Jens Kondrup

Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials

BACKGROUND & AIMSnA system for screening of nutritional risk is described. It is based on the concept that nutritional support is indicated in patients who are severely ill with increased nutritional requirements, or who are severely undernourished, or who have certain degrees of severity of disease in combination with certain degrees of undernutrition. Degrees of severity of disease and undernutrition were defined as absent, mild, moderate or severe from data sets in a selected number of randomized controlled trials (RCTs) and converted to a numeric score. After completion, the screening system was validated against all published RCTs known to us of nutritional support vs spontaneous intake to investigate whether the screening system could distinguish between trials with a positive outcome and trials with no effect on outcome.nnnMETHODSnThe total number of randomized trials identified was 128. In each trial, the group of patients was classified with respect to nutritional status and severity of disease, and it was determined whether the effect of nutritional intervention on clinical outcome was positive or absent.nnnRESULTSnAmong 75 studies of patients classified as being nutritionally at-risk, 43 showed a positive effect of nutritional support on clinical outcome. Among 53 studies of patients not considered to be nutritionally at-risk, 14 showed a positive effect (P=0.0006). This corresponded to a likelihood ratio (true positive/false positive) of 1.7 (95% CI: 2.3-1.2). For 71 studies of parenteral nutrition, the likelihood ratio was 1.4 (1.9-1.0), and for 56 studies of enteral or oral nutrition the likelihood ratio was 2.9 (5.9-1.4).nnnCONCLUSIONnThe screening system appears to be able to distinguish between trials with a positive effect vs no effect, and it can therefore probably also identify patients who are likely to benefit from nutritional support.

EuroOOPS: An international, multicentre study to implement nutritional risk screening and evaluate clinical outcome

BACKGROUND & AIMSnThe aim of the study was to implement nutritional risk screening (NRS-2002) and to assess the association between nutritional risk and clinical outcome.nnnMETHODSnNRS-2002 was implemented in 26 hospital departments (surgery, internal medicine, oncology, intensive care, gastroenterology and geriatrics) in Austria, the Czech Republic, Egypt, Germany, Hungary, Lebanon, Libya, Poland, Romania, Slovakia, Spain and Switzerland. Being a prospective cohort study, randomly selected adult patients were included at admission and followed during their hospitalisation. Data were collected on the nutritional risk screening, complications, mortality, length of stay and discharge. The correlation between risk status and clinical outcome was assessed and adjusted for confounders (age, speciality, diagnoses, comorbidity, surgery, cancer and region) by multivariate regression analysis.nnnRESULTSnOf the 5051 study patients, 32.6% were defined as at-risk by NRS-2002. At-risk patients had more complications, higher mortality and longer lengths of stay than not at-risk patients and these variables were significantly related to components of NRS-2002, also when adjusted for confounders.nnnCONCLUSIONSnComponents of NRS-2002 are independent predictors of poor clinical outcome.

Adult Starvation and Disease-Related Malnutrition A Proposal for Etiology-Based Diagnosis in the Clinical Practice Setting From the International Consensus Guideline Committee

BACKGROUND & AIMSnMultiple definitions for malnutrition syndromes are found in the literature resulting in confusion. Recent evidence suggests that varying degrees of acute or chronic inflammation are key contributing factors in the pathophysiology of malnutrition that is associated with disease or injury.nnnMETHODSnAn International Guideline Committee was constituted to develop a consensus approach to defining malnutrition syndromes for adults in the clinical setting. Consensus was achieved through a series of meetings held at the A.S.P.E.N. and ESPEN Congresses.nnnRESULTSnIt was agreed that an etiology-based approach that incorporates a current understanding of inflammatory response would be most appropriate. The Committee proposes the following nomenclature for nutrition diagnosis in adults in the clinical practice setting. Starvation-related malnutrition, when there is chronic starvation without inflammation, chronic disease-related malnutrition, when inflammation is chronic and of mild to moderate degree, and acute disease or injury-related malnutrition, when inflammation is acute and of severe degree.nnnCONCLUSIONSnThis commentary is intended to present a simple etiology-based construct for the diagnosis of adult malnutrition in the clinical setting. Development of associated laboratory, functional, food intake, and body weight criteria and their application to routine clinical practice will require validation.

How nutritional risk is assessed and managed in European hospitals: A survey of 21,007 patients findings from the 2007-2008 cross-sectional nutritionDay survey

BACKGROUND & AIMSnRecognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice.nnnOBJECTIVESnWe investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals.nnnMETHODSn1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey nutritionDay 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires.nnnRESULTSnFifty-two percent (range 21-73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being at nutritional risk, with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI <18.5 kg/m(2), unintentional weight loss, reduced food intake in the previous week and on nutritionDay (for all parameters, p < 0.0001). The energy goal was defined as >=1500 kcal in 76% of the patients, but 43% of patients did not reach this goal.nnnCONCLUSIONSnThe process of nutrition risk assessment varied between units and countries. Additionally, energy goals were frequently not met. More effort is needed to implement current guidelines within daily clinical practice.

Insufficient nutritional knowledge among health care workers

BACKGROUND & AIMSnThough a great interest and willingness to nutrition therapy, there is an insufficient practice compared to the proposed ESPEN guidelines for nutrition therapy. The aim of this questionnaire was to study doctors and nurses self-reported knowledge in nutritional practice, with focus on ESPENs guidelines in nutritional screening, assessment and treatment.nnnMETHODSnA questionnaire about different aspects of nutritional practice was answered by 4512 doctors and nurses in Denmark, Sweden and Norway.nnnRESULTSnThe most common cause for insufficient nutritional practice was lack of nutritional knowledge. Twenty-five percent found it difficult to identify patient in need of nutritional therapy, 39% lacked techniques for identifying malnourished patients, and 53% found it difficult to calculate the patients energy requirement and 66% lacked national guidelines for clinical nutrition. Twenty-eight percent answered that insufficient nutrition practice could lead to complications and prolonged hospital stay. Those that answered that their nutritional knowledge was good had also a better nutritional practice.nnnCONCLUSIONnThe self-reported nutritional knowledge was inadequate among Scandinavian doctors and nurses. Increased nutritional knowledge seems to improve the nutritional practice. A combination of an integrated nutrition curriculum during the education, together with post-graduated education for both physicians and nurses should be established.

Provision of protein and energy in relation to measured requirements in intensive care patients

BACKGROUND & AIMSnAdequacy of nutritional support in intensive care patients is still a matter of investigation. This study aimed to relate mortality to provision, measured requirements and balances for energy and protein in ICU patients.nnnDESIGNnProspective observational cohort study of 113 ICU patients in a tertiary referral hospital.nnnRESULTSnDeath occurred earlier in the tertile of patients with the lowest provision of protein and amino acids. The results were confirmed in Cox regression analyses which showed a significantly decreased hazard ratio of death with increased protein provision, also when adjusted for baseline prognostic variables (APACHE II, SOFA scores and age). Provision of energy, measured resting energy expenditure or energy and nitrogen balance was not related to mortality. The possible cause-effect relationship is discussed after a more detailed analysis of the initial part of the admission.nnnCONCLUSIONnIn these severely ill ICU patients, a higher provision of protein and amino acids was associated with a lower mortality. This was not the case for provision of energy or measured resting energy expenditure or energy or nitrogen balances. The hypothesis that higher provision of protein improves outcome should be tested in a randomised trial.

ESPEN guidelines on parenteral nutrition: hepatology.

Parenteral nutrition (PN) offers the possibility to increase or to ensure nutrient intake in patients, in whom sufficient nutrition by oral or enteral alone is insufficient or impossible. Complementary to the ESPEN guideline on enteral nutrition of liver disease (LD) patients the present guideline is intended to give evidence-based recommendations for the use of PN in LD. For this purpose three paradigm conditions of LD were chosen: alcoholic steatohepatitis (ASH), liver cirrhosis and acute liver failure. The guideline was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was presented on the ESPEN website and visitors criticism and suggestions were welcome and included in the final revision. PN improves nutritional state and liver function in malnourished patients with ASH. PN is safe and improves mental state in patients with cirrhosis and severe HE. Perioperative (including liver transplantation) PN is safe and reduces the rate of complications. In acute liver failure PN is a safe second-line option to adequately feed patients in whom enteral nutrition is insufficient or impossible.

Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk

OBJECTIVEnThis multicenter, prospective cohort study evaluated the effect of preoperative nutritional support in abdominal surgical patients at nutritional risk as defined by the Nutritional Risk Screening Tool 2002 (NRS-2002).nnnMETHODSnA consecutive series of patients admitted for selective abdominal surgery in the Peking Union Medical College Hospital and the Beijing University Third Hospital in Beijing, China were recruited from March 2007 to July 2008. Data were collected on the nutritional risk screening (NRS-2002), the application of perioperative nutritional support, surgery, complications, and length of stay. A minimum of 7 d of parenteral nutrition or enteral nutrition before surgery was considered adequate preoperative nutritional support.nnnRESULTSnIn total 1085 patients were recruited, and 512 of them were at nutritional risk. Of the 120 patients with an NRS score at least 5, the complication rate was significantly lower in the preoperative nutrition group compared with the control group (25.6% versus 50.6%, P = 0.008). The postoperative hospital stay was significantly shorter in the preoperative nutrition group than in the control group (13.7 ± 7.9 versus 17.9 ± 11.3 d, P = 0.018). Of the 392 patients with an NRS score from 3 to 4, the complication rate and the postoperative hospital stay were similar between patients with and those without preoperative nutritional support (P = 1.0 and 0.770, respectively).nnnCONCLUSIONnThis finding suggests that preoperative nutritional support is beneficial to patients with an NRS score at least 5 by lowering the complication rate.

Splanchnic and leg exchange of amino acids and ammonia in acute liver failure

BACKGROUND & AIMSnIn patients with acute liver failure, hyperammonemia is associated with cerebral herniation. We examined the splanchnic and leg exchange of amino acids, urea, and ammonia in such patients.nnnMETHODSnBedside liver vein catheterization was used in 22 patients after development of hepatic encephalopathy grades III-IV. Femoral venous blood was sampled in 7 of these patients.nnnRESULTSnArterial amino acid concentration (8.1 +/- 4.1 mmol/L) was increased 4-fold above normal. Glutamine (2.4 +/- 1.8 mmol/L) and alanine (0.57 +/- 0.35 mmol/L) were by far the predominant amino acids exchanged in the splanchnic and leg circulation. In the splanchnic circulation, there was a net uptake of glutamine (241 +/- 353 micromol/min) and ammonia and alanine were released in an almost 1:1 stoichiometry (r(2) = 0.47; P < 0.001). In the leg, ammonia and alanine were removed and glutamine released. The leg ammonia concentration difference was correlated to that of glutamine (r(2) = 0.80; P = 0.008) and alanine (r(2) = 0.67; P = 0.03).nnnCONCLUSIONSnSplanchnic metabolism of glutamine in combination with decreased hepatic function was responsible for the splanchnic release of ammonia and alanine. These processes were reversed in skeletal muscle. Stimulation of skeletal muscle metabolism of ammonia could be a important target for future treatment of patients with acute liver failure.

Clinical nutrition in Danish hospitals: a questionnaire-basednutrition among doctors and nurses

Abstract Specific nutrition standards are now developed by the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) in order to improve the nutritional status in hospitalized patients. We investigated the use of clinical nutrition in Danish hospitals and compared itwith the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals including internal medicine, gastroenterology, oncology, orthopedic departments and intensive care units (ICU). Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Seventy-seven percent stated that nutritional assessment ought to be performed on admission, but only 24% stated that it was a routine procedure. Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Twenty-two percent registered body weight in all patients, end 18% registered nutrient intake routinely. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up on individual plan, and 79% expressed a need for specific guidelines. Eighty-four percent would only accept a patient being on isotonic glucose and/or electrolyte infusion for The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition supportaccording to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.