Nutritional scoring system seen as ‘powerful’ mortality predictor in peritoneal dialysis
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When considering protein-energy wasting in patients on peritoneal dialysis, use of all four of the standard diagnostic criteria did not lead to more accurate mortality predictions than the use of individualized components.
Further, finding that a nutritional scoring system performed well, researchers suggested it might be the “better option” for assessing mortality risk in this patient population.
“Protein-energy wasting (PEW) is defined as a state of multiple metabolic and nutritional derangement in both predialysis chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients,” Piyawan Kittiskulnam, MD, of the department of internal medicine-nephrology in the faculty of medicine at Chulalongkorn University in Thailand, and colleagues wrote. “This terminology has been proposed by a panel of experts from the International Society of Renal Nutrition and Metabolism (ISRNM) to describe the co-existence of kidney disease-associated malnutrition, inflammation, and wasting that can occur independently of inadequate nutrient intake.”
The researchers noted no standardized definition of PEW currently exists; however, the following are the criteria suggested by the ISRNM:
- altered serum biochemistry (serum albumin level of less than 3.5 g/L);
- decreased body mass status (BMI of less than 23 kg/m2 or less than 10% total body fat);
- muscle wasting; and
- low dietary protein intake.
“In recognition of the variations in existing assessment tools and capability among different dialysis facilities, the ISRNM panel also recognizes other measures for detecting PEW, including the malnutrition inflammation score (MIS) as a composite nutritional scoring system specifically designed for dialysis patients,” the researchers wrote. “The MIS could be regarded as a potential, but not definitive, clue in the diagnosis of PEW.”
For the study, researchers compared the effectiveness of identifying PEW through the application of at least three of the four criteria (and individual components) or through MIS and considered associated mortality risk in 555 patients (prevalence of PEW was 27.3%).
During a mean follow-up of 25.5 months, 196 deaths were observed.
Researchers found fulfilling at least three of the four criteria was not associated with increased likelihood of mortality.
Individually, decreased serum albumin and low muscle mass were associated with increased mortality risk. More specifically, patients who had serum albumin less than 3.5 g/L were twice as likely to die as those with higher levels, while patients with low muscle mass had a higher risk of mortality compared with those with normal muscle mass (hazard ratio = 1.38). On the other hand, decreased body mass and low protein intake did not appear to have an impact on mortality.
Regarding MIS, a high score (defined as five points or more), as well as each one-point increase, were significantly associated with mortality.
“Although MIS was originally developed in maintenance HD patients, this study demonstrates that MIS is also a powerful predictor of death after adjusting for covariates among PD patients,” Kittiskulnam and colleagues concluded, adding that MIS might serve as an alternative to the “more stringent diagnostic ISRNM criteria.”
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