Elsevier

Nutrition

Volume 25, Issue 1, January 2009, Pages 11-19
Nutrition

Applied nutritional investigation
Predicting the outcome of artificial nutrition by clinical and functional indices

https://doi.org/10.1016/j.nut.2008.07.001Get rights and content

Abstract

Objective

Artificial nutrition (AN) is now considered medical therapy and 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. The clinical relevance of any therapy is based on its efficacy and effectiveness and thus on the improvement of its cost efficiency, i.e., the ability to provide benefits to the patients with minimal wasting of human and financial resources. The aim of the present study was to identify those indices, clinical, functional, or nutritional, that may reliably predict, before the start of AN, those patients who are likely not to benefit from nutritional support.

Methods

Three hundred twelve clinical charts of patients receiving AN between January 1999 and September 2006 were retrospectively examined. Data registered before starting AN were collected and analyzed: general data (age, sex), clinical conditions (comorbidity, quality of life, frailty), anthropometric and biochemical indices, type of AN treatment (total enteral nutrition, total parenteral nutrition, mixed AN), and outcome of treatment.

Results

The percentage of negative outcomes (death or interruption of AN due to worsening clinical conditions within 10 d after starting AN) was meaningfully higher in subjects >80 y of age and with reduced social functions, higher comorbidity and/or frailty, reduced level of albumin, prealbumin, lymphocyte count, and cholinesterase and a higher level of C-reactive protein. The multivariate analysis showed that prealbumin and comorbidity were the best predictors of AN outcome. The logistic regression model with these variables showed a predictive value equal to 84.2%.

Conclusion

Proper prognostic instruments are necessary to perform optimal evaluations. The present study showed that a patient's general status (i.e., comorbidity, social quality of life, frailty) and nutritional and inflammatory statuses (i.e., lymphocyte count, albumin, prealbumin, C-reactive protein) have good predictive value on the effectiveness of AN.

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

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    This work was supported by Rehabilitation Clinical Institute Villa delle Querce, Nemi, Rome, Italy.

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