Prognostic significance of malnutrition scores in elderly patients for the prediction of contrast-induced acute kidney injury

Prognostic nutritional index as a predictive marker for acute kidney injury in adult critical illness population: a systematic review and diagnostic test accuracy meta-analysis

BACKGROUND

The prognostic nutritional index (PNI), integrating nutrition and inflammation markers, has been increasingly recognized as a prognostic predictor in diverse patient cohorts. Recently, its effectiveness as a predictive marker for acute kidney injury (AKI) in various clinical settings has gained attention. This study aims to assess the predictive accuracy of the PNI for AKI in critically ill populations through systematic review and meta-analysis.

METHODS

A systematic review was conducted using the databases MEDLINE, EMBASE, PubMed, and China National Knowledge Infrastructure up to August 2023. The included trials reported the PNI assessment in adult population with critical illness and its predictive capacity for AKI. Data on study characteristics, subgroup covariates, and diagnostic performance of PNI, including sensitivity, specificity, and event rates, were extracted. A diagnostic test accuracy meta-analysis was performed. Subgroup analyses and meta-regression were utilized to investigate the sources of heterogeneity. The GRADE framework evaluated the confidence in the meta-analysis's evidence.

RESULTS

The analysis encompassed 16 studies with 17 separate cohorts, totaling 21,239 patients. The pooled sensitivity and specificity of PNI for AKI prediction were 0.67 (95% CI 0.58-0.74) and 0.74 (95% CI 0.67-0.80), respectively. The pooled positive likelihood ratio was 2.49 (95% CI 1.99-3.11; low certainty), and the negative likelihood ratio was 0.46 (95% CI 0.37-0.56; low certainty). The pooled diagnostic odds ratio was 5.54 (95% CI 3.80-8.07), with an area under curve of summary receiver operating characteristics of 0.76. Subgroup analysis showed that PNI's sensitivity was higher in medical populations than in surgical populations (0.72 vs. 0.55; p < 0.05) and in studies excluding patients with chronic kidney disease (CKD) than in those including them (0.75 vs. 0.56; p < 0.01). Overall, diagnostic performance was superior in the non-chronic kidney disease group.

CONCLUSION

Our study demonstrated that PNI has practical accuracy for predicting the development of AKI in critically ill populations, with superior diagnostic performance observed in medical and non-CKD populations. However, the diagnostic efficacy of the PNI has significant heterogeneity with different cutoff value, indicating the need for further research.

Association between nutritional status scores and the 30-day mortality in patients with acute kidney injury: an analysis of MIMIC-III database

BACKGROUND

Studies have proven that the risk of acute kidney injury (AKI) increased in patients with malnutrition. Prognostic nutritional index (PNI) and geriatric nutritional risk index (GNRI) were general tools to predict the risk of mortality, but the prognostic value of them for in-hospital mortality among patients with AKI have not been validated yet. Herein, this study aims to explore the association between PNI and GNRI and 30-day mortality in patients with AKI.

METHODS

Demographic and clinical data of 863 adult patients with AKI were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database in 2001-2012 in this retrospective cohort study. Univariate and multivariate Cox proportional regression analyses were used to explore the association between PNI and GNRI and 30-day mortality. The evaluation indexes were hazard ratios (HRs) and 95% confidence intervals (CIs). Subgroup analyses of age, Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology (SAPS-II) score were also performed.

RESULTS

Totally, 222 (26.71%) patients died within 30 days. After adjusting for covariates, PNI ≥ 28.5 [HR = 0.71, 95%CI: (0.51-0.98)] and GNRI ≥ 83.25 [HR = 0.63, 95%CI: (0.47-0.86)] were both associated with low risk of 30-day mortality. These relationships were also found in patients who aged ≥ 65 years old. Differently, high PNI level was associated with low risk of 30-day mortality among patients with SOFA score < 6 or SAPS-II score < 43, while high GNRI was associated with low risk of 30-day mortality among those who with SOFA score ≥ 6 or SAPS-II score ≥ 43 (all P < 0.05).

CONCLUSION

PNI and GNRI may be potential predictors of 30-day mortality in patients with AKI. Whether the PNI is more recommended for patients with mild AKI, while GNRI for those with severe AKI is needed further exploration.

Prognostic Nutritional Index Combined with Triglyceride-Glucose Index to Contrast a Nomogram for Predicting Contrast-Induced Kidney Injury in Type 2 Diabetes Mellitus Patients with Acute Coronary Syndrome After Percutaneous Coronary Intervention

Objective

Our objective was to develop and validate a nomogram model aiming at predicting the risk of contrast-induced acute kidney injury (CI-AKI) following percutaneous coronary intervention (PCI) in patients suffering from type 2 diabetes mellitus (T2DM) and also diagnosed with acute coronary syndrome (ACS).

Methods

The study gathered data from 722 T2DM patients with ACS who received PCI treatment at the Affiliated Hospital of Xuzhou Medical University between February 2019 and December 2022, serving as the training set. Considering the validation set, the study included 217 patients who received PCI at the East Affiliated Hospital of Xuzhou Medical University. The patients were classified into CI-AKI and non-CI-AKI groups. The study employed univariate and multivariate logistic analysis for identifying independent risk factors for CI-AKI, followed by developing a predictive nomogram model for CI-AKI risk using R software. The predictive performance and clinical utility of the nomogram were assessed through internal and external validation, utilizing the areas under the receiver operating characteristic curve (AUC-ROC), the Hosmer-Lemeshow test and calibration correction curve, and decision curve analysis (DCA).

Results

The nomogram comprised four variables: age, estimated glomerular filtration rate (eGFR), triglyceride-glucose (TyG) index, and prognostic nutritional index (PNI). The AUC-ROC were 0.785 (95% confidence interval (CI) 0.729-0.841) and 0.802 (95% CI 0.699-0.905) for the training and validation cohorts, respectively, indicating a high discriminative ability of the nomogram. The calibration assessment and decision curve analysis have substantiated the strong concordance and clinical usefulness of the aforementioned.

Conclusion

The nomogram exhibits favorable discrimination and accuracy, enabling it to visually and individually identify pre-procedure high-risk patients, and possesses a predictive capacity regarding CI-AKI incidence after PCI in patients diagnosed with both T2DM and ACS.

Association of Malnutrition with Risk of Acute Kidney Injury: A Systematic Review and Meta-Analysis

Background

Acute kidney injury (AKI) is a complex clinical syndrome of hospitalization that may be affected by undernutrition and metabolic changes. The aim of this meta-analysis was to systematically assess the association between malnutrition and the risk of prevalent AKI.

Materials and Methods

We searched PubMed, Embase, Ovid MEDLINE, Web of Science, and Chinese databases (WANFANG, VIP, and CKI) from database inception until May 1, 2023, for studies evaluating the association of malnutrition with the risk of AKI. Summary odds ratios (ORs) were estimated using a random-effects model.

Results

We identified 17 observational studies, which included 273,315 individuals. Compared with patients with normal nutritional status, those with malnutrition had a 125% increased risk of prevalent AKI (pooled ORs, 2.25; 95% confidence interval, 1.80-2.82). Malnutrition was also significantly associated with prevalent AKI across all subgroups when subgroup analyses were performed on covariates such as region, study design, age, sample size, malnutrition assessment method, patient characteristics, covariate adjustment degree, and risk of bias. Meta-regression models demonstrated no significant differences in AKI risk between patients with malnutrition and without malnutrition.

Conclusions

Our results suggest that malnutrition may be a potential target for AKI prevention. However, well-designed studies with ethnically or geographically diverse populations are needed to evaluate strategies and interventions to prevent or slow the development and progression of AKI in malnourished individuals.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Association of Controlling Nutritional Status Score With Adverse Outcomes in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis sought to examine the association between the controlling nutritional status (CONUT) score and adverse outcomes in patients with coronary artery disease (CAD). PubMed and Embase databases were searched for eligible studies from their inceptions to December 12, 2021 to identify studies investigating the association of the CONUT score with major adverse cardiovascular events (MACEs) and all-cause mortality in CAD patients. Twelve studies (36,198 CAD) patients satisfied the criteria. Comparison of the high with low CONUT score, the pooled multivariate adjusted risk ratios (RR) was 1.78 (95% confidence intervals [CI] 1.36-2.32) for MACEs and 1.45 (95% CI 1.27-1.66) for all-cause mortality, respectively. When compared with patients with normal nutrition, malnourished (defined by the CONUT score ≥2) patients conferred a 52% increased risk of MACEs. Additionally, per point CONUT score increment was associated with 15% and 11% higher risk of MACEs and all-cause mortality, respectively. Higher CONUT score independently predicts the MACEs all-cause mortality in CAD patients. Estimation of nutritional status using the CONUT score could be helpful for improving risk classification of CAD.

Association of prognostic nutritional index with risk of contrast induced nephropathy: A meta-analysis

Background

Although prognostic nutritional index (PNI) has been frequently applied in patients with malignancy or those during postoperative recovery, whether it is also an optimal indicator of the risk of contrast-induced nephropathy (CIN) in patients receiving coronary angiography remains uncertain. This meta-analysis aimed at investigating the clinical association of PNI with the risk of CIN in patients receiving coronary angiography or percutaneous coronary intervention.

Methods

Embase, Medline, Cochrane Library, and Google scholar were searched for studies until January 2023. The relationship between CIN risk and PNI (i.e., low vs. high) (primary outcome) as well as other variables (secondary outcomes) were analyzed using a random-effects model.

Results

Overall, 10 observational studies with 17,590 patients (pooled incidence of CIN: 18%) were eligible for analysis. There was a higher risk of CIN in patients with a low PNI compared to those with a high PNI [odd ratio (OR) = 3.362, 95% confidence interval (CI): 2.054 to 5.505, p < 0.0001, I ² = 89.6%, seven studies, 12,972 patients, certainty of evidence: very low]. Consistently, a lower PNI was noted in patients with CIN compared to those without (Mean difference = -5.1, 95% CI: -6.87 to -3.33, p < 0.00001, I ² = 96%, eight studies, 15,516 patients, certainty of evidence: very low). Other risks of CIN included diabetes and hypertension, while male gender and the use of statins were associated with a lower risk of CIN. Patients with CIN were older, had a higher creatinine level, and received a higher contrast volume compared to those without. On the other hand, pre-procedural albumin, estimated glomerular filtration rate, ejection fraction, hemoglobin, lymphocyte ratio were found to be lower in patients with CIN than in those without.

Conclusion

This meta-analysis highlighted an inverse association of PNI with the risk of CIN, which required further studies for verification.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42023389185].

Association between malnutrition and contrast-associated acute kidney injury in congestive heart failure patients following coronary angiography

BACKGROUND

Previous studies have shown that malnutrition is very common in patients with congestive heart failure (CHF) and is closely related to the occurrence of acute kidney injury. However, the relationship between malnutrition and contrast-associated acute kidney injury (CA-AKI) is unclear.

METHOD AND RESULTS

We obtained data from 842 patients who were diagnosed with CHF following coronary angiography (CAG) or percutaneous coronary angiography (PCI) and had follow-up information from January 2013 to February 2016. The patients were divided into 3 groups according to the Controlling Nutritional Status Score before CAG or PCI procedure (Group 1: Normal; Group 2: Mild Malnutrition; Group 3: Moderate to Severe Malnutrition). The main endpoint was CA-AKI. Univariate and multivariable logistic regression analyses were performed. 556 (60.0%) patients suffered from malnutrition before CAG or PCI. During a median follow-up of 2.1 years, A total of 49 (5.82%) patients developed CA-AKI. Additionally, 5 (1.75%), 26 (6.27%) and 18 (12.77%) events were documented in patients with normal, mild and moderate or severe malnutrition, respectively (p < 0.01). In multivariable-adjusted models, patients with malnutrition showed a significantly higher incidence of CA-AKI than those in the normal group.

CONCLUSION

Malnutrition is an independent risk factor for CA-AKI in CHF patients following CAG.

Prognostic significance of malnutrition risk in elderly patients with acute kidney injury in the intensive care unit

BACKGROUND

Malnutrition is common in critically ill patients, but nutrition status in critically ill patients with acute kidney injury (AKI) has been poorly studied. Our study aimed to investigate the relationship between malnutrition risk and the occurrence and prognosis of AKI in elderly patients in the intensive care unit (ICU).

METHODS

Data were extracted from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 1873 elderly patients were included and compared according to the clinical characteristics of AKI and non-AKI groups, and those of survivors and non-survivors of AKI in this study. Receiver operating characteristic (ROC) curves were used to analyse the predictive value of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for the occurrence and 28-day prognosis of AKI. Multivariate Cox regression analysis was used to evaluate the effect of the mNUTRIC score on the 28-day mortality in AKI patients.

RESULTS

Compared with the non-AKI group, AKI patients had higher mNUTRIC scores, and non-survivors had higher mNUTRIC scores than survivors in AKI population. Moreover, multivariate Cox regression showed that 28-day mortality in AKI patients increased by 9.8% (95% CI, 1.018-1.184) for every point increase in the mNUTRIC score, and the mNUTRIC score had good predictive ability for the occurrence of AKI and 28-day mortality in AKI patients. The mortality of AKI patients with mNUTRIC > 4 was significantly increased.

CONCLUSIONS

The elderly patients are at high risk of malnutrition, which affects the occurrence and prognosis of AKI. Adequate attention should be given to the nutritional status of elderly patients.

TRIAL REGISTRATION

This study was registered at www.chictr.org.cn (registration number Chi CTR-ONC-11001875) on 14 December 2011.

Serum Level of Complement C1q is Associated with Contrast-Associated Acute Kidney Injury in Patients Undergoing Emergency Percutaneous Coronary Intervention

Background

As an inflammatory factor, complement C1q is related to the prevalence and progression of atherosclerosis; however, in patients undergoing emergency percutaneous coronary intervention (PCI), it is unclear whether C1q is related to the prevalence of contrast-associated acute kidney injury (CA-AKI).

Methods

From November 2018 to March 2021, 1182 patients who underwent emergency PCI were continuously recruited. Patients were divided into CA-AKI group (n = 234) and non-CA-AKI group (n = 948). CA-AKI was defined as an increase in serum creatinine from the baseline level (≥25% or ≥0.5 mg/dL) 48–72 hours after contrast exposure. All subjects were tested for serum C1q levels when they were admitted to the hospital.

Results

Among the 1182 patients undergoing emergency PCI, 234 patients (19.80%) developed CA-AKI. The level of preoperative serum complement C1q in the CA-AKI group was significantly higher than that in the non-CA-AKI group. Logistic regression and restricted cubic spline analyses showed that the incidence of CA-AKI was positively associated with the serum C1q level pre-PCI. Univariate and multivariate logistic regression analyses showed that C1q was an independent predictor of whether CA-AKI occurred after emergency PCI. The area under the curve (AUC) of the C1q was 0.703 [95% confidence interval (CI) 0.667–0.739] in patients receiving emergency PCI. CA-AKI model included the following three predictors: C1q, eGFR, and IABP use. The AUC of forecast probability was 0.718 [95% CI 0.682–0.754].

Conclusion

In patients receiving emergency PCI procedure, a high C1q level before PCI is associated with the increased risk of CA-AKI.

Prognostic nutritional index is a predictor of mortality in elderly patients with chronic kidney disease

PURPOSE

Prognostic nutritional index (PNI), a composite indicator of inflammation and nutritional status, has recently been recognized as an independent prognostic marker for chronic kidney disease (CKD). We aimed to investigate PNI and its relationship with mortality in elderly patients with CKD.

METHODS

Three hundred and fifty-nine patients over the age of 80 years with stage 3-4 CKD were enrolled in this retrospective study. PNI was used to assess the nutritional status of the patients. Patients were divided into two different groups as deceased and survived and as low PNI (< 39) and high PNI (≥ 39) according to median value of PNI.

RESULTS

The mean age of the patients was 85.7 ± 3.7 years. One hundred and ninety-five (54.3%) patients died during follow-up. Multivariate analysis revealed that male gender, PNI, proteinuria, and diabetes mellitus (DM) were independent predictors of mortality in elderly patients with CKD. When patients with low PNI were compared to those with high PNI, initiation of dialysis and mortality rate were significantly higher whereas albumin, hemoglobin and lymphocyte count were lower. Pearson correlation analysis showed that PNI was significantly correlated with albumin (r = 1.000, p < 0.001), hemoglobin (r = 0.340, p < 0.001) and eGFR (r = 0.123, p = 0.020). Hemoglobin was an independent predictor of PNI in multivariate analysis.

CONCLUSION

In this study, we observed that PNI was significantly associated with mortality over the age of 80 years in patients with CKD and can be used to monitor nutritional status in this patient population.