Abstracts
Up to now, there is no single method that provides complete and unambiguous assessment of the nutritional status in chronic kidney disease (CKD). Therefore, it has been recommended the use of many nutritional markers. The subjective global assessment (SGA) contains questions regarding the clinical history and physical examination. Subsequently, other versions of the SGA were developed. The malnutrition inflammation score (MIS) was also developed from the original version of the SGA and consists of 70% of the items common to SGA in addition to objective questions. Since many modifications were proposed in the original form of SGA, the use of these questionnaires in CKD patients has increased substantially in clinical practice. Therefore, this paper aims to review the applicability of the SGA and MIS when applied to assess the nutritional status of CKD patients.
dialysis; malnutrition; nutrition assessment; renal insufficiency, chronic
Até o momento, não há um método único capaz de diagnosticar com fidedignidade a condição nutricional do paciente com doença renal crônica (DRC). Por essa razão, tem se recomendado o emprego de vários marcadores nutricionais. A avaliação global subjetiva (AGS) se baseia na história física e no exame clínico do paciente e, desde sua criação, novas versões foram elaboradas. A partir da AGS, foi criado o malnutrition inflammation score (MIS), composto por 70% das questões comuns à AGS acrescido de questões objetivas do estado nutricional. Como muitas modificações foram feitas na forma original da AGS e o emprego tanto da AGS quanto do MIS em pacientes com DRC aumentou significativamente na prática clínica, este trabalho tem como objetivo fazer uma revisão sobre a aplicabilidade desses métodos para avaliação do estado nutricional em pacientes com DRC.
avaliação nutricional; desnutrição; diálise; insuficiência renal crônica
Introduction
The prevalence of chronic kidney disease (CKD) in Brazil and around the world has
alarmingly increased in recent decades.11. Sesso RC, Lopes AA, Thomé FS, Lugon JR, Watanabe Y, Santos DR.
Diálise crônica no Brasil - Relatório do Censo Brasileiro de Diálise, 2011.
2012;34:272-7. DOI:
http://dx.doi.org/10.5935/0101-2800.20120009
http://dx.doi.org/10.5935/0101-2800.2012...
,22. USRDS. United States Renal Data System Anual Data Report -
Morbidity & Mortality in patients with CKD. 2012;1:11 [Acessed 11 April
2014]. Available from:
http://www.usrds.org/2012/slides/indiv/v1index.html
http://www.usrds.org/2012/slides/indiv/v...
In Brazil,
there is no data describing the CKD prevalence magnitude. However, if the
American reality, estimated in 10% of the population, were to be employed in our
country, we could estimate a prevalence of 15 million individuals with kidney
disease.33. Lugon JR. End-stage renal disease and chronic kidney disease in
Brazil. Ethn Dis 2009;19:S1-7-9.
Although dialysis techniques have advanced continuously, we note that mortality
rates in CKD patients remain high, reaching 20% in the U.S. during the first two
years of hemodialysis (HD).44. Himmelfarb J, Ikizler TA. Hemodialysis. N Engl J Med
2010;363:1833-45. PMID: 21047227 DOI:
http://dx.doi.org/10.1056/NEJMra0902710
http://dx.doi.org/10.1056/NEJMra0902710...
Protein-energy deficit (PED) is a leading cause of morbidity and mortality in
patients with CKD. This finding is typified by an inverse association between
mortality rates and nutritional status markers.55. Kovesdy CP, George SM, Anderson JE, Kalantar-Zadeh K. Outcome
predictability of biomarkers of protein-energy wasting and inflammation in
moderate and advanced chronic kidney disease. Am J Clin Nutr 2009;90:407-14.
PMID: 19535427 DOI: http://dx.doi.org/10.3945/ajcn.2008.27390
http://dx.doi.org/10.3945/ajcn.2008.2739...
,66. Pifer TB, McCullough KP, Port FK, Goodkin DA, Maroni BJ, Held PJ,
et al. Mortality risk in hemodialysis patients and changes in nutritional
indicators: DOPPS. Kidney Int 2002;62:2238-45. PMID: 12427151 DOI:
http://dx.doi.org/10.1046/j.1523-1755.2002.00658.x
http://dx.doi.org/10.1046/j.1523-1755.20...
Furthermore,
it is known that PED is a common nutritional disorder in CKD, ranging from 30%
to 74% in papers which used the subjective global assessment (SGA) for its
diagnosis.77. Campbell KL, Bauer JD, Ikehiro A, Johnson DW. Role of nutrition
impact symptoms in predicting nutritional status and clinical outcome in
hemodialysis patients: a potential screening tool. J Ren Nutr 2013;23:302-7.
DOI: http://dx.doi.org/10.1053/j.jrn.2012.07.001
http://dx.doi.org/10.1053/j.jrn.2012.07....
8. Carrero JJ, Chmielewski M, Axelsson J, Snaedal S, Heimbürger O,
Bárány P, et al. Muscle atrophy, inflammation and clinical outcome in incident
and prevalent dialysis patients. Clin Nutr 2008;27:557-64. DOI:
http://dx.doi.org/10.1016/j.clnu.2008.04.007
http://dx.doi.org/10.1016/j.clnu.2008.04...
9. Leinig CE, Moraes T, Ribeiro S, Riella MC, Olandoski M, Martins
C, et al. Predictive value of malnutrition markers for mortality in peritoneal
dialysis patients. J Ren Nutr 2011;21:176-83. DOI:
http://dx.doi.org/10.1053/j.jrn.2010.06.026
http://dx.doi.org/10.1053/j.jrn.2010.06....
-1010. Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, et
al. Multicenter study of the validity and reliability of subjective global
assessment in the hemodialysis population. J Ren Nutr 2007;17:336-42. DOI:
http://dx.doi.org/10.1053/j.jrn.2007.05.004
http://dx.doi.org/10.1053/j.jrn.2007.05....
PED etiology is multifactorial,
including inadequate food intake, increased protein catabolism and decreased
protein synthesis.1111. Carrero JJ, Stenvinkel P, Cuppari L, Ikizler TA, Kalantar-Zadeh
K, Kaysen G, et al. Etiology of the protein-energy wasting syndrome in chronic
kidney disease: a consensus statement from the International Society of Renal
Nutrition and Metabolism (ISRNM). J Ren Nutr 2013;23:77-90. DOI:
http://dx.doi.org/10.1053/j.jrn.2013.01.001
http://dx.doi.org/10.1053/j.jrn.2013.01....
Considering the high prevalence of PED and its close association with morbidity
and mortality, nutritional diagnosis in this group requires special attention,
especially in regards to the criteria or method used for that purpose. Since we
still lack a single method to reliably diagnose the nutritional status of CKD
patients, it has been recommended the use of multiple markers, which may be
objective and/or subjective.1212. National Kidney Foundation/Kidney Disease Outcome Quality
Initiative: National Kidney Foundation Clinical practice guidelines for
nutrition in chronic renal failure. Am J Kidney Dis
2000;35:S1-S3.,1313. Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B et
al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22:ii45-87. DOI:
http://dx.doi.org/10.1093/ndt/gfm020
http://dx.doi.org/10.1093/ndt/gfm020...
Among subjective nutritional markers, combined methods for nutritional status assessment have gained prominence. These methods are based on a combination of subjective and objective elements of nutritional status, which provide a set of information about nutritional deficit condition and its level. In the context of CKD, SGA and the malnutrition inflammation score (MIS) stand out among the combined methods employed in clinical practice and in studies. Therefore, this paper aims to review the use of SGA and MIS, focusing on their ability to differentiate between well-nourished patients from those with PED to diagnose the degree of PED (mild, moderate or severe) and evaluate their ability to predict clinical outcomes.
Subjective global assessment and malnutrition inflammation score
Subjective global assessment (SGA)
The SGA comprises a method involving subjective and objective aspects of
nutritional status, including components of the medical history and
physical examination. It is a simple and inexpensive tool that can be
applied by previously trained healthcare professionals.1414. Steiber AL, Kalantar-Zadeh K, Secker D, McCarthy M, Sehgal A,
McCann L. Subjective global assessment in chronic kidney disease: a review. J
Ren Nutr 2004;14:191-200. DOI:
http://dx.doi.org/10.1016/S1051-2276(04)00139-6
http://dx.doi.org/10.1016/S1051-2276(04)...
SGA was originally developed by
Detsky et al. in 1984,1515. Detsky AS, Baker JP, Mendelson RA, Wolman SL, Wesson DE,
Jeejeebhoy KN. Evaluating the accuracy of nutritional assessment techniques
applied to hospitalized patients: methodology and comparisons. JPEN J Parenter
Enteral Nutr 1984;8:153-9. DOI:
http://dx.doi.org/10.1177/0148607184008002153
http://dx.doi.org/10.1177/01486071840080...
aiming to assess the nutritional status of surgical
patients into (A) well-nourished; (B) moderate PED; and (C) severe PED.
Since it yielded good sensitivity and specificity in predicting
postoperative infections in this population, SGA was reformatted to be
used for specific groups in order to increase its reproducibility and
predictive value.1414. Steiber AL, Kalantar-Zadeh K, Secker D, McCarthy M, Sehgal A,
McCann L. Subjective global assessment in chronic kidney disease: a review. J
Ren Nutr 2004;14:191-200. DOI:
http://dx.doi.org/10.1016/S1051-2276(04)00139-6
http://dx.doi.org/10.1016/S1051-2276(04)...
Since then,
its application has increased in several population groups,1616. Bauer J, Capra S, Ferguson M. Use of the scored
Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition
assessment tool in patients with cancer. Eur J Clin Nutr 2002;56:779-85. PMID:
12122555 DOI: http://dx.doi.org/10.1038/sj.ejcn.1601412
http://dx.doi.org/10.1038/sj.ejcn.160141...
17. Christensson L, Unossons M, Ek AC. Measurement of perceived
health problems as a means of detecting elderly people at risk of malnutrition.
J Nutr Health Aging 2003;7:257-62.-1818. Stephenson GR, Moretti EW, El-Moalem H, Clavien PA,
Tuttle-Newhall JE. Malnutrition in liver transplant patients: preoperative
subjective global assessment is predictive of outcome after liver
transplantation. Transplantation 2001;72:666-70. PMID: 11544428 DOI:
http://dx.doi.org/10.1097/00007890200108270-00018
http://dx.doi.org/10.1097/00007890200108...
including those with CKD.1414. Steiber AL, Kalantar-Zadeh K, Secker D, McCarthy M, Sehgal A,
McCann L. Subjective global assessment in chronic kidney disease: a review. J
Ren Nutr 2004;14:191-200. DOI:
http://dx.doi.org/10.1016/S1051-2276(04)00139-6
http://dx.doi.org/10.1016/S1051-2276(04)...
The first SGA validation for individuals in HD and peritoneal dialysis
(PD) happened in 1993, by Enia et al.1919. Enia G, Sicuso C, Alati G, Zoccali C. Subjective global
assessment of nutrition in dialysis patients. Nephrol Dial Transplant
1993;8:1094-8. In that study, the authors
reported that PED patients diagnosed by SGA had lower serum albumin
levels, lower body fat percentage, lower arm muscle circumference and
lower protein intake. Subsequently, a multicentric study in PD,
conducted in the U.S. and Canada - CANUSA (1996) modified the original
SGA and proposed a new model with a 7-point scale. The authors reported
that the expanded scale provided greater association with mortality, and
a one-point decrease was associated with a 25% increase in
mortality.2020. Adequacy of dialysis and nutrition in continuous peritoneal
dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal
Dialysis Study Group. J Am Soc Nephrol 1996;7:198-207. This version was
subsequently validated by Steiber et al.1010. Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, et
al. Multicenter study of the validity and reliability of subjective global
assessment in the hemodialysis population. J Ren Nutr 2007;17:336-42. DOI:
http://dx.doi.org/10.1053/j.jrn.2007.05.004
http://dx.doi.org/10.1053/j.jrn.2007.05....
in HD patients.
SGA-7p is recommended by the American guide of approaches in nephrology,
National Kidney Foundation/Dialysis Outcome Quality Initiative1212. National Kidney Foundation/Kidney Disease Outcome Quality
Initiative: National Kidney Foundation Clinical practice guidelines for
nutrition in chronic renal failure. Am J Kidney Dis
2000;35:S1-S3. and by the European Best
Practice Guidelines on Nutrition (EBPG)1313. Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B et
al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22:ii45-87. DOI:
http://dx.doi.org/10.1093/ndt/gfm020
http://dx.doi.org/10.1093/ndt/gfm020...
as a valid method to identify patients with PED. This
version features a structure that is similar to the original one.
Other modifications of the original SGA have been proposed, varying as to
the score scale,2121. Kalantar-Zadeh K, Kleiner M, Dunne E, Lee GH, Luft FC. A
modified quantitative subjective global assessment of nutrition for dialysis
patients. Nephrol Dial Transplant 1999;14:1732-8. PMID: 10435884 DOI:
http://dx.doi.org/10.1093/ndt/14.7.1732
http://dx.doi.org/10.1093/ndt/14.7.1732...
,2222. Stenvinkel P, Barany P, Chung SH, Lindholm B, Heimbürger O. A
comparative analysis of nutritional parameters as predictors of outcome in male
and female ESRD patients. Nephrol Dial Transplant 2002;17:1266-74. DOI:
http://dx.doi.org/10.1093/ndt/17.7.1266
http://dx.doi.org/10.1093/ndt/17.7.1266...
components and mode of assessment.66. Pifer TB, McCullough KP, Port FK, Goodkin DA, Maroni BJ, Held PJ,
et al. Mortality risk in hemodialysis patients and changes in nutritional
indicators: DOPPS. Kidney Int 2002;62:2238-45. PMID: 12427151 DOI:
http://dx.doi.org/10.1046/j.1523-1755.2002.00658.x
http://dx.doi.org/10.1046/j.1523-1755.20...
,2323. Desbrow B, Bauer J, Blum C, Kandasamy A, McDonald A, Montgomery
K. Assessment of nutritional status in hemodialysis patients using
patient-generated subjective global assessment. J Ren Nutr 2005;15:211-6. DOI:
http://dx.doi.org/10.1053/j.jrn.2004.10.005
http://dx.doi.org/10.1053/j.jrn.2004.10....
Malnutrition inflammation score
Also stemming from the original SGA, Kalantar-Zadeh et
al.2424. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A
malnutrition-inflammation score is correlated with morbidity and mortality in
maintenance hemodialysis patients. Am J Kidney Dis 2001;38:1251-63. PMID:
11728958 DOI: http://dx.doi.org/10.1053/ajkd.2001.29222
http://dx.doi.org/10.1053/ajkd.2001.2922...
proposed a new
combined method called Malnutrition Inflammation Score (MIS). The MIS
has a total of 10 components, 70% of the items assessed are common to
the SGA and the remaining 30% are additional components (serum albumin,
iron binding capacity (TIBIC) and body mass index (BMI)). In the
original MIS paper, increased scores (closer to 30) were associated with
poorer nutritional status and higher hospitalizations and mortality
rates.2424. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A
malnutrition-inflammation score is correlated with morbidity and mortality in
maintenance hemodialysis patients. Am J Kidney Dis 2001;38:1251-63. PMID:
11728958 DOI: http://dx.doi.org/10.1053/ajkd.2001.29222
http://dx.doi.org/10.1053/ajkd.2001.2922...
Subjective global assessment and malnutrition inflammation score for PED diagnosis capacity
An important theme when referring to combined methods for assessing nutritional status is whether they are able to properly diagnose PED. To do so, we must assess whether these methods have good sensitivity (true positive) and specificity (false positive) for this purpose. When there is a gold standard method to assess nutritional status, sensitivity and specificity are evaluated by finding the cutoff point or value with the best ability to predict the outcome i.e. PED.
Since there is no gold standard for assessing nutritional status in CKD
patients, CKD and nutrition guidelines recommend the use of a combination of
methods to minimize errors with nutritional diagnosis. These can be
anthropometry, bioelectrical impedance analysis, serum albumin, food intake,
and others.1212. National Kidney Foundation/Kidney Disease Outcome Quality
Initiative: National Kidney Foundation Clinical practice guidelines for
nutrition in chronic renal failure. Am J Kidney Dis
2000;35:S1-S3.,1313. Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B et
al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22:ii45-87. DOI:
http://dx.doi.org/10.1093/ndt/gfm020
http://dx.doi.org/10.1093/ndt/gfm020...
Thus, most of the studies evaluating the accuracy of combined methods of
assessing nutritional status did so through concurrent validation, i.e.,
from the comparison between subjective and objective methods to evaluate
patient nutritional status.77. Campbell KL, Bauer JD, Ikehiro A, Johnson DW. Role of nutrition
impact symptoms in predicting nutritional status and clinical outcome in
hemodialysis patients: a potential screening tool. J Ren Nutr 2013;23:302-7.
DOI: http://dx.doi.org/10.1053/j.jrn.2012.07.001
http://dx.doi.org/10.1053/j.jrn.2012.07....
,1010. Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, et
al. Multicenter study of the validity and reliability of subjective global
assessment in the hemodialysis population. J Ren Nutr 2007;17:336-42. DOI:
http://dx.doi.org/10.1053/j.jrn.2007.05.004
http://dx.doi.org/10.1053/j.jrn.2007.05....
,2121. Kalantar-Zadeh K, Kleiner M, Dunne E, Lee GH, Luft FC. A
modified quantitative subjective global assessment of nutrition for dialysis
patients. Nephrol Dial Transplant 1999;14:1732-8. PMID: 10435884 DOI:
http://dx.doi.org/10.1093/ndt/14.7.1732
http://dx.doi.org/10.1093/ndt/14.7.1732...
,2424. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A
malnutrition-inflammation score is correlated with morbidity and mortality in
maintenance hemodialysis patients. Am J Kidney Dis 2001;38:1251-63. PMID:
11728958 DOI: http://dx.doi.org/10.1053/ajkd.2001.29222
http://dx.doi.org/10.1053/ajkd.2001.2922...
25. Amparo FC, Cordeiro AC, Carrero JJ, Cuppari L, Lindholm B,
Amodeo C, et al. Malnutrition-Inflammation Score is Associated With Handgrip
Strength in Nondialysis-Dependent Chronic Kidney Disease Patients. J Ren Nutr
2013;23:283-7. DOI: http://dx.doi.org/10.1053/j.jrn.2012.08.004
http://dx.doi.org/10.1053/j.jrn.2012.08....
26. Chan M, Kelly J, Batterham M, Tapsell L. Malnutrition
(subjective global assessment) scores and serum albumin levels, but not body
mass index values, at initiation of dialysis are independent predictors of
mortality: a 10-year clinical cohort study. J Ren Nutr 2012;22:547-57. DOI:
http://dx.doi.org/10.1053/j.jrn.2011.11.002
http://dx.doi.org/10.1053/j.jrn.2011.11....
27. Cooper BA, Bartlett LH, Aslani A, Allen BJ, Ibels LS, Pollock
CA. Validity of subjective global assessment as a nutritional marker in
end-stage renal disease. Am J Kidney Dis 2002;40:126-32. PMID: 12087570 DOI:
http://dx.doi.org/10.1053/ajkd.2002.33921
http://dx.doi.org/10.1053/ajkd.2002.3392...
28. Ho LC, Wang HH, Chiang CK, Hung KY, Wu KD.
Malnutrition-inflammation score independently determined cardiovascular and
infection risk in peritoneal dialysis patients. Blood Purif 2010;29:308-16. DOI:
http://dx.doi.org/10.1159/000280641
http://dx.doi.org/10.1159/000280641...
29. Hou Y, Li X, Hong D, Zou H, Yang L, Chen Y, et al. Comparison of
different assessments for evaluating malnutrition in Chinese patients with
end-stage renal disease with maintenance hemodialysis. Nutr Res 2012;32:266-71.
DOI: http://dx.doi.org/10.1016/j.nutres.2012.02.006
http://dx.doi.org/10.1016/j.nutres.2012....
30. Jones CH, Wolfenden RC, Wells LM. Is subjective global
assessment a reliable measure of nutritional status in hemodialysis? J Ren Nutr
2004;14:26-30.
31. Kalantar-Zadeh K, Kopple JD, Humphreys MH, Block G. Comparing
outcome predictability of markers of malnutrition-inflammation complex syndrome
in haemodialysis patients. Nephrol Dial Transplant 2004;19:1507-19. DOI:
http://dx.doi.org/10.1093/ndt/gfh143
http://dx.doi.org/10.1093/ndt/gfh143...
32. Molnar MZ, Novak M, Mucsi I. Management of restless legs
syndrome in patients on dialysis. Drugs 2006;66:607-24. DOI:
http://dx.doi.org/10.2165/00003495-200666050-00003
http://dx.doi.org/10.2165/00003495-20066...
33. Tayyem RF, Mrayyan MT, Heath DD, Bawadi HA. Assessment of
nutritional status among ESRD patients in Jordanian hospitals. J Ren Nutr
2008;18:281-7. DOI: http://dx.doi.org/10.1053/j.jrn.2007.12.001
http://dx.doi.org/10.1053/j.jrn.2007.12....
-3434. Yamada K, Furuya R, Takita T, Maruyama Y, Yamaguchi Y, Ohkawa S,
et al. Simplified nutritional screening tools for patients on maintenance
hemodialysis. Am J Clin Nutr 2008;87:106-13. PMID: 18175743 These
studies show that patients classified as well nourished by SGA and MIS had
significantly higher titers of nutritional markers when compared to those
classified as malnourished. The nutritional markers evaluated in these
studies were BMI, fat percentage, skinfolds, waist circumference, phase
angle, body cell mass and serum albumin. Thus, combined methods for
assessing nutritional status are able to differentiate the well-nourished
patients from those with PED.
However, the ability to diagnose the SGA and MIS degrees of PED (mild,
moderate or severe) is not clear. Studies which assessed the concurrent
validation by comparing the degrees of PED by SGA with anthropometric and
laboratory variables showed divergent results. While some studies found that
SGA was able to differentiate the degree of PED,1010. Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, et
al. Multicenter study of the validity and reliability of subjective global
assessment in the hemodialysis population. J Ren Nutr 2007;17:336-42. DOI:
http://dx.doi.org/10.1053/j.jrn.2007.05.004
http://dx.doi.org/10.1053/j.jrn.2007.05....
,3030. Jones CH, Wolfenden RC, Wells LM. Is subjective global
assessment a reliable measure of nutritional status in hemodialysis? J Ren Nutr
2004;14:26-30.,3535. Campbell KL, Ash S, Bauer JD, Davies PS. Evaluation of nutrition
assessment tools compared with body cell mass for the assessment of malnutrition
in chronic kidney disease. J Ren Nutr 2007;17:189-95. DOI:
http://dx.doi.org/10.1053/j.jrn.2006.12.005
http://dx.doi.org/10.1053/j.jrn.2006.12....
others
did not find differences between the groups.2727. Cooper BA, Bartlett LH, Aslani A, Allen BJ, Ibels LS, Pollock
CA. Validity of subjective global assessment as a nutritional marker in
end-stage renal disease. Am J Kidney Dis 2002;40:126-32. PMID: 12087570 DOI:
http://dx.doi.org/10.1053/ajkd.2002.33921
http://dx.doi.org/10.1053/ajkd.2002.3392...
,3333. Tayyem RF, Mrayyan MT, Heath DD, Bawadi HA. Assessment of
nutritional status among ESRD patients in Jordanian hospitals. J Ren Nutr
2008;18:281-7. DOI: http://dx.doi.org/10.1053/j.jrn.2007.12.001
http://dx.doi.org/10.1053/j.jrn.2007.12....
The
study by Cooper et al.,2727. Cooper BA, Bartlett LH, Aslani A, Allen BJ, Ibels LS, Pollock
CA. Validity of subjective global assessment as a nutritional marker in
end-stage renal disease. Am J Kidney Dis 2002;40:126-32. PMID: 12087570 DOI:
http://dx.doi.org/10.1053/ajkd.2002.33921
http://dx.doi.org/10.1053/ajkd.2002.3392...
which included patients on PD and HD evaluated SGA
sensitivity and specificity in diagnosing PED and its degree (mild to
moderate or severe) using the body nitrogen content assessed by the
in vitro neutron activation analysis as the standard
method. In this study, the SGA showed good sensitivity (true positive) to
find patients with PED, but low specificity (false positive) to assess its
degre.2727. Cooper BA, Bartlett LH, Aslani A, Allen BJ, Ibels LS, Pollock
CA. Validity of subjective global assessment as a nutritional marker in
end-stage renal disease. Am J Kidney Dis 2002;40:126-32. PMID: 12087570 DOI:
http://dx.doi.org/10.1053/ajkd.2002.33921
http://dx.doi.org/10.1053/ajkd.2002.3392...
The lack of consensus among studies regarding SGA's ability to classify the
degree of PED may be due to differences in study methodology, both in
regards to diversity of parameters and normal ranges used to classify
nutritional status and make the concurrent validation. Regarding MIS,
although some studies proposed values to classify the nutritional
status,3434. Yamada K, Furuya R, Takita T, Maruyama Y, Yamaguchi Y, Ohkawa S,
et al. Simplified nutritional screening tools for patients on maintenance
hemodialysis. Am J Clin Nutr 2008;87:106-13. PMID: 18175743,3636. Ho LC, Wang HH, Peng YS, Chiang CK, Huang JW, Hung KY, et al.
Clinical utility of malnutrition-inflammation score in maintenance hemodialysis
patients: focus on identifying the best cut-off point. Am J Nephrol
2008;28:840-6. DOI: http://dx.doi.org/10.1159/000137684
http://dx.doi.org/10.1159/000137684...
the lack of pre-established cutoff
points hampers the test's ability to measure the degree of PED. In a study
including patients on HD, which divided the sample into MIS score quartiles,
the authors noted that the objective markers of nutritional status differed
only between the 1st and 4th quartiles.3131. Kalantar-Zadeh K, Kopple JD, Humphreys MH, Block G. Comparing
outcome predictability of markers of malnutrition-inflammation complex syndrome
in haemodialysis patients. Nephrol Dial Transplant 2004;19:1507-19. DOI:
http://dx.doi.org/10.1093/ndt/gfh143
http://dx.doi.org/10.1093/ndt/gfh143...
This result suggests a reduced MIS
ability to differentiate the degree of PED. However; further studies on this
topic are needed to confirm these findings.
With regards to the SGA models, the one with the higher accuracy in
diagnosing PED is yet to be found. To our knowledge, only one study has been
carried out for this purpose. Campbell et al.3535. Campbell KL, Ash S, Bauer JD, Davies PS. Evaluation of nutrition
assessment tools compared with body cell mass for the assessment of malnutrition
in chronic kidney disease. J Ren Nutr 2007;17:189-95. DOI:
http://dx.doi.org/10.1053/j.jrn.2006.12.005
http://dx.doi.org/10.1053/j.jrn.2006.12....
evaluated the agreement of PED
diagnosed by body cell mass (BCM) (count of total body potassium) with that
obtained by the SGA in its original form, patient-generated subjective
global assessment (PG-SGA) and SGA-7p. Among these models, the SGA in its
original form had better agreement with the BCM. However, further studies
should be carried out so as to define which model offers greater accuracy in
PED diagnosis.
The intra -and interobserver variability is another important consideration
when applying combined methods. With this objective, Visser et
al.3737. Visser R, Dekker FW, Boeschoten EW, Stevens P, Krediet RT.
Reliability of the 7-point subjective global assessment scale in assessing
nutritional status of dialysis patients. Adv Perit Dial
1999;15:222-5. and Steiber
et al.1010. Steiber A, Leon JB, Secker D, McCarthy M, McCann L, Serra M, et
al. Multicenter study of the validity and reliability of subjective global
assessment in the hemodialysis population. J Ren Nutr 2007;17:336-42. DOI:
http://dx.doi.org/10.1053/j.jrn.2007.05.004
http://dx.doi.org/10.1053/j.jrn.2007.05....
evaluated the intra - and interobserver variability in the SGA group of
evaluators who received training. In both studies, we noticed a good
intraobserver agreement and moderate interobserver agreement. These findings
stress the importance of careful and regular training to use these methods
and prioritize, whenever possible, the same examiner in monitoring the
nutritional status.
Subjective global assessment and malnutrition inflammation score capacity in predicting outcome
The association between morbidity and mortality and PED evaluated by SGA and
MIS has been described in several studies in CKD patients. Studies including
patients with stage 5 CKD (non-dialysis-dependent)2222. Stenvinkel P, Barany P, Chung SH, Lindholm B, Heimbürger O. A
comparative analysis of nutritional parameters as predictors of outcome in male
and female ESRD patients. Nephrol Dial Transplant 2002;17:1266-74. DOI:
http://dx.doi.org/10.1093/ndt/17.7.1266
http://dx.doi.org/10.1093/ndt/17.7.1266...
and in HD2626. Chan M, Kelly J, Batterham M, Tapsell L. Malnutrition
(subjective global assessment) scores and serum albumin levels, but not body
mass index values, at initiation of dialysis are independent predictors of
mortality: a 10-year clinical cohort study. J Ren Nutr 2012;22:547-57. DOI:
http://dx.doi.org/10.1053/j.jrn.2011.11.002
http://dx.doi.org/10.1053/j.jrn.2011.11....
,3838. Fiedler R, Jehle PM, Osten B, Dorligschaw O, Girndt M. Clinical
nutrition scores are superior for the prognosis of haemodialysis patients
compared to lab markers and bioelectrical impedance. Nephol Dial Transplant
2009;24:3812-7. DOI: http://dx.doi.org/10.1093/ndt/gfp346
http://dx.doi.org/10.1093/ndt/gfp346...
showed
that the SGA score indicative of PED was a predictor of mortality, even
after adjustment for covariates such as gender, age, c-reactive protein and
cardiovascular disease (CVD).2222. Stenvinkel P, Barany P, Chung SH, Lindholm B, Heimbürger O. A
comparative analysis of nutritional parameters as predictors of outcome in male
and female ESRD patients. Nephrol Dial Transplant 2002;17:1266-74. DOI:
http://dx.doi.org/10.1093/ndt/17.7.1266
http://dx.doi.org/10.1093/ndt/17.7.1266...
,2626. Chan M, Kelly J, Batterham M, Tapsell L. Malnutrition
(subjective global assessment) scores and serum albumin levels, but not body
mass index values, at initiation of dialysis are independent predictors of
mortality: a 10-year clinical cohort study. J Ren Nutr 2012;22:547-57. DOI:
http://dx.doi.org/10.1053/j.jrn.2011.11.002
http://dx.doi.org/10.1053/j.jrn.2011.11....
,3838. Fiedler R, Jehle PM, Osten B, Dorligschaw O, Girndt M. Clinical
nutrition scores are superior for the prognosis of haemodialysis patients
compared to lab markers and bioelectrical impedance. Nephol Dial Transplant
2009;24:3812-7. DOI: http://dx.doi.org/10.1093/ndt/gfp346
http://dx.doi.org/10.1093/ndt/gfp346...
In line
with these findings, Mutsert et al.,3939. de Mutsert R, Grootendorst DC, Boeschoten EW, Brandts H, van
Manen JG, Krediet RT, et al.; Netherlands Cooperative Study on the Adequacy of
Dialysis-2 Study Group. Subjective global assessment of nutritional status is
strongly associated with mortality in chronic dialysis patients. Am J Clin Nutr
2009;89:787-93. DOI: http://dx.doi.org/10.3945/ajcn.2008.26970
http://dx.doi.org/10.3945/ajcn.2008.2697...
studying a cohort of patients in HD and PD, showed
that for each point reduction in the SGA score, the relative risk of death
increased significantly. Moreover, severe PED increased the risk of
mortality five times when compared to the group classified as
well-nourished. In another study including PD patients, the association
between mortality and PED diagnosed by SGA was not maintained after
adjustment for diabetes and CVD.99. Leinig CE, Moraes T, Ribeiro S, Riella MC, Olandoski M, Martins
C, et al. Predictive value of malnutrition markers for mortality in peritoneal
dialysis patients. J Ren Nutr 2011;21:176-83. DOI:
http://dx.doi.org/10.1053/j.jrn.2010.06.026
http://dx.doi.org/10.1053/j.jrn.2010.06....
Despite the less favorable outcome reported in the latter paper, these data
suggest that the PED - indicative SGA has good mortality-predictive power, a
result also shown for hospitalization in HD patients.2626. Chan M, Kelly J, Batterham M, Tapsell L. Malnutrition
(subjective global assessment) scores and serum albumin levels, but not body
mass index values, at initiation of dialysis are independent predictors of
mortality: a 10-year clinical cohort study. J Ren Nutr 2012;22:547-57. DOI:
http://dx.doi.org/10.1053/j.jrn.2011.11.002
http://dx.doi.org/10.1053/j.jrn.2011.11....
,3838. Fiedler R, Jehle PM, Osten B, Dorligschaw O, Girndt M. Clinical
nutrition scores are superior for the prognosis of haemodialysis patients
compared to lab markers and bioelectrical impedance. Nephol Dial Transplant
2009;24:3812-7. DOI: http://dx.doi.org/10.1093/ndt/gfp346
http://dx.doi.org/10.1093/ndt/gfp346...
Regarding MIS, its ability to predict the mortality outcome was also
demonstrated in studies including patients in HD2424. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A
malnutrition-inflammation score is correlated with morbidity and mortality in
maintenance hemodialysis patients. Am J Kidney Dis 2001;38:1251-63. PMID:
11728958 DOI: http://dx.doi.org/10.1053/ajkd.2001.29222
http://dx.doi.org/10.1053/ajkd.2001.2922...
,3131. Kalantar-Zadeh K, Kopple JD, Humphreys MH, Block G. Comparing
outcome predictability of markers of malnutrition-inflammation complex syndrome
in haemodialysis patients. Nephrol Dial Transplant 2004;19:1507-19. DOI:
http://dx.doi.org/10.1093/ndt/gfh143
http://dx.doi.org/10.1093/ndt/gfh143...
,3636. Ho LC, Wang HH, Peng YS, Chiang CK, Huang JW, Hung KY, et al.
Clinical utility of malnutrition-inflammation score in maintenance hemodialysis
patients: focus on identifying the best cut-off point. Am J Nephrol
2008;28:840-6. DOI: http://dx.doi.org/10.1159/000137684
http://dx.doi.org/10.1159/000137684...
and
kidney transplant.4040. Molnar MZ, Czira ME, Rudas A, Ujszaszi A, Lindner A, Fornadi K,
et al. Association of the malnutrition-inflammation score with clinical outcomes
in kidney transplant recipients. Am J Kidney Dis 2011;58:101-8. DOI:
http://dx.doi.org/10.1053/j.ajkd.2010.11.027
http://dx.doi.org/10.1053/j.ajkd.2010.11...
In particular,
the study by Ho et al.,3636. Ho LC, Wang HH, Peng YS, Chiang CK, Huang JW, Hung KY, et al.
Clinical utility of malnutrition-inflammation score in maintenance hemodialysis
patients: focus on identifying the best cut-off point. Am J Nephrol
2008;28:840-6. DOI: http://dx.doi.org/10.1159/000137684
http://dx.doi.org/10.1159/000137684...
which included HD patients followed for up to 12 months for
mortality events, deserves attention for showing that the likelihood of
death in patients with values above the MIS score of 5 was 80% and above 8,
it was 100%.
Thus, these results demonstrate, that the association between poor nutritional status and increased morbidity and mortality is present regardless of the model and/or combined method employed. Therefore, SGA and MIS have good predictive ability as far as outcomes are concerned.
Summary and conclusions
The use of combined methods to assess the nutritional status of patients with CKD has gained attention for its advantages such as generating a global assessment of nutritional status using reduced number of devices for its completion. Based on the studies presented, it can be concluded that these methods are able to differentiate the well-nourished patients from those with PED and that they have good power in predicting worse mortality outcomes. Therefore, these methods constitute a valid alternative, very much applicable for the diagnosis of PED. However, some peculiarities must be considered. With respect to SAG, different models have been proposed, and one cannot state which model provides more precision for the diagnosis of PED. Second, the cutoff points proposed for classifying nutritional status deserve careful attention for not accurately representing the degree of PED. Therefore, it is important to employ other objective methods for nutritional status assessment to supplement the information provided by the combined methods. Third, we highlight the importance of early and careful training of examiners, seeking to reduce intra -and interobserver variability.
-
Coordination of Higher Education Personnel Improvement (CAPES) - Master's Degree scholarships for authors FGB and LPR.
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» http://dx.doi.org/10.1159/000137684 -
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» http://dx.doi.org/10.1093/ndt/gfp346 -
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» http://dx.doi.org/10.3945/ajcn.2008.26970 -
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» http://dx.doi.org/10.1053/j.ajkd.2010.11.027
Publication Dates
-
Publication in this collection
Apr-Jun 2014
History
-
Received
06 May 2013 -
Accepted
06 Dec 2013