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1 From the Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands (RdM, DCG, JGvM, and FWD); the Hans Mak Institute, Naarden, Netherlands (EWB); the Department of Dietetics, Rijnstate Hospital, Arnhem, Netherlands (HB); and the Department of Nephrology, Academic Medical Center, Amsterdam, Netherlands (RTK).
2 The study sponsors had no role in the study design, data collection, analysis and interpretation, writing of the paper, or decision to submit for publication. 3 The NECOSAD Study was supported by unrestricted grants from the Dutch Kidney Foundation and from Amgen BV Netherlands. 4 Reprints not available. Address correspondence to R de Mutsert, Leiden University Medical Center, Clinical Epidemiology, C7-P, PO Box 9600, 2300 RC Leiden, Netherlands. E-mail: r.de_mutsert{at}lumc.nl.
ABSTRACT
Background: The subjective global assessment of nutritional status (SGA) is used to assess the nutritional status of chronic dialysis patients, but longitudinal data in relation to mortality risk are lacking.
Objective: Our objective was to study the long-term and time-dependent associations of the SGA with mortality risk in chronic dialysis patients.
Design: In a prospective longitudinal observational multicenter study of incident dialysis patients, the 7-point SGA [7 = normal nutritional status; 1 = severe protein-energy wasting (PEW)] was assessed 3 and 6 mo after the start of dialysis and subsequently every 6 mo during 7 y of follow-up. With Cox regression analysis we calculated hazard ratios (HRs) of the baseline and time-dependent SGA measurements, adjusted for age, sex, treatment modality, primary kidney diseases, and comorbidity.
Results: In total, 1601 patients were included [age: 59 ± 15 y; 61% men; 23% with moderate PEW (SGA4–5), and 5% with severe PEW (SGA1–3)]. There was a dose-dependent trend of the 7-point SGA with mortality. Compared with a normal nutritional status at baseline, SGA4–5 (HR: 1.6; 95% CI: 1.3, 1.9) and SGA1–3 (HR: 2.1; 95% CI: 1.5, 2.8) were associated with an increase in 7-y mortality. Time-dependently, these associations were stronger: SGA4–5 (HR: 2.1; 95% CI: 1.7, 2.5) and SGA1–3 (HR: 5.0; 95% CI: 3.8, 6.5).
Conclusions: In dialysis patients, PEW at baseline assessed with SGA was associated with a 2-fold increased mortality risk in 7 y of follow-up. Time-dependently, this association was even stronger, which indicated that PEW was associated with a remarkably high risk of short-term mortality. These data imply that the 7-point SGA may validly distinguish different degrees of PEW associated with increasing risks of mortality.
Received for publication September 12, 2008. Accepted for publication November 25, 2008.
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