Applied nutritional investigationComparison of three nutritional screening tools for predicting mortality in maintenance hemodialysis patients
Introduction
Protein–energy wasting (PEW) refers to the multiple nutritional and catabolic alterations in patients with chronic kidney disease (CKD) [1]. Because PEW is highly prevalent and strongly associated with increased risk for morbidity and mortality, as well as for poor quality of life [2], [3], it is important to detect it accurately and easily. There has been a great consensus that the key first step in the evaluation of nutritional status is to identify “at-risk” status by using validated screening tools [4], [5], [6], [7].
Accordingly, many nutritional screening tools have been developed for nutritional risk assessment among patients on maintenance hemodialysis (MHD). The subjective global assessment (SGA) [8] is a valid diagnostic tool for assessing nutritional status [9], [10], [11]. A more comprehensive tool, the malnutrition-inflammation score (MIS), was proposed by Kalantar-Zadeh et al. [12]. The MIS correlates well with morbidity, mortality, and various nutritional variables [12], [13], [14], [15]. However, the MIS requires a subjective assessment, which is time-consuming and cumbersome. As such, the objective screening nutrition dialysis (OSND) was developed as an alternative for the MIS in the assessment of the nutritional risk of patients on hemodialysis [16]. In fact, some simple, fully objective nutritional screening tools also can be used to assess the nutritional risk of patients on MHD [17]. The geriatric nutritional risk index (GNRI) was recommended as one of the simplest risk indexes for nutritional status assessment among patients on MHD [17]. However, the predictive effect of the GNRI on mortality remains in conclusive [18], [19], [20], [21], [22], [23], [24].
Among the screening tools just mentioned, the MIS has been validated as a better nutritional indicator than the SGA in a previous study [12]. Moreover, the predictive validity of the MIS was reported to be superior to the GNRI in a recent study [25]. More importantly, although the OSND has been validated as an effective nutritional screening tool [16], the predictive effects on mortality risk between the OSND and the MIS or the GNRI among patients on MHD have never been fully compared. Therefore, we aimed to compare the effect of the MIS, the OSND, and the GNRI on the predictability risk for all-cause and cardiovascular (CV) mortality in a Chinese MHD cohort. Of note, malnutrition refers to deficiencies, excesses, or imbalances in a person's intake of energy or nutrients [26]. The present study only focuses on undernutrition.
Section snippets
Study design and participants
This was a multicenter, prospective cohort study conducted from January 2014 to December 2015 in eight outpatient dialysis centers (including Nanfang Hospital, Foshan First People's Hospital, Shenzhen Second People's Hospital, Guangzhou Huadu District People's Hospital, Foshan Nanhai District People's Hospital, Guangzhou Red Cross Hospital, Third Affiliated Hospital of Southern Medical University, and First Affiliated Hospital of Jinan University) in the Guangdong province of China.
Eligible
Baseline characteristics of the participants
We included 1025 participants in the final analysis (Supplementary Fig. 1). The baseline characteristics of the study population between patients who died and those who survived at the end of follow-up are shown in Table 1. The patients who died during the follow-up period were older and had a higher prevalence of diabetes, hypertension, and CVDs, along with higher MIS, TC levels, and CRP levels and lower OSND, GNRI, TSF, albumin, and transferrin compared with patients who were still alive at
Discussion
The present study demonstrated that each of the three nutritional screening tools was significantly associated with an increased risk for all-cause, CV, and non-CV mortality in Chinese patients on MHD. Furthermore, the all-cause and CV mortality predictability of the MIS appears similar to the GNRI and greater than the OSND.
Consistently, previous studies found that the MIS [12], [16], [28], [29], [30], [31] and the OSND [16] were associated with all-cause mortality in patients on MHD. However,
Conclusion
In Chinese patients on MHD, all three nutritional screening tools—MIS, OSND, and GNRI—were significantly associated with an increased risk for all-causes and CV mortality. The mortality predictability of the MIS was similar to the GNRI and greater than the OSND. The present findings provided further evidence for the choice of the nutritional screening tool to predict mortality in patients on MHD. If further confirmed, GNRI may be used to identify patients on MHD who are at high risk for
References (40)
- et al.
A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic kidney disease
Kidney Int
(2008) - et al.
GLIM criteria for the diagnosis of malnutrition—a consensus report from the global clinical nutrition community
Clin Nutr
(2019) - et al.
ESPEN guidelines for nutrition screening 2002
Clin Nutr
(2003) - et al.
Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting
Clin Nutr
(2014) - et al.
Multicenter study of the validity and reliability of subjective global assessment in the hemodialysis population
J Ren Nutr
(2007) - et al.
Subjective global assessment of nutritional status is strongly associated with mortality in chronic dialysis patients
Am J Clin Nutr
(2009) - et al.
A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients
Am J Kidney Dis
(2001) - et al.
Performance of subjective global assessment and malnutrition inflammation score for monitoring the nutritional status of older adults on hemodialysis
Clin Nutr
(2018) - et al.
Malnutrition inflammation score cut-off predicting mortality in maintenance hemodialysis patients
Clin Nutr ESPEN
(2017) - et al.
Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients
Clin Nutr
(2019)
Simplified nutritional screening tools for patients on maintenance hemodialysis
Am J Clin Nutr
Comparison of nutritional risk scores for predicting mortality in Japanese chronic hemodialysis patients
J Ren Nutr
Geriatric nutritional risk index: a new index for evaluating at-risk elderly medical patients
Am J Clin Nutr
Geriatric nutritional risk index, muscle function, quality of life and clinical outcome in hemodialysis patients
Clin Nutr
A comparison of 8 nutrition-related tests to predict mortality in hemodialysis patients
J Ren Nutr
Concurrent and predictive validity of composite methods to assess nutritional status in older adults on hemodialysis
J Ren Nutr
Association of malnutrition-inflammation score with quality of life and mortality in hemodialysis patients: a 5-year prospective cohort study
Am J Kidney Dis
What is ideal body weight?
J Nutr Biochem
Simple estimation of ideal body weight from body mass index with the lowest morbidity
Diabetes Res Clin Pract
Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism
Kidney Int
Cited by (15)
Dietary Plant Protein and Mortality Among Patients Receiving Maintenance Hemodialysis: A Cohort Study
2021, American Journal of Kidney DiseasesCitation Excerpt :The study design and some of the results have been described previously elsewhere.6,7
Usual nutritional scores have acceptable sensitivity and specificity for diagnosing malnutrition compared to GLIM criteria in hemodialysis patients
2021, Nutrition ResearchCitation Excerpt :A lower OSND score indicates a more severe malnutrition. OSND has undergone external validation (in a multicenter study from China) as a predictor of all-cause and cardiovascular mortality in MHD patients [26]. The new nutritional risk index (NRI) combines BMI with serum levels of albumin, total cholesterol and creatinine [9].
Impact of polypharmacy on all-cause mortality and hospitalization in incident hemodialysis patients: a cohort study
2021, Clinical and Experimental Nephrology
This study was supported by the National Key Technology Support Program of China (2015 BAI12 B07), the High-level Matching Funds of Nanfang Hospital (2014070), the Science and Technology Planning Project of Guangzhou (2014Y2-00098), and the Key Clinical Research Program of Southern Medical University (LC2019ZD005). The funding sources had no role in the design, analysis, or interpretation of the data or the preparation, approval, or decision to submit the manuscript for publication. X.Q. reports grants from the National Natural Science Foundation of China [81730019] and Outstanding Youths Development Scheme of Nanfang Hospital, Southern Medical University [2017 J009]. F.F.H. reports grants from the Science and Technology Planning Project of Guangzhou, grants from the National Key Research and Development Program, grants from the Projects of the National Natural Science Foundation of China, grants from the National Innovation Team Program, grants from the Special Project on the Integration of Industry, Education, and Research of Guangdong Province, and grants from the Guangzhou Clinical Research Center for Chronic Kidney Disease Program.