Abstract

Malnutrition-inflammation complex syndrome, an outcome predictor in maintenance hemodialysis (MHD) patients, may be related to anorexia. We examined whether subjectively reported appetite is associated with adverse conditions and increased morbidity and mortality in MHD patients. A cohort of 331 MHD outpatients was asked to rate their recent appetite status on a scale from 1 to 4 (very good, good, fair, and poor appetite, respectively). Anemia indexes and nutritional and inflammatory markers-including serum concentrations of C-reactive protein, tumor necrosis factor alpha, and interleukin 6-were measured. The malnutrition-inflammation score was used to evaluate the malnutrition-inflammation complex syndrome, and the SF36 questionnaire was used to assess quality of life (QoL). Mortality and hospitalization were followed prospectively for up to 12 mo. Patients were aged 54.5 +/- 14.4 y. Diminished appetite (fair to poor) was reported by 124 patients (38%). Hemoglobin, protein intake, and QoL scores were progressively lower, whereas markers of inflammation, malnutrition-inflammation scores, and the required erythropoietin dose were higher across the worsening categories of appetite. The adjusted odds ratios of diminished versus normal appetite for increased serum tumor necrosis factor alpha and C-reactive protein concentrations were significant. Significant associations between a poor appetite and an increased rate of hospitalization and mortality were observed. The hazard ratio of death for diminished appetite was 4.74 (95% CI: 1.85, 12.16; P = 0.001). Diminished appetite (anorexia) is associated with higher concentrations of proinflammatory cytokines and higher levels of erythropoietin hyporesponsiveness and poor clinical outcome, including a 4-fold increase in mortality, greater hospitalization rates, and a poor QoL in MHD patients. Appetite status may yield significant insight into the clinical status of dialysis patients.

Highlights

  • Patients undergoing maintenance hemodialysis (MHD) have a high prevalence of protein-energy malnutrition (PEM) and inflammation [1,2,3]

  • We found that the response of the 331 MHD patients to a simple question about appetite was significantly associated with several measures of inflammatory and nutritional status

  • Some degree of association was found between selected markers of nutrition, such as normalized protein equivalent of total nitrogen appearance (nPNA) and total-iron-binding capacity (TIBC), and anorexia

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Summary

Introduction

Patients undergoing maintenance hemodialysis (MHD) have a high prevalence of protein-energy malnutrition (PEM) and inflammation [1,2,3]. MICS is reported to correlate with poor outcome, including a decreased quality of life (QoL) [7,8,9,10], refractory anemia [11,12,13], and significantly greater rates of hospitalization and mortality in MHD patients (3, 14 –16). An abnormally low appetite per se may be a risk factor in dialysis patients for such unfavorable outcomes as erythropoietin hyporesponsiveness, poor QoL, and increased mortality and hospitalization. Conclusion: Diminished appetite (anorexia) is associated with higher concentrations of proinflammatory cytokines and higher levels of erythropoietin hyporesponsiveness and poor clinical outcome, including a 4-fold increase in mortality, greater hospitalization rates, and a poor QoL in MHD patients.

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