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Association of geriatric nutritional risk index with infection-related mortality in patients undergoing hemodialysis: The Q-Cohort Study.
Clin Nutr. 2019 02; 38(1):279-287.CN

Abstract

BACKGROUND & AIMS

The geriatric nutritional risk index (GNRI) is a simple but useful nutritional marker for all-cause mortality and cardiovascular mortality in patients undergoing hemodialysis (HD). However, whether the GNRI can predict infection-related mortality in patients undergoing HD remains unclear, and there is insufficient evidence regarding whether the GNRI improves the predictive value for risk assessment beyond the existing conventional nutritional markers. Here, we investigated the association between the GNRI and infection-related mortality in patients undergoing HD and evaluated the predictive value of GNRI.

METHODS

A prospective cohort study was performed on a total of 3436 Japanese HD patients aged ≥18 years. Patients were divided into four groups by quartiles of GNRI: (Quartile 1 [Q1], >100.2; Q2, 95.9-100.2; Q3, 90.8-95.8; Q4, <90.8). We estimated the relationship between GNRI and all-cause mortality and infection-related mortality using a Cox proportional hazards model. To assess the additional predictive value of the GNRI in risk assessment, we compared the c-statistic, net reclassification improvement, and integrated discrimination improvement among serum albumin, serum creatinine, and the GNRI.

RESULTS

During follow-up period (median, 4.0 years), a total of 564 patients died; 120 of these patients died of infectious disease. All-cause mortality and infection-related mortality increased linearly with lower GNRI levels. After adjusting for confounding risk factors, the GNRI was an independent predictor of infection-related mortality as well as all-cause mortality (hazard ratio [HR], 5.89; 95% confidence interval [CI], 2.85-13.8; P < 0.001 for Q4 vs. Q1, HR, 2.62; 95% CI, 1.23-6.24; P = 0.01 for Q3 vs. Q1). Additionally, when the GNRI was incorporated into a model with potential risk factors instead of serum albumin, the c-statistic increased significantly (0.811 vs. 0.821, P = 0.03), and the net reclassification improvement and integrated discrimination improvement was 0.26 (P = 0.005) and 0.005 (P = 0.01). This association was more apparent in the older patients (0.739 vs. 0.760, P = 0.02) than in the younger patients (0.916 vs. 0.912, P = 0.35). Similar results were observed between serum creatinine and the GNRI, but the difference did not reach statistical significance.

CONCLUSIONS

Lower GNRI levels are an independent risk factor for infection-related mortality in patients undergoing HD. Moreover, addition of the GNRI to models with standard risk factors significantly improves the predictive ability of infection-related mortality, especially in older patients.

Authors+Show Affiliations

Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Division of Internal Medicine, Fukuoka Dental College, 2-15-1 Tamura, Sawara-ku, Fukuoka 814-0175, Japan.Fukuoka Renal Clinic, 4-6-20 Watanabedori, Chuo-ku, Fukuoka 810-0004, Japan.Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.Fukuoka Renal Clinic, 4-6-20 Watanabedori, Chuo-ku, Fukuoka 810-0004, Japan.Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. Electronic address: tsuruya@intmed2.med.kyushu-u.ac.jp.

Pub Type(s)

Journal Article
Multicenter Study
Observational Study
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

29398335

Citation

Matsukuma, Yuta, et al. "Association of Geriatric Nutritional Risk Index With Infection-related Mortality in Patients Undergoing Hemodialysis: the Q-Cohort Study." Clinical Nutrition (Edinburgh, Scotland), vol. 38, no. 1, 2019, pp. 279-287.
Matsukuma Y, Tanaka S, Taniguchi M, et al. Association of geriatric nutritional risk index with infection-related mortality in patients undergoing hemodialysis: The Q-Cohort Study. Clin Nutr. 2019;38(1):279-287.
Matsukuma, Y., Tanaka, S., Taniguchi, M., Nakano, T., Masutani, K., Hirakata, H., Kitazono, T., & Tsuruya, K. (2019). Association of geriatric nutritional risk index with infection-related mortality in patients undergoing hemodialysis: The Q-Cohort Study. Clinical Nutrition (Edinburgh, Scotland), 38(1), 279-287. https://doi.org/10.1016/j.clnu.2018.01.019
Matsukuma Y, et al. Association of Geriatric Nutritional Risk Index With Infection-related Mortality in Patients Undergoing Hemodialysis: the Q-Cohort Study. Clin Nutr. 2019;38(1):279-287. PubMed PMID: 29398335.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of geriatric nutritional risk index with infection-related mortality in patients undergoing hemodialysis: The Q-Cohort Study. AU - Matsukuma,Yuta, AU - Tanaka,Shigeru, AU - Taniguchi,Masatomo, AU - Nakano,Toshiaki, AU - Masutani,Kosuke, AU - Hirakata,Hideki, AU - Kitazono,Takanari, AU - Tsuruya,Kazuhiko, Y1 - 2018/02/15/ PY - 2016/11/01/received PY - 2017/07/02/revised PY - 2018/01/11/accepted PY - 2018/2/6/pubmed PY - 2020/3/26/medline PY - 2018/2/6/entrez KW - Geriatric nutritional risk index KW - Hemodialysis KW - Infection-related mortality KW - Malnutrition SP - 279 EP - 287 JF - Clinical nutrition (Edinburgh, Scotland) JO - Clin Nutr VL - 38 IS - 1 N2 - BACKGROUND & AIMS: The geriatric nutritional risk index (GNRI) is a simple but useful nutritional marker for all-cause mortality and cardiovascular mortality in patients undergoing hemodialysis (HD). However, whether the GNRI can predict infection-related mortality in patients undergoing HD remains unclear, and there is insufficient evidence regarding whether the GNRI improves the predictive value for risk assessment beyond the existing conventional nutritional markers. Here, we investigated the association between the GNRI and infection-related mortality in patients undergoing HD and evaluated the predictive value of GNRI. METHODS: A prospective cohort study was performed on a total of 3436 Japanese HD patients aged ≥18 years. Patients were divided into four groups by quartiles of GNRI: (Quartile 1 [Q1], >100.2; Q2, 95.9-100.2; Q3, 90.8-95.8; Q4, <90.8). We estimated the relationship between GNRI and all-cause mortality and infection-related mortality using a Cox proportional hazards model. To assess the additional predictive value of the GNRI in risk assessment, we compared the c-statistic, net reclassification improvement, and integrated discrimination improvement among serum albumin, serum creatinine, and the GNRI. RESULTS: During follow-up period (median, 4.0 years), a total of 564 patients died; 120 of these patients died of infectious disease. All-cause mortality and infection-related mortality increased linearly with lower GNRI levels. After adjusting for confounding risk factors, the GNRI was an independent predictor of infection-related mortality as well as all-cause mortality (hazard ratio [HR], 5.89; 95% confidence interval [CI], 2.85-13.8; P < 0.001 for Q4 vs. Q1, HR, 2.62; 95% CI, 1.23-6.24; P = 0.01 for Q3 vs. Q1). Additionally, when the GNRI was incorporated into a model with potential risk factors instead of serum albumin, the c-statistic increased significantly (0.811 vs. 0.821, P = 0.03), and the net reclassification improvement and integrated discrimination improvement was 0.26 (P = 0.005) and 0.005 (P = 0.01). This association was more apparent in the older patients (0.739 vs. 0.760, P = 0.02) than in the younger patients (0.916 vs. 0.912, P = 0.35). Similar results were observed between serum creatinine and the GNRI, but the difference did not reach statistical significance. CONCLUSIONS: Lower GNRI levels are an independent risk factor for infection-related mortality in patients undergoing HD. Moreover, addition of the GNRI to models with standard risk factors significantly improves the predictive ability of infection-related mortality, especially in older patients. SN - 1532-1983 UR - https://www.unboundmedicine.com/medline/citation/29398335/Association_of_geriatric_nutritional_risk_index_with_infection_related_mortality_in_patients_undergoing_hemodialysis:_The_Q_Cohort_Study_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0261-5614(18)30037-2 DB - PRIME DP - Unbound Medicine ER -