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PubMed1993

Epidemiologic evidence for a potentiating effect of malnutrition on child mortality.

OBJECTIVES: Despite broad agreement that severe malnutrition contributes to child mortality in developing countries and that malnutrition has a physiologically synergistic relationship with morbidity, evidence of an epidemiologic synergism has been lacking. Also, the literature provides conflicting evidence concerning the existence of elevated mortality among children with mild to moderate malnutrition. A review of published population-based studies of anthropometry-mortality relationships was undertaken to clarify these relationships. METHODS: Six studies with the relevant data were reanalyzed to test for synergism and elevated mortality in mild to moderate malnutrition. RESULTS: The results demonstrate that mortality increases exponentially with declining weight for age. This effect is consistent across studies and there is no apparent threshold effect on mortality. The primary difference across studies is in baseline levels of mortality, which determine the quantitative impact of malnutrition on mortality in a population. CONCLUSIONS: These results indicate that mild to moderate malnutrition is associated with elevated mortality and that there is an epidemiologic synergism between malnutrition and morbidity. This previously undemonstrated finding has significant implications for child survival policies and research.

Anthropometry↗
PubMedDate not supplied

[Infantile nutritional evaluation with the software EPI INFO (version 6.0), taking into consideration collective and individual approaches, degree and type of malnutrition].

OBJECTIVE: A systematization for an anthropometric infantile evaluation is proposed, employing the software Epi Info, version 6.0, considering the collective and individual approaches, as well as the degree and type of malnutrition. METHODS: The software Epi Info, sponsored by the World Health Organization, provides an infantile nutritional evaluation, which is based on three anthropometric indicators: weight-for-age, height-for-age and weight-for-height. In order to quantify the observed data of each individual, three scales can be used. Among them, the Z score, which discriminates more efficiently the severe cases, is employed as a first choice. The reference pattern of the NCHS is used. Many cutoff points between eutrophy and malnutrition can be chosen, but the -2 Z score is the most employed. The child can be classified in three diagnostic categories: stunting, for height-for- age deficits; wasting, for weight-for-height deficits; underweight, for weight-for-age deficits. Besides this, in a collective approach, the Epi Info software calculates the proportion of individuals in each populational group which have their anthropometric data deviated from the reference curve, constituting the percentage of observed abnormality (called standardized prevalence). RESULTS: In this paper, in which the analysis of a data file is presented as an example, the organization of the information provided by Epi Info is proposed, with the characteristics described below. In order to increase the diagnostic sensitivity, the collective approach is valued. Concerning the type of malnutrition, the English term "stunting" is substituted by "chronic malnutrition", "wasting" by "acute malnutrition" and "underweight" by "isolated weight deficit". Concerning the degree of malnutrition, the -2 and -3 Z scores are employed as cutoffs in order to define, respectively, a threshold between the moderate and severe forms. CONCLUSIONS: The proposed approach takes into account the identification of all forms of malnutrition, from the mildest to the most severe cases, takes into consideration both height and weight deficits and if the process is acute or chronic. Therefore, it is a tool for organizing data available with the use of the computer.

English Abstract↗
PubMed2000

Malnutrition: more than the eye can see.

OBJECTIVES: To assess the magnitude of malnutrition in a hospital setting and to relate anthropometric measures to the clinical diagnosis of malnutrition. DESIGN: A descriptive study whereby anthropometric measures (length and weight) were taken of every child under the age of five years who was admitted to the hospital. The anthropometric data were analysed using the EPI-Info statistical package, which calculates z-scores for weight-for-age, weight-for-height and height-for-age. As reference curve, the reference growth curves of the NCHS were used. Of all the children who were classified as being malnourished, it was recorded if the clinical diagnosis of malnutrition was made at the time of admission or during the hospital stay. SETTING: Misikhu Mission Hospital, western Kenya. SUBJECTS: Every child under the age of five years who was admitted to the hospital, was eligible to enter the study. The data of 1130 children were used. The data of 40 other children who were admitted in this period were not complete and could therefore not be used. RESULTS: An overall percentage for malnutrition of 44.3 was found. Only fourteen per cent of the malnourished children were clinically diagnosed as having malnutrition. CONCLUSION: Anthropometric measures are an easy, but time-consuming way of identifying children with malnutrition, it identifies more children with malnutrition than clinical diagnosis alone. Therefore it should be considered to implement standardised anthropometry in a hospital setting.

Anthropometry↗
PubMed1999

Malnutrition: detection and intervention.

Malnutrition is common in patients with renal failure. Causes of malnutrition in this population are varied and sometimes specific to the method of renal replacement therapy. No single marker absolutely identifies malnutrition or tracks changes in status. Renal dietitians use a variety of parameters and techniques to identify malnutrition because many of the traditional markers can be skewed by renal disease and its comorbidities. Once malnutrition is identified, treatment is also complex and not well defined. Treatment is usually progressive in nature, ranging from intense nutritional counseling to total parenteral nutrition. Further research is needed to define optimal nutrition status, to refine techniques to maintain optimal nutrition status, to simplify the identification of malnutrition, and to improve the treatment for malnutrition.

Humans↗
PubMedDate not supplied

["CLAPSEN", a global approach to the rehabilitation of severe childhood malnutrition in Bolivia].

The "CLAPSEN" approach was developed at the Hospital Materno Infantil German Urquidi in Cochabamba, to provide a global response for the study and treatment of childhood malnutrition. "CLAPSEN" is short for Clinical, Laboratory, Anthropometry, Psychology, Sociology, Nursing (Enfermera in Spanish) and Nutritional care. Most of the malnourished children admitted to Cochabamba Hospital are from poor families, more than three quarters of whom have only recently arrived in the city. Acute malnutrition is just one of the manifestations of a generally unfavorable environment. Malnutrition should not be considered as a simple deficiency in energy, protein or micronutrients, but rather as a multi-deficiency syndrome, also involving a lack of basic health and social care. This study demonstrates that malnourished children display a considerable degree of psychological retardation and of immune system depression. After five weeks of rehabilitation, the children were considered to have recuperated physically, as assessed by anthropometry, but not psychologically, as assessed by the adapted Dewer Score, or immunologically, as shown by the size of the thymus or the extent of maturation of lymphocytes. This strategy was not designed as a long-term approach for treating malnutrition, but rather as a research project to characterize the children arriving at the hospital, to determine the reasons for their malnutrition and to identify strategies that could be implemented earlier by health centers of social services, to prevent deterioration in the condition of these children to severe malnutrition requiring hospital admission. We believe that, in this Latin American context, in which the rate of acute malnutrition is low, the hospital should continue to be involved in the treatment of severely malnourished children with associated diseases. The child's stay in hospital should be short and once the child has recovered clinically, he should be sent home. In light of the observed levels of social deprivation, psychosocial and immune deficits, there appears to be a need for continued support for the family, to ensure the full recovery of the child and to prevent relapses.

Bolivia↗
PubMedDate not supplied

Risk factors for malnutrition in patients undergoing gastroenterological and hernia surgery: an analysis of 374 patients.

OBJECTIVE: The aim of this study was to assess the nutritional status of 374 surgical patients with gastrointestinal disease and hernias of the abdominal wall; to identify risk factors associated with a poorer nutritional status in this group of patients and to assess awareness of the patient's nutritional status by medical teams. SUMMARY BACKGROUND DATA: Malnutrition is prevalent among surgical patients and is associated with higher surgical complication rates and mortality. The major causes of poor nutritional status are related to the underlying disease, socio-economic factors, age, and length of hospitalization. Despite its high prevalence, medical teams often overlook malnutrition, and screening of these patients is not routine. It is of utmost importance to identify patients at risk for malnutrition in order to prevent related complications. METHODS: The 374 patients evaluated in this study were a subgroup of a larger multicenter, cross-sectional, randomized study that was carried out in 1996. Nutritional status was assessed by using Subjective Global Assessment. RESULTS: Malnutrition was present in 55% of the patients, with 19% of the patients severely malnourished. The presence of cancer, infection, age over 60 years, upper gastrointestinal disease, and longer length of hospital stay all negatively influenced nutritional status. Despite the high prevalence of malnutrition, the medical teams only assessed the nutritional status of a few patients. CONCLUSION: Malnutrition was highly prevalent in this setting of patients. Therefore, patients with the risk factors above presented should routinely undergo nutritional screening and/or assessment in order to be able to early diagnose or prevent malnutrition and its correlated morbidity and mortality.

Adult↗
PubMed2001

Malnutrition in children with congenital heart defects.

OBJECTIVE: To assess the frequency of malnutrition in children with congenital heart defects in a hospital outpatient setting. METHODS: One hundred and fifty-two children with congenital heart defects (patients), and an equal number of children with innocent cardiac murmurs (controls) attending the Pediatric Cardiology Outpatient Clinic at Sultan Qaboos University Hospital, Muscat, Oman from 1997 to 1998 were prospectively studied. Weight, height and head circumference were used for evaluation of nutritional status. Patients and controls were categorized into acute malnutrition (weight <3rd percentile for age, and height >3rd centile), and chronic malnutrition (weight and height <3rd centile), based on the National Centre for Health Statistics standards. Children with symptomatic congenital heart defects (Group I, number = 73) were also compared with those without symptoms (Group II, number = 79). RESULTS: The study patients showed a higher frequency of both acute (27%) and chronic (24%) malnutrition (p<0.01). Children in Group I had a significant reduction in weight (p<0.01), height (p=0.02) and head circumference (p<0.01) compared to controls, however for those in Group II the differences were not significant. Acute malnutrition was higher in both groups, 31% (p<0.01) and 16% (p=0.04), whilst chronic malnutrition was significantly higher only in Group I, 31% (p<0.01). Infants in Group I were more frequently affected (33/45) compared to older children (13/28; p=0.02). CONCLUSION: Malnutrition remains a problem among children with congenital heart defects, especially in those with either heart failure or cyanosis, and symptomatic infants are the worst affected. Greater attention is required in the dietary management, early diagnosis and intervention to restore normal growth.

Case-Control Studies↗
PubMed1953

Infant malnutrition in Indonesia.

Infant malnutrition, resulting frequently in the death of children of pre-school age, is a problem requiring urgent solution in Indonesia. Children suffering from malnutrition show a variety of symptoms, the most characteristic being emaciation, growth retardation, liver changes, dyspigmentation of skin and hair, other skin lesions, oedema, muscular wasting, anaemia, and xerophthalmia. The indicative value of xerophthalmia, which often leads to the development of keratomalacia, in the diagnosis of malnutrition is stressed by the author. Further research is required to determine the causes-and particularly the part played by diet-of the clinical differences observed in malnutrition cases. Far greater interest in the problem of malnutrition must be shown by the entire medical profession in Indonesia if treatment is to be carried out successfully. The specific symptom, xerophthalmia, is easily curable with cod-liver oil. General malnutrition can be prevented only if sufficient amounts, both quantitatively and qualitatively, of protein, vitamin A, and calories are provided for every child. The Indonesian must be taught, by practical example, the necessity of adequate feeding, and be encouraged to make maximum use of locally available foods. It is hoped that the centres to deal with malnutrition, envisaged by the Ministry of Health, will provide both curative and preventive treatment and facilities for propaganda and research.

Child↗
PubMed1992

[Malnutrition among the elderly admitted as emergencies to an internal medicine department. Possible causes and consequences].

The degree of malnutrition (number of criteria out of seven) in 104 elderly persons who were admitted acutely to a medical department was related to a number of factors, some of which might affect the development of their malnutrition and others which might be influenced by it. Malnutrition was more pronounced in patients who received no medication or had a high intake of tablets than in patients with a moderate intake. Malnutrition was inversely related to degree of physical activity. Malnourished patients stayed longer in hospital, and were more often discharged dead or to institutions providing long-term care than to their homes. Malnutrition was not related to complaints prior to admission, income, social class, marital status, number of meals per day, hot meals per week, eating together, alcohol consumption or final diagnosis. Malnutrition in the elderly upon admission to a medical department has a multifactorial etiology and serious consequences. This makes it important to recognize the malnutrition, and treat it.

Aged↗
PubMed1995

Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area.

OBJECTIVE: To identify common characteristics among infants with breastfeeding malnutrition in a region with an increasing incidence of breastfeeding malnutrition. DESIGN: Retrospective case series. SETTING: A 361-bed regional tertiary care children's hospital in a 1.7 million population metropolitan area. PATIENTS CASE SERIES: five infants with severe breastfeeding malnutrition and hypernatremia admitted to a tertiary care children's hospital over a 5-month period. Retrospective case review: 166 infants admitted between 1990 and 1994 with the diagnosis of dehydration, hypernatremia, or malnutrition. MAIN OUTCOME MEASURES: Maternal characteristics, age at presentation, percent loss from birth weight, serum sodium, average age at birth hospital discharge, neurologic, or cardiovascular complications. RESULTS: Five infants were admitted to a children's hospital over a 5-month period with severe breastfeeding malnutrition and hypernatremia. The average weight loss at time of readmission was 23% (+/- 8%) from birth weight. The average presenting sodium was 186 +/- 19 mmol/L. Three suffered significant complications. From 1990 through 1994, there was a statistically significant (P < .05) annual increase in the number of infants admitted with breastfeeding malnutrition and hypernatremia. CONCLUSIONS: While breastfeeding malnutrition and hypernatremia is not a new problem, this cluster of infants represents an increase in frequency and severity of the problem and could be a consequence of several factors, including inadequate parent education about breastfeeding problems and inadequate strategies for infant follow-up.

Adult↗
PubMed1997

Association between carriage of oral yeasts, malnutrition and HIV-1 infection among Tanzanian children aged 18 months to 5 years.

The objective was to determine whether there is an association between carriage of oral yeasts, malnutrition and HIV-1 infection among Tanzanian children. A case-control study design within a cross-sectional study was used, and the outcome was carriage of oral yeasts. The exposure variables were malnutrition and HIV-1 antibody, and confounders to be adjusted for were age, sex, and breastfeeding. The study was carried out in Dar-es-Salaam, Tanzania, in two maternal and child health (MCH) clinics that offer routine medical checkups to all expectant mothers and children aged between 0 and 5 years in the catchment area. A total of 882 children aged between 18 months and 5 years participated. Smears from the tongue and buccal mucosa were examined for oral yeasts. Malnutrition was categorized according to standards on the MCH chart and World Health Organization/Centers for Disease Control (WHO/CDC) standards as weight-for-height (wasted), weight-for-age (underweight), and height-for-age (stunted). HIV-1 infection was determined by an enzyme-linked immunosorbent assay. Reactive sera were confirmed by Western Blot. About 27% of the children were slightly or severely malnourished according to standards on the MCH chart. According to WHO/CDC standards, 2.6% were wasted, 16.3% were underweight, and 29.6% were stunted. Fourteen (1.6%) were seropositive for HIV-1 antibody. Hyphal forms and blastospores were much more frequent among children infected with HIV-1 with odds ratios ranging from 3.8 (95% CI: 1.3;11.2) to 6.2 (95% CI: 2.1;18.4) depending on categorization of malnutrition. Malnutrition was a risk factor, too, albeit to a much lesser and insignificant degree. The study supports our previous findings that malnutrition may predispose to carriage of oral yeasts and subsequent infection. However, in this study population HIV infection was clearly the predominant risk factor.

AIDS-Related Opportunistic Infections↗
PubMed1987

Effect of starvation, malnutrition, and trauma on the gastrointestinal tract flora and bacterial translocation.

We have previously shown, in an animal model, that viable indigenous bacteria will cross the intact gastrointestinal (GI) mucosa and spread systemically, a process termed bacterial translocation, if the normal bacterial ecology of the gut was sufficiently disrupted to allow bacterial overgrowth or if the animals were severely immunosuppressed. Starvation or protein malnutrition disrupts the normal indigenous GI tract microflora and impairs host antibacterial defenses. Consequently, we tested the effect of the combination of starvation or protein malnutrition plus burn trauma in promoting bacterial translocation from the GI tract. Bacterial translocation was measured by quantitatively culturing the mesenteric lymph nodes, spleens, livers, blood, and peritoneal cavities of normal or burned (30% of total body surface area) CD1 mice deprived of food for three days or fed a low-protein (0.03%) diet. The effect of starvation or protein malnutrition on the gut microflora was determined by quantitatively measuring the levels of bacteria present in the ceca. Both starvation and protein malnutrition increased the cecal levels of gram-negative enteric bacilli and decreased the levels of lactobacilli and strict anaerobes. Surprisingly, neither starvation nor protein malnutrition promoted bacterial translocation, even though these animals lost over 20% of their body weight and the ecology of the gut microflora was disrupted. In fact, the protein-malnourished animals exhibited lower incidences of bacterial translocation than normally nourished animals when both groups were monoassociated with Escherichia coli C-25 or monoassociated and burned. Thus, it appears that protein malnutrition does not promote bacterial translocation, even when combined with burn trauma.

Animals↗
PubMed1982

Overt and hidden forms of chronic malnutrition in the rat and their relevance to man.

We have examined the physiological weight changes seen in rat dams and their offspring as sequelae of either an overt or a hidden form of chronic protein malnutrition. In the overt model, which was produced by feeding dams a very low protein diet (6% casein) starting 5 weeks prior to conception and continued through lactation, the females showed significant weight losses at all ages compared to dams maintained on a normal diet (25% casein). This caused the malnourished 6% dams to have offspring that were categorized as small-for-date at birth in terms of their weight indices and peripheral metabolic profiles. Also, the inadequate milk production of these dams resulted in their pups displaying the almost total failure of growth (greater than 60% decreases in body weights) and peripheral imbalances characteristic of infantile marasmus by day 8 of lactation. Consequently, at all times examined the 6% dams and pups showed most of the typical responses seen in the more severe forms of in utero and lactational malnutrition of mankind. In contrast, the hidden form of malnutrition produced by feeding dams a somewhat higher protein diet (8% casein) throughout the same time periods caused no marked weight losses by these females during their pregnancy compared to the normal dams. Although the 8% pups had the same birth weight indices as the normal offspring, previous data from our group have indicated that the 8% progeny show many metabolic imbalances at birth which are indicators of severe gestational malnutrition in humans. Moreover, while the 8% dams displayed lactational insufficiencies as noted by their pups retarded postnatal growth, nursing of these offspring by 25% dams allowed them to maintain a normal lactational growth curve. However, not only was this cross-fostering unable to rehabilitate most of the prenatally determined biochemical alterations affecting the 8% pups but, additionally, this form of malnutrition will remain undetected if weight indices alone are used as assessors of normalcy. Thus, it appears that the 8% rats may serve as a useful model for the hidden forms of malnutrition in man.

Animals↗
PubMed2005

The prevalence of malnutrition in hospitals can be reduced: results from three consecutive cross-sectional studies.

AIMS: To assess and compare the rates of malnutrition in Hammersmith Hospital NHS Trust over a 5-year period following changes in hospital nutrition care strategies. METHODS DESIGN: Three consecutive cross-sectional studies carried out in 1998, 2000 and 2003. SETTING: Inpatients at Hammersmith Hospital NHS Trust. PARTICIPANTS: A total of 2283 inpatients aged over 16 years old, 686 in 1998, 780 in 2000, 817 in 2003. Inpatients excluded: ventilated patients, ante/post-natal women and people aged <16. INTERVENTIONS: Improvements in the catering service and nutrition education provision in 2000, and the implementation of a nutrition screening tool and 'Better Hospital Food' in 2003. MAIN OUTCOME MEASURE: Prevalence of malnutrition. RESULTS: There was a reduction in the prevalence of malnutrition in 2000 and 2003 from baseline data in 1998 (1998: 23.5%, 161/686; 2000: 20.4%, 159/780; 2003: 19.1%, 156/817; P<0.001). The odds ratio of being either at risk of malnutrition or malnourished was reduced in both 2000 and 2003 by approximately 33% (P=0.001). Indicators of good nutritional practice also improved: Weighing patients on admission increased from 37.5% (257/686) in 1998, to 42.9% (335/780) in 2000, and 59.6% (487/817) in 2003 (P0.001). Dietetic referrals also increased from 31.5% (216/686) in 1998 to 41.6% (340/817) in 2003 (P<0.001)(no change in 2000, 31%, 242/780). Appropriate referrals also improved, results showing that the proportion of malnourished patients who were referred showed a dramatic increase in 2003 (1998: 91/161, 56.5%; 2000: 85/159, 53.5%; 2003: 111/156, 71.2%; P=0.003). CONCLUSIONS: The prevalence of malnutrition in hospital can be influenced by the implementation of a variety of nutrition care strategies, which target identification of malnutrition and its treatment.

Aged↗
PubMed2003

Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study.

OBJECTIVE: We determined the nutrition status and prevalence of malnutrition as determined by the Subjective Global Assessment in Latin America, investigated the awareness of the health team with regard to nutrition status, evaluated the use of nutritional therapy, and assessed the governmental policies regulating the practice of nutritional therapy in each country. METHODS: This cross-sectional, multicenter epidemiologic study enrolled 9348 hospitalized patients older than 18 y in Latin America. Student's t test and chi-square tests were used to analyze univariate analysis and multiple logistic regression analysis, respectively. RESULTS: Malnutrition was present in 50.2% of the patients studied. Severe malnutrition was present in 11.2% of the entire group. Malnutrition correlated with age (>60 y), presence of cancer and infection, and longer length of hospital stay (P < 0.05). Fewer than 23% of the patients' records contained information on nutrition-related issues. Nutritional therapy was used in 8.8% of patients (6.3% enteral nutrition and 2.5% parenteral nutrition). Governmental policies ruling the practice of nutritional therapy exist only in Brazil and Costa Rica. CONCLUSIONS: Hospital malnutrition in Latin America is highly prevalent. Despite this prevalence, physicians' awareness of malnutrition is weak, nutritional therapy is not used routinely, and governmental policies for nutritional therapy are scarce.

Adult↗
PubMed2004

Prevalence of malnutrition in Nigerians with chronic renal failure.

In developed countries, malnutrition is common in patients with chronic renal failure (CRF) and has adverse effects on patient morbidity and mortality. The prevalence of malnutrition before the initiation of dialysis is poorly characterized in CRF patients in developing countries. We studied the prevalence of malnutrition among Nigerians with CRF before commencement of dialysis. Body mass index (BMI) and serum protein levels were measured in 74 dialysis naïve Nigerians with CRF and 48 controls. Patients with nephrotic syndrome, steroid use and failure of organs other than the kidneys were excluded. The mean BMI was significantly lower in the patients compared to the controls (22.4 +/- 14.9 kg/M2 Vs. 25.2 +/- 2.7 kg/M2; p = 0.0001). Low BMI (less than 20 Kg/M2) was present in 16 (21.6%) of the patients compared with one of the controls. The mean serum total protein and albumin were also significantly lower in the patients compared to controls (61.9 +/- 14.4 g/L Vs. 73.8 +/- 6.8 g/L; p < 0.0001, and 31.5 +/- 9.3 g/L Vs. 39.6 +/- 4.4 g/L; p < 0.0001 respectively). Protein malnutrition (serum albumin < 29 g/L) was present in 32 (43.2%) of patients with CRF and one (2.1%) of the control subjects. Malnutrition is common in Nigerian CRF patients before the commencement of dialysis. In these patients, emphasis should be placed on prevention and/or correction of malnutrition because of its documented adverse effects on the outcomes of maintenance dialysis.

Adult↗
PubMed2004

Assessment of malnutrition in mental health clients: nurses' judgement vs. a nutrition risk tool.

BACKGROUND: The existence of malnutrition in general hospitals is well documented. Psychiatric patients are known to have increased risk of malnutrition, yet physical examinations and nutritional assessments rarely take place in psychiatric hospitals. AIM: The purpose of this study was to adapt an established nutrition risk score for use with psychiatric patients, using criteria previously agreed by the care team, and to assess whether the clinical judgement of ward staff alone identified a similar group of patients to be at risk. METHOD: The risk score assessment was compared with a subjective risk assessment made by nursing staff as patients were admitted to the unit. Data were collected for 112 patients. RESULTS: The comparison revealed that nurses did not identify malnutrition in the same patients as the risk score, overlooking 27 (29%) at risk patients. Nurses associated malnutrition with psychotic illness, suggesting that depressed patients are more likely to be overlooked. STUDY LIMITATIONS: Although the risk score was based on a validated tool and its content and face validity were established, it has not itself been validated against criteria of nutritional status (malnutrition). CONCLUSIONS: Implementing routine nutritional screening on such units would assist in identifying at risk patients, enabling referral for dietetic intervention to be made. Providing nutrition education for staff might help to improve knowledge and awareness of malnutrition for this patient group.

Adolescent↗
PubMed2004

Protein malnutrition and hypoalbuminemia as predictors of vascular events and mortality in ESRD.

BACKGROUND: It is proposed that chronic inflammation is common to the pathogenesis of malnutrition and vascular disease, both frequently observed in patients with end-stage renal disease. However, previous studies were unable to differentiate between true protein malnutrition and hypoalbuminemia. METHODS: This study was undertaken to determine the associations between malnutrition, measured by total-body nitrogen (TBN), and albumin, a marker of both nutritional status and chronic inflammation, with mortality and morbidity. One hundred nine patients starting dialysis therapy underwent nutritional assessment (TBN level and anthropometric measurements), vascular risk assessment (hypertension, hypercholesterolemia, diabetes mellitus, and smoking status), and serum albumin measurement. Subsequent patient mortality and new vascular events were recorded. RESULTS: Survival was associated independently with both TBN (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1 to 2.5; P = 0.02 for every 10% decrease in nitrogen index) and serum albumin levels (HR, 1.1; 95% CI, 1.0 to 1.2; P = 0.004 for every 0.1-g/dL (1-g/L) decrease in serum albumin level) adjusted for other variables. Only low serum albumin level predicted subsequent vascular morbidity (HR, 2.2; 95% CI, 1.0 to 4.9; P = 0.049), as did increasing age (HR, 2.0; 95% CI, 1.4 to 3.0; P = 0.0004 for every 10-year increase in age) adjusted for other important risk factors. CONCLUSION: This study dissociates the effect of protein malnutrition and hypoalbuminemia on morbidity and mortality in patients starting dialysis therapy. Protein malnutrition and hypoalbuminemia are independently predictive of mortality, whereas hypoalbuminemia is predictive of vascular morbidity. The study supports the hypothesis that hypoalbuminemia is pathogenically associated with vascular disease, but dissociates this effect from protein malnutrition.

Cerebrovascular Disorders↗