Department of Nephrology, Sri Ramachandra Medical College and Research Institute (Deemed to be University), No 1, Ramachandra Nagar Porur, Chennai, 600 116, India.
Department of Nephrology, Sri Ramachandra Medical College and Research Institute (Deemed to be University), No 1, Ramachandra Nagar Porur, Chennai, 600 116, India.
Clin Nutr. 2019 Feb;38(1):341-347. doi: 10.1016/j.clnu.2018.01.001. Epub 2018 Jan 9.
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.
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.
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.
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.
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.
营养不良-炎症综合征（MICS）、高同型半胱氨酸血症、钙和磷酸盐水平紊乱已被预测为导致心血管负担加重的重要因素。在慢性肾脏病（CKD）早期阶段的患者中，低白蛋白血症和炎症被认为是非传统心血管危险因素，这给循环系统疾病、死亡率和快速进展到 CKD 第 5 期带来了更大的负担。
本研究旨在使用营养不良-炎症评分（MIS）评估未进行透析的 CKD 患者的炎症和营养状况，并验证其与随访期间死亡率的相关性。
在这项前瞻性队列研究中，纳入了 2013 年 6 月至 2014 年 8 月间的 129 名（66 名男性，63 名女性）未进行透析的 CKD 患者，并在 2017 年 3 月截止随访。使用营养不良-炎症评分评估营养不良和炎症情况。分析了血尿素氮、血清肌酐、白蛋白、白细胞介素-6、高敏 C 反应蛋白（hsCRP）、总胆固醇和人体测量数据。
在未进行透析的 CKD 患者中，MIS 评分从 0 到 18 分，中位数为 2 分。在 36 个月或更长的随访期间，有 30 名（23.2%）患者死亡，35 名（27%）患者开始接受血液透析，1 名（0.7%）患者开始接受腹膜透析，2 名（1.4%）患者接受了肾移植，2 名（1.4%）患者失访。在这项研究中，33%的患者存在不同程度的营养不良和炎症。MIS≥7 的患者，其白细胞介素-6（p=0.003）和高敏 C 反应蛋白水平（p<0.001）显著升高。MIS 的 ROC 曲线分析显示，在预测死亡率方面，MIS 的敏感性为 56.5%，特异性为 81%（AUC 0.709；95%CI 0.604-0.815，p<0.001）。Kaplan-Meier 生存分析显示，MIS≥7 与 36 个月及以上随访时间内的死亡率具有很强的相关性（对数秩检验，p<0.001）。在未调整分析中，MIS（HR 1.140；95%CI 1.054-1.233；p<0.05）和 hsCRP（HR 2.369；95%CI 1.779-3.154；p<0.001）被发现是死亡率的预测因素。即使在调整后，MIS 和 hsCRP 仍然是死亡率的预测因素。
这项研究表明，MIS 是决定未进行透析的 CKD 患者在 36 个月及以上随访时间内死亡率的重要因素。MIS≥7 的患者死亡率风险较高，需要密切监测。在临床实践中，MIS 在未进行透析的 CKD 患者中的应用具有更大的价值。需要进一步进行纵向评估 MIS 及其与结局的相关性的研究。应定期使用 MIS 对预透析 CKD 患者进行营养状况和炎症评估，通过适当的医疗和营养干预预防营养不良及其相关并发症。
