Applied nutritional investigationPredicting the outcome of artificial nutrition by clinical and functional indices
Introduction
Artificial nutrition (AN) has progressively become one of the mainstays of the different therapeutic options available for home or hospitalized patients, including surgical, medical, and critically ill patients. Also, AN is now included among the tools representing the standard of care for patients with diseases requiring highly specialized therapies, i.e., hematologic patients undergoing bone marrow transplantation. Therefore, AN is now considered medical therapy [1]. The clinical relevance of any therapy, particularly in periods of shrinking resources for national health care systems, is based on its efficacy (i.e., the ability to significantly affect the clinical course of a given disease) and effectiveness (i.e., the ability to significantly affect the clinical course of a patient with that disease). Delivering AN with efficacy and effectiveness will enhance its cost efficiency, i.e., the ability to provide benefits to patients with minimal wasting of human and financial resources. In this light, the systematic use in clinical practice of indices identifying those patients who are not likely to benefit from AN should increase the efficiency of AN.
The reliability of different indices predicting the outcome of AN has been tested in a number of clinical studies, mainly involving patients with percutaneous endoscopic gastrostomy (PEG) [2], [3], [4], [5]. However, these studies aimed at identifying those markers influencing clinically relevant parameters, i.e., long-term morbidity and mortality. By using this approach, the investigators assessed the efficacy of AN rather than its efficiency, which in turn received little attention. Also, these studies involved patients exclusively receiving total enteral nutrition, generally administered by PEG [2], [3], [4], [5], [6], [7], [8], or total parenteral nutrition (TPN) [9], [10], [11]. Therefore, the data obtained appear to pertain to specific groups of patients and cannot be extrapolated to the whole population. Further, some of the prognostic indices are detectable only when AN has been already started, i.e., when significant human and financial resources have been already committed.
We therefore designed the present study to identify those indices, clinical, functional, or nutritional, that may reliably predict, before starting AN, those patients who are likely not to benefit from nutritional support.
Section snippets
Subjects
The study was approved by the local ethics committee. Clinical charts of patients receiving AN in the Clinical Rehabilitation Institute Villa delle Querce (Nemi, Rome, Italy) between January 1999 and September 2006 were retrospectively examined.
The following data registered before starting AN were collected from patients' charts. Clinical conditions were assessed by determining:
- •
The comorbidity index, as measured by the Individual Disease Severity scale [12]. This scale classifies comorbidities
Sample description
The sample studied includes all 312 patients receiving AN from January 1999 to September 2006: 181 women (58% of total sample, 77 ± 12 y of age age) and 131 men (42% of total sample, 69 ± 17 y of age).
The main characteristics of the examined sample are listed in Table 2. In particular, 37.2% of the sample, at the moment of AN onset, was older than 80 y. QoL was characterized by a reduction or absence of social function in 84% of the sample. Moreover, clinical symptoms determined a serious
Discussion
The main findings of the present study are the demonstration that the assessment of a patient's general status (i.e., comorbidity, social QoL, frailty) and nutritional and inflammatory statuses (i.e., lymphocyte count, albumin, prealbumin, CRP) before AN is started reliably predicts the outcome of AN.
For the purposes of this study, weaning from AN or AN longer than 30 d was considered a positive outcome. Although the most recent guidelines indicate that a period of AN shorter than 7–10 d has no
Conclusion
Nutritional feeding support should be considered as a real therapeutic treatment, in addition to other vital support therapies. Costs and benefits (as patient nutritional status and/or clinical improvement) should be well evaluated for each patient (QoL, complications) or, in economics terms, for the entire community.
At present, internationally accepted and codified guidelines for appropriate prescription of nutritional feeding do not exist. This implies that, in these cases, it is difficult
References (47)
- et al.
A prospective evaluation of outcome in patients referred for PEG placement
Gastrointest Endosc
(2002) - et al.
Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia
Am J Gastroenterol
(2000) - et al.
Serum albumin as indicator of clinical evolution in patients on parenteral nutritionMultivariate study
Clin Nutr
(2001) - et al.
Monitoring of patients on home parenteral nutrition (HPN) in Europe: a questionnaire based study on monitoring practice in 42 centres
Clin Nutr
(2006) - et al.
Falls, frailty and osteoporosis in the elderly: a public health problem
Rev Med Interne
(2000) - et al.
Predictive factors for early mortality after percutaneous endoscopic gastrostomy
Gastrointest Endosc
(1995) - et al.
Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury
Lancet
(1985) - et al.
Hepatic proteins and nutrition assessment
J Am Diet Assoc
(2004) Linee Guida SINPE per la Nutrizione Artificiale Ospedaliera 2002
RINPE
(2002)- et al.
Prognostic morbidity and mortality factors in hospital enteral nutrition: prospective study
Nutr Hosp
(2005)
Percutaneous endoscopic gastrostomy in elderly patientsA prospective study in a geriatric hospital
Gastroenterol Clin Biol
Risk factors for mortality in patients undergoing percutaneous endoscopic gastrostomy
Endoscopy
Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups
Age Ageing
Prognosis factors of short and long-term survival in elderly hospitalized patients after percutaneous endoscopic gastrostomy
Gaestrenterol Clin Biol
Correlation between serum transferrin level and prognosis in patients receiving total parenteral nutrition
Zhonghua Yi Xue Za Zhi (Taipei)
Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition
Diabetes Care
The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacementComorbidity and outcomes after hip replacement
Med Care
Pressure sores: classification and management
Clin Orthop Relat Res
Manuale di riferimento per la standardizzazione antropometrica
Nutritional status: anthropometry
Eur J Clin Nutr
Quality-of-life measurements in the evaluation of treatment: proposed guidelines
Br J Clin Pharmacol
A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients
J Am Geriatr Soc
Progress in the development of the index of ADL
Gerontologist
Cited by (40)
ESPEN practical guideline: Clinical nutrition and hydration in geriatrics
2022, Clinical NutritionCitation Excerpt :All we know about EN therefore mainly comes from observational trials. EN is frequently commenced late after substantial weight loss has already developed, which is in the stage of severe malnutrition [128,129] and which hampers effective nutritional therapy [130]. In general, the survival after insertion of a percutaneous endoscopic gastrostomy (PEG) in geriatric patients is poor.
Predicting 30-day mortality following PEG insertion: External validation of the Sheffield Gastrostomy Score and analysis for additional predictors
2021, Clinical Nutrition ESPENCitation Excerpt :Little information exists describing the role of low lymphocyte count on short-term mortality following PEG, although a previous study described an association with one-year mortality in patients referred for PEG with malignancy [23]. A low lymphocyte count was also implicated in a study conducted to identify predictors of poor outcome following initiation of any form of artificial nutrition and hydration [24]. The reason for this relationship is uncertain, although it is perhaps indicative of an impaired immune response.
ESPEN guideline on clinical nutrition and hydration in geriatrics
2019, Clinical NutritionAn inflammation-based prognostic score, the C-reactive protein/albumin ratio predicts the morbidity and mortality of patients on parenteral nutrition
2018, Clinical NutritionCitation Excerpt :In clinical practice, parenteral nutrition (PN) efficiency could increase with the systematic use of scores identifying patients who are likely to benefit from it [1].
This work was supported by Rehabilitation Clinical Institute Villa delle Querce, Nemi, Rome, Italy.