Hiroshi Takahashi1, Keiko Inoue2, Kazue Shimizu3, Keiko Hiraga4, Erika Takahashi5, Kaori Otaki6, Taeko Yoshikawa7, Kumiko Furuta8, Chika Tokunaga9, Tomoyo Sakakibara5, Yasuhiko Ito10. 1. Department of Nephrology, School of Medicine, Fujita Health University, Toyoake, Japan. 2. Department of Nutrition, Faculty of Wellness, Shigakkan University, Obu, Japan. 3. Department of Nutrition, Hakuyokai Hospital, Nagoya, Japan. 4. Department of Nutrition, Shinseikai-Daiichi Hospital, Nagoya, Japan. 5. Department of Nutrition, Kaikokai-Central Clinic, Nagoya, Japan. 6. Department of Nutrition, Daiyukai Daiichi Hospital, Ichinomiya, Japan. 7. Department of Nutrition, Medical Satellite Nagoya, Nagoya, Japan. 8. Department of Nutrition, Tajimi Clinic, Tajimi, Japan. 9. Department of Nutrition, Suzuka Kidney Clinic, Suzuka, Japan. 10. Department of Nephrology and Renal Replacement Therapy, Graduate School of Medicine, Nagoya University, Nagoya, Japan. Electronic address: yasuito@med.nagoya-u.ac.jp.
Abstract
OBJECTIVE: Protein energy wasting (PEW) is consistently associated with poor prognosis in hemodialysis (HD) patients. We compared the predictability of PEW as diagnosed by The International Society of Renal Nutrition and Metabolism criteria (PEWISRNM) and geriatric nutritional risk index (GNRI) for all-cause mortality in Japanese HD patients. As cut-off values for body mass index (BMI) for PEW have not been established in PEWISRNM for Asian populations, these were also investigated. DESIGN AND SUBJECTS: The nutritional status from 409 HD patients was evaluated according to ISRNM and GNRI criteria. To compare the predictability of mortality, C-index, net reclassification improvement (NRI) and integrated discrimination improvement were evaluated. RESULTS: During follow-up (median, 52 months; range, 7 months), 70 patients (17.1%) presented PEW according to ISRNM and 131 patients (32.1%) according to GNRI; in addition, 101 patients (24.7%) died. PEWISRNM and GNRI were identified as independent predictors of death. Addition of PEWISRNM and GNRI to a predictive model based on established risk factors improved NRI and integrated discrimination improvement. However, no differences were found between models including PEWISRNM and GNRI. When lowering the criterion level of BMI per 1 kg/m2 sequentially, PEWISRNM at BMI <20 kg/m2 maximized the hazard ratio for mortality. The model including PEWISRNM at BMI <20 kg/m2 improved NRI compared with the model including GNRI. CONCLUSION: PEWISRNM and GNRI represent independent predictors of mortality, with comparable predictability. The diagnostic criterion of BMI in the ISRNM for Japanese population might be better at <20 kg/m2 than at <23 kg/m2.
OBJECTIVE: Protein energy wasting (PEW) is consistently associated with poor prognosis in hemodialysis (HD) patients. We compared the predictability of PEW as diagnosed by The International Society of Renal Nutrition and Metabolism criteria (PEWISRNM) and geriatric nutritional risk index (GNRI) for all-cause mortality in Japanese HDpatients. As cut-off values for body mass index (BMI) for PEW have not been established in PEWISRNM for Asian populations, these were also investigated. DESIGN AND SUBJECTS: The nutritional status from 409 HDpatients was evaluated according to ISRNM and GNRI criteria. To compare the predictability of mortality, C-index, net reclassification improvement (NRI) and integrated discrimination improvement were evaluated. RESULTS: During follow-up (median, 52 months; range, 7 months), 70 patients (17.1%) presented PEW according to ISRNM and 131 patients (32.1%) according to GNRI; in addition, 101 patients (24.7%) died. PEWISRNM and GNRI were identified as independent predictors of death. Addition of PEWISRNM and GNRI to a predictive model based on established risk factors improved NRI and integrated discrimination improvement. However, no differences were found between models including PEWISRNM and GNRI. When lowering the criterion level of BMI per 1 kg/m2 sequentially, PEWISRNM at BMI <20 kg/m2 maximized the hazard ratio for mortality. The model including PEWISRNM at BMI <20 kg/m2 improved NRI compared with the model including GNRI. CONCLUSION: PEWISRNM and GNRI represent independent predictors of mortality, with comparable predictability. The diagnostic criterion of BMI in the ISRNM for Japanese population might be better at <20 kg/m2 than at <23 kg/m2.