NDT Advance Access originally published online on April 6, 2004
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Nephrol Dial Transplant (2004) 19: 1507-1519
Nephrol Dial Transplant Vol. 19 No. 6 © ERA-EDTA 2004; all rights reserved
Original Article
Comparing outcome predictability of markers of malnutrition–inflammation complex syndrome in haemodialysis patients
1Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA, 2Division of Nephrology, San Francisco General Hospital, San Francisco, CA and 3Public Health Nutrition and Epidemiology, UC Berkeley, Berkeley, CA, USA
Correspondence and offprint requests to: Kamyar Kalantar-Zadeh, MD, MPH, PhD Assistant Professor of Medicine and Pediatrics, Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Harbor Mailbox 406, 1000 West Carson Street, Torrance, CA 90509-2910, USA. Email: kamkal{at}ucla.edu
Background. Markers of malnutrition–inflammation complex syndrome (MICS) are reported to predict mortality and hospitalization in maintenance haemodialysis (MHD) patients. However, it is not clear which one is a more sensitive and stronger predictor of outcome.
Methods. We examined the utility of 10 markers of MICS as predictors of prospective mortality and hospitalization, which included malnutrition–inflammation score (MIS), a fully quantitative score adopted from subjective global assessment, and serum levels of C-reactive protein (CRP), interleukin-6 (IL-6), tumour necrosis factor-
(TNF-), albumin, pre-albumin, total iron binding capacity, creatinine, total cholesterol and normalized protein nitrogen appearance. A cohort of 378 MHD patients, who were randomly selected from eight DaVita dialysis facilities in the South Bay Los Angeles area, was studied.
Results. Patients, aged 54.5±14.7 years, included 53% men, 47% Hispanics, 30% African-Americans and 55% diabetics, who had undergone MHD for 37±34 months. Over a 12-month follow-up, 39 patients died and 208 were hospitalized at least once. Multivariate Cox and Poisson models that included 11 covariates [gender, age, race, ethnicity, diabetes, dialysis vintage, Charlson co-morbidity index (CCI), insurance status, Kt/V, body mass index and history of cardiovascular disease] were explored for the highest quartiles of inflammatory markers or the lowest quartiles of nutritional markers. The magnitude of relative risk of death and hospitalization was greatest for MIS, CRP and IL-6. In extended multivariate models that included all 10 MICS markers and 11 additional covariates simultaneously, CRP, MIS and CCI were the only consistent predictors of mortality and hospitalization, and their outcome predictabilities were superior to serum albumin.
Conclusions. The MIS appears to be a useful, short-term tool to risk-stratify MHD patients and may circumvent the need for measuring inflammatory markers such as CRP or IL-6.
Keywords: cytokines; haemodialysis; hospitalization; mortality; malnutrition–inflammation complex syndrome; reverse epidemiology
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