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      Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease

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          Abstract

          Background

          Nutritional status, weight loss and cachexia have important prognostic implications in patients with chronic obstructive pulmonary disease (COPD). Body mass index (BMI) has been implicated in COPD risk assessment, but information is mostly limited to composite scores or to patients with stable disease. We aimed to analyse the association between BMI and mortality in acute exacerbation of COPD.

          Methods

          This retrospective survey included 968 patients hospitalized due to acute exacerbation of COPD at the University Clinic Golnik from February 2002 to June 2007. Vital status was ascertained with Central Population Registry, and database was censored on November 1, 2008.

          Results

          Median BMI was 25.08 kg/m 2 (interquartile range, 21.55–29.05 kg/m 2) and 210 patients (22%) had BMI < 21 kg/m 2. During median follow-up of 3.26 years (1.79–4.76 years), 430 patients (44%) died. Lowest mortality was found for BMI 25.09–29.05 kg/m 2. When divided per BMI decile, mortality was lowest for BMI 25.09–26.56 kg/m 2 (33%). In univariate analysis, BMI per quartile and BMI per unit increase were predictive for all-cause mortality. In an adjusted model, BMI per 1 kg/m 2 unit increase was associated with 5% less chance of death (hazard ratio 0.95, 95% confidence interval 0.93–0.97).

          Conclusions

          Low BMI < 21 kg/m 2 is frequent in patients hospitalized due to acute exacerbation of COPD. Higher BMI was independently predictive of better long-term survival. A better outcome in obese patients compared to normal weight is in contrast to primary prevention data but concurs with observations of an obesity paradox in other cardiovascular diseases.

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          Most cited references 25

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          Body composition and mortality in chronic obstructive pulmonary disease.

          Survival studies have consistently shown significantly greater mortality rates in underweight and normal-weight patients with chronic obstructive pulmonary disease (COPD) than in overweight and obese COPD patients. To compare the contributions of low fat-free mass and low fat mass to mortality, we assessed the association between body composition and mortality in COPD. We studied 412 patients with moderate-to-severe COPD [Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) stages II-IV, forced expiratory volume in 1 s of 36 +/- 14% of predicted (range: 19-70%). Body composition was assessed by using single-frequency bioelectrical impedance. Body mass index, fat-free mass index, fat mass index, and skeletal muscle index were calculated and related to recently developed reference values. COPD patients were stratified into defined categories of tissue-depletion pattern. Overall mortality was assessed at the end of follow-up. Semistarvation and muscle atrophy were equally distributed among disease stages, but the highest prevalence of cachexia was seen in GOLD stage IV. Forty-six percent of the patients (n = 189) died during a maximum follow-up of 5 y. Cox regression models, with and without adjustment for disease severity, showed that fat-free mass index (relative risk: 0.90; 95% CI: 0.84, 0.96; P = 0.003) was an independent predictor of survival, but fat mass index was not. Kaplan-Meier and Cox regression plots for cachexia and muscle atrophy did not differ significantly. Fat-free mass is an independent predictor of mortality irrespective of fat mass. This study supports the inclusion of body-composition assessment as a systemic marker of disease severity in COPD staging.
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            Survival advantages of obesity in dialysis patients.

            In the general population, a high body mass index (BMI; in kg/m(2)) is associated with increased cardiovascular disease and all-cause mortality. However, the effect of overweight (BMI: 25-30) or obesity (BMI: >30) in patients with chronic kidney disease (CKD) undergoing maintenance hemodialysis (MHD) is paradoxically in the opposite direction; ie, a high BMI is associated with improved survival. Although this "reverse epidemiology" of obesity or dialysis-risk-paradox is relatively consistent in MHD patients, studies in CKD patients undergoing peritoneal dialysis have yielded mixed results. Growing confusion has developed among physicians, some of whom are no longer confident about whether to treat obesity in CKD patients. A similar reverse epidemiology of obesity has been described in geriatric populations and in patients with chronic heart failure (CHF). Possible causes of the reverse epidemiology of obesity include a more stable hemodynamic status, alterations in circulating cytokines, unique neurohormonal constellations, endotoxin-lipoprotein interaction, reverse causation, survival bias, time discrepancies among competitive risk factors, and malnutrition-inflammation complex syndrome. Reverse epidemiology may have significant clinical implications in the management of dialysis, CHF, and geriatric patients, ie, populations with extraordinarily high mortality. Exploring the causes and consequences of the reverse epidemiology of obesity in dialysis patients can enhance our insights into similar paradoxes observed for other conventional risk factors, such as blood pressure and serum cholesterol and homocysteine concentrations, and in other populations such as those with CHF, advanced age, cancer, or AIDS. Weight-gaining interventional studies in dialysis patients are urgently needed to ascertain whether they can improve survival and quality of life.
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              Ethical guidelines for authorship and publishing in the Journal of Cachexia, Sarcopenia and Muscle

              The principles of ethical authorship and publishing in the Journal of Cachexia, Sarcopenia and Muscle (JCSM) are: all authors listed on the manuscript have approved its submission and publication as provided to JCSM; no person who has a right to be recognized as author has been omitted from the list of authors; each author has made an independent material contribution to the work submitted for publication; the submitted work is original and is neither under consideration elsewhere nor has it been published previously in whole or in part other than in abstract form; all original research work is approved by the relevant bodies such as institutional review boards or ethics committees; all conflicts of interest, financial or otherwise, that may affect the authors’ ability to present data objectively have been duly declared in the manuscript; the manuscript in its published form will be maintained on the servers of JCSM as a valid publication only as long as all statements in the guidelines on ethical publishing remain true; if any of the aforementioned statements ceases to be true, the authors have a duty to notify the editors of JCSM as soon as possible so that the information available online can be updated and/or the manuscript can be withdrawn.
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                Author and article information

                Contributors
                +386-425-69141 , +386-425-69117 , mitja.lainscak@guest.arnes.si
                Journal
                J Cachexia Sarcopenia Muscle
                Journal of Cachexia, Sarcopenia and Muscle
                Springer-Verlag (Berlin/Heidelberg )
                2190-5991
                2190-6009
                1 March 2011
                1 March 2011
                June 2011
                : 2
                : 2
                : 81-86
                Affiliations
                [1 ]Division of Cardiology, University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204 Golnik, Slovenia
                [2 ]Applied Cachexia Research, Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany
                [3 ]Center for Cardiovascular Research (CCR), Charité Medical School, Campus Mitte, Berlin, Germany
                [4 ]Center for Stroke Research Berlin, Charité Medical School, Berlin, Germany
                [5 ]University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
                [6 ]Center for Clinical and Basic Research, IRCCS San Raffaele, Rome, Italy
                Article
                23
                10.1007/s13539-011-0023-9
                3118008
                21766053
                © The Author(s) 2011
                Categories
                Original Article
                Custom metadata
                © Springer-Verlag 2011

                Orthopedics

                cachexia, survival, body mass index, chronic obstructive pulmonary disease

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