Elsevier

Nutrition

Volumes 67–68, November–December 2019, 110532
Nutrition

Applied nutritional investigation
Comparison of three nutritional screening tools for predicting mortality in maintenance hemodialysis patients

https://doi.org/10.1016/j.nut.2019.06.013Get rights and content

Highlights

  • The malnutrition-inflammation score (MIS), the objective score of nutrition on dialysis (OSND), and the geriatric nutritional risk index (GNRI) were correlated with mortality in patients on maintenance hemodialysis.

  • The mortality predictability of the MIS and the GNRI were greater than the OSND.

  • The mortality predictability of the MIS was similar to the GNRI.

  • The GNRI is more practical than the MIS for nutritional screening in patients on maintenance hemodialysis.

Abstract

Objectives

The aim of this study was to compare the effect of different nutritional screening tools on predicting the risk for mortality in patients on maintenance hemodialysis (MHD).

Methods

A cohort of 1025 patients on MHD were enrolled from eight hospitals. The malnutrition-inflammation score (MIS), objective score of nutrition on dialysis (OSND), and geriatric nutritional risk index (GNRI) were measured at baseline. All-cause mortality and cardiovascular (CV) mortality were the major study outcomes.

Results

The median follow-up duration was 28.1 mo. The MIS (per SD increase, hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.18–1.55), the OSND (per SD decrease, HR, 1.24; 95% CI, 1.09–1.42), and the GNRI (per SD decrease, HR, 1.26; 95% CI, 1.10–1.43) were significantly associated with the risk for all-cause mortality. More importantly, the mortality predictability of the MIS appears similar to the GNRI (P = 0.182) and greater than the OSND (MIS versus OSND: P = 0.001; GNRI versus OSND: P = 0.045). Similar results were found for CV mortality.

Conclusions

Each of the three nutritional screening tools was significantly associated with an increased risk for all-cause and CV mortality. The mortality predictability of the MIS was similar to the GNRI and greater than the OSND.

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)

Cited by (15)

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    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].

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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.

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