Abstract
Malnutrition is a prevalent condition in maintenance hemodialysis (MHD) patients. This study aimed to evaluate the performance of the recently developed GLIM (Global Leadership Initiative on Malnutrition) in MHD by assessing the agreement, accuracy, sensitivity, specificity, and survival prediction of GLIM when compared to 7-point subjective global assessment (7p-SGA) and malnutrition inflammation score (MIS). We investigated 2 cohorts: MHDltaly (121 adults from Italy; 67±16years, 65% men, body mass index 25±5kg/m2) and MHDBrazil (169 elderly [age>60years] from Brazil; 71±7years, 66% men, body mass index 25±4kg/m2), followed for all-cause mortality for median 40 and 17months, respectively. We applied the 2-step approach from GLIM: (1) screening and (2) confirming malnutrition by phenotypic and etiologic criteria. For 7p-SGA and MIS, a score ≤5 and ≥8, respectively, defined malnutrition. Malnutrition was present in 38.8% by GLIM, 25.6% by 7p-SGA, and 29.7% by MIS in the MHDItaly cohort, and in 47.9% by GLIM, 59.8% by 7p-SGA, and 49.7% by MIS in the MHDBrazil cohort. Cohen's kappa coefficient (κ) showed only "fair" agreement between GLIM and SGA (MHDItaly: κ = 0.26, P = .003; MHDBrazil: κ = 0.22, P = .003) and between GLIM and MIS (MHDItaly: κ= 0.33, P<.001; MHDBrazil: κ = 0.25, P = .001). Cox regression analysis showed that all 3 methods were able to predict mortality in crude analysis; however in the adjusted model, the association seemed more consistent and stronger in magnitude for 7p-SGA and MIS. In MHD patients, GLIM showed low agreement, sensitivity, and accuracy in identifying malnourished subjects by either 7p-SGA or MIS. Considering the specific wasting characteristics that predominate in MHD, the well-established 7p-SGA and MIS methods may be more useful in this clinical setting.
Highlights
MALNUTRITION IS HIGHLY prevalent in maintenance hemodialysis (MHD) patients as indicated by a global meta-analysis of 65 studies from 10 geographical regions, showing that half of the studies reported a malnutrition prevalence of 43% or higher.[1]
The assessment of nutritional status in MHD patients should consider specificities related to CKD per se and the impact of MHD including the following: (1) nutrient losses into dialysate; (2) an altered hydration status that changes at each dialysis session with subsequent body weight fluctuations; (3) a decreased serum albumin level in large part due to low-grade inflammation; and (4) a pattern of overall food intake that often varies between dialysis and a nondialysis day
The prevalence of malnutrition according to 7-point SGA (7p-SGA), MIS, and Global Leadership Initiative on Malnutrition (GLIM) was highest in the MHD Brazilian cohort
Summary
MALNUTRITION IS HIGHLY prevalent in maintenance hemodialysis (MHD) patients as indicated by a global meta-analysis of 65 studies from 10 geographical regions, showing that half of the studies reported a malnutrition prevalence (assessed by subjective global assessment [SGA] or malnutrition inflammation score [MIS]) of 43% or higher.[1]. The Global Leadership Initiative on Malnutrition (GLIM) was developed and is composed of a 2-step approach including a first screening to select patients at risk and a second assessment for the diagnosis and grading of the severity of malnutrition.[7] Because GLIM is a new nutritional score and not yet validated in the setting of renal care, we designed a study aiming at evaluating its applicability in MHD patients. For this purpose, we analyzed the agreement, accuracy, sensitivity, and specificity of GLIM compared to
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