Agreement between mnutric and NRS-2002 tools in nutritional risk screening at intensive care unit

T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 142 AGREEMENT BETWEEN mNUTRIC AND NRS-2002 TOOLS IN NUTRITIONAL RISK SCREENING AT INTENSIVE CARE UNIT Nguyen Thi Thu Hien1,2, Nguyen Thi Thu1 Nguyen Sy Thau1, Pham Duc Minh3 SUMMARY Objectives: To compare NUTRIC to NRS-2002 in malnutrition risk screening for critical ill patient. Subjects and methods: A prospective study on 181 patients hospitalized at Intensive Care Unit (ICU), Military Central Hospital 108 from 01/2020 - 7/2020. The mNUTRIC and NRS-2002 were collected within first 24 hours of ICU. Results: NRS-2002 and mNUTRIC had mean score of 4.7 and 3.9, respectively. The prevalance of malnutrition according to NUTRIC and NRS-2002 were 54.2% and 40.3%, respectively (p < 0.001) with a moderate agreement (Kappa: 0.5). The mNUTRIC (AUC: 0.71, 95%CI: 0.63 - 0.78) tended to have more ability than the NRS-2002 (AUC: 0.69, 95%CI: 0.61 - 0.76) at predicting death within 28 days (p > 0.05). Conclusion: There was a difference in performance between mNUTRIC and NRS-2002 in malnutrion screening in ICU. * Keywords: Nutrition; Screening; Intensice Care Unit; NUTRIC; NRS-2002; Clinical outcome. INTRODUCTION Malnutrition is common in hospitalized patients and highly prevalent in the population of critically ill individuals [1]. Hospital malnutrition is associated with increased morbidity, mortality, occurrence of nosocomial infections, prolonged hospitalization length of stay, worse functional status at discharge from ICU and increased hospital costs [2, 3]. Most of the tools used to assess nutritional risk include a variety of criteria to identify nutritional risk, such as food/nutritional intake, physical examination, severity of illness, anthropometric data and functional assessment. Patients treated in ICU are at risk of malnutrition not only due to the severity of the disease, but also due to insufficient nutrition. Most of the critical diseases cause increased metabolism, increased inflammatory response, thereby increasing energy consumption. On the other hand, there is a risk of reduced nutritional intake due to reduced absorption or delayed nutrient supply by the patient in connection with surgical procedures. It is noteworthy that the malnutrition in the critically illness is rapid and severe, up to 1 - 2 kg of protein, equivalent to 10 - 15% of the total protein intake of the patient at admission, within 10 days [4]. 1Military Central Hospital 108 2Thang Long University 3Nutrition Department, Military Hospital 103, Vietnam Military Medical University Corresponding author: Pham Duc Minh (drminh103@yahoo.com) Date received: 2/10/2020 Date accepted: 25/10/2020 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 143 The suitable provision of the nutrition needs of hospitalized patients is necessary for their survival, especially for those hospitalized in the ICU. In 2003, Kvale et al showed that 40% of critical patients lost > 10 kg of their body weight, depending on their length of stay in ICU [5]. More recently, Hodalova et al found that only two-thirds of patients could be physically recovered after ICU [6]. Interestingly, the nutrition status of critical patients is associated with a greater risk of mortality and the provision of nutrients may be a modifable risk factor for achieving better outcomes in this condition [7, 8]. Therefore, ICUs are required to have appropriately nutritional screening, assessment and interventions protocol for the patients. There are many methods and scales that can be applied to screen nutritional status, but only two scales of Nutrition Risk in the Critically ill (NUTRIC) and Nutritional Risk Screening 2002 (NRS-2002) are recommended for use in the ICU [8, 9]. The modified NUTRIC score (table 1) is specifically designed for critical care patients, which is a combination of five indicators with prognostic values of mortality, including: Age, APACHE II score, SOFA, number of co-morbilities and number of days from hospital to ICU admission [10]. The original NUTRIC includes interleukin-6 [11]. The NRS-2002 (table 2) combines three components: Nutritional status (assessed by weight loss, reduced dietary requirements and BMI), severity of illness, and age [12]. According to the guidelines of the American Society for Parenteral and Enteral Nutrition (ASPEN), the American Society of Critical Care Medicine (SCCM) combined with the American College of Gastroenterlogy (ACG): Patient is at high risk of malnutrition when mNUTRIC score ≥ 5 or NRS-2002 ≥ 5 [9]. However, there are not many data in Vietnam on the similarity and application between these two scales, or which scale is more optimal in patient prognosis at ICU. Our study aimed: To compare mNUTRIC and NRS-2002 scores in screening nutritional status of critcally ill patients. Table 1: Modified NUTRIC score (mNUTRIC). Points Variables 0 1 2 3 Age (year) < 50 50 - 74 ≥ 75 - APACHE II < 15 15 -19 20 - 27 ≥ 28 SOFA < 6 6 - 9 ≥ 10 - Number of co-morbilities 0 - 1 ≥ 2 - - Days from hospital to ICU admission 0 ≥ 1 - - Total mNUTRIC is the sum of the scores of the above indicators T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 144 Table 2: Nutritional Risk Screening 2002 Scale (NRS-2002). Impaired nutritional status Severity of disease (~ stress metabolism) Absent Score 0 Normal nutritional status Absent Score 0 Normal nutritional requirements Mild Score 1 Weight loss > 5% in 3 months. Or food intake below 50 - 75% of normal requirement in preceding week Mild Score 1 Hip fracture, chronic patients, in particular with acute complications: Cirrhosis, COPD, chronic hemodialysis, diabetes, oncology Moderate Score 2 Weight loss > 5% in 2 months. Or BMI 18.5 - 20.5 + impaired general condition Or food intake 25 - 50% of normal requirement in preceding week Moderate Score 2 Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy Severe Score 3 Weight loss > 5% in 1 month (~ >15% in 3 months) Or BMI < 18.5 + impaired general condition Or food intake 0 - 25% of normal requirement in preceding week. Severe Score 3 Head injury, bone marrow transplantation, intensive care patients (APACHE 10) Calculation the total score: 1. Find score (0 - 3) for impaired nutritional status (only one: choose the variable with highest score) and severity of disease (stress metabolism, i.e. increase in nutritional requirements) 2. Add the two scores (-> total score) 3. If age > 70 years: Add 1 to the total score to correct for frailty of elderly 4. If age-corrected total > 3: Start nutritional support SUBJECTS AND METHODS 1. Subjects 181 patients were hospitalized at ICU, Military Central Hospital 108 from 01/2020 - 7/2020. * Criteria for selection: Patients from 18 years of age or older were admitted at the ICU, Military Central Hospital 108 from January 2020 to July 2020. * Exclusion criteria: Treatment duration in the ICU less than 24 hours and/or admission in the ICU during the study period. 2. Methods Cohort study with analysis. * Screening system: Apply mNUTRIC and NRS-2002 scores to assess the patient's risk of malnutrition. Patients with NRS-2002 scores ≥ 5 were classified at high risk of malnutrition according to NRS-2002. Similarly, ones were at high risk of malnutrition on mNUTRIC if the score ≥ 5. * Data collection: + Energy demand, energy supply: Ask the patient directly; tapping through patient's T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 145 family member in case the patient is unable to communicate or not conscious enough; measure weight and height. + APACHE II score: Collect clinical and subclinical parameters at the time of admission. + SOFA score: Variables to calculate SOFA are selected according to their maximum value within 24 hours from admission of the ICU. + Other clinical and subclinical indicators were also collected for analysis, including: Age, sex, occupation, co-morbilities, diagnosis of primary disease, mortality at 28 days from the date of admission, length of staying at the ICU. * Statistical analysis: By using stata 14.0 software. Compare the suitability level of NRS-2002 and mNUTRIC by Kappa coefficient. Compare the mortality prognosis of NRS-2002 and mNUTRIC by the area under the ROC curve. Qualitative variables are represented as percentages, quantitative variables are represented in terms of mean (SD). Frequency (number) and percentage (%) were for categorical data. The criterion for determining significance was p < 0.05. * Ethics: The study was approved by the Scientific Board of Thang Long University in Decision No. 19110109/QD-DHTL of the President of VNU-HCM signed on November 1, 2019. RESULTS Table 3: General characteristics. General characteristics n = 181 Mean age (years) 62.4 ± 18.9 Male, n (%) 124 (68.5) Primary disease, n (%) Respiratory 49 (27.1) Sepsis and septic shock 28 (15.5) Cardiovascular and brain stroke 19 (10.5) Injury 37 (20.4) After surgery 30 (16.6) Others 18 (9.9) Co-morbility, n (%) Hypertension 71 (39.2) Diabetes 35 (19.3) T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 146 Cancer 24 (13.3) Post-stroke 22 (12.2) Chronic renal failure 22 (12.2) Clinical data (X̅ ± SD) 138 (76.2) APACHE II 14.4 (5.9) SOFA 8.4 (3.9) BMI (kg/m2) 21.1 (3.7) NRS-2002 4.7 (1.6) mNUTRIC 3.9 (2.0) Length of stay at ICU (days) 10.6 (7.7) Mortality at 28 days (n, %) 64 (35.4) Most of the patients were men (68.5%), the average age was over 60. The majority of patients had co-morbidities (76.2%), the most common was hypertension (39.2%) and diabetes (19.3%). The most common reasons for admission at the ICU were respiratory diseases (27.1%) and trauma (20.4%). Mean of NRS-2002 and mNUTRIC were 4.7 and 3.9, respectively. The 28-day mortality at the ICU was 35.4%. Table 4: Proportion of patients at high risk of malnutrition according to NRS-2002 and mNUTRIC. Yes (mNUTRIC ≥ 5) No (mNUTRIC < 5) Total High risk of malnutrition according to mNUTRIC High risk of Malnutrition according to NRS-2002 n (%) Yes (NRS-2002 ≥ 5) 64 (35.4) 35 (19.3) 99 (54.7) No (NRS-2002 < 5) 11 (6.1) 71 (39.2) 82 (45.3) Total 75 (41.4) 106 (58.6) 181 (100.0) Pearson Chi-Square = 48.5 (p < 0.001); Kappa = 0.5 (p < 0.001) The proportion of patients at high risk of malnutrition by the NRS-2002 (54.7%) was higher than by the mNUTRIC (40.3%). Two simultaneous consensus scales diagnosed a high risk of malnutrition in 33.7% of patients. If two scores were combined, 60.8% of the patients were at high risk of malnutrition. The NRS-2002 and mNUTRIC scales had moderate consensus (Kappa = 0.5). T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 147 0. 00 0. 25 0. 50 0. 75 1. 00 Se n si tiv ity 0.00 0.25 0.50 0.75 1.00 1-Specificity NRS2002 ROC area: 0.6851 mNUTRIC ROC area: 0.707 Reference Comparison mNutric and NRS2002 in 28day mortality rate prognostic Figure 1: 28-day mortality prognosis of NRS-2002 and mNUTRIC. AUC Asymptotic 95%CI pref pa-b NRS-2002 (a) 0.685 0.61 - 0.76 < 0.001 0.562 mNUTRIC (b) 0.707 0.63 - 0.78 < 0.001 pref: Comparison between each tool and AUC ROC area of 0.5; pa-b: Comparison of AUC ROC area between two tools. mNUTRIC (AUC: 0.707, 95%CI: 0.63 - 0.78) seem to have a higher 28-day prognosis of mortality than NRS-2002 (AUC: 0.685, 95%CI: 0.61 - 0.76) but no statistical difference (p > 0.05). DISCUSSION According to ESPEN’s guideline (2019) [8], no specific ICU nutritional score has been validated so far. The existing nutritional screening tools NRS-2002 [12] and the malnutrition universal screening tool (MUST) score [13] have not been designed specifically for critically ill patients. Recently, NUTRIC, a novel risk assessment tool [11] was proposed, based on age, severity of disease, reflected by the APACHE II and Sequential Organ Failure (SOFA) scores, co-morbidities, days from hospital to ICU admission, and with or without inflammation assessed by the level of interleukin-6. The final composite NUTRIC score correlated with mortality and the expected advantage of the score T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 148 was able to show interaction between the score and nutritional intervention regarding outcome, hypothesizing that nutritional support might decrease the mortality in patients with a high NUTRIC score (> 5). A limitation of this score is that no nutritional parameters are included. When the score was compared to traditional screening tools, a large variability was observed. The study results showed moderate consensus between NUTRIC and NRS- 2002 (Kappa = 0.5), although both scales are recommended for assessing nutritional status in ICU by the treatment guidelines of a reputable medical organization. This result was consistent with some international studies. Coruja MK et al studied 208 ICU patients at two hospitals in Brazil and found that mNUTRIC and NRS-2002 had fair agreement (Kappa = 0.39). In our study, 99/181 patients (54.7%) were at high risk of malnutrition according to NRS-2002, but only 75/181 (41.4%) were at risk. Other studies showed similar results. The proportion of patients at high risk of malnutrition according to NRS-2002/NUTRIC in the studies by Canales et al (n = 312) and Machado Dos Reis A et al (n = 384) was 100%/44% and 54.4%/44.4%, respectively. Although recommended for use in critical care patients, only NUTRIC has been developed and tested specifically for intensive patients. NRS-2002 is the common score for all patient subjects. Traditional parameters of nutritional status are part of NRS-2002 tool, but not covered on the mNUTRIC score. In contrast, the number of co-morbidities and the number of hospitalization days prior to admission to the recovery department were only on the NUTRIC scale. That may be one of the reasons causing the discrepancy between the evaluation results of the two scoring. In some studies, 2 tools have been evaluated by isolated and combined application in critally illness. When comparing, we used the ability to predict mortality within 28 days and malnutrition detection rate. Orginally, mNUTRIC and NRS-2002 are constructed by synthesizing indicators that are likely to predict mortality. They were then verified by their ability to screen a group of patients in the intensive care that could benefit from correctly nutritional intervention [12]. With a cut-off score of 5, NRS-2002 and mNUTRIC have demonstrated their ability to screen out a group of patients at high risk of malnutrition among those treated in the intensive care department. Our results showed that mNUTRIC AUC (0.707, 95%CI: 0.63 - 0.78) had slightly higher 28-day prognosis of death than NRS-2002 AUC (0.685, 95%CI: 0.61 - 0.76) but with no significant difference (p > 0.05). The published results by Coruja MK (n = 208) and Machado Dos Reis A (n = 384) also showed that NUTRIC was superior to NRS-2002 in screening patients at high risk of malnutrition at ICU. In particular, Canales used direct evaluation parameters of malnutrition (protein and caloric deficiencies) to compare NUTRIC and NRS-2002. As a result, NUTRIC was superior to NRS-2002 in screening nutritional status. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 149 CONCLUSION Research has shown a high incidence of malnutrition in intensive care patients on the two screening scales, mNUTRIC and NRS-2002. 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