Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients

doi:10.1093/ajcn/80.2.299

The American Journal of Clinical Nutrition

Volume 80, Issue 2, August 2004, Pages 299-307

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ABSTRACT

Background

Malnutrition-inflammation complex syndrome, an outcome predictor in maintenance hemodialysis (MHD) patients, may be related to anorexia.

Objectives

We examined whether subjectively reported appetite is associated with adverse conditions and increased morbidity and mortality in MHD patients.

Design

A cohort of 331 MHD outpatients was asked to rate their recent appetite status on a scale from 1 to 4 (very good, good, fair, and poor appetite, respectively). Anemia indexes and nutritional and inflammatory markers—including serum concentrations of C-reactive protein, tumor necrosis factor α, and interleukin 6—were measured. The malnutrition-inflammation score was used to evaluate the malnutrition-inflammation complex syndrome, and the SF36 questionnaire was used to assess quality of life (QoL). Mortality and hospitalization were followed prospectively for up to 12 mo.

Results

Patients were aged 54.5 ± 14.4 y. Diminished appetite (fair to poor) was reported by 124 patients (38%). Hemoglobin, protein intake, and QoL scores were progressively lower, whereas markers of inflammation, malnutrition-inflammation scores, and the required erythropoietin dose were higher across the worsening categories of appetite. The adjusted odds ratios of diminished versus normal appetite for increased serum tumor necrosis factor α and C-reactive protein concentrations were significant. Significant associations between a poor appetite and an increased rate of hospitalization and mortality were observed. The hazard ratio of death for diminished appetite was 4.74 (95% CI: 1.85, 12.16; P = 0.001).

Conclusion

Diminished appetite (anorexia) is associated with higher concentrations of proinflammatory cytokines and higher levels of erythropoietin hyporesponsiveness and poor clinical outcome, including a 4-fold increase in mortality, greater hospitalization rates, and a poor QoL in MHD patients. Appetite status may yield significant insight into the clinical status of dialysis patients.

Key Words

Dialysis

anorexia

inflammation

protein-energy malnutrition

outcome

appetite

Cited by (0)

¹: From the Division of Nephrology and Hypertension, Harbor-University of California, Los Angeles Medical Center, Torrance, CA (KK-Z and JDK); the David Geffen School of Medicine, University of California, Los Angeles (KK-Z and JDK); the Division of Public Health Nutrition and Epidemiology, School of Public Health, University of California, Berkeley (KK-Z and GB); DaVita, Inc, Torrance, CA (CJM); the Division of Nephrology, University of California, San Francisco, San Francisco General Hospital (MHH); and the School of Public Health, University of California, Los Angles (JDK)

²: Presented at the annual meeting of the American Federation for Medical Research, Baltimore, March 14–16, 2003.

³: Supported by a research grant from Amgen, Inc (to KK-Z and JDK) and grant M01-RR00425 from the General Clinical Research Center, the National Centers for Research Resources, National Institutes of Health. The Nutritional/Inflammatory Evaluation in Dialysis Study was supported by grant DK61162 from the National Institute of Digestive, Diabetes and Kidney Diseases (KK-Z).

⁴: Reprints not available. Address correspondence to K Kalantar-Zadeh, David Geffen School of Medicine, Division of Nephrology and Hypertension, Harbor–UCLA Medical Center, Harbor Mailbox 406, 1000 West Carson Street, Torrance, CA 90509-2910. E-mail: [email protected].