identify PEW risk in all patients, but 71.4% of patients identified may not have PEW risk. CONCLUSIONS: Both the 7-point SGA and the PEW score could identify PEW risk. The 7-point SGA was more specific, and the PEW score was more sensitive. Both scoring tools were found to be clinically confident in identifying patients who were actually not at PEW risk.

Air Displacement Plethysmography Versus Bioelectrical Impedance to Determine Body Composition in Pediatric Hemodialysis Patients.

OBJECTIVE: Protein energy wasting is difficult to assess in pediatric hemodialysis (HD) populations because of fluid shifts. Body composition (BC) analysis aids in monitoring nutrition therapy's effects on fat and lean mass. Air displacement plethysmography (ADP) is a "practical" gold standard for fat mass (FM) measurements. We aim to compare BC measures in a pediatric HD population via anthropometry, ADP, and bioelectrical impedance (BIA). DESIGN: The study was prospective cohort study and the setting was 1 pediatric HD unit in Houston, Texas. SUBJECTS: A total of 15 pediatric and young adult patients receiving maintenance HD. INTERVENTION: ADP, BIA, and anthropometry were obtained mid-week post HD for 3 consecutive months. MAIN OUTCOME MEASURE: The primary outcome was the difference in FM as defined by various assessment methods. Secondary outcomes included correlations with anthropometry. RESULTS: ADP demonstrated a strong positive correlation to body mass index, mid-upper arm circumference, and triceps skin fold (all P < .0001). No differences in FM assessment using ADP or BIA were found except in males with advanced tanner (P = .0004). BIA underestimated FM in obese subjects (P = .005). Analysis of malnutrition status by mid-upper arm circumference revealed an overestimation of FM in BIA measures (P = .02). CONCLUSIONS: This is the first pediatric dialysis study using ADP to assess BC. Estimation of FM in pediatric HD patients via ADP and BIA has significant error rates in 2 populations: (1) males tanner ≥4: BIA underestimates FM and (2) weight extremes: BIA underestimates FM for obese and overestimates FM for malnourished. BIA should be used with caution in these populations when estimating fluid content and leads to false estimates of dry weight. ADP is a useful adjunct in assessment of nutritional status via BC in pediatric HD patients.

Combining intra-dialytic exercise and nutritional supplementation in malnourished older haemodialysis patients: Towards better quality of life and autonomy.

Protein-energy wasting (PEW), defined as a loss of body protein mass and fuel reserves, is a powerful predictor of adverse outcomes in haemodialysis (HD) patients. Robust arguments suggest that intra-dialytic exercise, combined with oral/parenteral nutrition, enhances the effect of nutritional interventions in HD patients. This pilot randomized controlled trial investigated the feasibility and the effects of a 6 month intra-dialytic cycling program combined to a nutritional support on PEW, physical functioning (gait, balance, muscle strength) and quality of life (QoL) in older HD patients (mean age 69.7 ± 14.2 years).Twenty-one patients fulfilling diagnostic criteria of PEW were randomly assigned to Nutrition-Exercise group (GN-Ex , n = 10) or Nutrition group (GN , n = 11). Both groups received nutritional supplements in order to reach recommended protein and energy intake goals. In addition GN-Ex completed a cycling program. No significant difference between groups was found in the number of patients having reached remission of PEW. Likewise, no change was observed in serum-albumin, -prealbumin, C-reactive protein, body mass index, lean- and fat-tissue index, or quadriceps force. Interestingly, we found positive effects of exercise on physical function and QoL for the GN-Ex , as evidenced by a significant improvement in the 6-min walk test (+22%), the absence of decline in balance (unlike the GN ), and a noteworthy increase in QoL (+53%). Combining intra-dialytic exercise and nutrition in HD patients is feasible, and well accepted, improves physical function and QoL but it appears not to have the potential to reverse PEW.

Comparative analysis of undernutrition screening and diagnostic tools as predictors of hospitalisation costs.

BACKGROUND: Undernutrition is associated with higher hospitalisation costs. The present study aims (i) to explore whether undernutrition status at hospital admission, as evaluated by different screening and diagnostic tools, can predict patient's hospitalisation costs and (ii) to provide an updated economic analysis of undernutrition burden. METHODS: A prospective study was conducted in a university hospital. Participants' (n = 637) nutritional risk was evaluated within 72 h of admission using the Nutritional Risk Screening (NRS-2002) and the Malnutrition Universal Screening Tool ('MUST'). Undernutrition status was determined by Academy of Nutrition and Dietetics (AND) and American Society for Parenteral and Enteral Nutrition (ASPEN) recommended clinical characteristics and by the Patient Generated Subjective Global Assessment (PG-SGA). The hospitalisation cost was calculated for each inpatient using the diagnosis-related group system. Multivariable linear regression analysis was conducted to identify predictors of hospitalisation costs via percentage deviation from the mean cost, after adjustment for patients' characteristics and comorbidities. RESULTS: Undernutrition risk according to NRS-2002 and high undernutrition risk according to 'MUST' increased patient's costs, respectively, by 21.1% [95% confidence interval (CI) = 9.0-33.2%] and 28.8% (95% CI = 13.7-39.9%). Severe undernutrition by AND-ASPEN recommended clinical characteristics and by PG-SGA was also associated with higher hospitalisation costs, respectively 19.4% (95% CI = 7.3-31.5%) and 27.5% (95% CI = 14.0-41.1%). The cost of a nutritionally-at-risk or undernourished patient is between €416 (95% CI = €156-675) and €617 (95% CI = €293-855) higher than the average of the respective diagnosis-related group. CONCLUSIONS: Undernutrition is a predictor of hospitalisation costs, increasing costs by between 19% and 29%. Undernutrition screening tools have an ability for predicting hospitalisation costs similar to that of diagnostic tools. An updated analysis of undernutrition associated costs was provided, highlighting the economic burden of undernutrition.