NUTRIC score use around the world: a systematic review

A systematic literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Reviews, abstracts, dissertations, protocols and case reports were excluded from this review; to be included in the review, studies needed to specifically evaluate the NUTRIC score and to have been published in English, Spanish or Portuguese.

Results:

We included 12 (0.8%) studies from our search in this review. Ten studies (83.3%) were observational, 1 was a pilot study (8.3%) and 1 was a randomized control trial (8.3%). All of the included studies (100%) chose not to use IL-6 and considered a high nutritional risk cutoff point ≥ 5. There were 11 (91.7%) English language studies versus 1 (8.3%) Spanish language study. Mechanical ventilation and a high NUTRIC score were significantly correlated in four studies. The association between intensive care unit or hospital length of stay and nutritional high risk was significant in three studies. Seven studies found a statistically significant association between the NUTRIC score and mortality.

Conclusion:

The NUTRIC score is related to clinical outcomes, such as length of hospital stay, and is appropriate for use in critically ill patients in intensive care units.

Keywords:
Malnutrition; Nutritional status; Nutrition assessment; Critical illness; Intensive care units

Author, Country	Study	Sample	Exclusion criteria	APACHE II; SOFA (points)	Age; Gender (M)
Rahman et al.⁽⁷7 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(1):158-62.⁾ Canada	Randomized control trial.	1199 MV patients with multi-organ failure and expected length of stay > 5 days.	None	Not available	Not available
Moretti et al.⁽⁹9 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.⁾ Argentina	Prospective observational study.	368 patients aged ≥ 18 years old and MV within 24 hours of ICU admission.	Patients whose data could not be collected.	20.7; 7.7	52 (18 - 93); (68%)
Lee et al.⁽¹⁰10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.⁾ Malaysia	Prospective observational study.	154 patients aged ≥ 18 years old, and VM within 48 hours and in ICU > 72 hours.	Patients moribund, readmitted, or transferred from another ICU.	26.9; 12.4	51.29 ± 15.73; 83 (54%)
Mendes et al.⁽¹¹11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. 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.⁾ Portugal	Prospective observational multicenter study.	1143 patients aged ≥ 18 years old and in ICU > 72 hours.	Patients with brain dead or readmitted, or transferred from another ICU.	20; 7	64 (51 - 75); 740 (65%)
Mukhopadhyay et al.⁽¹²12 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(4):1143-8.⁾ Singapore	Prospective observational study.	401 patients aged ≥ 18 years old and in ICU > 24 hours.	Patients discharged or died within 24 hours.	27.3; 9.5	60.0 ± 16.3; (62%)
Rosa et al.⁽¹³13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.⁾ Brazil	Pilot study.	50 patients in ICU > 48 hours.	Not available.	18.5; 5	61.4 ± 15.3; 26 (52%)
Kalaiselvan et al.⁽¹⁴14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.⁾ Indian	Prospective observational study.	687 patients aged ≥ 18 years old in ICU and MV > 48 hours.	Readmitted, or transferred from another ICU.	22.2; 6.7	55.7 ± 17.5; 458 (68%)
Coltman et al.⁽¹⁵15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.⁾ United States	Prospective observational study.	139 patients aged ≥ 18 years.	Unable to communicate in English.	13; 2.7	59.0 ± 16.4; 146 (50%)
Özbilgin et al.⁽¹⁶16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.⁾ Turkey	Prospective descriptive and cross-sectional study.	152 postoperative patients aged ≥18 years.	Psychiatric disorder patients, difficulty cooperating, nutrition history not available, vomiting, taking appetite-enhancing medications, and pregnant or breastfeeding.	13.5; 3.1	Not available
de Vries et al.⁽¹⁷17 de Vries MC, Koekkoek WK, 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(3):428-35.⁾ The Netherlands	Retrospective study.	475 patients aged ≥ 18 years, requiring (non)-invasive VM within 24 hours.	Time between ICU admission and discharge < 24 hours, data incomplete, or pregnancy.	22; 8	71 (57 - 81); 215 (45%)
Lew et al.⁽¹⁸18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print] https://doi.org/10.1177/0148607117726060... ⁾ Singapore	Prospective observational study.	439 patients aged ≥18 years in ICU ≥ 24 hours.	Patients with inaccessible data.	24.5; 8.6	61.4 ± 15.8; 259 (59%)
Compher et al.⁽¹⁹19 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.⁾ Canada	Prospective observational study.	2,853 MV patients at least 4 ICU days.	Patients with very short LOS or expectation of imminent demise.	Not available	> 4 ICU days: 61.2 (17.3); 1739 (60.9%) > 12 ICU days: 59.7 (17.4); 1003 (62.5%)

Author, Country	Main results
Rahman et al.⁽⁷7 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(1):158-62.⁾ Canada	Mortality at 28 days was multiplied by 1.4 for every point increase of the NUTRIC score. There is a strong positive association between nutritional adequacy and 28-day survival in patients with a high NUTRIC score, but this association decreases with the decreasing NUTRIC score. Higher NUTRIC scores are also significantly associated with higher 6-month mortality (p < 0.001).
Moretti et al.⁽⁹9 Moretti D, Bagilet DH, Buncuga M, Settecase CJ, Quaglino MB, Quintana R. [Study of two variants of nutritional risk score "NUTRIC" in ventilated critical patients]. Nutr Hosp. 2014;29(1):166-72. Spanish.⁾ Argentine	Mortality increased in relation to the score (p < 0.001). The mean CRP was higher in mortality (p = 0.001) and VM time (p = 0.010), and the AUC increased in a similar way to IL-6 in the original work (0.008 and 0.007, respectively).
Lee et al.⁽¹⁰10 Lee ZY, Noor Airini I, Barakatun-Nisak MY. Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr. 2018;37(4):1264-70.⁾ Malaysia	For patients with low nutritional risk, mortality was increased by approximately 6 times in the group that received ≥ 2/3 of prescribed than both < 2/3 (p = 0.032).
Mendes et al.⁽¹¹11 Mendes R, Policarpo S, Fortuna P, Alves M, Virella D, Heyland DK; Portuguese NUTRIC Study Group. 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.⁾ Portugal	A high NUTRIC score was associated with longer hospitalization (p < 0.001), fewer days free of MV (p = 0.002) and higher 28-day mortality (p < 0.001).
Mukhopadhyay et al.⁽¹²12 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(4):1143-8.⁾ Singapore	The NUTRIC score (p < 0.001) was associated with 28-day mortality.
Rosa et al.⁽¹³13 Rosa M, Heyland DK, Fernandes D, Rabito EI, Oliveira ML, Marcadenti A. Translation and adaptation of the NUTRIC Score to identify critically ill patients who benefit the most from nutrition therapy. Clin Nutr ESPEN. 2016;14:31-6.⁾ 2016 Brazil	The Portuguese version was easily introduced into four Brazilian ICUs, and the prevalence of patients with a high score was 46%.
Kalaiselvan et al.⁽¹⁴14 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study. Indian J Crit Care Med. 2017;21(5):253-6.⁾ Indian	NUTRIC score (p < 0.001), use of vasopressor drug (p < 0.005) and BMI (p < 0.002) were associated with 28-day mortality. In 273 patients who received MV, significant differences were noted between the high and low NUTRIC groups in terms of mortality (p < 0.001), ICU LOS (p < 0.014), and duration of MV (p < 0.001).
Coltman et al.⁽¹⁵15 Coltman A, Peterson S, Roehl K, Roosevelt H, Sowa D. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr. 2015;39(1):28-33.⁾ United States	Patients determined to be at nutritional risk using the NUTRIC score alone or in combination with any other tool had the highest rates of death. A larger proportion of patients requiring additional rehabilitation after discharge was seen with NUTRIC score. Patients identified as being at nutritional risk or malnourished using NUTRIC had the longest hospital LOS and ICU LOS.
Özbilgin et al.⁽¹⁶16 Özbilgin S, Hanc V, Ömür D, Özbilgin M, Tosun M, Yurtlu S, et al. Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit. Medicine (Baltimore). 2016;95(40):e5038.⁾ Turkey	There was a positive correlation with mortality and the NUTRIC score (p=0.020) and pulmonary complications (p = 0.030).
de Vries et al.⁽¹⁷17 de Vries MC, Koekkoek WK, 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(3):428-35.⁾ The Netherlands	The discriminative ability of the NUTRIC score for 28-day mortality is (ROC-AUC) 0.768 (95% CI 0.722 - 0.814) with an associated LR+ of 1.73 (95% CI 1.53 - 1.95) and LR− of 0.24 (95% CI 0.14 - 0.39) when comparing low with high (> 4) scores.
Lew et al.⁽¹⁸18 Lew CC, Cheung KP, Chong MF, Chua AP, Fraser RJ, Miller M. Combining 2 Commonly Adopted Nutrition Instruments in the Critical Care Setting Is Superior to Administering Either One Alone. JPEN J Parenter Enteral Nutr. 2017 Aug 1:148607117726060. doi: 10.1177/0148607117726060. [Epub ahead of print] https://doi.org/10.1177/0148607117726060... ⁾ Singapore	High NUTRIC score was associated with hospital mortality (p < 0.001).
Compher et al.⁽¹⁹19 Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK. Greater Protein and Energy Intake May Be Associated with Improved Mortality in Higher Risk Critically Ill Patients: A Multicenter, Multinational Observational Study. Crit Care Med. 2017;45(2):156-63.⁾ Canada	In high-risk but not low-risk patients, mortality was lower with greater protein (4-d sample: p = 0.003; 12-d sample: p = 0.003) and energy (4-d sample: p < 0.001; 12-d sample: p < 0.001) intake. In high-risk but not low-risk patients, time to discharge alive was shorter with greater protein (4-d sample: p = 0.010; 12-d sample: p = 0.002) and energy intake (4-d sample: p = 0.020; 12-d sample: p = 0.002).

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[1] Corresponding author: Audrey Machado dos Reis, Departamento de Cirurgia do Hospital das Clínicas de Porto Alegre, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2.400, 7º andar, sala 733, Zip code: 90035-903 - Porto Alegre (RS), Brazil, E-mail: audreymreis@gmail.com