Dialysis Malnutrition Score Research Articles

Seasonal Variations of Nutritional Status in Maintenance Hemodialysis Patients.

Nutritional status of hemodialysis (HD) patients is influenced by a multitude of factors and it strongly correlates with morbidity and mortality. The aim of this study was to investigate the influence of seasonal changes on nutritional status in maintenance HD patients. A selected population of 84 adult (40 females and 44 males, aged 68.98 ± 13.45 years) HD (5.94 ± 6.44 years) patients were investigated. Clinical, biochemical and nutritional parameters (BMI, creatinine, urea, serum albumin, total cholesterol and Dialysis Malnutrition Score (DMS) were measured in cold (January and December) and mild (June and September) months, altogether in 336 HD sessions. Statistically significant differences between cold and mild months were found in BMI (P = 0.046), creatinine before HD (P = 0.011), urea before HD (P ≤ 0.001), urea after HD (P ≤ 0.001) and glucose (P = 0.001). Differences between male and female patients in DMS, serum albumin and creatinine level in cold and mild months were found; where females altogether had higher DMS score and lower serum albumin and creatinine levels. These results suggest that seasonal variations of clinical and laboratory variables that reflect nutritional status occur commonly among maintenance HD patients and might lead to biases in the interpretation of results in clinical studies in which measurement schedules vary during the year. Also, results suggested that female HD patients may constitute an especially vulnerable population for seasonal oscillations of nutritional status. The reasons for most of these variations are not apparent and require further investigation.

Complex Assessment of Risk Factors for the Development of Cardiovascular Calcification in Hemodialysis Patients

The aim of the present study was the integrated assessment of the role of non-traditional factors (inflammation, malnutrition, calcium-phosphorus disorder and imbalance in the concentration of inducers and inhibitors of calcification) in forming cardiovascular calcification (CVC) and the structural-functional rearrangement of LV myocardium in patients with chronic kidney disease (CKD) receiving hemodialysis (HD). Materials and Methods: The present study included 84 HD patients with CKD 5D stage. We evaluated 3 components of the Dialysis Malnutrition Score (DMS), according to which body mass index (BMI), the level of serum albumin, and the percent saturation of transferrin with iron were determined. We also analyzed CRP, fibrinogen, and beta-2 microglobulin, and calculated the number of points (from zero to 2) according to the Glasgow Prognostic Score (GPS), which allowed us to combine indicators of inflammation and make a common prognostic assessment. The serum levels of protein alpha-Klotho и FGF-23 were determined by enzyme immunoassay. Echocardiographic measurements were performed using B-mode, M-mode and Doppler-mode. Different patterns of LV geometry were identified according to Ganau et al. (1992). The severity of calcification was estimated by a semi-quantitative scale for assessing the degree of calcification of heart structures according to the National recommendations for CKD-MBD (2010). Results: The increased risk for development of CVC, LVH, and diastolic dysfunction was associated with markers of malnutrition, anemia, and inflammation in HD patients. Reduced serum alpha-Klotho level, hypoalbuminemia and a high level of FGF-23 had a prognostic value in CVC formation. (Int J Biomed. 2016;6(1):22-26.).

Relationship between the target dose for hemodialysis adequacy and nutritional assessment.

BACKGROUNDSome studies have shown an increased relative risk of death for patients with higher levels of Kt/V, which may be associated with marked malnutrition.OBJECTIVEThe aim of this study was to investigate the relationship between the target dose for hemodialysis adequacy, as measured by Kt/V, and various nutritional parameters in hemodialysis patients.DESIGNCross-sectional.SETTINGSSakarya University Faculty of Medicine, Turkey between February 2014 and March 2014.PATIENTS AND METHODSFor consecutive patients who met criteria, the following were recorded: nutritional status, dialysis malnutrition score (DMS), the geriatric nutritional risk index (GNRI), serum albumin level, anthropometric measurements, and bioelectrical impedance analysis. Patients were classified into two groups according to the target hemodialysis dose for single-pool Kt/V: patients with spKt/V ≥1.4 and patients with spKt/V <1.4.MAIN OUTCOME MEASURE(S)Association of hemodialysis adequacy by nutritional assessment.RESULTSThe prevalence of malnutrition in 286 patients with target dose hemodialysis (spKt/V ≥ 1.4) was significantly higher according to body mass index (BMI), DMS, and GNRI (P=.001, P=.006, and P=.004, respectively) compared with patients with a lower target dose (spKt/V < 1.4). BMI, biceps skinfolds, mid-arm circumference, calf circumference, fat free mass, and total body water were statistically significantly lower in patients at a higher target dose (spKt/V ≥ 1.4) (P<.001, P=.034, P=.010, P<.001, P<.001, and P<.001 respectively).CONCLUSIONSMalnutrition was more frequent in chronic hemodialysis patients who received the target hemodialysis. Evaluation of nutritional status in patients at the target hemodialysis dose should be considered.LIMITATIONSData collected from a single region; small sample size; cross-sectional design is disadvantageous.

FGF23 and Malnutrition in Maintenance Hemodialysis Patients: A Single-Center Study

Background: Malnutrition is a prevalent complication in patients on maintenance hemodialysis and is considered a major risk factor for mortality in those patients. FGF23 has also been associated with mortality in dialysis patients. Little is known about the association between FGF23 and malnutrition in such patients. Aim of the study: The aim of this study was to investigate possible relationship between FGF23 and malnutrition in maintenance hemodialysis patients. 85 patients on maintenance hemodialysis were studied. In addition to routine laboratory parameters, serum intact fibroblast growth factor-23 levels were done, and anthropometric measures were done after reaching dry weight which included MAC, WC and WHR. BMI was calculated for all patients. SGADMS (Subjective Global Assessment -Dialysis Malnutrition Score) was calculated based on medical history and clinical examination. Results: The mean BMI was 20.2 ± 3 kg/m2. The mean hemoglobin level was 9.7 ± 2 g/dl. The mean serum calcium level was 7.6 ± 1 mg/dl. The mean serum albumin was 3.9 ± 1 g/dl. The mean mid-arm circumference was 22.9 ± 2 cm. The mean waist circumference was 90.5 ± 11 cm. The mean malnutrition score was 28.2 ± 3 points. FGF23 levels ranged from 13.5 to 675 ng/L, and accordingly patients were divided into four quartiles. Patients in the lowest FGF23 quartile showed the shortest dialysis vintage, lowest serum calcium, phosphorus, creatinine, albumin, total proteins, MAC, and the highest iPTH level. The highest malnutrition score was associated with the lowest FGF23 quartile. There was highly significant positive correlation between FGF23 level and each of BMI, WHR (p=0.006 and 0.001 respectively) and a highly significant negative correlation with malnutrition score (p=0.000). Conclusion: Low FGF23 levels may be associated with malnutrition in maintenance hemodialysis patients. FGF23 used in conjunction with other objective nutritional assessment tools may be of value in determining nutritional status of hemodialysis patients.

Dialysis Malnutrition and Malnutrition Inflammation Scores: screening tools for prediction of dialysis-related protein-energy wasting in Malaysia.

Malnutrition is highly prevalent in Malaysian dialysis patients and there is a need for a valid screening tool for early identification and management. This cross-sectional study aims to examine the sensitivity of the Dialysis Malnutrition Score (DMS) and Malnutrition Inflammation Score (MIS) tools in predicting protein-energy wasting (PEW) among Malaysian dialysis patients. A total of 155 haemodialysis (HD) and 90 peritoneal dialysis (PD) patients were screened for risk of malnutrition using DMS and MIS and comparisons were made with established guidelines by International Society of Renal Nutrition and Metabolism (ISRNM) for PEW. MIS cut-off score of >=5 indicated presence of malnutrition in all patients. A total of 59% of HD and 83% of PD patients had PEW by ISRNM criteria. Based on DMS, 73% of HD and 71% of PD patients exhibited moderate malnutrition, whilst using MIS, 88% and 90%, respectively were malnourished. DMS and MIS correlated significantly in HD (r2=0.552, p<0.001) and PD (r2=0.466, p<0.001) patients. DMS and MIS had higher sensitivity values in PD (81% and 82%, respectively) compared to HD (59% and 60%, respectively) patients. The MIS cut-off scores for malnutrition classification were established (score >=5) for use amongst Malaysian dialysis patients. Both DMS and MIS are valid tools to be used for nutrition screening of dialysis patients especially those undergoing peritoneal dialysis. The DMS may be a more practical and simpler tool to be utilized in the Malaysian dialysis settings as it does not require laboratory markers.

Association of malnutrition-inflammation score, dialysis-malnutrition score and serum albumin with novel risk factors for cardiovascular diseases in hemodialysis patients

Background: This study was designed to investigate the associations between malnutrition-inflammation score (MIS), dialysis-malnutrition score (DMS) and serum albumin with novel risk factors for cardiovascular diseases (CVD) in hemodialysis (HD) patients. Methods: In this cross-sectional study, 291 HD patients were randomly selected from among 2302 adult HD patients in Tehran HD centers. The MIS and DMS were determined during one of the dialysis sessions in these patients. In addition, 4 mL blood was obtained before dialysis and analyzed for serum albumin and novel risk factors for CVD, including C-reactive protein (CRP), soluble intercellular adhesion molecule type 1 (sICAM-1), soluble vascular cell adhesion molecule type 1 (sVCAM-1), sE-selectin, malondialdehyde (MDA), nitric oxide (NO), endothelin-1 and lipoprotein (a) [Lp (a)]. Results: MIS and DMS were significantly positively correlated with serum CRP (p < 0.01) and sICAM-1 (p < 0.01), whereas serum albumin concentration was significantly negatively correlated with serum CRP (p < 0.01) and sICAM-1 (p < 0.01). There were no significant correlations between MIS, DMS and serum albumin with serum concentrations of sVCAM-1, sE-selectin, MDA, NO, endothelin-1 and Lp (a). Conclusion: This study indicates that protein-energy wasting indicators in HD patients are associated with serum CRP and sICAM-1, as two CVD risk factors.

Comparison of various scoring methods for the diagnosis of protein–energy wasting in hemodialysis patients

The present study was designed to determine the cutoff points for the diagnosis of mild-to-moderate and severe protein-energy wasting (PEW) based on dialysis malnutrition score (DMS) and malnutrition inflammation score (MIS), and the sensitivity, specificity, accuracy, area under receiver operating characteristic (ROC) curve, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR(+)) and negative likelihood ratio (LR(-)) of DMS and MIS in comparison with subjective global assessment (SGA) in hemodialysis (HD) patients. In this study, 291 HD patients were randomly selected from among 2,302 adult HD patients in Tehran hemodialysis centers. The PEW in these patients was determined by SGA, DMS and MIS. According to the cutoff points derived from the area under ROC curves, scores of 7-13 for DMS represented normal status or without PEW; 14-23, mild-to-moderate PEW; and 24-35, severe PEW. For MIS, scores of 0-7 represented normal status or without PEW; 8-18, mild-to-moderate PEW; and 19-30, severe PEW. In comparison with SGA, the sensitivity, specificity, accuracy, area under ROC curve, PPV, NPV, LR(+) and LR(-) of DMS were 94 %, 88 %, 92 %, 97 %, 93 %, 92 %, 7.8 and 0.07, respectively. Those of MIS were 87 %, 96 %, 91 %, 97 %, 97 %, 83 %, 22.0 and 0.13 in comparison with SGA, respectively. The results of the present study indicate that the DMS and MIS are almost similar to SGA for identifying PEW in HD patients, but it seems that the DMS is a more appropriate alternative tool for SGA in hospital routine assessments.

Cognitive‐Psychomotor Functions and Nutritional Status in Maintenance Hemodialysis Patients: Are They Related?

Both cognitive impairment and malnutrition are common in hemodialysis patients and associated with adverse clinical outcome. The aim of the study was to investigate performance on a detailed cognitive and psychomotor battery in maintenance hemodialysis patients in correlation to nutritional status. A selected population of 65 adult (20 females and 45 males, aged 57.84±12.28 years) hemodialysis (4.78±3.62 years) patients were investigated. The total time of test solving was correlated with Dialysis Malnutrition Score (DMS) in tests of simple visual discrimination of signal location (r=0.215, P=0.042), simple convergent visual orientation (r=0.262, P=0.020), and convergent thinking (r=0.244, P=0.034). The minimum time of test solving was also correlated with DMS in the test of simple convergent visual orientation (r=0.227, P=0.038), and in the test of convergent thinking (r=0.223, P=0.048). Total ballast, as a descriptor of stability in reaction time, was correlated with DMS in the test of simple visual discrimination of signal location (r=0.281, P=0.012), and in a test of short term memory actualization (r=0.239, P=0.028). Furthermore, significant correlation was noted between body mass index, serum creatinine, total cholesterol and albumin level with cognitive-psychomotor performance. Hemodialysis patients with a poorer nutritional status performed worse on cognitive and psychomotor tests. Further research is needed to assess the effects of treating malnutrition on cognitive-psychomotor performance in these patients.

The Impact of Malnutrition on Mortality in Patients on Maintenance Hemodialysis in Serbia

Numerous studies suggest a strong association between nutrition and clinical outcome in chronic hemodialysis (HD) patients. While determination of malnutrition is often based on objective measurements, such as biochemical parameters and anthropometric data, there is no single measurement that can reliably predict the risk for malnutrition or poor outcome. The aim of the present investigation was to determine the prevalence and severity of malnutrition among HD patients in a large university-affiliated HD center in Serbia, and to examine the relationship between various nutritional and nonnutritional factors, and the clinical outcome in the period of 20 months follow-up. The prospective observational cohort study included patients (n = 197) with more than 3 months on HD treatment before entering the study. Global nutritional status was evaluated by the dialysis malnutrition score (DMS). Body mass index (BMI), triceps skinfold thickness (TSF), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC), as well as several laboratory parameters and clinical examination, were recorded. Dose of HD and protein equivalence of nitrogen appearance normalized to ideal body weight (nPNA) were evaluated by the urea kinetic model. Mortality data were collected prospectively during the 20 months of follow-up. A moderate/severe degree of malnutrition was presented in 39.2% of female and 22.8% of male patients, while signs of mild malnutrition existed in 45.5% and 66.9% of patients, respectively. Kaplan-Meier survival analysis showed that in the entire group of patients with DMS score >10, the mortality rate was higher (log rank 5.61; P < 0.05) than in those with DMS score <or=10. Multiple logistic regression analysis (after adjusting for age and gender) showed that the predictors of malnutrition were: comorbidity expressed as index of coexistent diseases (ICED) (odds ratio [OR] 10.2; P < 0.001), length of time on HD treatment before entering the study (OR 1.29; P < 0.05), and nPNA (OR 23.62; P < 0.05). At the end of the 20 months follow-up period, a total of 40 patients died (20.3%) with cardiovascular diseases as the main cause of death (45% of the cases). After adjusting for age and sex, only comorbid medical problems expressed as ICED (OR 5.28; P < 0.01), DMS (OR 1.21; P < 0.01), and C-reactive protein (CRP) (OR 1.04; P < 0.05) were significant predictors of mortality. In conclusion, malnutrition in the Serbian cohort of patients on HD was very common. Nutritional status at enrollment (expressed as DMS), presence of comorbidity (ICED index), and CRP level were strong predictors of mortality during the 20 months of follow-up.

Use of the Dialysis Malnutrition Score to assess the nutritional status of mexican patients on maintenance hemodialysis.

Use of the Dialysis Malnutrition Score to assess the nutritional status of mexican patients on maintenance hemodialysis.

Association between serum ferritin and measures of inflammation, nutrition and iron in haemodialysis patients.

Serum ferritin is a frequently used marker of iron status in dialysis patients. Iron administration is to be withheld for ferritin values >800 ng/ml according to K/DOQI guidelines. We hypothesized that such non-iron-related factors as elements of the malnutrition-inflammation complex syndrome (MICS) may increase serum ferritin concentration independently of iron status. We studied 82 prevalent maintenance haemodialysis (MHD) patients (including 43 men), aged 55.7 +/- 15.3 years. The inflammatory and nutritional status was evaluated by serum C-reactive protein (CRP), Subjective Global Assessment (SGA) and its newer, fully quantitative versions, i.e. Dialysis Malnutrition Score (DMS) and Malnutrition-Inflammation Score (MIS). All but six patients had been on maintenance doses of intravenous iron dextran (between 100 and 200 mg/month) during the 10 weeks prior to the measurements. Serum ferritin levels were increased across SGA categories: (ANOVA P-value 0.03). Both unadjusted and multivariate adjusted correlation coefficients (r) for serum ferritin and CRP vs pertinent values were statistically significant for DMS and MIS and some other measures of nutritional status and iron indices. After deleting 10 MHD patients with either iron deficiency (ferritin <200 ng/ml) or iron overload (ferritin >2000 ng/ml), in the remaining 72 MHD patients both bivariate and multivariate correlations were much stronger and statistically significant (r = -0.33 and -0.29, respectively, P < 0.01). A multivariate model showed simultaneous, significant correlations between serum ferritin and both markers of inflammation and iron status independent of each other. After dividing the 72 MHD patients into two groups of serum ferritin based on a K/DOQI recommended serum ferritin cut-off of 800 ng/ml, the MIS and logarithm of serum CRP were significantly higher in the higher ferritin group. Serum ferritin values in the range of 200-2000 ng/ml may be increased due to non-iron-related factors including elements of MICS.

A Malnutrition-Inflammation Score is correlated with morbidity and mortality in maintenance hemodialysis patients

Malnutrition inflammation complex syndrome (MICS) occurs commonly in maintenance hemodialysis (MHD) patients and may correlate with increased morbidity and mortality. An optimal, comprehensive, quantitative system that assesses MICS could be a useful measure of clinical status and may be a predictor of outcome in MHD patients. We therefore attempted to develop and validate such an instrument, comparing it with conventional measures of nutrition and inflammation, as well as prospective hospitalization and mortality. Using components of the conventional Subjective Global Assessment (SGA), a semiquantitative scale with three severity levels, the Dialysis Malnutrition Score (DMS), a fully quantitative scoring system consisting of 7 SGA components, with total score ranging between 7 (normal) and 35 (severely malnourished), was recently developed. To improve the DMS, we added three new elements to the 7 DMS components: body mass index, serum albumin level, and total iron-binding capacity to represent serum transferrin level. This new comprehensive Malnutrition-Inflammation Score (MIS) has 10 components, each with four levels of severity, from 0 (normal) to 3 (very severe). The sum of all 10 MIS components ranges from 0 to 30, denoting increasing degree of severity. These scores were compared with anthropometric measurements, near-infrared-measured body fat percentage, laboratory measures that included serum C-reactive protein (CRP), and 12-month prospective hospitalization and mortality rates. Eighty-three outpatients (44 men, 39 women; age, 59 ± 15 years) on MHD therapy for at least 3 months (43 ± 33 months) were evaluated at the beginning of this study and followed up for 1 year. The SGA, DMS, and MIS were assessed simultaneously on all patients by a trained physician. Case-mix-adjusted correlation coefficients for the MIS were significant for hospitalization days (r = 0.45; P < 0.001) and frequency of hospitalization (r = 0.46; P < 0.001). Compared with the SGA and DMS, most pertinent correlation coefficients were stronger with the MIS. The MIS, but not the SGA or DMS, correlated significantly with creatinine level, hematocrit, and CRP level. During the 12-month follow-up, 9 patients died and 6 patients left the cohort. The Cox proportional hazard-calculated relative risk for death for each 10-unit increase in the MIS was 10.43 (95% confidence interval, 2.28 to 47.64; P = 0.002). The MIS was superior to its components or different subversions for predicting mortality. The MIS appears to be a comprehensive scoring system with significant associations with prospective hospitalization and mortality, as well as measures of nutrition, inflammation, and anemia in MHD patients. The MIS may be superior to the conventional SGA and the DMS, as well as to individual laboratory values, as a predictor of dialysis outcome and an indicator of MICS. © 2001 by the National Kidney Foundation, Inc.

A modified quantitative subjective global assessment of nutrition for dialysis patients.

Malnutrition, a predictor of increased mortality in dialysis patients, can be estimated using the subjective global assessment (SGA), a semiquantitative scale with three severity levels. This semiquantitative feature restricts the SGA's reliability and precision. Using the components of the conventional SGA, we developed a fully quantitative scoring system (the dialysis malnutrition score) consisting of seven variables: weight change, dietary intake, gastrointestinal symptoms, functional capacity, comorbidity, subcutaneous fat and signs of muscle wasting. Each component was assigned a score from 1 (normal) to 5 (very severe). The sum of all seven components in this malnutrition score lies between 7 (normal) and 35 (severely malnourished). To evaluate nutritional status in chronic dialysis patients, anthropometric measurements including mid-arm circumference (MAC), triceps skin-fold thickness, calculated mid-arm muscle circumference (MAMC), body mass index (BMI, ratio of weight to square of height) and laboratory parameters were used. Forty-one patients (20 men and 21 women) were randomly selected from a pool of 120 haemodialysis patients. Patients were aged between 26 and 81 years (mean SD, 57 +/- 12 years) and had undergone haemodialysis for between 7 months and 12 years (mean +/- SD, 3.0 +/- 2.1 years). The malnutrition score of each patient was assessed by a dietitian within 5-20 min (12.0 +/- 3.5 min) with no knowledge of anthropometric findings. Pearson correlation coefficients between the malnutrition score and biceps skin-fold (r= -0.32) MAC (r= -0.55), MAMC (r= -0.66), BMI (r= -0.35), total iron-binding capacity (TIBC, r= -0.77), the serum albumin concentration (r= -0.36) and total protein (r= -0.33) were all significant, whereas the conventional SGA had significant correlation only with TIBC (r= -0.35) and MAMC (r= -0.37). Malnutrition score showed a significant correlation with age (r= +0.34) and years dialysed (r= +0.28). Multiple regression analysis showed a significant correlation between the malnutrition score and the combination of the MAMC, BMI, serum albumin concentration and TIBC (r= 0.81, P<0.001). There was no correlation between the malnutrition score and sex, urea reduction ratio, protein catabolic rate, and the absolute lymphocyte count. We conclude that our invented malnutrition score, which can be performed in minutes, reliably assesses the nutritional status of haemodialysis patients. We suggest that our malnutrition score may be superior to the SGA. More comparative and longitudinal studies are needed to confirm the validity of this scoring system in nutritional evaluation of dialysis patients.