Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients

doi:10.1016/j.clnu.2018.01.001

Clinical Nutrition

Volume 38, Issue 1, February 2019, Pages 341-347

https://doi.org/10.1016/j.clnu.2018.01.001 Get rights and content

Summary

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.

Introduction

Cardiovascular related complications are the most important reason for poor survival in chronic kidney Disease (CKD) patients [1]. Malnutrition-inflammation complex syndrome (MICS), hyperhomocysteinemia, calcium and phosphate levels derangement have been determined as important contributing factors for the progression of cardiovascular burden [2]. There is an association between inflammation, atherosclerosis and malnutrition in CKD, hence the term malnutrition–inflammation complex syndrome. Among patients with CKD, hypoalbuminemia and inflammation contemplated as non-traditional cardiovascular risk factors, which add more burden to circulatory disease, mortality and rapid advancement to CKD stage 5 requiring renal replacement therapy [2], [3].

The prevalence of malnutrition reported between 28 and 65% on various studies depending on criteria used in diagnosis [4], [5], [6], [7]. Malnutrition Inflammation Score (MIS) could be a valid tool in evaluating the nutritional status of pre-dialysis CKD patients [8]. Most of the previous studies on malnutrition and inflammation were carried out in ESRD patients on dialysis with only a few studies available in CKD patients not on dialysis [4], [5], [6], [9].

The aim of the study is to evaluate inflammation and nutritional status of CKD patients' not on dialysis using MIS and to study the outcome of the patients with different tertiles of MIS. This study also aims to find the association between MIS with different patient related parameters such as age, gender, estimated Glomerular filtration rate (e-GFR), BMI, anthropometry such as MAMC, MAC and TSF in our study population. The other objectives of the study is to find the correlation between MIS with inflammatory mediators such as Interleukin-6 and HsCRP in pre-dialysis CKD patients and comparison of demographic, nutrition, inflammation related factors between survivors and non-survivors.

Section snippets

Study design and study participants

In this prospective, single center, study on pre-dialysis CKD patients, which included 129 pre-dialysis CKD patients in the period between June 2013 to August 2014. The patients who visited the nephrology out patient's clinic were enrolled into the study after meeting the inclusion criteria of the study. The study participants were CKD patients who met the following inclusion criteria: (i) age greater than 18 years and ≤65 years old (ii) no past history of malignancy (iii) CKD stages 3–5. The

Results

In this study 129 (66 males, 63 females) subjects were included. The study participants had a mean age of 50.6 ± 11.4 years. The clinical characteristics and demography of patients presented in Table 1.

The primary kidney disease was hypertensive nephrosclerosis (38%), diabetic nephropathy (34%) and other causes (28%). Fifteen percent of subjects had previous history of cardio vascular disease. Fifty (38.8%) subjects had stage 3 CKD (GFR range, 30–59 ml/min), 48 (37.2%) had stage 4 CKD (GFR

Discussion

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. The risk for mortality increases 13.7% with each point of MIS. MIS ≥7 is a high risk for mortality when compared with other groups of MIS. FC Amparo et al. [8] reported similar findings after comparing anthropometry and biomarkers of malnutrition with MIS which predicted the outcomes and concluded that higher MIS is related with increased risk for

Conflicts of interest

The authors declare no conflict of interest.

Acknowledgments

This study was partly funded by Sri Ramachandra University Young faculty grant (GATE).

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Original articleInflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients

Summary

Background

Aim

Methods and material

Results

Conclusions

Introduction

Section snippets

Study design and study participants

Results

Discussion

Conflicts of interest

Acknowledgments

Am J Kidney Dis

Kidney Int

Ren Nutr

J Ren Nutr

Am J Kidney Dis

Am J Kidney Dis

Cytokine

Kidney Int

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Original article
Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients