Protein-energy Nutritional Status Research Articles

Protein-Energy Nutritional Status of Moderately Low Protein Intake-Sago Diets Compared to Sufficiently Protein Intake-Rice Diets in Well-Nourished Lowlanders in Papua, Indonesia

Background: Protein inadequacy is prevalent in developing countries because of the high consumption of starchy staple foods. Sago, as a staple food in Papua Province, was eaten with less protein. This study aimed to analyze the nutritional status of protein-energy in well-nourished adults of the moderately low protein in-take (MLP)-sago group compared to the sufficient protein intake (SP)-rice group, in lowland Mimika, Papua. Methods: This cross-sectional-analytic study was conducted on 50 participants. Twenty-four-hour food recall, body composition, albumin, and complete blood count were used to assess the nutritional status. Results: There were no differences in the body compositions and albumin levels between the MLP-sago and SP-rice groups. Multivariate linear regression showed that the mean corpuscular volume (MCV) (β = -0.524, P = 0.007) was a predictive factor for albumin in the sago group, while in the rice group, hemoglobin (β = 0.354 P = 0.089) and white blood cell counts (β = 0.396, P = 0.059) were predictive factors. Conclusions: The MLP-sago and SP-rice groups exhibited no differences in the body and visceral protein; however different predictors of albumin were found be- tween the groups, suggesting an adaptive mechanism in the MLP-sago group to maintain normal albumin levels.

Algorithm on enteral nutrition in chronic kidney disease

Abstract Patients with chronic kidney disease (CKD) are a heterogenous group regarding the cause and grade of kidney injury, associated risk factors and metabolic complications related to the progression of kidney disease. The presence of comorbidities, especially diabetes mellitus and cardiovascular diseases, adds to the diversity of this patient group. In addition, even an individual patient needs different nutrition interventions in the course of his illness. Nutritional therapy is one of the pillars of CKD treatment from the early stages on. Later it becomes even more important, because the prevalence of patients with protein-energy wasting (PEW) is growing with the declining of renal function. PEW is manifested by poor appetite, low serum levels of albumin, sarcopenia and unintenional weight loss. The causes of PEW in CKD are multifactorial , but all are leading to imbalance between energy and protein intake and demand, and finally in higher susceptibility for infections, frailty and lower quality of life. PEW is also among the strongest predictors of mortality. More and more randomized studies prove the positive effects of nutritional therapy on measures of protein-energy nutritional status. The strongest predictor of outcomes and mortality seems to be low serum albumin, regardless if hypoalbuminemia is of nutritional or non-nutritional (e.g. inflammatory) cause. Also evidence is growing for benefits of enteral nutrition therapy on survival of patients with CKD, at least for the dialysis patients. The evidence for pre-dialysis CKD patients is still scarce. With the periodical nutritional assessment of CKD patients by means of diatery interviews and diaries, biochemical markers, antropometric measures and nutritional scoring systems (MIS, SGA), we can select patients with PEW and start with enteral nutrition therapy. Simultaneously we must identify and treat the reason for malnutrition. We have to start with nutritional counselling to enhance the spontaneous intake of proper nutrients and calories and if not adequate, continue with oral supplements. Enteral nutrition includes also tube feeding, if oral intake is not possible (e.g. a swallow disorder). Enteral intake of nutritients is important for the gastrointestinal system, because it stimulates the metabolism and appetite, keeps the gut barrier intact, which has a major role on the immune system, is physiologic and is cheaper than for example parenteral nutrition. Patients with CKD 3-5 not on dialysis differ from patients with CKD 5 on dialysis treatment, especially, but not exclusively, in their demand for protein intake. In the predialysis era a low protein, low phosphorus diet is indicated (intake < 0,8 g proteins / kg / day), because it lowers the burden of phosphorus and uremic toxins deriving mostly from proteins, decreases metabolic acidosis and pobably slows the progression of renal decline. With counselling and adding protein supplements without or with low phophate content, we can prevent malnutrition, which is otherwise inevitable when adhering to the prescribed diet. With supplements we can also assure that the patient receives 50% proteins of high biological value. Dialysis patients on hemodialysis and peritoneal dialysis have higher demand on protein intake: 1,2 g / kg / day and 1,3 g / kg / day respectively, because of the catabolic processes elicited by the pocedure and losses of amino acids and proteins during the treatment. Oral supplements can make up for the deficit in patients who may not succeed in getting the proper amount of proteins by spontaneous food intake.Besides protein and energy we also have to provide other macro- and micronutrients, like vitamins and minerals, during the therapy. A periodic assessment of the nutrition status during enteral nutrition therapy is necessary to evaluate the efficacy and need for continuing of the interventions. In this presentation an algorithm for enteral nutrition in patients with CKD 3-5 and patients on dialysis is proposed. The algorithm is based on recent guidelines for enteral nutrition in CKD patients and adapted in our clinical practice. Keywords: chronic kidney disease, enteral nutrition, dialysis

Comparing Tests Assessing Protein-Energy Wasting: Relation With Quality of Life

Protein-energy wasting (PEW), a state of decreased bodily protein and energy fuels, is highly prevalent among hemodialysis patients. The best method to determine PEW, however, remains debated. As an independent, negative association between PEW and quality of life (QOL) has been demonstrated, establishing which nutrition-related test correlates best with QOL may help to identify how PEW should preferably be assessed. Data were used from CONTRAST, a cohort of end-stage kidney disease patients. At baseline, Subjective Global Assessment (SGA), Malnutrition Inflammation Score (MIS), Geriatric Nutritional Risk Index, composite score on protein-energy nutritional status, normalized protein nitrogen appearance, body mass index, serum albumin, and serum creatinine were determined. QOL was assessed by the Kidney Disease Quality of Life Short Form 1.3. The present study reports on 2 general and 11 kidney disease-specific QOL scores. Spearman's rho (ρ) was calculated to determine correlations between nutrition-related tests and QOL domains. Twelve months after randomization, a sensitivity analysis was performed to test the robustness of the results. Of 714 patients, 489 representative subjects were available for analysis. All tests correlated with the Physical Component Score, except body mass index. Only SGA and MIS correlated significantly with the Mental Component Score. SGA correlated significantly with 10 of 11 kidney disease-specific QOL domains. The MIS not only correlated significantly with all (11) kidney disease-specific QOL domains but also with higher correlation coefficients. Of the 8 investigated nutrition-related tests, only MIS correlates with all QOL domains (13 of 13) with the strongest associations.

A Comparison of 8 Nutrition-Related Tests to Predict Mortality in Hemodialysis Patients

Protein-energy wasting (PEW) describes a state of decreased protein and energy fuels and is highly prevalent in hemodialysis patients. As PEW is associated with mortality, it should be detected accurately and easily. This study investigated which nutrition-related test predicts mortality and morbidity best in hemodialysis patients. Data were used from CONTRAST, a cohort of end-stage kidney disease patients. Subjective Global Assessment (SGA), Malnutrition Inflammation Score (MIS), Geriatric Nutritional Risk Index (GNRI), composite score of Protein-Energy Nutritional Status (cPENS), serum albumin, serum creatinine, body mass index, and normalized protein nitrogen appearance rate were assessed at baseline. End points were all-cause mortality, cardiovascular events, and infection. Discriminative value of every test was assessed with Harrell's C statistic and calibration tested using the Hosmer-Lemeshow goodness-of-fit test. Ultimately, in every test, 4 groups were created to compare (1) hazard ratios (HR; worst vs best group), (2) HR increase per group, and (3) HR of worst group versus other groups. In total, 489 patients were analyzed. Median follow-up was 2.97 years (interquartile range, 1.67-4.47 years). MIS, GNRI, albumin, and creatinine discriminated all-cause mortality equally. SGA, cPENS, body mass index, and normalized protein nitrogen appearance were inferior. cPENS and creatinine were inadequately calibrated. Of the remaining tests, GNRI predicted mortality less when comparing HRs. MIS and albumin predicted mortality equally well. In a subanalysis, these also predicted infection equally well, but MIS predicted cardiovascular events better. Of the 8 investigated nutrition-related tests, MIS and albumin predict mortality best in hemodialysis patients. As one has no added value over the other, we conclude that mortality is most easily predicted in hemodialysis patients by serum albumin.

Prevalence of protein-energy undernutrition evaluated by the measurement of triceps skinfold thickness and mid-arm muscle circumference of 103 adults with cirrhosis of the liver hospitalized in the department of hepatology and gastroenterology of the Lomé Campus University Hospital (Togo)

To evaluate by a reliable method the protein-energy nutritional status of adults hospitalized in the hepatology and gastroenterology department of the Lomé Campus University Hospital. This cross-sectional prospective study conducted from March 1 to September 15, 2012, included 103 inpatients aged at least 16 years. The variables evaluated were: triceps skinfold thickness (TST), mid-arm muscle circumference (MAMC), serum albumin, CRP, and orosomucoid. The Child-Pugh classification was used to evaluate the clinical severity of liver disease. Within this population of patients with cirrhosis, 40 were alcohol-dependent (39.0%) and 85 had anorexia (82.5%); 49 were in group B of the Child-Pugh classification, and 37 in group C. We found a non-significant (p = 0.324) difference in TST measurement between the three Child-Pugh groups: A (8.4 ± 4.5); B (6.1 ± 3.7); and C (6.4 ± 7.2). The prevalence of protein-energy malnutrition ranged from 52.0% to 82.5%, when evaluated by MAMC or TST. Our results confirm the need to pay additional attention to the protein-energy nutritional status of inpatients in this department, by adding reliable tools, such as the TST and MAMC, to the biochemistry analysis to characterize undernutrition.

AB0201 Assessment of protein-energy nutritional status and physical activity of ankylosing spondylitis and rheumatic arthritis patients - preliminary report.

BackgroundActive rheumatic diseases can lead to malnutrition. However, the influence of the remission on the nutritional status is not clear.ObjectivesTo assess nutritional status and physical activity in ankylosing spondylitis (AS)...

Effectiveness of Dietetic Intervention on Nutritional Status and Hydration Status in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients

In Hong Kong, more than 3,000 patients with end-stage renal failure (ESRF) on CAPD in 20091. Protein-energy malnutrition and volume overload are common problems in CAPD patients and associated with high morbidity and mortality2-6. Hyperphosphatemia is also a frequent complication in Chinese CAPD patients and is associated with development of renal bone disease or osteodystrophy7. The Kidney Dialysis Outcomes Quality Initiative (KDOQI) guidelines suggested a combination of valid, complementary measures should be used to assess nutritional status in CAPD patients and anthropometric measurements are valid and clinically useful indicators of protein-energy nutritional status in maintenance dialysis patients8. Bioelectrical Impedance Analysis (BIA), which is a simple, inexpensive and non-invasive method, provides another powerful tool for monitoring of nutrition and hydration in CAPD patients9—10. The objective of this study is to evaluate the effectiveness of dietetic intervention in a local acute hospital on nutritional status and hydration status of patients on CAPD in outpatient setting. This is a retrospective study of 22 ESRF patients receiving dietetic intervention during CAPD training from February 2010 to January 2011. Patients with cognitive impairment or contraindicated with bioimepdence analysis (BIA) were excluded. Baseline demographic and clinical data were retrieved from the dietetic consultation record and the electronic records in Clinical Management System (CMS). The parameters related to the nutrition and hydration status in the first and follow-up dietetic consultation were also collected from the record. They included the dietary protein and energy intakes estimated from the dietary history, anthropometric measurements such as weight, height, body mass index (BMI), skeletal muscle mass (SMM), body fat mass (BFM), body fat percentage (BF%), intracellular water (ICW), extracellular water (ECW) measured by body composition analyzer (InBody720, Biospace Inc., UK), and the biochemical parameters such as albumin, haemoglobin, sodium, potassium, urea, creatinine and phosphate.

Protein-Energy Nutritional Status and Kidney Disease-specific Quality of Life in Hemodialysis Patients

Health-related quality of life (HRQOL) is an important outcome in dialysis care. Previous research has related protein-energy nutritional status to generic HRQOL domains, but it is still not clear as to how it relates to HRQOL domains that are unique to hemodialysis patients. Therefore, our aim was to study the relation between protein-energy nutritional status and kidney disease-specific HRQOL domains in hemodialysis patients. This was a cross-sectional study. This study was performed at multiple centers. We evaluated the first 590 hemodialysis patients who had enrolled in the Convective Transport Study. We measured protein-energy nutritional status by using the Subjective Global Assessment, albumin, normalized nitrogen appearance, creatinine, body mass index, and cholesterol. HRQOL was assessed by using the Kidney Disease Quality Of Life-Short Form. In all, 83% of the cohort was found to be well-nourished on the basis of the Subjective Global Assessment. Multiple nutritional parameters were positively related to the physical summary of generic HRQOL and to the following kidney disease-specific HRQOL scales: the effects of the kidney disease on daily life, the burden of the kidney disease, and overall health. This study showed that, even in predominantly well-nourished hemodialysis patients, protein-energy nutritional status was significantly related to kidney disease-specific HRQOL.

A composite score of protein-energy nutritional status predicts mortality in haemodialysis patients no better than its individual components

Protein-energy wasting is tightly associated with mortality in haemodialysis patients. An expert panel of the International Society of Renal Nutrition and Metabolism (ISRNM) has published a consensus on the parameters that define protein-energy nutritional status and posed the question, 'which scoring system most effectively predicts outcome?' The aim of our study was therefore to develop a composite score of protein-energy nutritional status (cPENS) and to assess its prediction of all-cause mortality. We used the data of 560 haemodialysis patients participating in the CONvective TRAnsport STudy (CONTRAST). All participants were followed for occurrence of death. Internationally recommended nutritional targets were used as components of the cPENS, including the subjective global assessment (target score ≥ 6), albumin (≥ 4.0g/dL), normalized protein nitrogen appearance (≥ 0.8g/kg/day), cholesterol (≥ 100mg/dL), creatinine (≥ 10mg/dL) and BMI (> 23kg/m(2)). A Cox regression model was used to analyse the relation between different cPENS variants and mortality. The median follow-up time was 1.4years (max 4.2). One hundred and five patients (19%) died. A cPENS variant based on albumin, BMI, creatinine and the nPNA yielded the strongest relation with mortality (hazard ratio 0.63, 95% confidence interval 0.54-0.74, P < 0.001), after adjustments for confounders. Some of the individual parameters of the cPENS, notably albumin and creatinine, were related to mortality with similar strength and magnitude. In conclusion, albumin reflects mortality risk similarly to multiple nutritional parameters combined. This questions the clinical value of the proposed diagnostic criteria for protein-energy wasting.

L-carnitine infusions may suppress serum C-reactive protein and improve nutritional status in maintenance hemodialysis patients

Scattered reports indicate that L-carnitine may suppress proinflammatory cytokines in sick individuals without renal disease and may improve protein synthesis or nitrogen balance either in patients without renal disease or in maintenance hemodialysis (MHD) or chronic peritoneal dialysis patients. We conducted an experimental study in MHD patients to evaluate the effects of L-carnitine treatment on inflammatory and protein-energy nutritional status. MHD patients were assigned to receive intravenous injections of L-carnitine 20 mg/kg (n = 48) or placebo (n = 65) thrice weekly at the end of each hemodialysis treatment for 6 months. The carnitine-treated group showed a statistically significant decrease in serum C-reactive protein and increase in serum albumin and transferrin, blood hemoglobin, and body mass index. Conversely, in the placebo-treated group, a significant decrease was reported for serum albumin, serum transferrin, and body mass index, whereas the other considered measures did not change significantly. These preliminary findings suggest that in MHD patients, L-carnitine therapy may suppress inflammation, particularly among those patients with C-reactive protein > or =3 mg/dL, and may improve protein-energy nutritional status.

Improvement of nutritional status after initiation of maintenance hemodialysis

Background: Recent data suggest that serum albumin concentrations increase during the several month-period that follows the initiation of maintenance hemodialysis (MHD) therapy. Some investigators have shown that the rate of increase in serum albumin level is related directly to 24-hour urine protein losses before the initiation of dialysis therapy. However, serum albumin levels increase even in patients starting MHD therapy without significant proteinuria, suggesting that this increase may be one manifestation of improving protein-energy nutritional status associated with commencing MHD therapy. We examined this question by reviewing records of all patients admitted to our outpatient dialysis unit within 30 days of initiation of MHD therapy. Methods: Ninety-seven patients qualified for the study. Their routine laboratory test results beginning with the time of admission to the outpatient unit until month 6 of chronic dialysis therapy were analyzed. Results: Between months 1 and 6, there was a statistically significant increase in values for predialysis serum albumin, iron, transferrin saturation, creatinine, and normalized protein equivalent of total nitrogen appearance (nPNA). Many of these values were still increasing by month 6. Body weight declined initially until month 4, then increased. There was a strong curvilinear relationship between mean nPNA and final serum albumin level. Conclusions: Our results suggest that an improvement in nutritional status, including an increase in dietary protein intake and serum albumin level, often occurs with the initiation of MHD therapy. The improvement in nutritional status may be related to the increase in dietary protein intake. © 2002 by the National Kidney Foundation, Inc.

Effect of creatinine generation rate on the relationship between hemodialysis prescription and health-related quality of life

Reports to date have indicated no strong relationship between hemodialysis (HD) prescription and health-related quality of life (HRQOL). However, none of these reports addressed the effect of protein-energy nutritional status on the relationship between HD prescription and HRQOL. Thus, taking the creatinine (Cr) generation rate as a marker of protein-energy nutritional status, we divided maintenance HD patients into two groups with high and low Cr generation rates compared with the average rate. We then investigated the relationship between HD prescription and HRQOL in the two groups. The subjects were 1887 patients receiving HD three times weekly. Together with conducting an HRQOL survey using SF-36 on these patients, we surveyed Kt/V, K/V, and Cr generation rate. In the present study, K/V (the marker of HD efficiency) was obtained by dividing Kt/V by the duration of the HD session. Lower HRQOL scores tended to be associated with higher Kt/V only in patients with a low Cr generation rate; in patients with a high Cr generation rate, almost no association was found between Kt/V and HRQOL scores. In patients with a low Cr generation rate, lower HRQOL scores were associated with higher K/V, whereas in those with a high Cr generation rate, there was almost no association between K/V and HRQOL scores. In terms of duration of the HD session, almost no relationship was found between HD prescription and HRQOL scores in other patient group. These results suggest that a high HD efficiency lowers HRQOL among patients with poor protein-energy nutritional status. In such patients, HRQOL could be improved by extending the duration of the HD session with lowering of the HD efficiency.

Observations with Regard to the National Kidney Foundation K/DOQI Clinical Practice Guidelines Concerning Serum Transthyretin in Chronic Renal Failure

The National Kidney Foundation K/DOQI Guidelines state that, "Serum prealbumin is a valid and clinically useful measure of protein-energy nutritional status in maintenance dialysis (MD) patients." Prealbumin, also known as serum transthyretin (TTR), was not recommended as a nutritional parameter of the same usefulness as the serum albumin. This decision was made, in part, because published research at that time suggested that serum TTR was not a more sensitive index of nutritional status than serum albumin and there was much more clinical and research experience with serum albumin as a nutritional and inflammatory marker. Evidence, including more recently published research data, which is reviewed in this paper has led to the following conclusions by the current authors: 1) In MD patients either protein-energy malnutrition or inflammation can lead to a reduction in serum TTR concentrations. 2) Hence, in MD patients, serum TTR concentrations can be used as a measure of both nutritional and inflammatory status. 3) Serum TTR concentrations are typically increased in MD patients. 4) In maintenance hemodialysis (MHD) patients, serum TTR is a risk factor for mortality that is somewhat independent of serum albumin. 5) Current epidemiological evidence suggests that a serum TTR value of 25 or 30 mg/dl or greater is associated with increased survival and, hence, is desirable in MHD patients. 6) MHD patients with serum TTR levels less than 25-30 mg/dl should be evaluated for protein-energy malnutrition and inflammation.

National Kidney Foundation K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Renal Failure was recently published in the American Journal of Kidney Diseases . This publication provides 27 clinical practice guidelines for adults and 10 clinical practice guidelines for children. The adult guidelines focus primarily on patients undergoing maintenance dialysis therapy, although there are several clinical practice guidelines on nutritional issues for patients with advanced chronic renal failure (CRF) not undergoing dialysis therapy. The pediatric guidelines focus entirely on children undergoing maintenance dialysis treatment. The present article discusses a number of the more prominent clinical practice guidelines for the adults. Among these is the recommendation that the protein-energy nutritional status in these patients should be assessed by a panel of measures rather than by any single measure. Also, non-dialyzed patients with advanced CRF (ie, glomerular filtration rate <25 mL/min) and those undergoing maintenance hemodialysis or chronic peritoneal dialysis should be prescribed a dietary energy intake of 35 kcal/kg/day for patients who are <60 years of age and 30 kcal/kg for patients ≥60 years of age. Maintenance hemodialysis patients should be prescribed 1.2 g protein/kg/d; chronic peritoneal dialysis patients should be prescribed 1.2 to 1.3 g protein/kg/d. For non-dialyzed patients with CRF (glomerular filtration rate <25 mL/min), 0.60 g protein/kg/d should be prescribed. For patients who will not accept such a diet or are unable to maintain an adequate energy intake on that diet, a protein intake of up to 0.75 g protein/kg/d may be prescribed. At least 50% of the protein intake for all of these patients should be of high biologic value. A guideline concerning indications for inaugurating maintenance dialysis treatment or renal transplantation on the basis of deteriorating nutritional status is also given.

Prealbumin is as important as albumin in the nutritional assessment of hemodialysis patients

Although serum prealbumin is considered a valid indicator of nutritional status in hemodialysis patients, there is relatively little evidence that its determination is of major prognostic significance. In this study, we aimed to determine the independent association of serum prealbumin with survival in hemodialysis patients, after adjusting for serum albumin and other indicators of protein energy nutritional status. Serum prealbumin was measured in more than 1600 maintenance hemodialysis patients. We determined the correlations among prealbumin and other indicators of nutritional status, including serum albumin, and bioimpedance-derived indicators of body composition. The relationship between serum prealbumin and survival was determined using proportional hazards regression. The serum albumin was directly correlated with the serum prealbumin (r = 0.47, P < 0.0001), but still explained <25% of the variability in prealbumin. Prealbumin was inversely related to mortality, with a relative risk reduction of 6% per 1 mg/dL increase in prealbumin, even after adjusting for case mix, serum albumin, and other nutritional indicators. The increase in risk with lower serum prealbumin concentrations was observed whether the serum albumin was high or low. In hemodialysis patients, the serum prealbumin provides prognostic value independent of the serum albumin and other established predictors of mortality in this population.

Relationship between nutritional status and the glomerular filtration rate: Results from the MDRD Study

The relationship between the protein-energy nutritional status and renal function was assessed in 1785 clinically stable patients with moderate to advanced chronic renal failure who were evaluated during the baseline phase of the Modification of Diet in Renal Disease Study. Their mean +/- SD glomerular filtration rate (GFR) was 39.8 +/- 21.1 mL/min/1.73 m2. The GFR was determined by 121I-iothalamate clearance and was correlated with dietary and nutritional parameters estimated from diet records, biochemistry measurements, and anthropometry. The following parameters correlated directly with the GFR in both men and women: dietary protein intake estimated from the urea nitrogen appearance, dietary protein and energy intake estimated from dietary diaries, serum albumin, transferrin, percentage body fat, skinfold thickness, and urine creatinine excretion. Serum total cholesterol, actual and relative body weights, body mass index, and arm muscle area also correlated with the GFR in men. The relationships generally persisted after statistically controlling for reported efforts to restrict diets. Compared with patients with GFR > 37 mL/min/1.73 m2, the means of several nutritional parameters were significantly lower for GFR between 21 and 37 mL/min/1.73 m2, and lower still for GFRs under 21 mL/min/1.73 m2. In multivariable regression analyses, the association of GFR with several of the anthropometric and biochemical nutritional parameters was either attenuated or eliminated completely after controlling for protein and energy intakes, which were themselves strongly associated with many of the nutritional parameters. On the other hand, few patients showed evidence for actual protein-energy malnutrition. These cross-sectional findings suggest that in patients with chronic renal disease, dietary protein and energy intakes and serum and anthropometric measures of protein-energy nutritional status progressively decline as the GFR decreases. The reduced protein and energy intakes, as GFR falls, may contribute to the decline in many of the nutritional measures.

Nutritional assessment and serum zinc and copper concentration in leukemic children.

Malnutrition in childhood cancer is commonly a serious problem. Changes in blood zinc and copper have also been found in malignant diseases. To describe the protein-energy nutritional status and serum zinc and copper of children with newly diagnosed leukemia. Cross-sectional study. University referral center. 23 children with newly diagnosed acute lymphocytic leukemia (ALL) or acute non-lymphocytic leukemia (ANLL) between the ages of 1 and 10 years. The control subjects were 31 healthy school children of similar age from local schools. Anthropometric measurements of height/age and weight/height, food intake and serum levels of zinc and copper. Almost the entire group of children were eutrophic. Zinc and copper intake were below the recommended values. Serum zinc levels were significantly lower and serum copper levels were significantly higher in the leukemic group when compared to normal children. At the time of diagnosis the children suffering from leukemia were not overtly malnourished but blood analysis showed alterations in concentrations of the trace elements zinc and copper.

Nutritional Status as a Predictor of Morbidity and Mortality in Maintenance Dialysis Patients

Many epidemiologic studies indicate that protein-energy malnutrition is a strong predictor of morbidity and mortality in maintenance hemodialysis and chronic peritoneal dialysis patients. Those parameters of protein-energy malnutrition that have been most clearly associated with morbidity or mortality include serum albumin, dietary protein intake as indicated by the protein equivalent of total nitrogen appearance (PNA, also referred to as PCR), and the predialysis serum urea nitrogen. In large scale clinical surveys, low predialysis serum creatinine, cholesterol, potassium, phosphorus, calcium, and bicarbonate also correlate with increased mortality rates in maintenance hemodialysis patients. These correlations may reflect an association between dietary intake and mortality. The paucity of data correlating energy intake or body composition (e.g., total body protein or nitrogen, skeletal muscle mass, total body fat) with clinical outcome may reflect the difficulty of obtaining these data in large scale prospective or retrospective analyses. The correlation between protein-energy malnutrition and increased morbidity and mortality rates does not prove that a higher protein and/or energy intake or a more optimal body composition will improve the patient's outcome. Prospective, randomized studies will be necessary to examine this question. However, two retrospective analyses of the effect of intradialytic parenteral nutrition on mortality rates in maintenance hemodialysis patients are consistent with the thesis that increased nutrient intake will reduce mortality in maintenance hemodialysis patients. Methods for assessing protein-energy nutritional status are discussed. There are essentially no data indicating that the more complicated and expensive techniques for nutritional assessment have important advantages over the more simple methods for the clinical management of maintenance dialysis patients.

Laboratory assessment of protein-energy status

Laboratory and non-laboratory methods for assessing protein-energy nutritional status are reviewed. These are classified into methods for assessing adequacy of recent nutritional intake, methods for assessing whole body status, and tests which assist in the interpretation of these assessments. Each measurement is critically discussed in terms of the rationale for its use, the method of analysis, reference values, technical interference and limitations of methods, the effects of nutritional status and of other factors on the results, its overall usefulness in nutritional assessment, and its value relative to other methods. Non-laboratory tests, such as dietary assessment, indirect calorimetry, functional tests and the many methods available for assessment of body composition, including anthropometry, bioelectrical impedance and isotope and imaging techniques, are compared with the clinical chemistry tests in common use, such as nitrogen balance, plasma protein measurements and urinary markers of muscle metabolism. This review provides comprehensive and practical advice on the use and limitations of these tests in the assessment of protein-energy nutritional status of a group, or of an individual patient.

The risk of life-threatening complications in a select population of geriatric patients: the impact of nutritional status.

The primary objective of this study was to assess the interrelationship between protein-energy nutritional status, disease severity, and life-threatening complications in a population of elderly rehabilitation patients. Three-hundred and fifty randomly selected admissions to Geriatric Rehabilitation Unit of a Veterans Administration hospital were prospectively studied. The average age of the study subjects was 76 years, nearly all (99%) were male, and 75% were white. At admission, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications. Of the 96 variables evaluated, the best predictors of developing at least one life-threatening complication were serum albumin, body mass index, the presence of renal disease (i.e. blood urea nitrogen > 30 mg/L), the Katz Index of Activities of Daily Living score, and the amount of weight loss in the year prior to admission. When all of these variables were included in the logistic regression analysis, the final model was highly significant by the -2Log Likelihood Chi-square goodness-of-fit criterion (Chi-square of 64.1 with 5 d.f., p < 0.0001) with a sensitivity of 77%, a specificity of 77% and an overall predictive accuracy of 77%. When the predictive accuracy of the logistic model was tested using a second sample of 110 patients, the model differentiated those who developed a life-threatening complication from those who had not with a sensitivity of 88%, a specificity of 61%, and an overall predictive accuracy of 65%. As indicated by the Chi-square test, these results were significant (p < 0.0001). Protein-energy undernutrition appears to be a strong independent risk factor for life-threatening morbidity during hospitalization.