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      Evaluation of Malnutrition Risk in Lung Transplant Candidates Using the Nutritional Risk Index

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          Abstract

          Supplemental Digital Content is available in the text.

          Abstract

          Background.

          Malnutrition in lung transplant (LTx) candidates is an important risk factor for adverse outcomes. We sought to evaluate the Nutritional Risk Index (NRI) in LTx candidates, a validated measure of malnutrition risk in chronic disease. We aimed to characterize malnutrition risk using NRI, evaluate change in body weight between nutritional risk groups, and assess association of malnutrition risk with pretransplant and posttransplant outcomes.

          Methods.

          Retrospective, single-center cohort study of LTx candidates (2014–2015) evaluated by a dietitian before listing. Nutritional parameters, weight change pretransplant and posttransplant, and clinical outcomes were abstracted up to 1-year posttransplant. NRI was calculated as follows: (1.519 × albumin) + (41.7 × current weight/ideal weight) with high malnutrition risk defined as the lowest quartile of NRI for cystic fibrosis (CF) and non-CF patients.

          Results.

          The cohort comprises 247 LTx candidates (57% male; median age 59 y; non-CF 88%). Non-CF candidates had a greater mean NRI compared with CF patients (109 ± 11 versus 95 ± 12; P < 0.0001). 86% with high malnutrition risk maintained/gained weight (≥5%) pretransplant. In 196 LTx recipients, malnutrition risk was not associated with hospital stay, discharge disposition, or 1-year mortality. The median percent weight gain for LTx recipients in the first year was 10.5% (4.0–20.1), with high malnutrition risk recipients having comparable or greater weight gain to the low-risk group (mean difference for non CF: 6.8%; P = 0.02 and CF: −3.8%; P = 0.65).

          Conclusions.

          Malnutrition risk assessed with NRI was not prognostic of posttransplant outcomes in this retrospective cohort. LTx candidates with high malnutrition risk were able to maintain their weight pretransplant and demonstrated considerable weight gain in the first-year posttransplant.

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          Most cited references53

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          Serum albumin: relationship to inflammation and nutrition.

          Hypoalbuminemia is the result of the combined effects of inflammation and inadequate protein and caloric intake in patients with chronic disease such as chronic renal failure. Inflammation and malnutrition both reduce albumin concentration by decreasing its rate of synthesis, while inflammation alone is associated with a greater fractional catabolic rate (FCR) and, when extreme, increased transfer of albumin out of the vascular compartment. A vicious cascade of events ensues in which inflammation induces anorexia and reduces the effective use of dietary protein and energy intake and augments catabolism of the key somatic protein, albumin. Hypoalbuminemia is a powerful predictor of mortality in patients with chronic renal failure, and the major cause of death in this population is due to cardiovascular events. Inflammation is associated with vascular disease and likely causes injury to the vascular endothelium, and hypoalbuminemia as two separate expressions of the inflammatory process. Albumin has a myriad of important physiologic effects that are essential for normal health. However, simply administering albumin to critically ill patients with hypoalbuminemia has not been shown to improve survival or reduce morbidity. Thus the inference from these clinical studies suggests that the cause of hypoalbuminemia, rather than low albumin levels specifically, is responsible for morbidity and mortality.
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            2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary.

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              Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group.

              G. Buzby (1991)
              We undertook this study to test the hypothesis that perioperative total parenteral nutrition (TPN) decreases the incidence of serious complications after major abdominal or thoracic surgical procedures in malnourished patients. We studied 395 malnourished patients (99 percent of them male) who required laparotomy or noncardiac thoracotomy. They were randomly assigned to receive either TPN for 7 to 15 days before surgery and 3 days afterward (the TPN group) or no perioperative TPN (the control group). The patients were monitored for complications for 90 days after surgery. The rates of major complications during the first 30 days after surgery in the two groups were similar (TPN group, 25.5 percent; control group, 24.6 percent), as were the overall 90-day mortality rates (13.4 percent and 10.5 percent, respectively). There were more infectious complications in the TPN group than in the controls (14.1 vs. 6.4 percent; P = 0.01; relative risk, 2.20; 95 percent confidence interval, 1.19 to 4.05), but slightly more noninfectious complications in the control group (16.7 vs. 22.2 percent; P = 0.20; relative risk, 0.75; 95 percent confidence interval, 0.50 to 1.13). The increased rate of infections was confined to patients categorized as either borderline or mildly malnourished, according to Subjective Global Assessment or an objective nutritional assessment, and these patients had no demonstrable benefit from TPN. In contrast, severely malnourished patients who received TPN had fewer noninfectious complications than controls (5 vs. 43 percent; P = 0.03; relative risk, 0.12; 95 percent confidence interval, 0.02 to 0.91), with no concomitant increase in infectious complications. The use of preoperative TPN should be limited to patients who are severely malnourished unless there are other specific indications.
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                Author and article information

                Journal
                Transplant Direct
                Transplant Direct
                TXD
                Transplantation Direct
                Wolters Kluwer Health
                2373-8731
                July 2020
                23 June 2020
                : 6
                : 7
                : e574
                Affiliations
                [1 ] Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
                [2 ] Soham and Shaila Ajmera Family Transplant Centre, Nutrition, University Health Network, Toronto, ON, Canada.
                [3 ] Division of Pulmonary Medicine, Department of Medicine, University of Calgary, Calgary, AB, Canada.
                [4 ] Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
                [5 ] Toronto Lung Transplant Program, Soham and Shaila Ajmera Family Transplant Centre, University Health Network, Toronto, ON, Canada.
                [6 ] Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute, University of Toronto, Toronto, ON, Canada.
                Author notes
                Correspondence: Dmitry Rozenberg, MD, PhD, Department of Medicine, Division of Respirology, Toronto General Hospital, 200 Elizabeth St, 13 EN-229, Toronto, ON M5G 2N2, Canada. ( Dmitry.Rozenberg@ 123456uhn.ca ).
                Article
                00011
                10.1097/TXD.0000000000001028
                7339342
                c891616e-ee2d-4b70-92af-37198a9a9aad
                Copyright © 2020 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 23 April 2020
                : 13 May 2020
                : 14 May 2020
                Categories
                Lung Transplantation
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