MO936: Oral Nutritional Supplementation Support in HEmodialysis Patients: Impact on Nutritional Rehabilitation

BACKGROUND AND AIMS

Nutritional status management and rehabilitation are significant concern treating maintenance haemodialysis (HD) patients. Oral nutritional supplements are essential to complement insufficient dietary intake, namely of energy and protein, and to rehabilitate a patient's nutritional status. Therefore, the objective of this preliminary study was to assess the impact of oral nutritional supplementation (ONS) prescription patterns on patients’ nutritional status.

METHOD

We did a cross-sectional analysis of HD patients’ first oral nutritional supplementation with commercial formulas between October 2018 and March 2020 in 25 outpatient HD clinics. The registered nutritionist dietitian decided to initiate, choosing the type of supplement and dose as part of a routine protocol of a comprehensive nutritional intervention and assessment. We assessed albumin, normalized protein catabolic rate, potassium and phosphate at the beginning (t = 0) and end (t = 1) of the supplementation period to understand the nutritional impact. We also estimated the daily proportion of energy, and protein contribution of each oral nutritional supplementation implemented, categorizing in cut-offs of 100 kcal and 5 g of protein.

RESULTS

We analyzed 398 patients, 217 (54.5%) males, 165 (41.5%) diabetic, with a median age of 79 years. Concerning feeding support status, 24.6% were autonomous, 54.8% had family care and 20.6% were institutionalized.

  Globally, the ONS impact was significant in the increment of albumin (P < 0.001) and nPCR (P = 0.002), although nPCR was not significant in the categorized group providing <5 g of protein/day (Table 2). The increment of K was also significant (P < 0.001) but not clinically relevant in increasing the risk of hyperkalaemia. There was no significant difference in P (P = 0.086).

CONCLUSION

ONS significantly impacted nutritional rehabilitation, with an albumin and nPCR increase (except for the categorized group of < 5 g protein/day). Although the increment of potassium was statistically significant, it was not clinically relevant in increasing the risk of hyperkalaemia. Further analyses are needed to understand the best targets for the energy and protein contribution of ONS.

Prognostic Value of the Malnutrition-inflammation Score in Hospitalization and Mortality on Long-term Hemodialysis

OBJECTIVE

Since its development, cumulative evidence has accumulated regarding the prognostic value of the Malnutrition-Inflammation Score (MIS/Kalantar score) prognostic value; however, there is a shortage of recent and large studies with comprehensive statistical methodologies that contribute to support a higher level of evidence and a consensual cutoff. The aim of this study was to assess the strength of MIS association with hospitalization and mortality in a nationwide cohort.

METHODS

This was a historical cohort study of hemodialysis patients from 25 outpatient centers followed up for 48 months. Univariable and multivariable Cox additive regression models were used to analyze the data. The C-index was estimated to assess the performance of the final model.

RESULTS

Two thousand four hundred forty-four patients were analyzed, 59.0% males, 32.0% diabetic, and median age of 71 years (P₂₅ = 60, P₇₅ = 79). During a median period of 45-month follow-up, with a maximum of 48 months (P₂₅ = 31; P₇₅ = 48), 875 patients presented an MIS <5 (35.8%) and 860 patients (35.2%) died. The proportion of deaths was 23.1% for patients with the MIS <5 and 41.9% if the MIS ≥5 (P < .001). A total of 1,528 patients (62.5%) were hospitalized with a median time to the first hospitalization of 26 months (P₂₅ = 9; P₇₅ = 45). A new cutoff point regarding the risk of death, MIS ≥6, was identified for this study data set. In multivariable analysis for hospitalization risk, a higher MIS, higher comorbidity index, and arteriovenous graft or catheter increased the risk, whereas higher Kt/V and higher albumin had a protective effect. In multivariable analysis for mortality risk, adjusting for age, albumin, normalized protein catabolic rate, Charlson comorbidity index, interdialytic weight gain, Kt/V, diabetes, hematocrit, and vascular access, patients with the MIS ≥6 showed a hazard ratio of 1.469 (95% confidence interval: 1.262-1.711; P < .001). Higher age, higher interdialytic weight gain, higher comorbidity index, and catheter increased significantly the risk, whereas higher Kt/V, higher albumin, and higher normalized protein catabolic rate (≥1.05 g/kg/d) reduced the risk.

CONCLUSION

The MIS maintains its relevant and significant association with hospitalization and mortality.

MO901ASSOCIATION OF MALNUTRITION AND INFLAMMATION WITH ERYTHROPOIETIN RESISTANCE INDEX

Background and Aims

Erythropoietin Resistance Index (EPORI) has been previously associated with higher risk of mortality and morbidity in hemodialysis (HD) patients (pts). The objectives of this study were to identify which factors, such as the risk of malnutrition, are associated with EPORI and to assess its association with mortality and hospitalization risk.

Method

Historical cohort study in a group of high-flux HD pts from 25 outpatient HD clinics, starting from a baseline group of 2975 pts. We evaluated EPORI, interdialytic weigh gain (IDWG), Malnutrition Inflammation Score (MIS) and the other parameters at the study baseline. For a better understanding of weight gain patterns, we calculated the average of the IDWG at the day of monthly blood sample collection of the previous 3 months, values &gt;4% were considered high. A MIS&gt;5 indicated nutritional risk.

Results

We analyzed 2044 pts, 1148 (56%) males, 642 (31%) diabetic, with a mean age 68.4±14.12 years, a mean HD vintage 105±74 months and mean EPORI 7.23±7.51 (U/week/kg)/(g/dL). During a follow-up of 48 months, 719 pts (35%) died and 1291 pts (63%) were hospitalized at least once after baseline assessment, 531 pts and 400 pts were excluded because follow up was not possible and EPORI data was not available, respectively.

ROC curve analysis identified different cut-off values for EPORI in relation with all-cause mortality and hospitalizations.

Univariable analysis

An EPORI&gt;5 was associated with higher MIS (7.06±3.9, vs 6.02±3.48, p&lt;0.001), higher IDWG (3.15±1.23 vs 1.26±1.09, p&lt;0.001), lower Hematocrit (Htc) (33.26±3.17 vs 33.69±2.61, p&lt;0.001), higher C-Reactive Protein (CRP) 14.94±24.45 vs 10.4±18.9, p&lt;0.001), female gender (57% vs 48%, p&lt;0.001), death (58% vs 49%, p&lt;0.001) and hospitalization (55% vs 47%, p&lt;0.001).

When analyzing with Kaplan-Meier estimator using log-rank test to compare survival curves, mortality and hospitalizations were increased in all sub-groups with higher values for EPORI (cut-offs of 5 to 8) when compared, respectively, with lower EPORI values.

Multivariable analysis

The predictors of EPORI were MIS&gt;5 (OR 1.564, p&lt;0.001), IDWG (OR 1.234, p&lt; 0.001), CRP (OR 1.010, p&lt;0.001) and Htc (OR 0.948, p&lt;0.001).

In similar models, adjusting for MIS&gt;5 (p&lt;0.001), gender (p&lt;0.001), age (p&lt;0.001), CRP (p&lt;0.001) and dialysis vintage (p&lt;0.001), different EPORI cut-off values were associated with higher risk of mortality and hospitalizations.

Conclusion

In the modern hemodialysis era, higher EPORI cut-off values were associated with a progressive higher risk of mortality and of hospitalization. The modification of the EPORI predictors that are susceptible to improvement, such as the nutritional and inflammation status, may contribute for a better prognosis in this population.

SO045DOES MALNUTRITION INFLAMMATION SCORE MAINTAINS ITS PREDICTIVE RISK ASSESSMENT IN THE MODERN HEMODIALYSIS ERA?

Background and Aims

Malnutrition Inflammation score (MIS) is a risk score published in 2001 (Kalantar-Zadeh, 2001) and validated in 2008 (Rambod, 2009). It is associated with a high mortality and morbidity risk in hemodialysis (HD) patients (pts).

Currently, HD pts population is composed of much older individuals, submitted to a high efficient treatment with access to pharmacological and nutritional therapy, assured by a bundled payment, when comparing with the validation study population.

The objective of this study is to evaluate if MIS maintain its predictive risk assessment.

Method

Cross sectional analysis of HD pts from 25 outpatient clinics. MIS was evaluated at the study baseline. Univariable and multivariable Cox additive regression models were used to analyze the data. C-index was estimated to assess the performance of the final model. A level of significance of α= 0.05 was considered.

Results

A total of 2444 pts were analyzed (59.0% males; 32.0% diabetic) during a median period of 48 months (P25=31; P75=48), 875 patients registered MIS&lt;5, corresponding to 35.8%. All-cause mortality was observed in 860 pts (35.2%). There were 202 (35.8%) events in the group of patients with MIS&lt;5, while in the group with MIS≥5, the number of deaths was higher (658 pts, 41.9%).

In univariable analysis using Cox additive model, the main results were:

In multivariable analysis, adjusting for age, nPNA, IDWG, Kt/V and diabetes, a MIS ≥ 5 and ≥ 7 showed, respectively, a HR of 1.761 (IC 95%, p&lt;0.001) and 1.822 (IC 95%, p&lt;0.001).

Conclusion

The findings of this analysis confirms that MIS maintains a discriminative power to identify higher risk of mortality. In this model, age and diabetes also correlate with mortality risk increase, while nPNA, IDWG and Kt/V have the opposite effect.