Geriatric nutrition risk index is associated with renal progression, cardiovascular events and all-cause mortality in chronic kidney disease

Association of Geriatric Nutritional Risk Index with short-term mortality in patients with severe acute kidney injury: a retrospective cohort study

OBJECTIVES

Geriatric Nutritional Risk Index (GNRI) is a new and simple index recently introduced to assess nutritional status, and its predictive value for clinical outcomes has been demonstrated in patients with chronic kidney disease. However, the association between the GNRI and prognosis has not been evaluated so far in patients with acute kidney injury (AKI), especially in those receiving continuous renal replacement therapy (CRRT).

METHODS

A total of 1096 patients with severe AKI initiating CRRT were identified for inclusion in this retrospective observational study. Patients were divided into three groups according to GNRI tertiles, with tertile 1 as the reference. The outcomes of interest were the 28- and 90-days of all-cause mortality. The associations between GNRI and clinical outcomes were estimated using multivariate Cox proportional hazards model analysis.

RESULTS

The overall mortality rates at 28- and 90-days were 61.6% (675/1096) and 71.5% (784/1096), respectively. After adjusting for multiple confounding factors, GNRI was identified as an independent prognostic factor for 28-days all-cause mortality (HR, 0.582; 95% CI, 0.467-0.727; p < .001 for tertile 3 vs. tertile 1) as well as 90-days all-cause mortality (HR, 0.540; 95% CI, 0.440-0.661; p < .001 for tertile 3 vs. tertile 1). The observed inverse associations were robust across subgroup analysis, and were more pronounced in elderly patients over 65 years of age. Finally, incorporating GNRI in a model with established risk factors might significantly improve its predictive power for the short-term death.

CONCLUSIONS

GNRI is considered to be a useful prognostic factor in patients with severe AKI initiating CRRT, especially in elderly patients.

Geriatric Nutritional Risk Index is associated with adverse outcomes in patients with hypertension: the Fukushima Cohort study

Malnutrition is reportedly associated with adverse clinical outcomes in various populations. However, associations between nutritional status and adverse outcomes in patients with hypertension have not been sufficiently elucidated. We therefore aimed to investigate the impact of nutritional status as evaluated by the Geriatric Nutritional Risk Index (GNRI) on adverse outcomes in patients with hypertension. We conducted a retrospective cohort study of 1588 hypertensive patients enrolled in the Fukushima Cohort Study. Participants were categorized into tertiles (T1-T3) according to GNRI at baseline. The primary endpoint of the present study was a kidney event, defined as a combination of a 50% decline in eGFR from baseline and end-stage kidney disease requiring kidney replacement therapy. Associations between GNRI and kidney events were assessed using Kaplan-Meier curves and multivariate Cox regression analyses. Median age was 64 years, 55% were men, median eGFR was 63.1 mL/min/1.73 m2, and median GNRI was 101.3. The lower GNRI group (T1) showed an increased incidence of kidney events in the Kaplan-Meier curve analysis. Compared to the highest GNRI group (T3), lower GNRI carried a higher risk of kidney events for both T2 (hazard ratio [HR] 1.38, 95% confidence interval [CI] 0.71-2.68) and T1 (HR 3.59, 95%CI 1.96-6.63). Similar relationships were observed for risks of all-cause death and cardiovascular events. Lower GNRI was associated with kidney events, all-cause death, and cardiovascular events in patients with hypertension. Nutritional status as evaluated by GNRI could offer a simple and useful predictor of adverse outcomes in this population.

Geriatric nutrition risk index in the prediction of all-cause and cardiovascular mortality in older adults with hyperlipidemia: NHANES 1999-2018

BACKGROUND

Malnutrition is linked to a higher risk of unfavorable outcomes in various illnesses. The present investigation explored the correlation between inadequate nutritional condition and outcomes in older individuals diagnosed with hyperlipidemia.

METHODS

The geriatric nutritional risk index (GNRI) was used to evaluate the nutritional status. All patients were divided into two groups according to GNRI. A Kaplan-Meier analysis was used to assess the survival rates of different groups at risk of malnutrition. In addition, GNRI was used in COX proportional risk regression models to evaluate its predictive effect on both overall mortality and cardiovascular mortality among patients with hyperlipidemia. Furthermore, the study employed restricted cubic splines (RCS) to examine the nonlinear correlation between GNRI and mortality.

RESULTS

The study included 4,532 elderly individuals diagnosed with hyperlipidemia. During a median follow-up duration of 139 months, a total of 1498 deaths from all causes and 410 deaths from cardiovascular causes occurred. The Kaplan-Meier analysis demonstrated significantly poorer survival among individuals at risk of malnutrition, as indicated by the GNRI. In the malnutrition risk group, the modified COX proportional hazards model revealed that a decrease in GNRI was associated with a higher risk of all-cause mortality (HR=1.686, 95% CI 1.212-2.347) and cardiovascular mortality (HR=3.041, 95% CI 1.797-5.147). Furthermore, the restricted cubic splines revealed a non-linear association between GNRI and both all-cause mortality and cardiovascular mortality (p-value for non-linearity = 0.0039, p-value for non-linearity=0.0386).

CONCLUSIONS

In older patients with hyperlipidemia, lower levels of GNRI are associated with mortality. The GNRI could potentially be used to predict all-cause mortality and cardiovascular mortality.

The association between physical activity and cardiovascular events, tumors and all-cause mortality in patients with maintenance hemodialysis with different nutritional status

The current research focuses on the effects of nutritional supplementation and exercise on dialysis patients, but whether physical activity (PA) can reduce the risk of adverse outcomes for patients with different nutritional status is not clear. The maintenance hemodialysis (MHD) patients were recruited from April 2021 to April 2022. The information of PA was obtained from the international physical activity questionnaire (IPAQ). The outcomes were cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor and all-cause death. We used COX proportional risk model to estimate the association between PA and the outcomes of MHD patients. Patients are classified into two groups based on geriatric nutritional risk index (GNRI) and classified by age, and we used COX proportional risk model to estimate the association of PA and outcomes in subgroups. The isotemporal substitution model (ISM) was used to estimate the effects of replacing light physical activity (LPA) with moderate physical activity (MPA) or vigorous physical activity (VPA) on risk of cardiovascular events, tumors, and all-cause death in different subgroups. The effects of PA on ankle-brachial index (ABI) and body fat content were analyzed in different IPAQ groups. A total of 241 maintenance hemodialysis patients were included, 105 peoples developed cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor and all-cause death (43.6%). The median follow-up time was 12 months. MPA reduced the risk of outcome in MHD patients or high GNRI patients (40% vs 39%).In MHD patients who was under 65 years with high GNRI, MPA reduced cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor and all-cause death by 55%.PA reduced the risk of cardiovascular event by 65%, but did not reduce the risk of tumor or all-cause death. Replacing LPA with VPA did not improve clinical outcomes. It actually increases the risk of heart failure 0.4%. MPA reduced the risk of cardiovascular death, myocardial infarction, stroke, heart failure, atrial fibrillation, tumor, all-cause death in MHD patients under 65 years, while VPA had no health benefit.Trial registration: ChiCTR210050998.

Geriatric Nutritional Risk Index as a Possible Predictor of Decline in Kidney Function in Older People

BACKGROUND

The Geriatric Nutritional Risk Index (GNRI) is associated with morbidity and mortality in older individuals. Our study explored the relationship between GNRI, decline in kidney function, and all-cause mortality in older individuals.

METHODS

This retrospective cohort study analyzed data from participants aged ≥60 years who underwent a general health checkup between 2002 and 2018. The primary exposure was the GNRI, divided into quartiles. The primary and secondary outcomes were a decline in kidney function assessed using the 5-year estimated glomerular filtration rate (eGFR) and all-cause mortality, respectively.

RESULTS

The analysis included a total of 1,599 participants (median age, 63 years; interquartile range [IQR], 61-67; 54% males). The mean±standard deviation of GNRI was 114±7. Compared with the highest GNRI quartile, the lower GNRI quartiles were associated with steeper 5-year slopes in eGFR, with a fully adjusted beta coefficient and 95% confidence intervals (CIs) of -0.50 (-0.86, -0.14), -0.29 (-0.63, 0.05), and -0.19 (-0.53, 0.14) for the first, second, and third GNRI quartiles, respectively. The median follow-up duration was 7.4 years (IQR, 4.6-12.4). During this period, we identified 108 deaths (7.8 per 1,000 person-years). The first GNRI quartile was associated with all-cause mortality compared to the highest GNRI quartile (hazard ratio of 2.20; 95% CI 1.23, 3.95).

CONCLUSION

Nutritional status, as evaluated using the GNRI, was associated with 5-year changes in kidney function and all-cause mortality in older individuals.

Role of composite objective nutritional indexes in patients with chronic kidney disease

Malnutrition persists as one of the most severe symptoms in patients with chronic kidney disease (CKD) globally. It is a critical risk factor for cardiovascular and all-cause mortality in patients with CKD. Readily available objective indicators are used to calculate composite objective nutritional assessment indexes, including the geriatric nutritional risk index, prognostic nutritional index, and controlling nutritional status score. These indexes offer a straightforward and effective method for evaluating nutritional status and predicting clinical outcomes in patients with CKD. This review presents supporting evidence on the significance of composite nutritional indexes.

Comparative analysis of four nutritional scores in predicting adverse outcomes in biopsy-confirmed diabetic kidney Disease

Malnutrition is associated with adverse outcomes in patients with diabetic kidney disease (DKD). However, it is uncertain which nutritional assessment tools are most effective in predicting the adverse outcomes of DKD. This retrospective study was conducted at a single center and included 367 patients diagnosed with DKD based on biopsy results between August 2009 and December 2018. Four nutritional assessment indices, namely the Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Triglycerides (TG) × Total Cholesterol (TC) × Body Weight (BW) Index (TCBI), and Controlling Nutritional Status (CONUT) score, were selected and calculated. We aimed to assess the association between these nutritional scores and adverse outcomes, including progression to end-stage kidney disease (ESKD), cardiovascular diseases events (CVD), and all-cause mortality. Univariate and multivariate Cox regression analyses, Kaplan-Meier analysis, along with Restricted cubic spline analysis were used to examine the relationship between nutritional scores and adverse outcomes. Furthermore, the area under the curve (AUC) was calculated using time-dependent receiver operating characteristics to determine the predictive value of the four nutritional scores alone and some combinations. Lastly, ordered logistic regression analysis was conducted to explore the correlation between the four nutritional scores and different renal histologic changes. The incidence of ESKD, CVD, and all-cause mortality was significantly higher in patients with DKD who had a lower PNI, lower GNRI, and higher CONUT score. Additionally, The TCBI performed the worst in terms of grading and risk assessment. The PNI offer the highest predictive value for adverse outcomes and a stronger correlation with renal histologic changes compared to other nutritional scores. Patients diagnosed with DKD who have a worse nutritional status are more likely to experience higher rates of adverse outcomes. The PNI might offer more valuable predictive values and a stronger correlation with different renal histologic changes compared to other nutritional scores.

Association of malnutrition with all-cause and cardiovascular mortality in patients with mild to severe chronic kidney disease undergoing coronary angiography: a large multicenter longitudinal study

PURPOSE

Evidence on the prognostic impact of malnutrition was focused on patients with advanced kidney disease. The relationships between malnutrition and all-cause and cardiovascular mortality in patients with different severity of chronic kidney disease (CKD) have not been adequately addressed. We aimed to reveal the prevalence of malnutrition and its prognostic value in patients with different severity of CKD undergoing coronary angiography (CAG).

METHODS

This was a multicenter, longitudinal, and retrospective cohort study of 12,652 patients with non-dialysis dependent CKD (defined as estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2) undergoing CAG from five tertiary hospitals between January 2007 and December 2020. The controlling nutritional status (CONUT) score was applied to assess nutritional status. Cox regression models and competing risk Fine and Gray models were used to examine the relationships between malnutrition, all-cause and cardiovascular mortality. Further stratified analysis was performed according to baseline CKD severity (mild, moderate and severe, defined by eGFR < 30, 30-44 and 45-59 ml/min/1.73 m2).

RESULTS

During a median follow-up of 5.5 years (interquartile range: 3.2 to 8.6 years), 3801 patients (30.0%) died, and 2150 (17.0%) definitely died of cardiovascular disease. After controlling for confounders, patients had higher all-cause mortality (mild, moderate, and severe vs. absent: HR 1.27, 95 CI % [1.17-1.39]; HR 1.54, 95 CI % [1.39-1.71]; HR 2.22, 95 CI % [1.78-2.77], respectively; P for trend < 0.001) and cardiovascular mortality (mild, moderate and severe vs. absent: HR 1.35, 95 CI % [1.21-1.52]; HR 1.67, 95 CI % [1.45-1.92]; HR 2.10, 95 CI % [1.55-2.85], respectively; P for trend < 0.001) with the severity of malnutrition. In further stratified analysis, a similar prognostic impact of malnutrition was observed in patients with mild to moderate CKD, while mild malnutrition did not seem to have a consistent effect on severe CKD patients.

CONCLUSION

Malnutrition is common among patients with mild to severe CKD undergoing CAG and is strongly associated with increased risk of all-cause and cardiovascular mortality. Malnutrition seems to have a modestly stronger impact on mortality in patients with mild to moderate CKD. This study was registered at Clinicaltrials.gov as NCT05050877.

Geriatric Nutritional Risk Index as a Prognostic Factor for Renal Progression in Patients with Type 2 Diabetes Mellitus

The aim of this study was to evaluate whether the geriatric nutritional risk index (GNRI) is associated with chronic kidney disease (CKD) progression in patients with type 2 diabetes mellitus (DM). In total, 1100 patients with type 2 DM with a follow-up duration > 1 year were included in this longitudinal study. The risk of CKD progression was assessed according to GNRI quartiles. Patients in the lowest GNRI quartile exhibited a significantly lower estimated glomerular filtration rate (eGFR), compared with those in quartile four. Moreover, these patients had poorer glycemic control and lower hemoglobin levels, body mass index, and albumin levels. Additionally, they exhibited a greater annual decline in eGFR. Multivariate logistic regression analysis showed that old age (>60 years), baseline eGFR, the presence of proteinuria, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and low GNRI were significantly associated with CKD progression. GNRI may serve as a valuable predictive tool for identifying the risk of adverse renal outcomes in patients with type 2 DM. It may potentially serve as a more feasible measure for assessing the nutritional status of these patients, as well as for predicting their clinical outcomes.

Geriatric nutrition risk index in the prediction of all-cause and cardiovascular mortality in elderly hypertensive population: NHANES 1999-2016

Background

Hypertension is a major risk factor for the global burden of disease, and nutrition is associated with an increased risk of mortality from multiple diseases. Few studies have explored the association of nutritional risk with all-cause mortality and cardiovascular mortality in hypertension, and our study aims to fill this knowledge gap.

Method

We included data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2016 on a total of 10,037 elderly patients with hypertension. The nutritional status was evaluated using the Geriatric Nutrition Risk Index (GNRI). Kaplan-Meier survival analysis was performed to analyze the survival rates of different nutritional risk groups. COX proportional risk regression models were used to analyze the predictive effect of GNRI on all-cause mortality and cardiovascular mortality in hypertensive patients. Restricted cubic splines (RCS) were used to explore the nonlinear relationship between GNRI and mortality.

Result

The mean age of the hypertensive patients was 70.7 years. A total of 4255 (42.3%) all-cause mortality and 1207 (17.2%) cardiovascular mortality occurred during a median follow-up period of 106 months. Kaplan-Meier showed a more significant reduction in survival for the moderate to severe malnutrition risk of GNRI. The adjusted COX proportional hazards model showed that the hazard ratios for all-cause mortality and cardiovascular mortality in the moderate to severe malnutrition risk group for GNRI were 2.112 (95% CI, 1.377,3.240) and 2.604 (95% CI, 1.603,4.229), respectively. The RCS showed that increased GNRI was associated with a reduced risk of all-cause mortality and cardiovascular mortality risk reduction.

Conclusion

Malnutrition exposure assessed by GNRI effectively predicts the risk of all-cause mortality and cardiovascular mortality in the elderly with hypertension.

Combined evaluation of Geriatric nutritional risk index and Neutrophil to lymphocyte ratio for predicting all-cause and cardiovascular mortality in hemodialysis patients

OBJECTIVE

Malnutrition, accompanied by an inflammatory profile, is a risk factor for poor prognosis in hemodialysis patients. The purpose of this study was to investigate the predictive value of NLR combined with GNRI for all-cause and cardiovascular mortality in hemodialysis patients.

METHODS

A total of 240 maintenance hemodialysis (MHD) patients in hemodialysis centers were enrolled in this retrospective study. The influencing factors of all-cause death in hemodialysis patients were analyzed by COX regression. The cut-off values of GNRI and NLR for predicting mortality in enrolled MHD patients were 89.01 and 4, respectively. Based on these cut-off values, the patients were divided into four groups: G1: high GNRI (≥ 89.01) + high NLR (≥ 4) group; G2: high GNRI (≥ 89.01) + low NLR (<4) group, G3: low GNRI (< 89.01) + high NLR (≥4) group; G4: low GNRI (< 89.01) + low NLR (<4).

RESULTS

During the follow-up period (average: 58 months), the all-cause mortality was 20.83%(50/240) and the cardiovascular mortality was 12.08%(29/240). Both NLR and GNRI were independent risk factors for the prognosis of MHD patients (P<0.05). Survival analysis showed that patients with low GNRI had a lower survival rate than those with high GNRI, whereas patients with high NLR had a lower survival rate than those with low NLR. Kaplan-Meier curve for all-cause mortality revealed that compared to G1, G2, and G4, G3 had the lowest survival rate, while G2 had the highest survival rate among all groups (P < 0.05). Kaplan-Meier curve for cardiovascular mortality showed that G3 had lower survival than G1, G2, and G4 (P < 0.001).

CONCLUSIONS

Our study demonstrates that bothGNRI and NLR are associated with all-cause mortality and cardiovascular mortality in MHD patients. Combining these two factorsmay contribute to a prognostic evaluation for MHD patients.

Geriatric Nutrition Risk Index as a predictor of cardiovascular and all-cause mortality in older Americans with diabetes

BACKGROUND AND AIMS

Few studies have examined the relationship between malnutrition, as defined by the Geriatric Nutrition Risk Index (GNRI), and all-cause mortality and cardiovascular mortality events, particularly in persons with diabetes. The study aimed at the association between GNRI and all-cause mortality and cardiovascular mortality in older Americans with diabetes.

METHODS

Data from this retrospective study were obtained from the National Health and Nutrition Examination (NHANES) 1999-2016. Using data from The NHANES Public-Use Linked Mortality Files to assess all-cause mortality (ACM) and cardiovascular mortality (CVM). After excluding participants younger than 60 years and without diabetes, and with missing follow-up data, 4400 cases were left in this study. Persons with diabetes were divided by GNRI into 3 groups: GNRI ≥ 98; 92 ≤ GNRI < 98; and GNRI < 92; (No; Low; Moderate/Severe (M/S) group). We used Cox proportional hazard regression model to explore the predictive role of GNRI on ACM and CVM in elderly persons with diabetes. Restricted cubic splines to investigate the existence of a dose-response linear relationship between them.

RESULT

During a median follow-up period of 89 months, a total of 538 (12.23%) cardiovascular deaths occurred and 1890 (42.95%) all-cause deaths occurred. Multifactorial COX regression analysis showed all-cause mortality (hazard ratio [HR]: 2.58, 95% CI: 1.672-3.994, p < 0.001) and cardiovascular mortality (HR: 2.29, 95% CI: 1.063-4.936, p = 0.034) associated with M/S group risk of malnutrition in GNRI compared to no group. A negative association between GNRI and all-cause mortality was observed across gender and ethnicity. However, the same negative association between GNRI and cardiovascular mortality was observed only for males (HR:0.94, 95% CI:0.905-0.974, p < 0.001) and other races (HR:0.92, 95% CI:0.861-0.976, p = 0.007). And there was no significant correlation between low malnutrition and cardiovascular mortality (p = 0.076). Restricted cubic splines showed a nonlinear relationship between GNRI and all-cause mortality and cardiovascular mortality (non-linear p < 0.001, non-linear p = 0.019).

CONCLUSIONS

Lower GNRI levels are associated with mortality in older patients with diabetes. GNRI may be a predictor of all-cause mortality and cardiovascular mortality risk in older patients with diabetes.

Association between geriatric nutritional risk index and pathological phenotypes of IgA nephropathy

Background

IgA nephropathy (IgAN) is an immune disease related to oxidative stress and inflammation. It is the most common type of glomerulonephritis in the world and is the cause of chronic kidney disease and end-stage renal disease (ESRD). The Geriatric Nutritional Risk Index (GNRI) is a practical and uncomplicated method to assess the risk of morbidity and mortality, but its ability to assess IgAN is still unclear. Here, we evaluated the association between the GNRI and clinical and histologic findings of IgAN.

Methods

In a cross-sectional study, we included 348 biopsy-verified IgAN patients. The Oxford classification was used to analyze the pathological characteristics of the included patients. Based on previous studies, the participants were divided into two groups using a cutoff value of 92. Differences in clinicopathological indices between the two groups were compared. The correlation between the GNRI and the indicators was evaluated by using a bivariate correlation analysis. A binary logistic regression analysis was conducted to determine the factors associated with the crescent lesions in IgAN.

Results

In this study, 138 out of 348 patients (39.7%) had low GNRI scores (GNRI < 92). Patients in the low GNRI group tended to have a significantly lower body mass index; lower hemoglobin, serum albumin, serum IgG, and serum C3 levels; and higher 24-h proteinuria. The proportions of females, Oxford M1 and Oxford C1/2 were higher in the low GNRI group. The GNRI was positively correlated with body mass index (r = 0.57, P < 0.001), hemoglobin (r = 0.35, P < 0.001), serum albumin (r = 0.83, P < 0.001), serum IgG (r = 0.32, P < 0.001), and serum C3 (r = 0.26, P < 0.001) and negatively correlated with 24-h proteinuria (r = -0.36, P < 0.001) and the proportion of crescents (r = -0.24, P < 0.001). The GNRI scores and serum IgG levels were considered independent factors influencing the crescent lesions in IgAN.

Conclusions

The GNRI can reflect the severity of clinical and histologic phenotypes in IgAN patients. Lower GNRI and serum IgG levels may suggest an increased risk of crescent lesions and are potential markers for disease monitoring in IgAN.

Association between the geriatric nutritional risk index and the risk of stroke in elderly patients with hypertension: A longitudinal and cohort study

Objective

We aimed to investigate the association between the GNRI and the risk of stroke in elderly patients with hypertension.

Methods

A total of 5312 elderly hypertensive patients free of history of stroke were included. Multivariate Cox models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs) for stroke and its subtypes.

Results

The average time of follow-up was 3.8 years, and the median time was 3.2 years. We identified 640 individuals with stroke, of whom 526 had an ischemic stroke (IS) and 114 had a hemorrhagic stroke (HS). After adjusting for confounding variables, compared with participants in the lowest quartile of the GNRI, those in the third and fourth quartiles were associated with a decreased risk of stroke (adjusted HR 0.72, 95% CI 0.58-0.90, and adjusted HR 0.58, 95% CI 0.46-0.74, respectively, P for trend < 0.001). Similar results were found for IS and HS. Moreover, there were L-shaped associations of GNRI with new-onset HS (P for non-linearity = 0.034). Multiple sensitivity analyses and stratified analyses did not materially change the results.

Conclusions

In summary, we found that a lower GNRI was associated with a higher risk of incident stroke in elderly hypertensive patients. Additional prospective data collection is required to confirm our findings.

Geriatric nutritional risk index is associated with retinopathy in patients with type 2 diabetes

The geriatric nutritional risk index (GNRI) is a nutrition-related risk assessment tool and has been used in various clinical settings. The relationship between body mass index (BMI) and the associated risk of diabetic retinopathy (DR) remains inconclusive. We aimed to evaluate the association between GNRI and DR in patients with type 2 diabetes. We included a total of 1359 patients with type 2 diabetes who followed up in our diabetes clinic and underwent fundus photographic examinations from August 2006 to February 2014. DR was assessed by retinal ophthalmologists using comprehensive ophthalmologic examinations. Patients were divided into tertiles according to their GNRI category. Patients in a lower GNRI tertile tended to have a higher proportion of nonproliferative DR (NPDR) and proliferative DR (PDR) compared with those in the other tertiles. The risk of PDR was higher in patients included in GNRI tertile 1 (Odds ratio (OR) 2.252, 95% Confidence Interval (CI) 1.080–4.823, P = 0.033) and GNRI tertile 2 (OR 2.602, 95% CI 1.323–5.336, P = 0.007) compared with those in GNRI tertile 3. In patients with lower GNRIs, the prevalence of DR was higher than in those with higher GNRIs. When GNRI was compared with BMI using the area under the curve, overall accuracy was high in GNRI. The risk of PDR was high in patients with low GNRI and there is an inverse association between GNRI scores and prevalence of DR. GNRI might be a useful tool to predict DR in patients with type 2 diabetes.

Prognostic values of geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) in elderly patients with Diffuse Large B-Cell Lymphoma

Background: Geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) are associated with prognosis of various malignancies. Although GNRI and PNI indicates prognosis in some clinical settings, the values of GNRI and PNI on the prognosis of geriatric patients with Diffuse Large B‐Cell Lymphoma (DLBCL) is unclear. This retrospective analysis aimed to explore the prognostic values of GNRI and PNI in elderly DLBCL patients.

Methods: A total of 133 geriatric patients with DLBCL were recruited from Affiliated Hospital of Xuzhou Medical University, and clinicopathological variables were analyzed. X-Tile program, restricted cubic spline (RCS) and time-dependent receiver operating characteristic (ROC) analysis were used to determine optimal cut-off points of GNRI, PNI and other continuous variables; univariate and multivariate Cox proportional hazards analyses were used for variables selection; Kaplan‐Meier curve was utilized to analyze the influence of variables on prognosis; log-rank test was performed for difference evaluation between groups.

Results: The optimal cut-off points for GNRI and PNI were 106.26 and 47 by using RCS. Multivariate analysis showed that PNI, age, hemoglobin, liver invasion and central nervous system invasion were independent prognostic factors for elderly patients with DLBCL, and PNI was (P = 0.001, HR = 0.413, 95% CI (0.240-0.710) a stronger predictor. Low PNI could predict worse prognosis independently of elderly patients of DLBCL and could re-stratify patients in GCB group, CD5 positive group BCL-2 positive group, and BCL-6 positive group.

Conclusions: PNI was an independent adverse factor for elderly DLBCL and patients with low PNI in GCB group, CD5 positive group and BCL-6 positive group were with poor survival.

Lower Geriatric Nutritional Risk Index (GNRI) Is Associated with Higher Risk of Fractures in Patients Undergoing Hemodialysis

BACKGROUND

Although malnutrition and bone fracture are both major complications in patients undergoing hemodialysis, their association has not been clarified. The aim of our study was to clarify the association between the geriatric nutritional risk index (GNRI), an indicator of nutritional status, and the incidence of bone fractures in patients undergoing hemodialysis.

METHODS

We included 1342 registered patients undergoing hemodialysis and performed a post hoc analysis. We divided patients into the high GNRI group (≥92), considered to have a low risk of malnutrition, and the low GNRI group (<92), considered to have a high risk of malnutrition. Fracture-free survival in the low and high GNRI groups was evaluated by the Kaplan-Meier method. Cox proportional hazards models were used to identify the risk factors for fractures requiring hospitalization. All results were stratified by sex.

RESULTS

New bone fractures developed in 108 (8.0%) patients in 5 years of follow-up. Bone fractures occurred more frequently in the low GNRI group compared with the high GNRI group (HR: 3.51, 95% CI: 1.91-6.42, p < 0.01 in males; HR: 2.47, 95% CI: 1.52-4.03, p < 0.01 in females). A low GNRI was significantly associated with an increased incidence of bone fractures, even after adjustment for covariates. However, the serum levels of calcium, phosphate, parathyroid hormone, and alkaline phosphatase were not associated with the incidence of bone fractures.

CONCLUSIONS

A low GNRI is an independent risk factor for bone fractures in patients undergoing hemodialysis. Early intervention for the low GNRI group may be important in preventing the occurrence of fractures.

Uremic Toxins and Frailty in Patients with Chronic Kidney Disease: A Molecular Insight

The accumulation of uremic toxins (UTs) is a prototypical manifestation of uremic milieu that follows renal function decline (chronic kidney disease, CKD). Frailty as a potential outcome-relevant indicator is also prevalent in CKD. The intertwined relationship between uremic toxins, including small/large solutes (phosphate, asymmetric dimethylarginine) and protein-bound ones like indoxyl sulfate (IS) and p-cresyl sulfate (pCS), and frailty pathogenesis has been documented recently. Uremic toxins were shown in vitro and in vivo to induce noxious effects on many organ systems and likely influenced frailty development through their effects on multiple preceding events and companions of frailty, such as sarcopenia/muscle wasting, cognitive impairment/cognitive frailty, osteoporosis/osteodystrophy, vascular calcification, and cardiopulmonary deconditioning. These organ-specific effects may be mediated through different molecular mechanisms or signal pathways such as peroxisome proliferator-activated receptor γ coactivator 1-α (PGC-1α), mitogen-activated protein kinase (MAPK) signaling, aryl hydrocarbon receptor (AhR)/nuclear factor-κB (NF-κB), nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), Runt-related transcription factor 2 (RUNX2), bone morphogenic protein 2 (BMP2), osterix, Notch signaling, autophagy effectors, microRNAs, and reactive oxygen species induction. Anecdotal clinical studies also suggest that frailty may further accelerate renal function decline, thereby augmenting the accumulation of UTs in affected individuals. Judging from these threads of evidence, management strategies aiming for uremic toxin reduction may be a promising approach for frailty amelioration in patients with CKD. Uremic toxin lowering strategies may bear the potential of improving patients’ outcomes and restoring their quality of life, through frailty attenuation. Pathogenic molecule-targeted therapeutics potentially disconnect the association between uremic toxins and frailty, additionally serving as an outcome-modifying approach in the future.

Development of muffins as dialysis snacks for patients undergoing hemodialysis: results of chemical composition and sensory analysis

Objective

This study aimed to develop two non-industrial food products as financially accessible options to prevent and treat malnutrition in hemodialysis (HD) patients. These food products were developed and intended for use as dialysis snacks.

Methods

This is a cross-sectional and multi-step study. First, 183 adult HD patients (55 ± 14 years; 50.8% males), replied to a questionnaire with their food preferences regarding taste (salty, sweet, bitter, sour) and consistency (liquid, solid, pasty) for a dialysis snack. Most patients preferred a food product with a solid consistency (90%) and a salty flavor (81.4%). Second, three muffin formulations of fine herbs were developed; one enriched with whey protein concentrate (WPC), a second with textured soy protein (TSP) and a third standard formulation without protein for comparison with the protein-enriched muffins, for which the chemical and nutritional compositions were analyzed. In the third step, 60 patients on HD (61 ± 15 years; 53% males) were enrolled in a sensory analysis by applying a 9-point structured hedonic scale, ranging from “extremely liked” (score 9) to “extremely disliked” (score 1).

Results

When compared with the standard formulation, the formulations enriched with WPC and TSP protein had a significantly higher amount of protein/serving (Standard: 5.9 ± 0.3 g vs WPC: 14.5 ± 0.9 g and TSP 10.8 ± 0.7 g; P < 0.05) but a lower amount of carbohydrate (Standard: 13.1 ± 2.2 g vs WPC: 5.6 ± 0.8 g and TSP 6.0 ± 1.2 g vs; P < 0.05). The mineral content/serving of the protein-enriched muffins was low in phosphorus (50 mg) and sodium (180 mg). The potassium content/serving was moderate for the WPC muffin (225.2 mg) and low for the TSP muffin (107.9 mg). The acceptability index (AI) for the enriched protein muffins was higher than 70% and similar to the standard formulation.

Conclusion

The muffins with fine herbs and enriched with protein were well-accepted by all patients and appropriate to serve as dialysis snacks for HD patients.