Reliability of Mini Nutritional Assessment in Hemodialysis Compared With Subjective Global Assessment

Hemodialysis-Nutritional Flaws in Diagnosis and Prescriptions. Could Amino Acid Losses be the Sharpest "Sword of Damocles"?

This review aims to highlight the strengths and weaknesses emerging from diagnostic evaluations and prescriptions in an intent to prevent progression over time of malnutrition and/or protein-energy wasting (PEW) in hemodialysis (HD) patients. In particular, indications of the most effective pathway to follow in diagnosing a state of malnutrition are provided based on a range of appropriate chemical-clinical, anthropometric and instrumental analyses and monitoring of the nutritional status of HD patients. Finally, based on the findings of recent studies, therapeutic options to be adopted for the purpose of preventing or slowing down malnutrition have been reviewed, with particular focus on protein-calorie intake, the role of oral and/or intravenous supplements and efficacy of some classes of amino acids. A new determining factor that may lead inexorably to PEW in hemodialysis patients is represented by severe amino acid loss during hemodialysis sessions, for which mandatory compensation should be introduced.

The screening score of Mini Nutritional Assessment (MNA) is a useful routine screening tool for malnutrition risk in patients on maintenance dialysis

PURPOSE

Malnutrition is prevalent in patients on dialysis and is associated with morbidity and mortality. Nutritional status can be assessed by a variety of biochemical and physical parameters or nutritional assessment scores. Most of these methods are expensive or cumbersome to use and are not suitable for routine repetitive follow-up in dialysis patients. The Mini Nutritional Assessment (MNA) has a short form screening set (MNA-SF), which would be suitable as a screening tool, but has not been validated yet in dialysis patients. We aimed to assess whether the MNA is an appropriate tool for identifying nutritional problems in dialysis patients.

METHOD

MNA, routine biochemistry, physical parameters, comorbidities were assessed in cross-sectional multicentric cohorts of hemodialysis and peritoneal dialysis patients with a longitudinal follow up of 2 years for mortality.

RESULTS

In this cohort of 216 patients, mortality was 27.3% at a follow up of 750±350 days. The mean MNA-SF score was 9.9±1.8, with 30.1%, 59.3% and 10.6% of patients categorized as having normal nutritional status, at risk for malnutrition and malnourished, respectively. The screening score was associated with mortality (HR 0.86, 95% CI 0.75-0.98 per point). With normal nutrition as reference, adjusted mortality was 2.50 (95% CI 1.16-5.37) and 3.89 (95% CI 1.48-10.13) for patients at risk for malnutrition and with malnutrition, respectively. After recalibrating the MNA full score for the specificity of some of its domains for dialysis patients, the MNA-SF had a good sensitivity and specificity for not being well nourished (0.95 and 0.63 respectively) in the full score, and a high negative predictive value (0.91).

CONCLUSION

The MNA-SF is independently associated with 2 year mortality in dialysis patients. It has a high negative predictive value for excluding being at risk or having malnutrition in the full score. Therefore, it can be advocated as a screening tool for nutritional status in dialysis patients.

Does nutritional status affect Parkinson's Disease features and quality of life?

Objectives

The aim of this study was to determine the relationship between nutritional status and Parkinson's Disease (PD) features in association with depression, anxiety and quality of life in people with PD.

Materials and methods

This study was conducted on 96 patients with idiopathic PD to whom the following scales were applied: Unified Parkinson’s Disease Rating Scale (UPDRS), 39-item PD questionnaire (PDQ-39), Hospital Anxiety and Depression Score (HADS), Mini Nutritional Assessment (MNA). The scales and measurements were applied to patients at their first assessment. Patients with malnutrition or at risk of malnutrition were assessed by the dietitian and nutrition nurse. These patients received nutritional support through personalized diet recommendations and appropriate enteral nutritional products, considering factors such as age, comorbidity, socioeconomic and cultural conditions. At the end of 6 weeks, the scales and measurements applied during the first visit were again applied to the patients.

Results

A significant and inverse correlation was determined between mental (Spearman r:-0.510, p<0.001), activities of daily living (Spearman r:-0.520, p<0.001), motor (Spearman r:-0.480, p<0.001), complications (Spearman r:-0.346, p<0.001) UPDRS subdivisions and total scores (Spearman r:-0.644, p<0.001) and total MNA score. A significant and inverse correlation was found between all PDQ-39 subdomains and total MNA score (p<0.05). The highest inverse correlations were found in mobility (Spearman r:-0.690, p<0.001) and stigma (Spearman r:-0.570, p<0.001). Both depression (Spearman r:-0.631, p<0.001) and anxiety (Spearman r:-0.333, p<0.001) scores were determined to be inversely correlated with total MNA score. At the 6-week control visit, significantly lower scores were found in all subdivisions and in the total UPDRS score, PDQ-39 score and in the patients' anxiety and depression scores (p<0.05). MNA scores were found to be significantly higher in the assessment performed after 6 weeks of support for patients who had abnormal nutritional status at inception (p<0.001).

Conclusion

PD motor and nonmotor functions, disease duration and severity are related to nutritional status. Quality of life was also shown to be affected by changes in the nutritional status. These results show that nutritional status assessment should be a standard approach in the PD treatment and follow-up processes.

Evaluation of malnutrition and its association with biochemical parameters in patients with end stage renal disease undergoing hemodialysis using subjective global assessment

Background:

Malnutrition is a common problem in patients with end stage renal disease (ESRD) undergoing hemodialysis that increases morbidity and mortality rate in them. Subjective global assessment (SGA) is a tool used by health care providers to assess nutritional status in these patients. In addition, biochemical parameters are used to assess the nutritional status in all people.

Objectives:

In this study, we evaluated the nutritional status of patients with ESRD undergoing hemodialysis using SGA and assessed probable association between biochemical parameters and malnutrition in this population.

Patients and Methods:

Using SGA, the nutritional status of 105 patients (60 males and 45 females) of two dialysis centers in Sari, Iran, was evaluated during years 2007-2008. It is a semiquantitative scoring system that has seven variables derived from medical history and physical examination. The biochemical parameters including hemoglobin, albumin, cholesterol, BUN, and creatinine were also measured.

Results:

Among 105 patients, 98 (93.33%) patients consisted of 56 males and 42 females had mild to moderate malnutrition and 3 (2.86%) women had severe malnutrition. In addition, all of the patients without malnutrition were men. We found significant association between patient’s sex and the SGA score (P = 0.03) but no significant association was seen between age and duration of hemodialysis with SGA score. In addition, we did not find significant association between the measured biochemical parameters and malnutrition.

Conclusions:

According to high prevalence of malnutrition in our patients with ESRD undergoing hemodialysis, periodic assessment of nutritional status is necessary in them. Meanwhile we found SGA as the best tool to assess nutritional status in patients with ESRD undergoing hemodialysis, because it can recognize various degrees of malnutrition that may remain undetected by a single laboratory assessment.

Motor, psychiatric and fatigue features associated with nutritional status and its effects on quality of life in Parkinson's disease patients

Objectives

Parkinson’s disease (PD) patients are more likely to develop impaired nutritional status because of the symptoms, medications and complications of the disease. However, little is known about the determinants and consequences of malnutrition in PD. This study aimed to investigate the association of motor, psychiatric and fatigue features with nutritional status as well as the effects of malnutrition on different aspects of quality of life (QoL) in PD patients.

Methods

One hundred and fifty patients with idiopathic PD (IPD) were recruited in this study. A demographic checklist, the Unified Parkinson’s Disease Rating Scale (UPDRS), the Hospital Anxiety and Depression Scale (HADS) and the Fatigue Severity Scale (FSS) were completed through face-to-face interviews and clinical examinations. The health-related QoL (HRQoL) was also evaluated by means of the Parkinson’s Disease Questionnaire (PDQ-39). For evaluation of nutritional status, the Mini Nutritional Assessment (MNA) questionnaire was applied together with anthropometric measurements.

Results

Thirty seven (25.3%) patients were at risk of malnutrition and another 3 (2.1%) were malnourished. The total score of the UPDRS scale (r = −0.613, P<0.001) and PD duration (r = −0.284, P = 0.002) had a significant inverse correlation with the total MNA score. The median score of the Hoehn and Yahr stage was significantly higher in PD patients with abnormal nutritional status [2.5 vs. 2.0; P<0.001]. More severe anxiety [8.8 vs. 5.9; P = 0.002], depression [9.0 vs. 3.6; P<0.001] and fatigue [5.4 vs. 4.2; P<0.001] were observed in PD patients with abnormal nutritional status. Except for stigma, all other domains of the PDQ-39 were significantly correlated with the total score of the MNA.

Conclusion

Our study demonstrates that disease duration, severity of motor and psychiatric symptoms (depression, anxiety) and fatigue are associated with nutritional status in PD. Different aspects of the HRQoL were affected by patients’ nutritional status especially the emotional well-being and mobility domains.

Long-form but not short-form Mini-Nutritional Assessment is appropriate for grading nutritional risk of patients on hemodialysis--a cross-sectional study

BACKGROUND

Routine screening/assessment of protein-energy status is essential for preventing uremic malnutrition in patients on hemodialysis (HD). A simple, low cost, reliable and non-invasive tool is greatly desired.

OBJECTIVE

This study aimed to evaluate the appropriateness of using the long-form (LF) and the short-form (SF) Mini Nutritional Assessment (MNA) for grading the risk of protein-energy malnutrition in patients on HD. DESIGN AND SAMPLING: A cross-sectional study with purposive sampling.

SETTING

A hospital-managed hemodialysis center.

PARTICIPANTS

152 adult ambulatory patients on hemodialysis.

METHODS

The nutritional status of each patient was graded with MNA-LF and MNA-SF, each in two versions--a normalized-original (content-equivalent) version (by adopting population-specific anthropometric cut-off points) and an alternative version that replaced calf circumference for BMI in the scale. The SGA, serum albumin and serum creatinine served as references. Cross-tabulation test was used to evaluate the consistency of the versions.

RESULTS

MNA-SF versions rated fewer HD subjects malnourished or at risk of malnutrition (32.2% and 24.3% for T1 and T2, respectively) compared to MNA-LF versions (40.8% and 36.2%) or the SGA (47.4%). MNA-SF versions (kappa=0.450 and 0.446) also did not perform as well as MNA-LF versions (kappa=0.734 and 0.666) in predicting the risk of malnutrition in HD patients using the SGA as the reference. MNA-SF also did not perform as well as the MNA-LF using serum albumin or serum creatinine as the reference.

CONCLUSIONS

The MNA-LF is appropriate for predicting protein-energy malnutrition in HD patients but MNA-SF may under-rate these patients. Effort should be made to improve the MNA-SF for HD patients since the short-form is more time-efficient and thus, greatly desired in clinical practice.

Bedside nutrition assessment past, present, and future: a review of the Subjective Global Assessment

Bedside nutrition assessment remains an essential skill for the practicing clinician to master as the nutrition status of our patients directly influences clinical outcomes and mortality rates. Dr Charles E. Butterworth Jr's initial report of malnutrition in hospitalized patients, the so-called "skeleton in the closet," riveted the medical community. Two other studies in the 1970s published prevalence rates of hospital malnutrition of 48% in adult medical patients and 50% in adult surgical patients. Even more disturbing, 75% of patients at risk for malnutrition on admission had worsening nutrition parameters during their hospitalization. These findings led to a search to find an integrated bedside nutrition assessment tool to identify malnutrition in hospitalized patients. Initially reported in 1982, The Subjective Global Assessment is an integrated tool that utilizes the clinical judgment of a practitioner to identify patients at risk of or with malnutrition. It is a clinically useful tool that can be applied at the bedside by the average practitioner. It is a simple, safe, and inexpensive tool allowing for widespread use by trained clinicians and remains the gold standard for new bedside assessment tools.

The Mini Nutritional Assessment--its history, today's practice, and future perspectives

In the early 1990s, the Mini Nutritional Assessment (MNA; Nestle Nutrition, Vevey, Switzerland) was developed for nutrition screening in the elderly. Since then, it became the most established and widespread screening tool for older persons and has been translated into many different languages. The MNA shows prognostic relevance with regard to functionality, morbidity, and mortality of the elderly in different settings. This article recalls the development of the MNA with its short form (MNA-SF) and reviews the literature, focusing on the most recent publications. Specific features of the application of the MNA in different settings (community, nursing home, hospital) are considered. Minor shortcomings of the tool, such as the resources and the cooperation necessary for completion of the MNA, are discussed. Future options for the adaptation of this valuable tool are briefly characterized.