Geriatric Nutritional Risk Index as a Screening Tool for Malnutrition in Patients on Chronic Peritoneal Dialysis

Malnutrition: A risk factor for vascular access problems

BACKGROUND

Vascular access problems are leading causes of morbidity, hospitalization, and impaired quality of life in chronic hemodialysis patients. Native arteriovenous fistula is the gold standard of vascular access. Geriatric nutritional risk index (GNRI), has recently been shown to be an easy and objective instrument for assessing nutritional status in these patient groups. Considering the association between arteria-venous fistula patency and inflammation, as well as the fact that inflammation is a component of malnutrition, the objective of this study was to determine the relation of malnutrition identified by GNRI with fistula patency.

METHODS

This is a single-center, retrospective, observational study. Hemodialysis patients with AVF were included in the research. Preoperative and postoperative GNRI values were computed and laboratory data were recorded. The patients were analyzed in two groups as the ones without thrombosis history (Group 1) and with thrombosis history (Group 2). According to GNRI, patients were investigated in four groups: G0 (non-risk group, >98), G1 (low risk, 92-98), G2 (moderate risk, 82-91), and G3 (high risk, 82).

RESULTS

Of the 331 patients, 60.1% (199) were male and the average age was 55 ± 15 years. Preoperative GNRI levels were significantly higher in group 1. In correlation analysis, patency time was positively correlated with preoperative GNRI values. Among the preoperative GNRI groups, the G3 group had a patency duration of 6 months (4.9-7.04), whereas the G0 group had a patency length of 37.59 (35.5-39.65) months. By linear regression analysis, preoperative GNRI and postoperative albumin level were determined to be the significant indicators of patency time.

CONCLUSION

GNRI a new tool for detecting malnutrition was strongly associated with fistula patency in hemodialysis patients. Detection of malnutrition before fistula operation may be helpful for the future follow up of the patients in terms of fistula patency.

Impact of nutrition and inflammation indicators on peritoneal dialysis initiation and management

BACKGROUND

The clinical significance of nutrition and inflammation in dialysis patients is well established. This study aimed to evaluate the association between prognosis and indicators of nutrition and inflammation.

METHODS

A total of 253 consecutive patients who underwent peritoneal dialysis (PD) as primary renal replacement therapy at our institute between 2006 and 2021 were included. We retrospectively reviewed the patient's medical charts and obtained their clinical information. Nine nutritional and two inflammatory indicators were assessed. Patient outcomes were investigated, and predictive factors were explored.

RESULTS

The median age and follow-up period were 65 years and 54 months, respectively. Most nutritional indicators and C-reactive protein (CRP) levels showed a significant correlation with residual renal function. Multivariate analysis revealed that the survival index, nutritional risk index for Japanese hemodialysis patients, and CRP levels were independent indicators of patient survival (P < 0.001, P = 0.034, and P = 0.005, respectively) and cardiovascular disease-free survival (P = 0.009, P = 0.04, and P = 0.017, respectively). Patients with a survival index < 19 and CRP ≥ 0.5 had a high risk of mortality and cardiovascular death (P < 0.0001 and P = 0.0002, respectively).

CONCLUSIONS

Our findings suggest that indicators of nutrition and inflammation play important roles in predicting patient outcomes. Further research is warranted to establish optimal management strategies for patients on PD.

Clinical Significance of Nutritional Status, Inflammation, and Body Composition in Elderly Hemodialysis Patients-A Case-Control Study

Nutritional and inflammatory disorders are factors that increase the risk of adverse clinical outcomes and mortality in elderly hemodialysis (HD) patients. This study aimed to examine nutritional and inflammation status as well as body composition in older adults on HD compared to matched controls. A case-control study was conducted on 168 older participants (84 HD patients (cases) and 84 controls) age- and sex-matched. Demographic, clinical, anthropometric, and laboratory parameters were collected from medical records. The primary outcome was nutritional status assessment using a combination of nutritional and inflammatory markers along with the geriatric nutritional risk index (GNRI). Sarcopenic obesity (SO) was studied by the combined application of anthropometric measures. Body composition and hydration status were assessed by bioelectrical impedance analysis (BIA). Univariate and multivariate regression analyses were performed to identify nutritional and inflammatory independent risk indicators in elderly HD patients and controls. A significantly high prevalence of nutritional risk measured by the GNRI was found in HD patients (32.1%) compared to controls (6.0%) (p < 0.001). Elderly HD patients were overweight and had lower percent arm muscle circumference, phase angle (PA), serum albumin (s-albumin), as well as higher percent extracellular body water (ECW%) and serum C-reactive protein (s-CRP) than controls (all at least, p < 0.01). SO was higher in HD patients (15.50%) than in controls (14.30%). By multi-regression analyses, age < 75 years (OR: 0.119; 95%CI: 0.036 to 0.388), ECW% (OR: 1.162; 95%CI: 1.061 to 1.273), PA (OR: 0.099; 95%CI: 0.036 to 0.271), as well as BMI, s-albumin ≥ 3.8 g/dL, and lower s-CRP were independently related between cases and controls (all at least, p < 0.05). Elderly HD patients had increased nutritional risk, SO, inflammation, overhydration, and metabolic derangements compared to controls. This study highlights the importance of identifying nutritional risk along with inflammation profile and associated body composition disorders in the nutritional care of elderly HD patients. Further studies are needed to prevent nutritional disorders in elderly HD patients.

Inferior Nutritional Status Significantly Differentiates Dialysis Patients with Type 1 and Type 2 Diabetes

Diabetes mellitus is currently the leading cause of end-stage renal disease. Assessing nutritional status is an important component of care in this group. This prospective observational study aimed to assess the nutritional status of type 1 and type 2 diabetes patients on hemodialysis or peritoneal dialysis and its relationship with hospitalizations and all-cause death. Adult patients with end-stage renal disease, treated with dialysis, and suffering from type 1 or type 2 diabetes, being treated with insulin, were included in the study. Exclusion criteria comprised other types of diabetes, the patient's refusal to participate in the study, and severe disorders impacting verbal-logical communication. The nutritional status based on the Nutritional Risk Index, the Geriatric Nutritional Risk Index, fat distribution measures, and the Charlson Comorbidity Index was estimated for 95 Caucasian dialysis patients with type 1 (n = 25) or type 2 (n = 70) diabetes. Patients with type 1 diabetes exhibited significantly inferior nutritional status and increased nutritional risk than those with type 2 diabetes. Lower values of nutritional indices significantly differentiated patients with type 1 from those with type 2 diabetes, with ≥84% sensitivity and specificity. Inferior nutritional status was related to all-cause hospitalizations, whereas higher comorbidity was associated with a greater likelihood of cardiovascular hospitalizations and all-cause death. The significant difference between patients with type 1 and type 2 diabetes being treated with dialysis indicates that these patients should not be considered as a homogeneous group, while also considering the greater age of patients with type 2 diabetes.

Relationship between gut microbiota and nutritional status in patients on peritoneal dialysis

Malnutrition is a common complication in the dialysis population, both hemodialysis and peritoneal dialysis (PD). We report our exploratory study on the characteristics of intestinal microbiota and nutritional status in PD patients. The nutritional status of our PD patients were evaluated, and their feces were collected for 16S rRNA gene V3-V4 regions amplification and high-throughput sequencing. The characteristics and differences of microbiota between the well-nourished (W) and malnourished (M) groups were compared. We studied the genera and the operational taxonomic units (OTUs) within the genus of our patients, initially comparing the malnourished and the well- nourished groups and later on reanalyzing the whole group using these OTUs. At the OTU level, 6 bacteria were significantly correlated with the serum albumin level. The abundances of 2 OTUs (OTU208 Lachnospiraceae_incertae_sedi and OTU4 Bacteroides) were more in W group. Meanwhile, 4 OTUs (OTU225 Akkermansia, OTU87 Megasphaera, OTU31 Peptostreptococcaceae_incertae_sedi and OTU168 Clostridium_sensu_strictu) displayed higher abundance among individuals in M group. Notably, the OTU168 Clostridium_sensu_stricto was the only bacteria that significantly correlated with serum albumin (r = - 0.356, P = 0.05), pre-albumin (r = - 0.399, P = 0.02), and SGA (r = 0.458, P = 0.01). The higher the OTU168 Clostridium_sensu_strictu, the lower serum albumin and pre-albumin and a higher score of SGA signifying a worse nutritional status. Our preliminary findings suggested a relationship between the nutrition status and microbiota in PD patients. Our results provide a basis for further exploration of the interactions between malnutrition and intestinal flora in PD patients with potential interventions using probiotics and prebiotics.

Sex difference in the association among nutrition, muscle mass, and strength in peritoneal dialysis patients

Many peritoneal dialysis (PD) patients are malnourished, which leads to weakening owing to a decrease in muscle mass. However, this straightforward association could differ based on the sex of individuals. Further, studies on the sex-based association among nutrition, muscle mass, and strength would be helpful in choosing optimal interventions to improve the strength of patients on dialysis. The study aimed to assess the association between these three variables using mediation analysis. This retrospective study included prevalent PD patients (n = 199). Mediation analysis was conducted to investigate the effect of the appendicular lean mass (ALM) index on the association between the geriatric nutritional risk index (GNRI) and handgrip strength (HGS). The numbers of PD patients with a low ALM index, low HGS, or low GNRI score were 121 (60.8%), 109 (54.8%), and 70 (35.2%), respectively. The proportion of patients with a low ALM index was lower in females than in males, and those with a low HGS were less in patients without diabetes than that in those with diabetes. Patients ≥ 65 years old had a higher proportion of low ALM index or HGS than those < 65 years old. Low HGS was significantly associated with mortality in both sexes. In males, the HGS was correlated with the GNRI and ALM index; however, in females, partial correlation did not demonstrate an association among the GNRI, ALM index, and HGS. Mediation analysis showed that, in males, the GNRI was associated with HGS, and the association was partially mediated through the ALM index. These data reveal that the ALM index accounts for some, but not all, of the relationship between GNRI and HGS. There is not only a significant relationship between the ALM index and HGS, but also some direct relationship between GNRI and HGS. In females, there was no significant association between the GNRI or ALM index and HGS. These suggest that, for both sexes, nutritional supplementation and exercise should be recommended as the primary intervention for improving strength; however, other interventions for improving muscle quality could be considered as alternatives for maintaining strength in women undergoing PD.

Utility of Geriatric Nutritional Risk Index in Patients with Chronic Kidney Disease: A Mini-Review

Chronic kidney disease (CKD) is one of the most significant risk factors for cardiovasculardisese. Malnutrition has been recognized as a significant risk factor for cardiovascular disease in patients with CKD, including those on chronic dialysis. Current studies showed higher all-cause and cardiovascular mortality rates in patients with CKD and malnutrition. Geriatric nutritional risk index (GNRI), a simple and validated nutritional screening measure for both elderly people and patients on dialysis, is based only on three objective parameters: body weight, height, and serum albumin level. Recently, we demonstrated that the cutoff GNRI for predicting all-cause and cardiovascular mortality was 96 in patients on hemodialysis. Moreover, together with left ventricular hypertrophy and low estimated glomerular filtration rate, the utility of GNRI as a significant determinant of cardiovascular events was demonstrated in non-dialysis-dependent patients with CKD. In the present review, we summarize available evidence regarding the relationship of GNRI with all-cause and cardiovascular mortality in patients with CKD including those on dialysis.

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Association of impedance ratio with corrected Geriatric Nutritional Risk Index in older patients with nondialysis chronic kidney disease stage 5

BACKGROUND

The usual calculation of body mass index (BMI) can be misleading in patients with advanced chronic kidney disease (CKD) because their altered fluid balances may not be reflected. We obtained corrected BMI (cBMI) and corrected Geriatric Nutritional Risk Index (cGNRI) values and investigated whether the impedance ratio (IR) of 200/5 kHz, measured using bioimpedance spectroscopy, was associated with cGNRI in older patients with nondialysis CKD stage 5 (CKD5-ND).

METHODS

Patients over 65 years old (n = 118) were divided into groups by cGNRI tertiles. The differences between the correlations were tested using Steiger's z-test. The IR and cBMI were used as both continuous and categorical variables in the regression analyses to determine the factors that were independently associated with the cGNRI.

RESULTS

Patients in the third cGNRI tertile had a significantly lower mean IR than those in the other 2 tertiles (P < .001). Across the 3 cGNRI tertile groups, the IR was incrementally lower in the higher cGNRI tertiles (P for trend < .001). The Steiger's z-test showed that the IR had a significantly stronger correlation with cGNRI than cBMI had with cGNRI. In the multivariable linear regression analyses, the IR was independently associated with the cGNRI, after adjusting for various confounders.

CONCLUSION

The current results revealed that the IR was a more sensitive indicator of nutrition risk than BMI and was independently associated with cGNRI in older patients with CKD5-ND. Our study suggests that the IR is an appropriate tool for nutrition risk screening.

Association between modified simple protein-energy wasting (PEW) score and all-cause mortality in patients receiving maintenance hemodialysis

Background

Protein-energy wasting (PEW) is a frequently observed complication that leads to increased mortality in hemodialysis patients. However, a multifaceted assessment of PEW by combined objective nutritional parameters has not yet been established.

Methods

In total, 144 Japanese patients receiving maintenance hemodialysis at a hemodialysis center were retrospectively followed for 7 years. The primary outcome was all-cause death. The main exposure was a modified simple PEW score (0, 1, 2, 3, or 4), calculated from four parameters: serum albumin and creatinine levels, normalized protein catabolic rate, and body mass index. These parameters are included in the subcategories of PEW as defined by the International Society of Renal Nutrition and Management. The cutoff values of the modified simple PEW score components were based on the receiver operating characteristics curves determined by univariate logistic regression analyses. Risk estimates for all-cause mortality were calculated by the Cox proportional hazards model adjusted for potential confounding factors.

Results

During the median 5.7-years follow-up period, 37 patients died of any cause. When patients were divided into three subgroups (G1–G3) based on the modified simple PEW score, a multivariable-adjusted analysis showed that the risks of all-cause death in groups G2 and G3 were significantly higher than in the lowest score group (G1), with hazard risk (95% confidence interval) 3.10 (1.16–8.26) (P = 0.024) and 5.68 (1.85–17.45) (P = 0.002), respectively.

Conclusions

The modified simple PEW score is a useful composite indicator of nutritional status that stratifies the risk of all-cause mortality in patients undergoing maintenance hemodialysis.

Vitamin D deficiency is associated with reduced mobility after hip fracture surgery: a prospective study

BACKGROUND

Hip fractures are associated with a high rate of morbidity and mortality, and successful ambulation after surgery is an important outcome in this patient population.

OBJECTIVE

This study aims to determine whether 25-hydroxyvitamin D [25(OH)D] concentration or the Geriatric Nutritional Risk Index (GNRI) is associated with mortality or rates of walking in a patient cohort after hip fracture surgery.

METHODS

Patients undergoing hip fracture repair from a multisite study in North America were included. Mortality and mobility were assessed at 30 and 60 d after surgery. Serum albumin, 25(OH)D, and intact parathyroid hormone were measured. Patients were characterized according to 25(OH)D <12 ng/mL, 12 to <20 ng/mL, 20 to <30 ng/mL, or ≥30 ng/mL. GNRI was categorized into major/moderate nutritional risk (<92), some risk (92 to <98), or in good nutritional status (≥98).

RESULTS

Of the 290 patients [aged 82 ± 7 y, BMI (kg/m2): 25 ± 5], 73% were women. Compared with patients with <12 ng/mL, those with higher 25(OH)D concentrations had higher rates of walking at 30 d (P = 0.031): 12 to <20 ng/mL (adjusted OR: 2.61; 95% CI: 1.13, 5.99); 20 to <30 ng/mL (3.48; 1.53, 7.95); ≥30 ng/mL (2.84; 1.12, 7.20). In addition, there was also greater mobility at 60 d (P = 0.028) in patients with higher 25(OH)D compared with the reference group (<12 ng/mL). Poor nutritional status (GNRI <92) showed an overall trend to reduce mobility (unadjusted P = 0.044 and adjusted P = 0.056) at 30 but not at 60 d. There was no association of vitamin D or GNRI with mortality at either time.

CONCLUSIONS

Vitamin D deficiency (<12 ng/mL) is associated with reduced ambulation after hip fracture surgery, whereas GNRI also contributes to immobility but is a less reliable predictor. Mechanisms that can explain why vitamin D deficiency is associated with mobility should be addressed in future studies.

Association between the Geriatric Nutritional Risk Index, bone mineral density and osteoporosis in type 2 diabetes patients

AIMS/INTRODUCTION

Low bodyweight and hypoalbuminemia are independently associated with osteoporosis. In this study, the relationship among the Geriatric Nutritional Risk Index (GNRI), bone mineral density (BMD) and osteoporosis in type 2 diabetes mellitus patients was explored, and the GNRI predictive value was evaluated.

MATERIALS AND METHODS

We enrolled 225 men and 192 women with type 2 diabetes mellitus. Their general condition, and laboratory and BMD data were collected. Spearman's partial correlation analysis adjusting for age, body mass index and albumin was used for exploring the association among the GNRI, BMD and bone metabolism markers. Statistical analyses, including multivariate regression analysis and receiver operating characteristic curve analysis, were also applied in this study.

RESULTS

On Spearman's partial correlation analysis, GNRI was positively associated with BMD and albumin-corrected calcium (r = 0.145-0.561, P < 0.01). For the multivariate regression analysis, we observed that the GNRI was dramatically related to high total lumbar, total hip, femur neck BMD and osteoporosis (odds ratio 0.857 for men and 0.927 for women, all P < 0.05). The area under the receiver operating characteristic curve of the GNRI (0.876 for men and 0.704 for women, all P < 0.01) was the largest compared with that of albumin and body mass index in osteoporosis prediction.

CONCLUSIONS

In this study, it was shown that the GNRI was positively correlated with BMD, and inversely correlated with osteoporosis in type 2 diabetes mellitus patients. In addition, compared with body mass index, albumin and age, the GNRI was a more powerful indicator for osteoporosis.

Geriatric nutritional risk index is associated with mortality in peritoneal dialysis patients

BACKGROUND

Malnutrition is one of the most common complications among dialysis patients. The Geriatric Nutritional Risk Index (GNRI) is rarely used in dialysis patients, especially peritoneal dialysis (PD).

AIM

To use the GNRI to evaluate the initial nutritional state of PD patients and to examine the association between the GNRI and mortality in chronic PD patients.

METHODS

We retrospectively examined the medical records at our centre to identify all adults (≥18 years) who had undergone PD for over 3 months before recruitment from January 2005 to December 2017. The correlation between the GNRI and mortality was examined by Kaplan-Meier and Cox proportional hazards analyses.

RESULTS

A total of 1804 patients was enrolled in the study. Significant correlations were noted between the initial GNRI and Charlson index, uric acid, blood calcium, potassium, triglycerides, low-density lipoprotein cholesterol, haemoglobin and so on. Multivariate Cox proportional hazards analyses demonstrated that the GNRI was associated with all-cause mortality (hazard ratio = 0.96, P < 0.001, 95% confidence interval: 0.95-0.98) after adjustment. Compared with the lowest GNRI group, all-cause mortality decreased significantly for each level of GNRI after adjusting for various influencing factors, and the mortality risk of the highest GNRI grade decreased by 66%. The Kaplan-Meier analysis survival rate was significantly different among the four groups in terms of all-cause mortality and cardiovascular and cerebrovascular mortality (log-rank test, P < 0.05).

CONCLUSIONS

These results demonstrated that the GNRI is significantly associated with mortality and can be a simple, clinically useful marker for the assessment of nutritional status in PD patients.

Clinical Significance of Phase Angle in Non-Dialysis CKD Stage 5 and Peritoneal Dialysis Patients

Background: Fluid overload and protein-energy wasting (PEW) are common in patients with end-stage renal disease (ESRD) and lead to a poor prognosis. We aimed to evaluate the volume and nutritional status of ESRD patients and to determine the clinical significance of phase angle (PhA). Methods: This study was a cross-sectional comparison of bioimpedance spectroscopy (BIS) findings in patients with non-dialysis chronic kidney disease (CKD) stage 5 (CKD5-ND, N = 80) and age/sex-matched peritoneal dialysis patients (PD, N = 80). PEW was defined as a PhA less than 4.5°. Results: The PhA was found to be positively associated with a geriatric nutritional risk index (GNRI, r = 0.561, p < 0.001), lean tissue index (LTI, r = 0.473, p < 0.001), and albumin (r = 0.565, p < 0.001) while OH/ECW (r = −0.824, p < 0.001) showed an inverse correlation. The CKD5-ND group had more overhydration (p = 0.027). The PD group had significantly higher PhA (p = 0.023), GNRI (p = 0.005), hemoglobin (p < 0.001), and albumin (p = 0.003) than the CKD5-ND group. The cut-off values predicting PEW were found to be 3.55 g/dL for albumin, 94.9 for GNRI, and 12.95 kg/m² for LTI in PD patients. Conclusions: This study demonstrated that PhA could be used as a marker to reflect nutritional status in patients with ESRD. Since BIS can inform both volume and nutritional status, regular monitoring will provide the basis for active correction of fluid overload and nutritional supplementation, which may improve outcomes in patients with ESRD.

Geriatric Nutritional Risk Index as a prognostic factor in patients with esophageal squamous cell carcinoma -retrospective cohort study

PURPOSE

The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced to predict the risk of nutrition-related complications and mortality. Our aim is to examine the association between the GNRI and long-term prognosis in patients with esophageal squamous cell carcinoma (ESCC) who underwent esophagectomy.

METHODS

The present study enrolled consecutive 216 patients with ESCC who underwent esophagectomy. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin, g/l) + (41.7 × present/ideal body weight). The characteristics and long-term prognosis were compared between four groups: the severe risk (GNRI: <82), moderate risk (GNRI: 82 to <92), low risk (GNRI: 92 to <98) and no risk (GNRI: >98) groups. The 5-year overall survival and independent prognostic factors were investigated, respectively.

RESULTS

A decreased GNRI significantly correlated with unfavorable overall survival (p < 0.001). In all patients, a multivariate analysis demonstrated that the severe and moderate risk groups (GNRI: <92) (hazard ratio 0.50; p = 0.002), T factor (≥T2) (hazard ratio 0.52; p = 0.026), and N positive factor (hazard ratio 0.47; p = 0.004) were independent prognostic factors. In the subgroup analysis, which excluded patients with preoperative chemoradiotherapy, the severe and moderate risk groups (GNRI: <92) (hazard ratio 0.48; p = 0.0057), and T factor (≥T2) (hazard ratio; p = 0.021) were independent prognostic factors.

CONCLUSIONS

GNRI is considered to be a useful prognostic factor in patients with ESCC undergoing esophagectomy.

Association between Bone Mineral Density of Femoral Neck and Geriatric Nutritional Risk Index in Rheumatoid Arthritis Patients Treated with Biological Disease-Modifying Anti-Rheumatic Drugs

Treatment of rheumatoid arthritis (RA) with biological disease-modifying anti-rheumatic drugs (bDMARDs) induces rapid remission. However, osteoporosis and its management remains a problem. The Geriatric Nutritional Risk Index (GNRI) evaluates the risk of malnutrition-related complications in elderly patients and has been shown to be a significant predictor of many diseases. We evaluated the correlation between GNRI and RA activity. In addition, risk factors for femoral neck bone loss were evaluated in RA patients treated with bDMARDs. We retrospectively examined the medical records of 146 patients with RA, collecting and recording the patients’ demographic and clinical characteristics. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Inverse correlations were observed between GNRI and disease duration, disease activity score-28 joint count serum C-reactive protein (CRP), simple disease activity index, modified health assessment questionnaire score and CRP. GNRI showed correlation with femoral neck BMD and femoral neck BMD ≤ 70% of young adult men (YAM). Multiple regression analysis showed that female sex, increased age and lower GNRI were risk factors for lower BMD of the femoral neck. Multivariate binomial logistic regression analysis showed that female sex (odd ratio: 3.67) and lower GNRI (odd ratio: 0.87) were risk factors for BMD ≤ 70% of YAM. Because the GNRI is a simple method, it might be a simple predictor for RA activity and BMD status in RA patients. Complementary nutritional therapies might improve RA activity and osteoporosis in RA patients who have undergone treatment with bDMARDs.

Changes in geriatric nutritional risk index and risk of major adverse cardiac and cerebrovascular events in incident peritoneal dialysis patients

Background

Geriatric nutritional risk index (GNRI) is a validated nutritional assessment method, and lower GNRI values are closely associated with adverse clinical outcomes in dialysis patients. This study investigated the impact of changes in GNRI during the first year of dialysis on cardiovascular outcomes in incident peritoneal dialysis (PD) patients.

Methods

We reviewed medical records in 133 incident PD patients to determine GNRI at the start of PD and after 12 months. Patients were categorized into improved (delta GNRI > 0) and worsening/stationary (delta GNRI ≤ 0) groups. The primary outcome was major adverse cardiac and cerebrovascular events (MACCEs).

Results

During a mean follow-up of 51.1 months, the primary outcome was observed in 42 patients (31.6%). The baseline GNRI at PD initiation was not significantly associated with MACCEs (log-rank test, P = 0.40). However, the cumulative event-free rate was significantly lower in the worsening or stationary GNRI group than in the improved group (log-rank test, P = 0.004). Multivariate Cox analysis revealed that a worsening or stationary GNRI was independently associated with higher risk for MACCEs (hazard ratio, 2.47; 95% confidence interval, 1.15–5.29; P = 0.02). In subgroup analysis, patients with worsening or stationary GNRI were at significantly greater risk for MACCEs in both the lower (P = 0.04) and higher (P = 0.01) baseline GNRI groups.

Conclusion

Baseline GNRI was not associated with MACCEs, but patients with deteriorating or stationary nutritional status were at significantly greater risk for MACCEs, suggesting that serial monitoring of nutritional status is important to stratify cardiovascular risk in incident PD patients.

Assessment of physical activity, capacity and nutritional status in elderly peritoneal dialysis patients

Background

This study aimed to evaluate the prevalence of sedentarism, and to assess physical capacity and nutritional status in a cohort of older patients on peritoneal dialysis (PD), with respect to age-matched non-dialysis CKD population, using highly accessible, simple methods, namely the Rapid Assessment of Physical activity (RAPA) test and the 30″ Sit-to-stand (STS) test.

Methods

This cross-sectional multicenter study included 151 renal patients older than 60 years; 71 pts. (44 m, age 72 ± 7 yrs) were on PD and 80 pts. (63 m, age 74 ± 7 yrs) were affected by 3–4 stage CKD.

Results

The prevalence of sedentary/underactive patients was double of that of the active patients as assessed by RAPA test, both in the PD (65.3%) and in the CKD (67.5%) cohort.

The 30"STS test showed a reduced physical performance in both groups: 84.5% of PD patients and 87.5% of CKD patients did not reach the expected number of stands by age and gender. A malnutrition-inflammation score (MIS) ≥ 6 occurred in 37 % of PD patients and in 2.5 % of CKD patients. In PD patients, an independent significant association was observed between 30”STS test and MIS (beta -0.510, p = 0.013), as well as between RAPA and MIS (beta -0.544, p = 003) and phase angle (beta -0.506, p = 0.028).

Conclusions

A high prevalence of low- performance capacity and sedentarism has been detected among elderly patients on PD or with CKD stage 3–4. Apart from age, a condition of malnutrition-inflammation was the major determinant of poor physical activity and capacity in PD patients. Better body composition seems to be positively associated with physical activity in PD and with physical capacity in CKD patients. Routine clinical management should include a close evaluation of nutritional status and evaluation of physical activity and capacity which can be easily assessed by RAPA and 30″STS tests.

Validity of nutrition risk index as a malnutrition screening tool compared with subjective global assessment in end-stage renal disease patients on peritoneal dialysis

We undertook this study to compare subjective global assessment (SGA) and nutrition risk index (NRI) as malnutrition screening tools in peritoneal dialysis (PD) patients. Nutrition status of the patients was categorized into low, moderate and high risk of malnutrition based on both NRI and SGA. The sensitivity, specificity and predictive values of NRI were compared with SGA, an already validated tool of nutrition status assessment in PD patients. Two hundred and eighty-three end-stage renal disease patients (age 50.02 ± 13.76 years; 204 males, 150 diabetic) were included. Based on SGA, 71/283 (25.08%) had normal nutrition, 192/283 (67.84%) mild-moderate and 20/283 (7.07%) severe malnutrition. Based on NRI, 38/283 (13.43%) patients had normal nutritional status, 193/283 (68.20%) mild-moderate and 52/283 (18.37%) severe malnutrition. Twenty-three of 283 (8.1%) were correctly classified as normal by NRI (true negative) and 197/283 (69.6%) as malnourished (true positive), 15/283 (5.3%) as false negative, 48/283 (16.96%) were misclassified as malnourished (false positive). NRI has sensitivity of 92.9% and specificity of 32.39%. Positive predictive value and Negative predictive values (NPVs) of NRI are 80.41% and 60.53%, respectively. Accuracy of the test is 78%. The receiver operating characteristic curve of NRI is 0.63. To conclude, NRI carries high sensitivity but low specificity as compared to SGA. It can be used as screening tool but not as a diagnostic tool for assessment of nutritional status in PD patients because of its low specificity and NPV.

Is the Geriatric Nutritional Risk Index a Significant Predictor of Postoperative Complications in Patients with Esophageal Cancer Undergoing Esophagectomy?

Background: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced for predicting the risk of nutrition-related complications. The GNRI has mainly been reported as a simple and accurate tool to assess the nutritional status and prognosis of elderly patients. So far, there have been no reports of the GNRI in patients with gastrointestinal cancer. Our objective was to examine the association between the GNRI and short-term outcomes, especially postoperative complications, in patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. Materials and Methods: The present study enrolled 122 consecutive patients with esophageal cancer who underwent esophagectomy and gastric tube reconstruction. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin in g/l) + (41.7 × present/ideal body weight). The characteristics and short-term outcomes were compared between two groups: the high (GNRI ≥90) and the low (GNRI <90) GNRI group. The mortality and morbidity rates, especially the rates regarding respiratory complications and anastomotic leakage, were investigated. Results: The mean age of the 122 patients was 63.9 ± 9.1 years (range 43-83). There were no significant differences in either patient or operative characteristics. The low GNRI group had a significantly higher rate of respiratory complications (p = 0.002). A multivariate analysis demonstrated that the GNRI was the only independent significant factor predicting respiratory complications (hazard ratio 3.41, 95% confidence interval 1.19-9.76; p = 0.022). Conclusion: The GNRI is considered to be a clinically useful marker that can be used to assess the nutritional status and predict the development of postoperative respiratory complications in patients with esophageal cancer undergoing esophagectomy and gastric tube reconstruction.

Correlation between nutritional markers and appetite self-assessments in hemodialysis patients

OBJECTIVE

Protein-energy malnutrition is among the comorbidities that most strongly affect the prognosis of patients with chronic kidney disease. Anorexia, defined as a loss of desire to eat, is one cause of such malnutrition. Tools that evaluate appetite and the correlation between appetite and nutritional parameters require further study. To evaluate the appetite status in patients from 2 hemodialysis clinics in Fortaleza, Brazil and the correlations between appetite (evaluated in the past week and in the past 4 weeks) and demographic, laboratory, and nutritional parameters.

METHODS

This was a cross-sectional study of patients aged ≥18 years who had undergone dialysis for >3 months. Appetite was evaluated using the first 3 questions of the Appetite and Diet Assessment Tool (ADAT) questionnaire, which evaluate the appetite status during the past week as well as 1 question from the Kidney Disease and Quality of Life™ Short Form that assesses appetite in the past 4 weeks. The patients were divided into 3 groups according to the degree of appetite: group 1: very good and good appetite (ADAT) or not and somewhat (Kidney Disease and Quality of Life™ Short Form); group 2: fair or moderately; and group 3: poor and very poor, or very much and extremely. The nutritional parameters evaluated were body mass index (BMI), serum albumin, Geriatric Nutritional Risk Index (GNRI) and lean body mass index (lean mass in kilogram per square meter) as obtained by multifrequency bioelectrical impedance analysis. Patients with a BMI <23 kg/m(2), albumin <4 g/dL, GNRI <98, and lean body mass index below the lowest quartile were considered malnourished. The associations between appetite and nutritional variables were tested using Fisher exact test and by comparing the means of the variables in the 3 groups using the analysis of variance and Kruskal-Wallis tests.

RESULTS

A total of 136 patients were included in the study with a mean age of 50.9 years and a median time on dialysis of 45 months; 57% of the patients were male. Regarding the first question on the ADAT questionnaire, 36% of patients exhibited anorexia in the past week. Furthermore, 28.7% of the population reported a lack of appetite in the last month. Moreover, 34.3% of the patients were considered malnourished according to BMI, 34.1% according to albumin, and 31.6% according to GNRI. Among the studied variables, the mean values of the following variables were different between groups 1, 2, and 3: hemoglobin (P = .0186), creatinine (P = .0392), albumin (P = .0065), GNRI (P = .0274), and lean BMI (P = .0274).

CONCLUSIONS

The prevalence of a lack of appetite in hemodialysis patients in both the past week and the past month was high in the present study. The questionnaire evaluating appetite in the last 4 weeks could be used as a malnutrition screening tool in hemodialysis patients as suggested by the correlation of decreased appetite in the last month with variables that assess nutritional status such as albumin, lean body mass index, and GNRI.

Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients

BACKGROUND AND OBJECTIVES

This study aimed to compare the longitudinal performance of the malnutrition-inflammation score (MIS) and the geriatric nutritional risk index (GNRI), two nutritional scores for patients on maintenance hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Nutritional scores, dietary intake, biochemical markers, and body composition analysis were performed at baseline and at 6, 12, and 18 months after enrollment (which took place from January through December 2006) on 75 prevalent hemodialysis patients (43% women, mean age 64.8 ± 11.9 years). The patients underwent simultaneous MIS and GNRI assessments calculated by two independent examiners from baseline. The study period was 46.8 ± 16.4 months.

RESULTS

GNRI had higher interobserver agreement (weighted κ-score 0.98) than MIS (weighted κ-score 0.62). Longitudinally, a 1-unit increase in MIS was associated with a 0.41 kcal/kg per day reduction in daily energy intake (P<0.001) and with a 0.014 g/kg per day reduction in nPNA (P=0.02). GNRI did not correlate with the change over time of dietary intake. Longitudinal changes of both scores were associated with appropriate changes over time in levels of nutritional biomarkers, inflammation (IL-6), and body composition parameters. Both scores expressed significant associations with prospective hospitalization, whereas only MIS was associated with mortality in this cohort. The multivariate Cox proportional hazard ratio was 1.15 for death for each 1-unit increase in the MIS (95% confidence interval, 1.03-1.3; P=0.02).

CONCLUSIONS

Both MIS and GNRI are valid tools for longitudinal assessment of hemodialysis patients' nutritional status. MIS has lower interobserver reproducibility than GNRI; however, MIS is more comprehensive than GNRI.

Geriatric Nutritional Risk Index as a prognostic factor in peritoneal dialysis patients

BACKGROUND

The Geriatric Nutritional Risk Index (GNRI) might be a useful screening tool for malnutrition in dialysis patients. However, data concerning the GNRI as a prognostic factor in peritoneal dialysis (PD) patients are scarce.

METHODS

We reviewed the medical records at Yeungnam University Hospital in Korea to identify all adults (>18 years) who received PD; 486 patients were enrolled in the study.

RESULTS

The initial low, middle, and high GNRI tertiles included 162, 166, and 158 patients respectively. Significant correlations were noted between the initial GNRI and body mass index, creatinine, albumin, arm circumference, fat mass index, and comorbidities. The cut-off value for the time-averaged GNRI over 1 year was 96.4, and the sensitivity and specificity for a diagnosis of a decline in lean mass were 77.1% and 40.0% respectively. A multivariate analysis adjusted for age, risk according to the Davies comorbidity index, and C-reactive protein showed that an low initial GNRI tertile was associated with mortality in PD patients.

CONCLUSIONS

The GNRI is a simple method for predicting nutrition status and clinical outcome in PD patients.