Impact of prognostic nutritional index on outcomes in patients with Mycobacterium avium complex pulmonary disease

Protein-energy restriction-induced lipid metabolism disruption causes stable-to-progressive disease shift in Mycobacterium avium-infected female mice

BACKGROUND

Disease susceptibility and progression of Mycobacterium avium complex pulmonary disease (MAC-PD) is associated with multiple factors, including low body mass index (BMI). However, the specific impact of low BMI on MAC-PD progression remains poorly understood. This study aims to examine the progression of MAC-PD in the context of low BMI, utilising a disease-resistant mouse model.

METHODS

We employed a MAC infection-resistant female A/J mouse model to compare the progression of MAC-PD under two dietary conditions: one group was fed a standard protein diet, representing protein-energy unrestricted conditions, and the other was fed a low protein diet (LPD), representing protein-energy restriction.

FINDINGS

Our results reveal that protein-energy restriction significantly exacerbates MAC-PD progression by disrupting lipid metabolism. Mice fed an LPD showed elevated fatty acid levels and related gene expressions in lung tissues, similar to findings of increased fatty acids in the serum of patients who exhibited the MAC-PD progression. These mice also exhibited increased CD36 expression and lipid accumulation in macrophages upon MAC infection. In vitro experiments emphasised the crucial role of CD36-mediated palmitic acid uptake in bacterial proliferation. Importantly, in vivo studies demonstrated that administering anti-CD36 antibody to LPD-fed A/J mice reduced macrophage lipid accumulation and impeded bacterial growth, resulting in remarkable slowing disease progression.

INTERPRETATION

Our findings indicate that the metabolic status of host immune cells critically influences MAC-PD progression. This study highlights the potential of adequate nutrient intake in preventing MAC-PD progression, suggesting that targeting CD36-mediated pathways might be a host-directed therapeutic strategy to managing MAC infection.

FUNDING

This research was funded by the National Research Foundation of Korea, the Korea Research Institute of Bioscience and Biotechnology, and the Korea National Institute of Health.

Treatable traits and challenges in the clinical management of non-tuberculous mycobacteria lung disease in people with cystic fibrosis

INTRODUCTION

Over the last ten years an increasing prevalence and incidence of non-tuberculous mycobacteria (NTM) has been reported among patients with cystic fibrosis (CF) Viviani (J Cyst Fibros, 15(5):619-623, 2016). NTM pulmonary disease has been associated with negative clinical outcomes and often requires pharmacological treatment. Although specific guidelines help clinicians in the process of diagnosis and clinical management, the focus on the multidimensional assessment of concomitant problems is still scarce.

MAIN BODY

This review aims to identify the treatable traits of NTM pulmonary disease in people with CF and discuss the importance of a multidisciplinary approach in order to detect and manage all the clinical and behavioral aspects of the disease. The multidisciplinary complexity of NTM pulmonary disease in CF requires careful management of respiratory and extra-respiratory, including control of comorbidities, drug interactions and behavioral factors as adherence to therapies.

CONCLUSIONS

The treatable trait strategy can help to optimize clinical management through systematic assessment of all the aspects of the disease, providing a holistic treatment for such a multi-systemic and complex condition.

A Systematic Review of Factors Associated with Mortality among Patients with Mycobacterium avium Complex Lung Disease

PURPOSE

As the number of patients with Mycobacterium avium complex lung disease is significantly increasing worldwide, several studies have focused on the prognostic factors associated with the disease. This systematic review investigated the factors associated with mortality among patients with Mycobacterium avium complex lung disease.

METHODS

Two investigators independently identified studies that were designed to determine risk factors for mortality in patients with Mycobacterium avium complex lung disease from PubMed, the Cochrane Register of Control Trial database, and EMBASE (accessed on 25 November 2022).

RESULTS

Of the 1133 titles and abstracts screened, 54 full texts were selected for review, and 15 studies were finally included in this systematic review. The most commonly studied risk factors were advanced age and low body mass index (11 studies for each), followed by male sex (8 studies), hypoalbuminemia (5 studies), and cavity (5 studies). In each study, these factors were mostly associated with increased all-cause mortality among patients with Mycobacterium avium complex lung disease as confirmed via multivariate analysis.

CONCLUSIONS

Advanced age, male sex, low body mass index, hypoalbuminemia, and cavity are likely to be the common risk factors for all-cause mortality among patients with Mycobacterium avium complex lung disease, suggesting that patients with these factors need to be carefully monitored.

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.

Clinical impact of postoperative malnutrition after pancreaticoduodenectomy: prediction based on estimated functional remnant pancreatic volume, prognostic nutritional index, and body mass index

BACKGROUND

The present study aimed to evaluate the association between estimated functional remnant pancreatic volume (eFRPV) and postoperative malnutrition after pancreaticoduodenectomy (PD).

METHODS

The medical records of 131 patients who underwent PD and preoperative computed tomography were retrospectively reviewed. Onodera's prognostic nutritional index (PNI) was assessed 6-months after PD. Patients with PNI values of at least 45 were included in the non-malnutrition group, while those with values <45 and <40 were included in the mild and severe malnutrition groups, respectively. Associations between eFRPV and postoperative nutritional status were evaluated to identify factors predictive of severe malnutrition after PD.

RESULTS

Fifty-three patients (40%) were included in the non-malnutrition group, while 38 (29%) and 40 (31%) were included in the mild and severe malnutrition groups, respectively. Overall survival was significantly shorter in the severe malnutrition group (p < 0.001). The eFRPV was significantly lower in the severe malnutrition group (p = 0.003; Jonckheere-Terpstra trend test, p < 0.001). In the multivariate analysis, eFRPV ≤55.2 mL·HU (odds ratio [OR] = 5.20; p = 0.004), preoperative PNI ≤41.9 (OR = 6.37; p = 0.010), and body mass index ≤19.1 kg/m2 (OR = 3.43; p = 0.031) were independent predictors of severe malnutrition after PD.

CONCLUSION

The current results indicate that eFRPV may predict low PNI values after PD.

Myosteatosis as a prognostic factor of Mycobacterium avium complex pulmonary disease

Quantitative body composition affects the prognosis of patients with Mycobacterium avium complex pulmonary disease (MAC-PD). However, whether the qualitative body composition obtained indirectly through computed tomography (CT) affects their prognosis is debatable. We retrospectively analyzed patients with MAC-PD who underwent non-contrast CT at MAC-PD diagnosis. The cross-sectional area of the erector spinae muscle (ESM area), the Hounsfield unit of the erector spinae muscle (ESM HU), and the cross-sectional area of subcutaneous fat (SQF area) were measured at the level of the first lumbar vertebra. Myosteatosis were defined below the median value of ESM HU for each sex. Of 377 patients, 45 (11.9%) died during the follow-up. Patients who died were older and had a lower ratio of females (33.3%). In body compositions, SQF area and ESM HU were lower in the patients who died. In multivariable analysis, a low ESM HU was associated with increased mortality (ESM HU adjusted hazard ratio [aHR] 0.95, 95% confidence interval [CI] 0.93-0.97) through body composition. SQF area revealed protective effects in MAC-PD patients with body mass index ≥ 18.5 kg/m2 (aHR 0.98, 95% CI 0.95-1.00). In conclusion, the decrease in ESM HU, which indirectly reflects myosteatosis, is associated with mortality in patients with MAC-PD.

The factors associated with mortality and progressive disease of nontuberculous mycobacterial lung disease: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to comprehensively evaluate the factors associated with mortality and progressive disease in NTM-LD patients. We conducted a literature search to identify the eligible studies, dated between January 1, 2007, and April 12, 2021. Forty-one studies with total 10,452 patients were included. The overall all-cause mortality rate was 20% (95% CI 17-24%). The overall rates of clinical and radiographic progressive disease were 46% (95% CI 39-53%) and 43% (95% CI 31-55%), respectively. Older age, male sex, history of TB, diabetes, chronic heart disease, malignancy, systemic immunosuppression, chronic liver disease, presence of cavity, consolidative radiologic features, acid-fast bacillus (AFB) smear positivity, hypoalbuminemia, anemia, increasing platelet count, high CRP, and high ESR were significantly associated with increased all-cause mortality, whereas increasing body mass index (BMI), hemoptysis, and treatment with rifamycin regimen (in M. xenopi) were significantly associated with decreased all-cause mortality in multivariable analysis. History of TB, Aspergillus co-infection, cough, increased sputum, weight loss, presence of cavity, and AFB smear positivity were significantly associated with increased clinical progression with treatment, while older age and low BMI were significantly associated with decreased clinical progression in multivariable analysis. Older age, interstitial lung disease, presence of cavity, consolidative radiologic feature, anemia, high CRP, and leukocytosis were significantly associated with increased radiographic progression after adjusting for covariates. Older age, history of tuberculosis, presence of cavity, consolidative radiologic features, AFB smear positivity, anemia, and high C-reactive protein were common significant factors associated with the all-cause mortality and clinical or radiographic progressive disease of NTM-LD. These factors are thought to directly affect NTM-LD related mortality. The future prediction models for the prognosis of NTM-LD should be established considering these factors.

Can prognostic nutritional index predict mortality in intensive care patients with COVID-19?

OBJECTIVES

PNI is a calculated parameter using the albumin and the lymphocyte count from the CBC, which demonstrates the immunological and nutritional status of the patient. The aim of this study is to show the relationship between PNI and mortality in COVID-19 patients and to reveal a PNI cut-off value for mortality.

MATERIALS AND METHODS

Data of 690 PCR positive COVID-19 ICU patients were recorded. COVID-19 ICU patients were divided into two groups; the first group consisted of survivors, while the second group consisted of patients who died in the ICU. Patients were also evaluated in two groups according to the PNI cut-off value that predicted mortality (PNI ≤ 42.00, PNI ≥ 43) and were compared in terms of demographics, laboratory parameters, clinical findings and mortality rates.

RESULTS

When 690 COVID-19 patients were divided into two groups as survivors (50.6%) and deceased (49.4%) in intensive care, PNI value was significantly lower in the deceased group compared to the surviving group (P < .001). The PNI cut-off value predicting mortality was determined as ≤42. Patients were classified into two groups according to the PNI cut-off value. PNI ≤42 was determined as an independent risk factor for mortality (OR:2.9 P < .001). AUC values for PNI, albumin, and lymphocyte were 0.628, 0.612, and 0.590, respectively; P < .001 for all.

CONCLUSION

PNI is an inexpensive method that can be easily calculated on the basis of routine laboratory parameters. We believe that the PNI value of COVID-19 patients on admission to the ICU may be an independent factor to predict mortality.

A Low Body Mass Index Is Associated with Unsuccessful Treatment in Patients with Mycobacterium avium Complex Pulmonary Disease

Background: A low body mass index (BMI) has been reported to be a poor prognostic factor for Mycobacterium avium complex pulmonary disease (MAC-PD). The purpose of this study was to clarify the clinical features of MAC-PD in cases with a low BMI. Methods: This retrospective study analyzed the data of patients diagnosed with MAC-PD at Saga University Hospital between 2008 and 2019. The analyzed patient characteristics included age, gender, BMI, symptoms, laboratory data, chest computed tomography findings, and the treatment courses. We also investigated the factors associated with successful treatment. Results: In total, 144 patients were included in this study. The low-BMI group (BMI < 18.5 kg/m²) had a higher incidence of sputum, Mycobacterium intracellurare infection, and cavitary lesions, in addition to lower blood lymphocyte counts, higher neutrophil–lymphocyte ratios, and a lower prognostic nutritional index (PNI) when compared to the preserved-BMI group (BMI ≥ 18.5 kg/m²). Sixty-six of the 144 patients (45.8%) received treatment. Hemosputum, acid-fast bacillus sputum smear positivity, low lymphocyte counts, a low PNI, and unsuccessful treatment (48.5% vs. 24.2%, p < 0.05) were found to be associated with a low BMI. Conclusions: A low BMI is associated with cavitary lesions, malnutrition, and unsuccessful treatment in MAC-PD.

Impact of nutritional index on contrast-associated acute kidney injury and mortality after percutaneous coronary intervention

The risk of malnutrition in acute kidney injury and mortality in coronary artery disease patients has not been studied. This study aimed to evaluate whether nutritional status assessed by Onodera's prognostic nutritional index (PNI) was related to percutaneous coronary intervention (PCI) outcomes. A total of 3731 patients who received PCI between January 2010 and December 2018 were included. The relationship between PNI at the time of PCI and the occurrence of contrast-associated acute kidney injury (AKI) and all-cause death was evaluated using logistic regression and Cox proportional hazards models, respectively. AKI occurred in 271 patients (7.3%). A low PNI was independently associated with an increased risk of AKI on multivariate logistic regression analysis (OR 0.96, 95% CI 0.94-0.98, P = 0.001). During the median follow-up of 4.3 years, Kaplan-Meier analysis showed that patients with AKI/low PNI < 47.8 had a higher death rate. After adjusting for various risk factors, a low PNI was a significant risk factor for mortality (HR 0.98, CI 0.96-0.99, P = 0.003). A low level of PNI was associated with increased mortality, especially in the group aged over 70 years and female sex. PNI was closely associated with acute kidney outcomes and patient mortality after PCI.