Fiaccadori E, Lombardi M, Leonardi S, Rotelli C F, Tortorella G, Borghetti A
Dipartimento di Clinica Medica, Nefrologia & Scienze della Prevenzione, Universita' degli Studi di Parma, Italy.
J Am Soc Nephrol. 1999 Mar;10(3):581-93. doi: 10.1681/ASN.V103581.
Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prognostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutritional status was also evaluated by anthropometric, biochemical, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltration) were performed in 67% of patients (206 of 309); APACHE II score was 23.1+/-8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional indexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P < 0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P < 0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P < 0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P < 0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P < 0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P < .001), and acute respiratory failure with mechanical ventilation need (OR 3.35; 95% CI, 3.35 to 8.74, P < 0.05). Hospital length of stay was significantly increased (P < 0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P < 0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P < 0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P < 0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources.
营养不良在住院患者中很常见，并且与随后的院内发病和死亡风险增加相关。在因急性肾衰竭（ARF）而转入肾病科病房的患者中，既往存在的营养不良的患病率及其预后相关性仍不清楚。本研究检验了这样一个假设：在这种临床情况下营养不良很常见，并且与院内发病率和死亡率过高相关。对一个前瞻性队列进行了研究，该队列包括在42个月期间因ARF诊断而入住肾脏中级护理病房的309例患者。入院时通过主观全面营养状况评估法（SGA）识别营养不良患者；还通过人体测量、生化和免疫参数评估营养状况。结局指标包括院内死亡率和发病率，以及医疗资源的使用情况。院内死亡率为39%（309例中的120例）；67%的患者（309例中的206例）接受了肾脏替代治疗（血液透析或连续性血液滤过）；急性生理与慢性健康状况评分系统（APACHE II）评分为23.1±8.2（范围为10至52）。42%的ARF患者经SGA评估为严重营养不良；与营养状况正常的患者相比，该组患者的人体测量、生化和免疫营养指标显著降低。与营养状况正常的患者相比，严重营养不良的患者败血症发病率显著增加（优势比[OR]2.88；95%置信区间[CI]，1.53至5.42，P<0.001）、感染性休克发病率显著增加（OR 4.05；95%CI，1.46至11.28，P<0.01）、出血发病率显著增加（OR 2.98；95%CI，1.45至6.13，P<0.01）、肠梗阻发病率显著增加（OR 5.57；95%CI，1.57至19.74，P<0.01）、心律失常发病率显著增加（OR 2.29；95%CI，1.36至3.85，P<0.01）、心源性休克发病率显著增加（OR 4.39；95%CI，1.83至10.55，P<0.001）以及需要机械通气的急性呼吸衰竭发病率显著增加（OR 3.35；95%CI，3.35至8.74，P<0.05）。住院时间显著延长（P<0.01），严重营养不良与院内死亡率显著增加相关（OR 7.21；95%CI，4.08至12.73，P<0.001）。在多变量逻辑回归分析中，无论是与合并症（OR 2.02；95%CI，1.50至2.71，P<0.001），还是与合并症和并发症（OR 2.12；95%CI，1.61至2.89，P<0.001）相比，既往存在的营养不良都是院内死亡率的一个具有统计学意义的独立预测因素。营养不良在ARF患者中非常普遍，并增加了院内死亡、并发症及医疗资源使用的可能性。
