The Effect of Nutritional Interventions on Long-Term Patient Survival in Advanced Chronic Kidney Disease.

Patients with end-stage kidney disease (ESKD) are at high risk of malnutrition and subsequent related mortality when starting dialysis. However, there have been few clinical studies on the effect of nutritional interventions on long-term patient survival. A 2-year longitudinal study was conducted from January 2012 to December 2016. A total of 186 patients with non-dialysis ESKD started the nutritional education program (NEP), and 169 completed it. A total of 128 patients participated in a NEP over 6 months (personalized diet, education and oral supplementation, if needed). The control group (n = 45) underwent no specific nutritional intervention. The hospitalization rate was significantly lower for the patients with NEP (13.7%) compared with the control patients (26.7%) (p = 0.004). The mortality odds ratio for the patients who did not receive NEP was 2.883 (95% CI 0.993-8.3365, p = 0.051). The multivariate analysis showed an independent association between mortality and age (OR, 1.103; 95% CI 1.041-1.169; p = 0.001) and between mortality and the female sex (OR, 3.332; 95% CI 1.054-10.535; p = 0.040) but not between mortality and those with NEP (p = 0.051). Individualized nutrition education has long-term positive effects on nutritional status, reduces hospital admissions and increases survival among patients with advanced CKD who are starting dialysis programs.

Protein-Energy Wasting Assessment and Clinical Outcomes in Patients with Acute Kidney Injury: A Systematic Review with Meta-Analysis.

Nutritional assessment is essential to identify patients with acute kidney injury (AKI) who are protein-energy wasting (PEW) and at risk of poor clinical outcomes. This systematic review aimed to investigate the relationship of nutritional assessments for PEW with clinical outcomes in patients with AKI. A systematic search was performed in PubMed, Scopus, and Cochrane Library databases using search terms related to PEW, nutrition assessment, and AKI to identify prospective cohort studies that involved AKI adult patients with at least one nutritional assessment performed and reported relevant clinical outcomes, such as mortality, length of stay, and renal outcomes associated with the nutritional parameters. Seventeen studies reporting eight nutritional parameters for PEW assessment were identified and mortality was the main clinical outcome reported. A meta-analysis showed that PEW assessed using subjective global assessment (SGA) was associated with greater mortality risk (RR: 1.99, 95% CI: 1.36-2.91). Individual nutrition parameters, such as serum chemistry, body mass, muscle mass, and dietary intakes, were not consistently associated with mortality. In conclusion, SGA is a valid tool for PEW assessment in patients with AKI, while other nutrition parameters in isolation had limited validity for PEW assessment.

Association of protein-energy wasting and inflammation status with mortality after coronary revascularisation in patients on haemodialysis.

OBJECTIVE: Protein-energy wasting is associated with chronic inflammation and advanced atherosclerosis in haemodialysis (HD) patients. We investigated association of geriatric nutritional risk index (GNRI), C reactive protein (CRP) with prediction of mortality after coronary revascularisation in chronic HD patients. METHODS: We enrolled 721 HD patients electively undergoing coronary revascularisation. They were divided into tertiles according to preprocedural GNRI levels (tertile 1 (T1):<91.5, T2: 91.5-98.1 and T3:>98.1) and CRP levels (T1:≤1.4 mg/L, T2: 1.5-7.0 mg/L and T3:≥7.1 mg/L). RESULTS: Kaplan-Meier 10 years survival rates were 32.3%, 44.8% and 72.5% in T1, T2 and T3 of GNRI and 60.9%, 49.2% and 23.5% in T1, T2 and T3 of CRP, respectively (p<0.0001 in both). Declined GNRI (HR 2.40, 95% CI 1.58 to 3.74, p<0.0001 for T1 vs T3) and elevated CRP (HR 2.31, 95% CI 1.58 to 3.43, p<0.0001 for T3 vs T1) were identified as independent predictors of mortality. In combined setting of both variables, risk of mortality was 5.55 times higher (95% CI 2.64 to 13.6, p<0.0001) in T1 of GNRI with T3 of CRP than in T3 of GNRI with T1 of CRP. Addition of GNRI and CRP in a model with established risk factors improved C-statistics (0.648 to 0.724, p<0.0001) greater than that of each alone. CONCLUSION: Preprocedural declined GNRI and elevated CRP were closely associated with mortality after coronary revascularisation in chronic HD patients. Furthermore, combination of both variables not only stratified risk of mortality but also improved the predictability.

Nutritional risk in critically ill patients: how it is assessed, its prevalence and prognostic value: a systematic review.

CONTEXT: Nutritional risk (NR) screening is the first step of nutrition care process. Few data are available in literature about its prevalence, nor, to our knowledge, is a universally accepted reference method for the intensive care unit (ICU). OBJECTIVE: The aim for this systematic review was to summarize evidence regarding the prevalence of NR and the predictive validity of different tools applied for NR screening of critically ill patients. DATA SOURCES: The PubMed, Embase, and Scopus databases were searched up to December 2019 using the subject headings related to critically ill patients and NR screening. The current systematic review is registered with PROSPERO (identifier: CRD42019129668). DATA EXTRACTION: Data on NR prevalence, predictive validity of nutritional screening tools, and interaction between caloric-protein balance and NR in outcome prediction were collected. DATA ANALYSIS: Results were summarized qualitatively in text and tables, considering the outcomes of interest. RESULTS: From 15 669 articles initially identified, 36 fulfilled the inclusion criteria, providing data from 8 nutritional screening tools: modified Nutrition Risk in the Critically Ill (mNUTRIC; n = 26 studies) and Nutritional Risk Screening-2002 (NRS-2002; n = 7 studies) were the most frequent; the NR prevalence was 55.9% (range, 16.0% to 99.5%). Nutritional risk was a predictor of 28-day and ICU mortality in 8 studies. Interactions between caloric-protein balance and NR on outcome prediction presented were scarcely tested and presented heterogeneous results (n = 8). CONCLUSIONS: Prevalence of NR in patients in the ICU varies widely; a satisfactory predictive validity was observed, especially when mNUTRIC or NRS-2002 were applied.

Mortality due to malnutrition in older adults, Colombia, 2014-2016 / Mortalidad por desnutrición en el adulto mayor, Colombia, 2014-2016

Introduction: Older people are positioned within the context of public health and nutrition as a vulnerable group. The priorities of the attention programs focus on eating habits and monitoring their nutritional status to improve their vital prognosis. Objective: To estimate the cases of death due to malnutrition of the population over 65 years old in Colombia for 2014 to 2016 to contribute to the analysis and decision-making in health to improve the nutritional situation of this population. Materials and methods: A retrospective descriptive study was carried out analizing death certificates from 2014 to 2016, whose basic cause of death was nutritional deficiencies and anemias. Mortality rates were estimated by sex and department of residence, and distribution frequencies were built based on demographic variables. Results: There were 3,275 deaths due to malnutrition in Colombia for the elderly in the study period (0.5% of total deaths). The mortality rate varied between 5.4 and 108.3 per 100,000 older adults. The highest mortality occurred in those over 80 years of age, especially in men. Conclusion: Caloric protein malnutrition in older adults is the most frequent cause of death due to malnutrition, followed by nutritional anemias. The highest mortality occurs in the age group over 80 years of age and the Amazonas, Guainía and Vaupés departments have the highest rates for all age groups.

Introducción. En el contexto de la salud pública y la nutrición, las personas mayores se consideran un colectivo vulnerable. Los programas de atención en salud dan prioridad a los hábitos alimentarios y a la vigilancia del estado nutricional para mejorar su pronóstico vital. Objetivo. Estimar los casos de muerte por desnutrición de la población mayor de 65 años en Colombia entre el 2014 y el 2016, para contribuir al análisis y la toma de decisiones en salud encaminadas a mejorar la situación nutricional de esta población. Materiales y métodos. Se trata de un estudio descriptivo y retrospectivo en el cual se analizaron los certificados de defunción de los años 2014 a 2016, cuya causa básica de muerte fuesen las deficiencias y anemias nutricionales. Se estimaron las tasas de mortalidad por sexo y departamento de residencia, y las frecuencias de distribución según las variables demográficas. Resultados. Las defunciones por desnutrición en Colombia para el adulto mayor en el periodo de estudio, fueron 3.275 (0,5 % del total de muertes). La tasa de mortalidad varió entre 5,4 y 108,3 por cada 100.000 adultos mayores. La mayor mortalidad se presentó en los mayores de 80 años, especialmente en hombres. Conclusión. La desnutrición proteico-calórica en los adultos mayores es la causa más frecuente de muerte por desnutrición, seguida de las anemias nutricionales. La mayor mortalidad se presentó en el grupo de edad de mayores de 80 años, y en los departamentos de Amazonas, Guainía y Vaupés, los cuales tienen las mayores tasas para todos los grupos de edad.

GLIM Criteria Using Hand Grip Strength Adequately Predict Six-Month Mortality in Cancer Inpatients.

Protein-calorie malnutrition is very frequent in cancer patients and is associated with an increase in morbidity and mortality. Recently, the Global Leadership Initiative on Malnutrition (GLIM) criteria were proposed to standardize the diagnosis of malnutrition. Nevertheless, these criteria were not validated in prospective studies. Our objective is to determine the prevalence of malnutrition in cancer inpatients using different diagnostic classifications, including GLIM criteria, and to establish their association with length of stay and mortality. Hence, we designed a prospective study. Within the first 24 hours of admission to the Inpatient Oncology Unit, subjective global assessment (SGA) was carried out, and anthropometric data (body mass index (BMI), mid-arm circumference (MAC), arm muscle circumference (AMC), fat-free mass index (FFMI)) and hand grip strength (HGS) were obtained to assess the reduction of muscle mass according to GLIM criteria. Length of stay, biomarkers (albumin, prealbumin, C-reactive protein (CRP)), and in-hospital and six-month mortality were evaluated. Regarding the 282 patients evaluated, their mean age was 60.4 ± 12.6 years, 55.7% of them were male, and 92.9% had an advanced-stage tumor (17.7% stage III, 75.2% stage IV). According to SGA, 81.6% of the patients suffered from malnutrition (25.5% moderate malnutrition, and 56.1% severe malnutrition), and, based on GLIM criteria, malnutrition rate was between 72.2 and 80.0% depending on the used tool. Malnourished patients (regardless of the tool used) showed significantly worse values concerning BMI, length of stay, and levels of CRP/albumin, albumin, and prealbumin than normally nourished patients. In logistic regression, adjusted for confounding variables, the odds ratio of death at six months was significantly associated with malnutrition by SGA (odds ratio 2.73, confidence interval (CI) 1.35-5.52, p = 0.002), and by GLIM criteria calculating muscle mass with HGS (odds ratio 2.72, CI 1.37-5.40, p = 0.004) and FFMI (odds ratio 1.87, CI 1.01-3.48, p = 0.047), but not by MAC or AMC. The prevalence of malnutrition in advanced-stage cancer inpatients is very high. SGA and GLIM criteria, especially with HGS, are useful tools to diagnose malnutrition and have a similar predictive value regarding six-month mortality in cancer inpatients.

Protein Energy Malnutrition Is Associated with Worse Outcomes in Sepsis-A Nationwide Analysis.

BACKGROUND: Protein-energy malnutrition (PEM), resulting from depleted energy and nutrient stores, compromises the body's defense systems and may exacerbate sepsis and its impact. However, population-based studies examining the association of PEM on the prevalence and health-care burden of sepsis are lacking. OBJECTIVE: To investigate the relationship between PEM and sepsis, influence of PEM on clinical outcomes of sepsis, and impact of PEM on trends in sepsis mortality. DESIGN: The primary study is a retrospective cohort analysis of the 2012-2014 National Inpatient Sample (NIS) patient discharge records. Secondary analyses are cross-sectional study on the 2014 NIS and trend analysis on 2007-2014 NIS. PARTICIPANTS/SETTING: The primary study included adult inpatient hospitalizations for sepsis in the United States. MAIN OUTCOME MEASURES: Mortality, complicated sepsis, and 10 other metrics of clinical outcomes and health care utilization. STATISTICAL ANALYSIS: First, patients with sepsis (2014 NIS) were stratified into two groups: uncomplicated (without shock) and complicated (with shock). The adjusted odds ratio of having sepsis (total, uncomplicated, and complicated) was estimated with PEM as predictor using logistic regressions (binomial and multinomial). Second, among patients with sepsis (2012-2014 NIS), PEM cases were matched to cases without PEM (no-PEM) using a greedy-algorithm based propensity-matching methodology (1:1), and the outcomes were measured with conditional regression models. Finally, the trend in mortality from sepsis was calculated, stratified by PEM status, as an effect modifier, using Poisson models (2007-2014 NIS). All models accounted for the complex sampling methodology (SAS 9.4). RESULTS: In 2014, PEM was associated with higher odds for sepsis (3.97 [3.89 to 4.05], P<0.0001) and complicated vs uncomplicated sepsis (1.74 [1.67 to 1.81], P<0.0001). From 2012-2014, about 18% (167,133 of 908,552) of hospitalizations for sepsis had coexisting PEM. After propensity matching, PEM was associated with higher mortality (adjusted odds ratio: 1.35 [1.32 to 1.37], P<0.0001), cost ($160,724 [159,517 to 161,940] vs $86,650 [85,931 to 87,375], P<0.0001), length of stay (14.8 [14.9 to 14.8] vs 8.5 [8.5 to 8.6] days, P<0.0001), adverse events, and resource utilization. Although mortality in sepsis has been trending down from 2007-2014 (-1.19% per year, P trend<0.0001), the decrease was less pronounced among those with PEM vs no-PEM (-0.86% per year vs -1.29% per year, P<0.0001). CONCLUSIONS: PEM is a risk factor for sepsis and associated with poorer outcomes among patients with sepsis. A concerted effort involving all health care workers in the prevention, identification, and treatment of PEM in community-dwelling people before hospitalization might mitigate against these devastating outcomes.

Criteria for classification of protein-energy wasting in dialysis patients: impact on prevalence.

Malnutrition is highly prevalent in dialysis patients and associated with poor outcomes. In 2008, protein-energy wasting (PEW) was coined by the International Society of Renal Nutrition and Metabolism (ISRNM), as a single pathological condition in which undernourishment and hypercatabolism converge. In 2014, a new simplified score was described using serum creatinine adjusted for body surface area (sCr/BSA) to replace a reduction of muscle mass over time in the muscle wasting category. We have now compared PEW-ISRNM 2008 and PEW-score 2014 to evaluate the prevalence of PEW and the risk of death in 109 haemodialysis patients. This was a retrospective analysis of cross sectional data with a median prospective follow-up of 20 months. The prevalence of PEW was 41 % for PEW-ISRNM 2008 and 63 % for PEW-score 2014 (P <0·002). Using PEW-score 2014: twenty-nine patients (27 %) had severe malnutrition (PEW-score 2014 0-1) and forty (37 %) with moderate malnutrition (score 2). Additionally, thirty-three (30 %) patients had mild wasting and only seven patients (6 %) presented a normal nutritional status. sCr/BSA correlated with lean total mass (R 0·46. P<0·001). A diagnosis of PEW according to PEW-score 2014, but not according to PEW-ISRNM 2008, was significantly associated with short-term mortality (P=0·0349) in univariate but not in multivariate analysis (P=0·069). In conclusion, the new PEW-score 2014 incorporating sCr/BSA identifies a higher number of dialysis PEW patients than PEW-ISRNM 2008. Whereas PEW-score-2014 provides timelier and therefore more clinically relevant information, its association with early mortality needs to be confirmed in larger studies.

Evaluating haemodialysis patient's nutritional status: Body mass index or body cell mass index?

OBJECTIVE: Evaluate which of two combinations of parameters based on International Society of Renal Nutrition and Metabolism recommendations could better identify patients with protein-energy wasting (PEW) and to compare the relationship of these two combinations with other clinical and body composition parameters. METHODS: This was a multicentre longitudinal study with 24 months of follow-up. The PEW patients were characterized by: Group A (GA ) - normalized protein catabolic rate (nPCR) < 1.0 g/kg per day, albumin <3.8 g/dL and body cell mass index (BCMI) < 6.4 kg/m2 (n = 203); Group B (GB ) - nPCR <1.0 g/kg per day, albumin <3.8 g/dL and body mass index (BMI) <23 kg/m2 (n = 109). All the patients who did not meet these requirements were considered "well-nourished" (GA : n = 1818; GB : n = 3292). RESULTS: When compared to the well-nourished patients, PEW patients in the GA presented higher age, Kt/V, C-reactive protein, relative overhydration, fat tissue index (FTI); lower creatinine, albumin, nPCR, PTH, haemoglobin, phosphorus, calcium X phosphorus product, potassium, dry weight, BMI, BCMI, lean tissue index, %IDWG . In the GB , well-nourished patients FTI was significantly higher. In Cox analysis, the combination with BCMI was a strong independent predictor of mortality in these patients (hazard ratio: 1.48; confidence interval: 1.00-2.19; P = 0.048), even after adjustment. Although GB combination seemed to be also a predictor of death (hazard ratio: 2.67; confidence interval: 1.92-3.71; P < 0.001), when adjusted, the association remained no longer significant. CONCLUSION: A new combination of parameters including protein intake, albumin and BCMI demonstrated significant associations with other nutrition and inflammation parameters as well as with mortality.

Complementary Biomarker Assessment of Components Absorbed from Diet and Creatinine Excretion Rate Reflecting Muscle Mass in Dialysis Patients.

To prevent protein energy malnutrition (PEM) and accumulation of waste products, dialysis patients require diet adjustments. Dietary intake assessed by self-reported intakes often provides biased information and standard 24-h urinary excretion is inapplicable in dialysis patients. We aimed to assess dietary intake via a complementary, less biased biomarker method, and to compare this to dietary diaries. Additionally, we investigated the prospective association of creatinine excretion rate (CER) reflecting muscle mass with mortality. Complete intradialytic dialysate and interdialytic urinary collections were used to calculate 24-h excretion of protein, sodium, potassium, phosphate and creatinine in 42 chronic dialysis patients and compared with protein, sodium, potassium, and phosphate intake assessed by 5-day dietary diaries. Cox regression analyses were employed to investigate associations of CER with mortality. Mean age was 64 ± 13 years and 52% were male. Complementary biomarker assessed (CBA) and dietary assessed (DA) protein intake were significantly correlated (r = 0.610; p < 0.001), but there was a constant bias, as dietary diaries overestimated protein intake in most patients. Correlations were found between CBA and DA sodium intake (r = 0.297; p = 0.056), potassium intake (r = 0.312; p = 0.047) and phosphate uptake/intake (r = 0.409; p = 0.008). However, Bland-Altman analysis showed significant proportional bias. During a median follow-up of 26.6 (25.3⁻31.5) months, nine dialysis patients (23%) died. CER was independently and inversely associated with survival (HR: 0.59 (0.42⁻0.84); p = 0.003). Excretion measurements may be a more reliable assessment of dietary intake in dialysis patients, as this method is relatively free from biases known to exist for self-reported intakes. CER seems to be a promising tool for monitoring PEM.

Is Dietary Protein Intake Predictive of 1-Year Mortality in Dialysis Patients?

BACKGROUND: High mortality in dialysis patients may be associated with protein-energy wasting (PEW) syndrome characterized by progressively depleted protein and energy stores. While early diagnosis and treatment of PEW can reduce mortality, clinically practical measures for its detection are lacking. Poor dietary protein intake (DPI) is associated with risk of malnutrition and PEW. However, the impact of DPI on mortality is unclear. The purpose of this study is to examine the ability of DPI to predict 1-year mortality in dialysis patients. METHODS: This prospective, secondary study using data from the Comprehensive Dialysis Study and United States Renal Data System examined risk factors associated with 1-year mortality in dialysis patients. RESULTS: Seventeen (7.5%) of the 227 subjects died within 1 year following baseline data collection. One year survivors were significantly younger (60 ± 13.6 versus 71 ± 12.8; P = 0.0043), had a lower Charlson Comorbidity Index score (1.6 ± 2.3 versus 4.0 ± 3.6; P = 0.0157), higher serum albumin level (3.5 ± 0.5 versus 3.3 ± 0.4; P = 0.0173) and had higher DPI (63 ± 33.7 versus 49.5 ± 21.5 g/day; P = 0.0386) than those who died. In multivariable Cox proportional hazards model analyses, only the Charlson Comorbidity Index adjusted hazard ratio for death (1.24) was significantly associated with increased mortality. The Comprehensive Dialysis Study data showed no association between DPI and 1-year mortality in dialysis patients. CONCLUSIONS: Future studies using more precise measures should further examine the impact of DPI on mortality given the known association of DPI with PEW syndrome and the definitive link between PEW syndrome and survival in dialysis 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.

Survival and Recovery in Severely Wasted Under-five Children Without Community Management of Acute Malnutrition Programme.

OBJECTIVE: To evaluate recovery and survival of severely wasted children without community management of acute malnutrition programme. DESIGN: Single time point follow-up (24th December 2013 - 2nd April, 2014) of severely wasted children identified in a community-based cross-sectional survey (September 2012 - October 2013). SETTING: Rural Meerut District, Uttar Pradesh, India. PARTICIPANTS: 409 severely wasted (WHO weight-for-height <-3Z), 6- to 59-month-old children. OUTCOME MEASURES: Survival and recovery (weight-for-height ≥-2Z). RESULTS: Median (IQR) follow-up contact duration was 7.4 (6.6, 10.1) months. Among 11 deaths, there were 5 (case-fatality 1.2%), 6 (1.5%), 8 (2.0%) and 10 (2.4%) events within 1, 1.5, 4 and 6 months of enrolment, respectively. Ten deaths occurred in children aged between 6 and 24 months. Younger age (P=0.04), poorer household-head occupation (P=0.04) and lower enrolment anthropometry (any variable; P<0.001) were significant predictors of mortality. Children below 18 months of age had higher adjusted mortality risk (HR 4.7; 95% CI 0.95, 22.51; P=0.053). At follow-up, 30% of survivors were still severely wasted, 39% were moderately wasted (weight-for-height -3 to <-2Z) and 31% had recovered spontaneously. Younger age (P<0.001), female gender (P=0.04) and longer follow-up duration (P=0.003) were significant independent predictors of recovery. The adjusted OR (95% CI) for recovery <24 months was 2.81 (1.70, 4.65). CONCLUSION: Without community management of acute malnutrition in rural Meerut District, severely wasted children had low (1.2%-2.7%) case-fatality with long-term spontaneous recovery of around 25-30%.

OUTCOME AND NUTRITIONAL ASSESSMENT OF CHRONIC LIVER DISEASE PATIENTS USING ANTHROPOMETRY AND SUBJECTIVE GLOBAL ASSESSMENT.

BACKGROUND:: Protein-calorie malnutrition is common in chronic liver disease (CLD) but adequate clinical tools for nutritional assessment are not defined. OBJECTIVE:: In CLD patients, it was aimed: 1. Characterize protein-calorie malnutrition; 2. Compare several clinical, anthropometric and functional tools; 3. Study the association malnutrition/CLD severity and malnutrition/outcome. METHODS:: Observational, prospective study. Consecutive CLD ambulatory/hospitalised patients were recruited from 01-03-2012 to 31-08-2012, studied according with age, gender, etiology, alcohol consumption and CLD severity defined by Child-Turcotte-Pugh. Nutritional assessment used subjective global assessment, anthropometry, namely body-mass index (BMI), triceps skinfold, mid upper arm circumference, mid arm muscular circumference and handgrip strength. Patients were followed during two years and survival data was recorded. RESULTS:: A total of 130 CLD patients (80 men), aged 22-89 years (mean 60 years) were included. Most suffered from alcoholic cirrhosis (45%). Hospitalised patients presented more severe disease ( P <0.001) and worst nutritional status defined by BMI ( P =0.002), mid upper arm circumference ( P <0.001), mid arm muscular circumference ( P <0.001), triceps skinfold ( P =0.07) and subjective global assessment ( P <0.001). A third presented deficient/low handgrip strength. Alcohol consumption ( P =0.03) and malnutrition detected by BMI ( P =0.03), mid upper arm circumference ( P =0.001), triceps skinfold ( P =0.06), mid arm muscular circumference ( P =0.02) and subjective global assessment ( P <0.001) were associated with CLD severity. From 25 patients deceased during follow-up, 17 patients were severely malnourished according with triceps skinfold. Malnutrition defined by triceps skinfold predicted mortality ( P <0.001). CONCLUSION:: Protein-calorie malnutrition is common in CLD patients and alcohol plays an important role. Triceps skinfold is the most efficient anthropometric parameter and is associated with mortality. Nutritional assessment should be considered mandatory in the routine care of CLD patients.

Prognóstico e avaliação nutricional de doentes com doença hepática crônica com recurso à antropometria e avaliação global subjetiva / Outcome and nutritional assessment of chronic liver disease patients using anthropometry and subjective global assessment

ABSTRACT BACKGROUND: Protein-calorie malnutrition is common in chronic liver disease (CLD) but adequate clinical tools for nutritional assessment are not defined. OBJECTIVE: In CLD patients, it was aimed: 1. Characterize protein-calorie malnutrition; 2. Compare several clinical, anthropometric and functional tools; 3. Study the association malnutrition/CLD severity and malnutrition/outcome. METHODS: Observational, prospective study. Consecutive CLD ambulatory/hospitalised patients were recruited from 01-03-2012 to 31-08-2012, studied according with age, gender, etiology, alcohol consumption and CLD severity defined by Child-Turcotte-Pugh. Nutritional assessment used subjective global assessment, anthropometry, namely body-mass index (BMI), triceps skinfold, mid upper arm circumference, mid arm muscular circumference and handgrip strength. Patients were followed during two years and survival data was recorded. RESULTS: A total of 130 CLD patients (80 men), aged 22-89 years (mean 60 years) were included. Most suffered from alcoholic cirrhosis (45%). Hospitalised patients presented more severe disease ( P <0.001) and worst nutritional status defined by BMI ( P =0.002), mid upper arm circumference ( P <0.001), mid arm muscular circumference ( P <0.001), triceps skinfold ( P =0.07) and subjective global assessment ( P <0.001). A third presented deficient/low handgrip strength. Alcohol consumption ( P =0.03) and malnutrition detected by BMI ( P =0.03), mid upper arm circumference ( P =0.001), triceps skinfold ( P =0.06), mid arm muscular circumference ( P =0.02) and subjective global assessment ( P <0.001) were associated with CLD severity. From 25 patients deceased during follow-up, 17 patients were severely malnourished according with triceps skinfold. Malnutrition defined by triceps skinfold predicted mortality ( P <0.001). CONCLUSION: Protein-calorie malnutrition is common in CLD patients and alcohol plays an important role. Triceps skinfold is the most efficient anthropometric parameter and is associated with mortality. Nutritional assessment should be considered mandatory in the routine care of CLD patients.

RESUMO CONTEXTO: A desnutrição calórico-proteica é frequente na doença hepática crônica (DHC), no entanto, ferramentas clínicas adequadas para avaliação nutricional destes doentes não estão definidas. OBJETIVO: Em doentes com DHC, pretendeu-se: 1. Caracterizar a desnutrição calórico-proteica; 2. Comparar diferentes ferramentas clínicas, antropométricas e funcionais de avaliação nutricional; 3. Estudar a associação desnutrição/gravidade da DHC e desnutrição/prognóstico. MÉTODOS: Estudo observacional e prospetivo. Foram recrutados doentes ambulatórios/hospitalizados de 01-03-2012 a 31-08-2012 e estudados tendo em conta a idade, gênero, etiologia, consumo alcoólico e gravidade da DHC definida pelo score Child-Turcotte-Pugh. A avaliação nutricional incluiu a utilização da avaliação global subjetiva, antropometria nomeadamente índice de massa corporal (IMC), perímetro braquial, circunferência muscular do braço, prega cutânea tricipital e dinamometria. Os doentes foram seguidos durante 2 anos e foi registada a respectiva sobrevida. RESULTADOS: Foram incluídos 130 doentes com DHC (80 homens) com idade 22-89 anos (média 60 anos). A maioria apresentava cirrose alcoólica (45%). Os doentes hospitalizados apresentaram doença hepática mais severa ( P <0,001) e pior estado nutricional, definido pelo IMC ( P =0,002), perímetro braquial ( P <0,001), circunferência muscular do braço ( P <0,001), prega cutânea tricipital ( P =0,07) e avaliação global subjetiva ( P <0,001). Um terço apresentava força de preensão manual deficiente/baixa. O consumo alcoólico ( P =0,03) e a desnutrição detetada pelo IMC ( P =0,03), perímetro braquial ( P =0,001), prega cutânea tricipital ( P =0,06), circunferência muscular do braço ( P =0,02) e avaliação global subjetiva ( P <0,001) encontraram-se associados à gravidade da DHC. Dos 25 doentes que faleceram durante o seguimento, 17 apresentavam desnutrição severa definida pela prega cutânea tricipital. A desnutrição definida pela prega cutânea tricipital revelou ser um fator preditivo de mortalidade ( P <0,001). CONCLUSÃO: A desnutrição calórico-proteica é comum na DHC para a qual o álcool desempenha um papel importante. A prega cutânea tricipital é o parâmetro antropométrico mais eficiente e encontra-se associado à mortalidade. A avaliação nutricional deve ser considerada mandatória na abordagem rotineira de doentes com DHC.

Nutritional Status Predicts 10-Year Mortality in Patients with End-Stage Renal Disease on Hemodialysis.

Protein-energy wasting (PEW) is associated with mortality in patients with end-stage renal disease (ESRD) on maintenance hemodialysis. The correct diagnosis of PEW is extremely important in order to predict clinical outcomes. However, it is unclear which parameters should be used to diagnose PEW. Therefore, this retrospective observational study investigated the relationship between mortality and nutritional parameters in ESRD patients on maintenance hemodialysis. A total of 144 patients were enrolled. Nutritional parameters, including body mass index, serum albumin, dietary intake, normalized protein catabolic rate (nPCR), and malnutrition inflammation score (MIS), were measured at baseline. Fifty-three patients died during the study. Survivors had significantly higher nPCR (1.10 ± 0.24 g/kg/day vs. 1.01 ± 0.21 g/kg/day; p = 0.048), energy intake (26.7 ± 5.8 kcal/kg vs. 24.3 ± 4.2 kcal/kg; p = 0.009) and protein intake (0.91 ± 0.21 g/kg vs. 0.82 ± 0.24 g/kg; p = 0.020), and lower MIS (5.2 ± 2.3 vs. 6.1 ± 2.1, p = 0.039). In multivariable analysis, energy intake <25 kcal/kg (HR 1.860, 95% CI 1.018-3.399; p = 0.044) and MIS > 5 (HR 2.146, 95% CI 1.173-3.928; p = 0.013) were independent variables associated with all-cause mortality. These results suggest that higher MIS and lower energy intake are harmful to ESRD patients on maintenance hemodialysis. Optimal energy intake could reduce mortality in these patients.

Comparison of Nutritional Risk Scores for Predicting Mortality in Japanese Chronic Hemodialysis Patients.

OBJECTIVE: Protein energy wasting (PEW) is consistently associated with poor prognosis in hemodialysis (HD) patients. We compared the predictability of PEW as diagnosed by The International Society of Renal Nutrition and Metabolism criteria (PEWISRNM) and geriatric nutritional risk index (GNRI) for all-cause mortality in Japanese HD patients. As cut-off values for body mass index (BMI) for PEW have not been established in PEWISRNM for Asian populations, these were also investigated. DESIGN AND SUBJECTS: The nutritional status from 409 HD patients was evaluated according to ISRNM and GNRI criteria. To compare the predictability of mortality, C-index, net reclassification improvement (NRI) and integrated discrimination improvement were evaluated. RESULTS: During follow-up (median, 52 months; range, 7 months), 70 patients (17.1%) presented PEW according to ISRNM and 131 patients (32.1%) according to GNRI; in addition, 101 patients (24.7%) died. PEWISRNM and GNRI were identified as independent predictors of death. Addition of PEWISRNM and GNRI to a predictive model based on established risk factors improved NRI and integrated discrimination improvement. However, no differences were found between models including PEWISRNM and GNRI. When lowering the criterion level of BMI per 1 kg/m2 sequentially, PEWISRNM at BMI <20 kg/m2 maximized the hazard ratio for mortality. The model including PEWISRNM at BMI <20 kg/m2 improved NRI compared with the model including GNRI. CONCLUSION: PEWISRNM and GNRI represent independent predictors of mortality, with comparable predictability. The diagnostic criterion of BMI in the ISRNM for Japanese population might be better at <20 kg/m2 than at <23 kg/m2.

Diagnosis and prevalence of protein-energy wasting and its association with mortality in Japanese haemodialysis patients.

AIM: The International Society of Renal Nutrition and Metabolism (ISRNM) has proposed the diagnostic criteria for protein-energy wasting (PEW). We studied Japanese haemodialysis (HD) patients to verify the diagnostic method, especially with respect to the body mass index (BMI) criterion, as well as the prevalence of PEW and its association with mortality. METHODS: Japanese patients receiving maintenance HD at three outpatient clinics in Tokyo (n = 210) were enrolled, and prospectively followed-up for 3 years. PEW was diagnosed at baseline, according to the four categories (serum chemistry, body mass, muscle mass and dietary intake) recommended by the ISRNM. For the category of body mass, we select a body mass index (BMI) and set up three thresholds, <18.5, <20.0 and <23.0 kg/m2 , as the diagnostic criterion. The patients who satisfied at least three out of the four categories were diagnosed as PEW. RESULTS: Protein-energy wasting, when the threshold of a BMI among the diagnostic criteria was defined as <18.5 kg/m2 , was recognized as an independent risk factor for mortality. However, PEW was not recognized as a risk factor when the BMI diagnostic criterion was set at <20.0 or <23.0 kg/m2 . Overall, 14.8% of the patients had PEW. The survival rate of PEW patients was significantly lower than that of non-PEW patients (log rank, P < 0.001). CONCLUSIONS: The diagnosis algorithm of PEW proposed by an expert panel of the ISRNM strongly associates with mortality. However, given differences in body size in Japan, we suggest to revise the BMI criterion from <23.0 kg/m2 to <18.5 kg/m2 .

Metabolomic Changes in Serum of Children with Different Clinical Diagnoses of Malnutrition.

BACKGROUND: Mortality in children with severe acute malnutrition (SAM) remains high despite standardized rehabilitation protocols. Two forms of SAM are classically distinguished: kwashiorkor and marasmus. Children with kwashiorkor have nutritional edema and metabolic disturbances, including hypoalbuminemia and hepatic steatosis, whereas marasmus is characterized by severe wasting. The metabolic changes underlying these phenotypes have been poorly characterized, and whether homeostasis is achieved during hospital stay is unclear. OBJECTIVES: We aimed to characterize metabolic differences between children with marasmus and kwashiorkor at hospital admission and after clinical stabilization and to compare them with stunted and nonstunted community controls. METHODS: We studied children aged 9-59 mo from Malawi who were hospitalized with SAM (n = 40; 21 with kwashiorkor and 19 with marasmus) or living in the community (n = 157; 78 stunted and 79 nonstunted). Serum from patients with SAM was obtained at hospital admission and 3 d after nutritional stabilization and from community controls. With the use of targeted metabolomics, 141 metabolites, including amino acids, biogenic amines, acylcarnitines, sphingomyelins, and phosphatidylcholines, were measured. RESULTS: At admission, most metabolites (128 of 141; 91%) were lower in children with kwashiorkor than in those with marasmus, with significant differences in several amino acids and biogenic amines, including those of the kynurenine-tryptophan pathway. Several phosphatidylcholines and some acylcarnitines also differed. Patients with SAM had profiles that were profoundly different from those of stunted and nonstunted controls, even after clinical stabilization. Amino acids and biogenic amines generally improved with nutritional rehabilitation, but most sphingomyelins and phosphatidylcholines did not. CONCLUSIONS: Children with kwashiorkor were metabolically distinct from those with marasmus, and were more prone to severe metabolic disruptions. Children with SAM showed metabolic profiles that were profoundly different from stunted and nonstunted controls, even after clinical stabilization. Therefore, metabolic recovery in children with SAM likely extends beyond discharge, which may explain the poor long-term outcomes in these children. This trial was registered at isrctn.org as ISRCTN13916953.