D Jagadeswaran1, E Indhumathi2, A J Hemamalini3, V Sivakumar4, P Soundararajan5, M Jayakumar2. 1. Department of Nephrology, Sri Ramachandra Medical College and Research Institute (Deemed to be University), No 1, Ramachandra Nagar Porur, Chennai, 600 116, India. Electronic address: jagadeswaran@hotmail.com. 2. Department of Nephrology, Sri Ramachandra Medical College and Research Institute (Deemed to be University), No 1, Ramachandra Nagar Porur, Chennai, 600 116, India. 3. Department of Clinical Nutrition, Sri Ramachandra Medical College and Research Institute (Deemed to be University), No 1, Ramachandra Nagar, Porur, Chennai, 600 116, India. 4. Department of Nephrology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, 517 507, Andhra Pradesh, India. 5. Department of Nephrology, Saveetha Medical College, Saveetha Nagar, Thandalam, Chennai, 602 105, India.
Abstract
BACKGROUND: Malnutrition-inflammation complex syndrome (MICS), hyperhomocysteinemia, calcium and phosphate levels derangement have been predicted as important contributing factors for the progression of cardiovascular burden. Among patients with earlier stage of CKD, hypoalbuminaemia and inflammation deliberated as non-traditional cardiovascular risk factors, which add more burden to circulatory disease, mortality and rapid advancement to CKD stage 5. AIM: The aim of the study is to evaluate inflammation and nutritional status of CKD patients not on dialysis using Malnutrition inflammation score (MIS) and to verify the association with mortality in the follow-up period. METHODS AND MATERIAL: In this prospective cohort study 129 (66 males, 63 females) pre-dialysis CKD patients enrolled between June 2013 to August 2014 and censored until March 2017. Malnutrition and Inflammation assessed using Malnutrition inflammation score. Blood urea nitrogen, serum creatinine, albumin, Interleukin - 6, highly sensitive C reactive protein (hsCRP), total cholesterol and anthropometric data were analyzed. RESULTS: The Malnutrition inflammation score in pre-dialysis CKD patients ranged from 0 to 18 with the median score of two. During 36 or more months of follow-up, there were 30 (23.2%) deaths, 35 (27%) patients initiated on hemodialysis, one (0.7%) patient was initiated on peritoneal dialysis, two (1.4%) patients underwent renal transplantation and two (1.4%) patients were lost for follow-up. In this study, 33% had varying degree of malnutrition and inflammation. Patients who had MIS ≥7 had significant increase in IL-6 (p = 0.003) and HsCRP levels (p < 0.001) when compared with other tertiles of MIS. ROC curve analysis of MIS showed 56.5% sensitivity and 81% specificity in predicting death rate (AUC 0.709; 95% CI 0.604-0.815, p < 0.001). Kaplan-Meier survival analysis showed MIS ≥7 had a strong association (log rank test, p < 0.001) with mortality during 36 and more months of follow-up time. In unadjusted analyses, MIS (HR 1.140; 95% CI 1.054-1.233; p < 0.05) and HsCRP (HR 2.369; 95% CI 1.779-3.154; p < 0.001) found to be predictors of mortality. MIS and HsCRP remained predictors of mortality even after adjustments. CONCLUSIONS: This study shows MIS is an important factor that determines mortality in pre-dialysis CKD patients during 36 and more months of follow-up time. Patients with MIS ≥7 have high risk for mortality and needs close monitoring. In clinical setting application of MIS has a greater utilization in pre-dialysis CKD patients. Further research with longitudinal assessment of MIS and its association with outcomes are warranted. Pre-dialysis CKD patients should be assessed for their nutritional status and inflammation using MIS regularly to prevent malnutrition and its associated complications through appropriate medical and nutritional intervention.
BACKGROUND:Malnutrition-inflammation complex syndrome (MICS), hyperhomocysteinemia, calcium and phosphate levels derangement have been predicted as important contributing factors for the progression of cardiovascular burden. Among patients with earlier stage of CKD, hypoalbuminaemia and inflammation deliberated as non-traditional cardiovascular risk factors, which add more burden to circulatory disease, mortality and rapid advancement to CKD stage 5. AIM: The aim of the study is to evaluate inflammation and nutritional status of CKDpatients not on dialysis using Malnutrition inflammation score (MIS) and to verify the association with mortality in the follow-up period. METHODS AND MATERIAL: In this prospective cohort study 129 (66 males, 63 females) pre-dialysis CKDpatients enrolled between June 2013 to August 2014 and censored until March 2017. Malnutrition and Inflammation assessed using Malnutrition inflammation score. Blood ureanitrogen, serum creatinine, albumin, Interleukin - 6, highly sensitive C reactive protein (hsCRP), total cholesterol and anthropometric data were analyzed. RESULTS: The Malnutrition inflammation score in pre-dialysis CKDpatients ranged from 0 to 18 with the median score of two. During 36 or more months of follow-up, there were 30 (23.2%) deaths, 35 (27%) patients initiated on hemodialysis, one (0.7%) patient was initiated on peritoneal dialysis, two (1.4%) patients underwent renal transplantation and two (1.4%) patients were lost for follow-up. In this study, 33% had varying degree of malnutrition and inflammation. Patients who had MIS ≥7 had significant increase in IL-6 (p = 0.003) and HsCRP levels (p < 0.001) when compared with other tertiles of MIS. ROC curve analysis of MIS showed 56.5% sensitivity and 81% specificity in predicting death rate (AUC 0.709; 95% CI 0.604-0.815, p < 0.001). Kaplan-Meier survival analysis showed MIS ≥7 had a strong association (log rank test, p < 0.001) with mortality during 36 and more months of follow-up time. In unadjusted analyses, MIS (HR 1.140; 95% CI 1.054-1.233; p < 0.05) and HsCRP (HR 2.369; 95% CI 1.779-3.154; p < 0.001) found to be predictors of mortality. MIS and HsCRP remained predictors of mortality even after adjustments. CONCLUSIONS: This study shows MIS is an important factor that determines mortality in pre-dialysis CKDpatients during 36 and more months of follow-up time. Patients with MIS ≥7 have high risk for mortality and needs close monitoring. In clinical setting application of MIS has a greater utilization in pre-dialysis CKDpatients. Further research with longitudinal assessment of MIS and its association with outcomes are warranted. Pre-dialysis CKDpatients should be assessed for their nutritional status and inflammation using MIS regularly to prevent malnutrition and its associated complications through appropriate medical and nutritional intervention.
Authors: Nidhi Sukul; Elodie Speyer; Charlotte Tu; Brian A Bieber; Yun Li; Antonio A Lopes; Koichi Asahi; Laura Mariani; Maurice Laville; Hugh C Rayner; Bénédicte Stengel; Bruce M Robinson; Ronald L Pisoni Journal: Clin J Am Soc Nephrol Date: 2019-04-11 Impact factor: 8.237
Authors: Almudena Pérez-Torres; M Elena González García; Marta Ossorio-González; Laura Álvarez García; M Auxiliadora Bajo; Gloria Del Peso; Ana Castillo Plaza; Rafael Selgas Journal: Nutrients Date: 2021-02-14 Impact factor: 5.717
Authors: Xiaohui Bian; Tomás P Griffin; Xiangyang Zhu; Md Nahidul Islam; Sabena M Conley; Alfonso Eirin; Hui Tang; Paula M O'Shea; Allyson K Palmer; Rozalina G McCoy; Sandra M Herrmann; Ramila A Mehta; John R Woollard; Andrew D Rule; James L Kirkland; Tamar Tchkonia; Stephen C Textor; Matthew D Griffin; Lilach O Lerman; LaTonya J Hickson Journal: BMJ Open Diabetes Res Care Date: 2019-12-15