Association of Malnutrition-Inflammation Score With Quality of Life and Mortality in Hemodialysis Patients

A 5-Year Prospective Cohort Study

Mehdi Rambod, Rachelle Bross, Jennifer Zitterkoph, Deborah Benner, Juhi Pithia, Sara Colman, Csaba Kovesdy, Joel D. Kopple, Kamyar Kalantar-Zadeh

Research output: Contribution to journalArticle

177 Citations (Scopus)

Abstract

Background: The Malnutrition-Inflammation Score (MIS), an inexpensive and easy-to-assess score of 0 to 30 to examine protein-energy wasting (PEW) and inflammation, includes 7 components of the Subjective Global Assessment, body mass index, and serum albumin and transferrin concentrations. We hypothesized that MIS risk stratification of hemodialysis (HD) patients in predicting outcomes is better than its components or laboratory markers of inflammation. Study Design: 5-Year cohort study. Setting & Participants: We examined 809 stable HD outpatients and followed them for up to 5 years (October 2001 to December 2006). Predictors: MIS and other nutritional and inflammatory markers. Outcomes & Measurements: Prospective all-cause mortality, health-related quality of life using the 36-Item Short Form Health Survey (SF-36), and tests of body composition. Results: The MIS correlated with logarithm of serum interleukin 6 level (r = +0.26; P < 0.001), logarithm of C-reactive protein level (r = +0.16; P < 0.001), and several measures of nutritional status. Patients with a higher MIS had lower SF-36 scores. After multivariate adjustment for case-mix and other measures of PEW, HD patients in the second (3 to 4), third (5 to 7), and fourth (≥8) quartiles of MIS had worse survival rates than those in the first (0 to 2) quartile (P < 0.001). Each 2-unit increase in MIS was associated with a 2-fold greater death risk, ie, adjusted death hazard ratio of 2.03 (95% confidence interval, 1.76 to 2.33; P < 0.001). Cubic spline survival models confirmed linear trends. Adding MIS to the constellation of age, sex, race/ethnicity, and vintage significantly improved the area under the receiver operating characteristic curve developed for predicting mortality (0.71 versus 0.67; P < 0.001). Limitations: Selection bias and unknown confounders. Conclusions: In HD patients, the MIS is associated with inflammation, nutritional status, quality of life, and 5-year prospective mortality. The mortality predictability of the MIS appears equal to serum interleukin 6 and somewhat greater than C-reactive protein levels. Controlled trials are warranted to examine whether interventions to improve the MIS can also improve clinical outcomes in HD patients.

Original languageEnglish (US)
Pages (from-to)298-309
Number of pages12
JournalAmerican Journal of Kidney Diseases
Volume53
Issue number2
DOIs
StatePublished - Feb 1 2009
Externally publishedYes

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Malnutrition
Renal Dialysis
Cohort Studies
Quality of Life
Prospective Studies
Inflammation
Mortality
Nutritional Status
C-Reactive Protein
Interleukin-6
Risk Adjustment
Selection Bias
Transferrin
Body Composition
Health Surveys
Serum
Serum Albumin
ROC Curve
Linear Models
Proteins

All Science Journal Classification (ASJC) codes

  • Nephrology

Cite this

Association of Malnutrition-Inflammation Score With Quality of Life and Mortality in Hemodialysis Patients : A 5-Year Prospective Cohort Study. / Rambod, Mehdi; Bross, Rachelle; Zitterkoph, Jennifer; Benner, Deborah; Pithia, Juhi; Colman, Sara; Kovesdy, Csaba; Kopple, Joel D.; Kalantar-Zadeh, Kamyar.

In: American Journal of Kidney Diseases, Vol. 53, No. 2, 01.02.2009, p. 298-309.

Research output: Contribution to journalArticle

Rambod, Mehdi ; Bross, Rachelle ; Zitterkoph, Jennifer ; Benner, Deborah ; Pithia, Juhi ; Colman, Sara ; Kovesdy, Csaba ; Kopple, Joel D. ; Kalantar-Zadeh, Kamyar. / Association of Malnutrition-Inflammation Score With Quality of Life and Mortality in Hemodialysis Patients : A 5-Year Prospective Cohort Study. In: American Journal of Kidney Diseases. 2009 ; Vol. 53, No. 2. pp. 298-309.
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abstract = "Background: The Malnutrition-Inflammation Score (MIS), an inexpensive and easy-to-assess score of 0 to 30 to examine protein-energy wasting (PEW) and inflammation, includes 7 components of the Subjective Global Assessment, body mass index, and serum albumin and transferrin concentrations. We hypothesized that MIS risk stratification of hemodialysis (HD) patients in predicting outcomes is better than its components or laboratory markers of inflammation. Study Design: 5-Year cohort study. Setting & Participants: We examined 809 stable HD outpatients and followed them for up to 5 years (October 2001 to December 2006). Predictors: MIS and other nutritional and inflammatory markers. Outcomes & Measurements: Prospective all-cause mortality, health-related quality of life using the 36-Item Short Form Health Survey (SF-36), and tests of body composition. Results: The MIS correlated with logarithm of serum interleukin 6 level (r = +0.26; P < 0.001), logarithm of C-reactive protein level (r = +0.16; P < 0.001), and several measures of nutritional status. Patients with a higher MIS had lower SF-36 scores. After multivariate adjustment for case-mix and other measures of PEW, HD patients in the second (3 to 4), third (5 to 7), and fourth (≥8) quartiles of MIS had worse survival rates than those in the first (0 to 2) quartile (P < 0.001). Each 2-unit increase in MIS was associated with a 2-fold greater death risk, ie, adjusted death hazard ratio of 2.03 (95{\%} confidence interval, 1.76 to 2.33; P < 0.001). Cubic spline survival models confirmed linear trends. Adding MIS to the constellation of age, sex, race/ethnicity, and vintage significantly improved the area under the receiver operating characteristic curve developed for predicting mortality (0.71 versus 0.67; P < 0.001). Limitations: Selection bias and unknown confounders. Conclusions: In HD patients, the MIS is associated with inflammation, nutritional status, quality of life, and 5-year prospective mortality. The mortality predictability of the MIS appears equal to serum interleukin 6 and somewhat greater than C-reactive protein levels. Controlled trials are warranted to examine whether interventions to improve the MIS can also improve clinical outcomes in HD patients.",
author = "Mehdi Rambod and Rachelle Bross and Jennifer Zitterkoph and Deborah Benner and Juhi Pithia and Sara Colman and Csaba Kovesdy and Kopple, {Joel D.} and Kamyar Kalantar-Zadeh",
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T2 - A 5-Year Prospective Cohort Study

AU - Rambod, Mehdi

AU - Bross, Rachelle

AU - Zitterkoph, Jennifer

AU - Benner, Deborah

AU - Pithia, Juhi

AU - Colman, Sara

AU - Kovesdy, Csaba

AU - Kopple, Joel D.

AU - Kalantar-Zadeh, Kamyar

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N2 - Background: The Malnutrition-Inflammation Score (MIS), an inexpensive and easy-to-assess score of 0 to 30 to examine protein-energy wasting (PEW) and inflammation, includes 7 components of the Subjective Global Assessment, body mass index, and serum albumin and transferrin concentrations. We hypothesized that MIS risk stratification of hemodialysis (HD) patients in predicting outcomes is better than its components or laboratory markers of inflammation. Study Design: 5-Year cohort study. Setting & Participants: We examined 809 stable HD outpatients and followed them for up to 5 years (October 2001 to December 2006). Predictors: MIS and other nutritional and inflammatory markers. Outcomes & Measurements: Prospective all-cause mortality, health-related quality of life using the 36-Item Short Form Health Survey (SF-36), and tests of body composition. Results: The MIS correlated with logarithm of serum interleukin 6 level (r = +0.26; P < 0.001), logarithm of C-reactive protein level (r = +0.16; P < 0.001), and several measures of nutritional status. Patients with a higher MIS had lower SF-36 scores. After multivariate adjustment for case-mix and other measures of PEW, HD patients in the second (3 to 4), third (5 to 7), and fourth (≥8) quartiles of MIS had worse survival rates than those in the first (0 to 2) quartile (P < 0.001). Each 2-unit increase in MIS was associated with a 2-fold greater death risk, ie, adjusted death hazard ratio of 2.03 (95% confidence interval, 1.76 to 2.33; P < 0.001). Cubic spline survival models confirmed linear trends. Adding MIS to the constellation of age, sex, race/ethnicity, and vintage significantly improved the area under the receiver operating characteristic curve developed for predicting mortality (0.71 versus 0.67; P < 0.001). Limitations: Selection bias and unknown confounders. Conclusions: In HD patients, the MIS is associated with inflammation, nutritional status, quality of life, and 5-year prospective mortality. The mortality predictability of the MIS appears equal to serum interleukin 6 and somewhat greater than C-reactive protein levels. Controlled trials are warranted to examine whether interventions to improve the MIS can also improve clinical outcomes in HD patients.

AB - Background: The Malnutrition-Inflammation Score (MIS), an inexpensive and easy-to-assess score of 0 to 30 to examine protein-energy wasting (PEW) and inflammation, includes 7 components of the Subjective Global Assessment, body mass index, and serum albumin and transferrin concentrations. We hypothesized that MIS risk stratification of hemodialysis (HD) patients in predicting outcomes is better than its components or laboratory markers of inflammation. Study Design: 5-Year cohort study. Setting & Participants: We examined 809 stable HD outpatients and followed them for up to 5 years (October 2001 to December 2006). Predictors: MIS and other nutritional and inflammatory markers. Outcomes & Measurements: Prospective all-cause mortality, health-related quality of life using the 36-Item Short Form Health Survey (SF-36), and tests of body composition. Results: The MIS correlated with logarithm of serum interleukin 6 level (r = +0.26; P < 0.001), logarithm of C-reactive protein level (r = +0.16; P < 0.001), and several measures of nutritional status. Patients with a higher MIS had lower SF-36 scores. After multivariate adjustment for case-mix and other measures of PEW, HD patients in the second (3 to 4), third (5 to 7), and fourth (≥8) quartiles of MIS had worse survival rates than those in the first (0 to 2) quartile (P < 0.001). Each 2-unit increase in MIS was associated with a 2-fold greater death risk, ie, adjusted death hazard ratio of 2.03 (95% confidence interval, 1.76 to 2.33; P < 0.001). Cubic spline survival models confirmed linear trends. Adding MIS to the constellation of age, sex, race/ethnicity, and vintage significantly improved the area under the receiver operating characteristic curve developed for predicting mortality (0.71 versus 0.67; P < 0.001). Limitations: Selection bias and unknown confounders. Conclusions: In HD patients, the MIS is associated with inflammation, nutritional status, quality of life, and 5-year prospective mortality. The mortality predictability of the MIS appears equal to serum interleukin 6 and somewhat greater than C-reactive protein levels. Controlled trials are warranted to examine whether interventions to improve the MIS can also improve clinical outcomes in HD patients.

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