Although intradialytic parenteral nutrition (IDPN) is a method used widely to combat protein-calorie malnutrition in hemodialysis patients, its effect on survival has not been thoroughly studied. We conducted a prospective, randomized trial in which 186 malnourished hemodialysis patients received oral nutritional supplements with or without 1 year of IDPN. IDPN did not improve 2-year mortality (primary end point), hospitalization rate, Karnofsky score, body mass index, or laboratory markers of nutritional status. Instead, both groups demonstrated improvement in body mass index and the nutritional parameters serum albumin and prealbumin (P 30 mg/L within 3 months, a marker of nutritional improvement, independently predicted a 54% decrease in 2-year mortality, as well as reduced hospitalizations and improved general well-being as measured by the Karnofsky score. Therefore, although we found no definite advantage of adding IDPN to oral nutritional supplementation, this is the first prospective study demonstrating that an improvement in prealbumin during nutritional therapy is associated with a decrease in morbidity and mortality in malnourished hemodialysis patients.
Results: In the systematic review, 25 of the 28 studies used the Mini-Nutritional Assessment (long or short form) for malnutrition screening. For frailty assessment, 23 of the 28 studies focused on the physical frailty phenotype, of which 19 followed the original Fried phenotype. Fifteen studies analyzed the association between malnutrition and frailty, which was significant in 12 of these. The meta-analysis included 10 studies with a total of 5447 older adults. In this pooled population of community-dwelling older adults [mean (standard deviation) age: 77.2 (6.7) years], 2.3% was characterized as malnourished and 19.1% as physically frail. The prevalence of malnutrition was significantly associated with the prevalence of physical frailty (P
malnourished
Conclusions: The systematic review and meta-analysis revealed that malnutrition and physical frailty in community-dwelling older adults are related, but not interchangeable geriatric syndromes. Two out of 3 malnourished older adults were physically frail, whereas close to 10% of the physically frail older adults was identified as malnourished.
Background: International guidelines on the nutritional management of patients with cancer recommend intervention with dietary advice and/or oral nutritional supplements in patients who are malnourished or those judged to be at nutritional risk, but the evidence base for these recommendations is lacking. We examined the effect of oral nutritional interventions in this population on nutritional and clinical outcomes and quality of life (QOL).
Methods: Electronic searches of several databases including MEDLINE, EMBASE, and CINAHL (from the first record to February 2010) were searched to identify randomized controlled trials of patients with cancer who were malnourished or considered to be at risk of malnutrition and receiving oral nutritional support compared with routine care. We performed a meta-analysis using a fixed effect model, or random effects models when statistically significant heterogeneity was present, to calculate relative risk (mortality) or mean difference (weight, energy intake, and QOL) with 95% confidence intervals (CIs). Heterogeneity was determined by using the χ(2) test and the I(2) statistic. All statistical tests were two-sided.
Conclusion: Oral nutritional interventions are effective at increasing nutritional intake and improving some aspects of QOL in patients with cancer who are malnourished or are at nutritional risk but do not appear to improve mortality.
Currently there is no consensus on how to identify pregnant women as acutely malnourished and when to enroll them in nutritional programmes. Médecins Sans Frontières Switzerland undertook a literature review with the purpose of determining values of anthropometric indicators for acute malnutrition that are associated with adverse birth outcomes (such as low birth weight (LBW)), pre-term birth and intra-uterine growth retardation (IUGR). A literature search in PUBMED was done covering 1 January 1995 to 12 September 2012 with the key terms maternal anthropometry and pregnancy. The review focused on the humanitarian context. Mid-upper-arm circumference (MUAC) was identified as the preferential indicator of choice because of its relatively strong association with LBW, narrow range of cut-off values, simplicity of measurement (important in humanitarian settings) and it does not require prior knowledge of gestational age. The MUAC values below which most adverse effects were identified were
We curated 45 existing TB-related signature gene sets and developed our TBSignatureProfiler software toolkit that estimates gene set activity using multiple enrichment methods and allows visualization of single- and multi-pathway results. The TBSignatureProfiler software is available through Bioconductor and on GitHub. For evaluation in malnutrition, we used whole blood gene expression profiling from 23 severely malnourished Indian individuals with TB and 15 severely malnourished household contacts with latent TB infection (LTBI). Severe malnutrition was defined as body mass index (BMI)
In this work, we curated almost four dozen existing TB-related signature gene sets and developed our TBSignatureProfiler software toolkit. We also added two single-gene biomarkers to this comparison that were compared in a previous meta-analysis [21]. This platform was used to evaluate the function of these signatures for distinguishing between TB and LTBI in severely malnourished individuals. We applied the TBSignatureProfiler to this condition to determine whether existing TB gene sets work in a severely malnourished population. While it is unlikely that these signatures will be implemented in clinical practice for detecting TB disease, we do note that many existing signatures were developed for this purpose. Thus, comparisons between prevalent and latent TB is the logical first step in evaluating and validating these signature gene sets in the setting of malnutrition. Once these signatures are established and validated, they can be used for more innovative and useful applications, such as predicting risk of progression or worsening disease, monitoring treatment efficacy, or the diagnosis of extrapulmonary disease.
A heatmap displaying the scaled ssGSEA scores for all 45 gene sets (rows) for the samples of malnourished TB and LTBI individuals (columns). Higher scores trend towards yellow-green and lower scores trend towards blue-purple. The color bar at the top designates whether the sample is from an LTBI individual (blue) or an individual with active TB (red). These signatures are able to separate most of the TB samples from the LTBI samples. The pathway signature scores are largely concordant. This heatmap was generated using the SignatureHeatmap() function from the TBSignatureProfiler
a Boxplots of the ssGSEA scores for each signature individually show that some of the signatures are highly predictive of TB compared to LTBI in malnourished individuals. b Boxplots for the AUCs (y-axis) from bootstrapped samples for each pathway (x-axis) demonstrate that that most of the signatures were able to classify TB from LTBI, although some of the signatures there of the signatures, including Maertzdorf _4, Lee_4, and Sloot_HIV_2, had boxplots arms below the 0.5 mark. These figures were generated using the SignatureBoxplot() and AUCBoxplot() functions of the TBSignatureProfiler
We had hypothesized that malnutrition might modulate the transcriptional profiles in different ways and using different mechanisms than in well-nourished individuals, but this was generally not the case. Malnutrition clearly affects the immune response with effects on macrophage activity and phagocytosis, antigen presentation, and induction of the Th1 immune response among other sequelae [29]. It is plausible that these effects were not detected because the dominant immunomodulatory effect of TB that are common between well-nourished and malnourished individuals outweigh the more specific transcriptional impacts induced by changes in nutritional status. It is also likely that some of the signature gene sets themselves were developed in settings with high rates of malnutrition, so the effect of malnutrition on TB signature gene sets was incorporated. For example, Sambarey_HIV_10 signature was trained on data obtained from participants in Chennai and Bengaluru, India where malnutrition is highly prevalent. Further investigation is needed to understand the role of inflammation and immune response in the setting of malnutrition, although we show here that most existing TB signature gene sets work well in the setting of malnutrition.
This work is a demonstration that existing signature gene sets can be effectively used on samples from comorbid TB contexts, although the efficacy of the gene sets may vary. While it is unlikely that these gene signatures will be used in clinical practice to distinguish pulmonary TB from LTBI controls, our work does provide the promise that existing gene sets can be used to detect TB in circumstances where existing diagnostics are less effective, e.g. distinguishing extrapulmonary, paucibacillary, and pediatric TB from controls in malnourished individuals. In addition, evaluation of the subtle differences between signature gene set performance combined with the dissection of the gene set content may provide insight on potential mechanisms specific to demographic, comorbidities, or other context-related specifics for each patient group under consideration. 2ff7e9595c
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