Identifying critically ill patients with cirrhosis who benefit from nutrition therapy: the mNUTRIC score study
Background and aim: Malnutrition increases risk of mortality in critically ill patients with cirrhosis. Modified Nutrition Risk in Critically ill (mNUTRIC) score is a validated tool to identify at risk patients who may benefit from goal-directed nutrition therapy. We aimed to study the association between mNUTRIC score and 28-day mortality in critically ill patients with cirrhosis.
Methods: A prospective study was conducted in the liver intensive care unit of a quaternary teaching institute. Baseline and follow-up data pertaining to mNUTRIC score, clinical-, hemodynamic-, biochemical-, nutritional parameters, mechanical ventilation, length of ICU stay, and development of sepsis were collected. Correlation between mNUTRIC score and its modulation by nutritional adequacy was determined.
Results: One hundred and fifty patients were enrolled. Out of these, 116 (77%) had a high NUTRIC score (HNS) and 34 (23%) had a low NUTRIC score (LNS). Patients with HNS had higher mortality (54% vs. 10%; p = 0.008), longer mechanical ventilation (p = 0.02), and high incidence of sepsis (32% vs. 2.6%; p = 0.002) compared to LNS. The probability of survival increased with increase in nutritional adequacy (p < 0.01) in patients with HNS.
Conclusion: mNUTRIC score is a useful tool for identifying nutrition risk in critically ill patients with cirrhosis. Goal-directed nutrition therapy in patients with HNS can significantly improve survival.
Relevance for patients: Critically ill patients with cirrhosis who are at a higher nutritional risk as identified by the mNUTRIC score may have a better survival benefit if higher calorie and protein adequacy is achieved in the ICU.
[1] European Association for the Study of the Liver, Electronic Address, easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines on Nutrition in Chronic Liver Disease. J Hepatol 2019;70:172-93.
[2] Nadim MK, Durand F, Kellum JA, Levitsky J, O’Leary JG, Karvellas CJ, et al. Management of the Critically ill Patient with Cirrhosis: A Multidisciplinary Perspective. J Hepatol 2016;64:717-35.
[3] McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN J Parenter Enteral Nutr 2016;40:159-211.
[4] Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. J Clin Med 2019;8:1065.
[5] Tandon P, Raman M, Mourtzakis M, Merli M. A Practical Approach to Nutritional Screening and Assessment in Cirrhosis. Hepatology 2017;65:1044-57.
[6] Heyland DK, Dhaliwall R, Jiang X, Day AG. Identifying Critically Ill Patients Who Benefit the Most from Nutrition Therapy: The Development and Initial Validation of a Novel Risk Assessment Tool. Crit Care 2011;15:R268.
[7] Fleming KM, Aithal GP, Solaymani-Dodaran M, Card TR, West J. Incidence and Prevalence of Cirrhosis in the United Kingdom, 1992-2001: A General Population-Based Study. J Heptol 2008;49:732-8.
[8] Rahman A, Hasan RM, Agarwala R, Martin C, Day AG, Heyland DK. Identifying Critically-ill Patients Who will Benefit Most from Nutritional Therapy: Further Validation of the “Modified NUTRIC” Nutritional Risk Assessment Tool. Clin Nutr 2016;35:148-62.
[9] Plautha M, Cabre´ E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, et al. ESPEN Guidelines on Enteral Nutrition: Liver Disease. Clin Nutr 2006;25:285-94.
[10] Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315:801-10.
[11] Van Vught LA, Klouwenberg PM, Spitoni C, Scicluna BP, Wiewel MA, Horn J, et al. Incidence, Risk Factors, and Attributable Mortality of Secondary Infections in the Intensive Care Unit after Admission for Sepsis. JAMA 2016;315:1469-79.
[12] Nayak SL, Maiwall R, Nandwani A, Ramanarayanan S, Mathur RP, Kumar R, et al. Management of Acute Kidney Injury in Cirrhosis. Hepatol Int 2013;7:813-9.
[13] De Vries MC, Koekkoek WC, Opdam MH, Van Blokland D, Van Zanten AR. Nutritional Assessment of Critically Ill Patients: Validation of the Modified NUTRIC Score. Eur J Clin Nutr 2018;72:428-35.
[14] Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK, et al. Nutritional Risk Assessment and Cultural Validation of the Modified NUTRIC Score in Critically Ill Patients-A Multicenter Prospective Cohort Study. J Crit Care 2017;37:45-9.
[15] Mukhopadhyay A, Henry J, Ong V, Leong CS, Teh AL, Van Dam RM, et al. Association of Modified NUTRIC Score with 28-day Mortality in Critically Ill Patients. Clin Nutr 2017;36:1143-8n.
[16] Kondrup J, Allison SP, Elia M, Vellas B, Plauth M, Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22:415-21.
[17] Baker JP, Detsky AS, Wesson DE, Wolman SL, Stewart S, Whitewell J, et al. Nutritional Assessment: A Comparison of Clinical Judgement and Objective Measurements. N Engl J Med 1982;306:969-72.
[18] Saliba F, Ichai P, Levesque E, Samuel D. Cirrhotic Patients in the ICU: Prognostic Markers and Outcome. Curr Opin Crit Care 2013;19:154-60.
[19] Kondrup J. Nutritional Risk Scoring Systems in the Intensive Care Unit. Curr Opin Clin Nutr Metab Care 2014;17:177-82.
[20] Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, et al. Acute Skeletal Muscle Wasting in Critical Illness. JAMA 2013;310:1591-600.
[21] Vincent JL. Give Your Patient a Fast Hug (at least) Once a Day. Crit Care Med 2005;3:1225-9.
[22] Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early Enteral Nutrition, Provided within 24 h of Injury or Intensive Care Unit Admission, Significantly Reduces Mortality in Critically Ill Patients: A Metaanalysis of Randomised Controlled Trials. Intensive Care Med 2009;35:2018-27.
[23] Jayaram R, Ramakrishnan N. Cost of Intensive Care in India. Indian J Crit Care Med 2008;12:55-61.
[24] Jeong DH, Hong SB, Lim CM, Koh Y, Seo J, Kim Y, et al. Comparison of Accuracy of NUTRIC and Modified NUTRIC Scores in Predicting 28-day Mortality in Patients with Sepsis: ASingle Center Retrospective Study. Nutrients 2018;10:911.
[25] Rehman HM, Ishtiaq W, Yousaf M, Bano S, Mujahid AM, Akhtar A. Modified Nutrition Risk in Critically Ill (mNUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study from the Pakistani Population. Cureus 2018;10:e3786.
[26] Tsai MH, Huang HC, Peng YS, Chen YC, Tian YC, Yang CW, et al. Nutrition Risk Assessment Using the Modified NUTRIC Score in Cirrhotic Patients with Acute Gastroesophageal Variceal Bleeding: Prevalence of High Nutrition Risk and its Independent Prognostic Value. Nutrients 2019;11:2152.
[27] McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN J Parenter Enteral Nutr 2009;33:277-316.
[28] Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P, Canadian Critical Care Clinical Practice Guidelines Committee. Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients. JPEN J Parenter Enteral Nutr 2003;27:355-73.
[29] Chourdakis M, Grammatikopoulou MG, Day AG, BourasE, Heyland DK. Are all low-NUTRIC-Score Patients the Same? Analysis of a Multi-center Observational Study to Determine the Relationship between Nutrition Intake and Outcome. Clin Nutr 2019;38:2783-9.
[30] Lew CC, Wong GJ, Cheung KP, Fraser RJ, Chua AP, Chong MF, et al. When Timing and Dose of Nutrition Support Were Examined, the Modified Nutrition Risk in Critically Ill (mNUTRIC) Score did not Differentiate High-risk Patients Who would Derive the Most Benefit from Nutrition Support: A Prospective Cohort Study. Ann Intensive Care 2018;8:98.