Complementarity of modified NUTRIC score with or without C-reactive protein and subjective global assessment in predicting mortality in critically ill patients

Oliveira, Manoela Lima; Heyland, Daren Keith; Silva, Flávia Moraes; Rabito, Estela Iraci; Rosa, Mariane; Tarnowski, Micheli da Silva; Fernandes, Daieni; Marcadenti, Aline

doi:10.5935/0103-507X.20190086

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Revista Brasileira de Terapia Intensiva

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ORIGINAL ARTICLES • Rev. bras. ter. intensiva 31 (4) • Oct-Dec 2019 • https://doi.org/10.5935/0103-507X.20190086 copy

Complementarity of modified NUTRIC score with or without C-reactive protein and subjective global assessment in predicting mortality in critically ill patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To evaluate the concordance between the modified NUTRIC and NUTRIC with C-reactive protein instruments in identifying nutritional risk patients and predicting mortality in critically ill patients. The risk of death in patient groups was also investigated according to nutritional risk and malnutrition detected by subjective global assessment.

Methods:

A cohort study of patients admitted to an intensive care unit. Nutritional risk was assessed by modified NUTRIC and a version of NUTRIC with C-reactive protein. Subjective global assessment was applied to diagnose malnutrition. Kappa statistics were calculated, and an ROC curve was constructed considering modified NUTRIC as a reference. The predictive validity was assessed considering mortality in 28 days (whether in the intensive care unit or after discharge) as the outcome.

Results:

A total of 130 patients were studied (63.05 ± 16.46 years, 53.8% males). According to NUTRIC with C-reactive protein, 34.4% were classified as having a high score, while 28.5% of patients had this classification with modified NUTRIC. According to SGA 48.1% of patients were malnourished. There was excellent agreement between modified NUTRIC and NUTRIC with C-reactive protein (Kappa = 0.88, p < 0.001). The area under the ROC curve was equal to 0.942 (0.881 - 1.000) for NUTRIC with C-reactive protein. The risk of death within 28 days was increased in patients with high modified NUTRIC (HR = 1.827; 95%CI 1.029 - 3.244; p = 0.040) and NUTRIC with C-reactive protein (HR = 2.685; 95%CI 1.423 - 5.064; p = 0.002) scores. A high risk of death was observed in patients with high nutritional risk and malnutrition, independent of the version of the NUTRIC score applied.

Conclusion:

An excellent agreement between modified NUTRIC and NUTRIC with C-reactive protein was observed. In addition, combining NUTRIC and subjective global assessment may increase the accuracy of predicting mortality in critically ill patients.

Keywords:
Nutritional assessment; Nutrition; Screening; Critical care; Inflammation; Mortality; Intensive care units

Variables	Scores
Variables	0	1	2	3
Age (years)	≤ 49	50 - 74	≥ 75
APACHE II (points)	≤ 14	15 - 19	20 - 28	≥ 29
SOFA (points)	≤ 5	6 - 9	≥ 10
Number of comorbidities	≤ 1	≥ 2
Days of hospitalization prior to ICU admission	0	≥ 1
CRP (mg/dL)	< 68	68 - 167	≥ 167
mNUTRIC (without CRP)
Low score	0 - 4 points
High score	5 - 9 points
NUTRIC-CRP (with CRP)
Low score	0 - 5 points
High score	6 - 11 points

Variables	All sample (n = 130)	mNUTRIC score			NUTRIC-CRP score
Variables	All sample (n = 130)	Low score (n = 93)	High score (n = 37)	p value	Low score (n = 59)	High score (n = 31)	p value
Age (years)	63.05 ± 16.46	60.2 ± 16.6	69.5 ± 13.4	0.003^* * Student's t test;	60.2 ± 16.5	70.2 ± 14.1	0.005^* * Student's t test;
Males	53.8	55.9	48.6	0.40^† † Pearson's Chi-square test;	57.6	48.4	0.40^† † Pearson's Chi-square test;
APACHE II	6.0 (4.5 - 20.0)	6.0 (3.0 - 12.0)	26.0 (20.0 - 32.0)	< 0.001^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).	6.0 (3.0 - 12.0)	26.0 (20.0 - 32.0)	< 0.001^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).
SOFA	0.0 (0.0 - 6.3)	0.0 (0.0 - 2.0)	10.0 (7.0 - 11.0)	< 0.001^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).	0.0 (0.0 - 2.0)	10.0 (7.0 - 11.0)	< 0.001^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).
mNUTRIC (points)	3.0 (2.0 - 5.0)	3.0 (2.0 - 3.0)	7.0 (6.0 - 8.0)	< 0.001^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).	3.0 (2.0 - 3.0)	7.0 (6.0 - 8.0)	< 0.001^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).
NUTRIC- CRP (points)	5.16 ± 2.37	4.0 (3.0 - 5.0)	8.0 (6.8 - 9.0)	< 0.001^* * Student's t test;	3.7 ± 1.1	7.9 ± 1.6	< 0.001^* * Student's t test;
CRP (mg/dL)	112.3 (41.4 - 198.0)	100.7 (33.2 - 174.6)	130.0 (52.5 - 236.3)	0.159^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).	92.3 (31.6 - 153.0)	179.0 (67.7 - 240.0)	0.009^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).
Malnutrition	48.1	41.9	64.9	0.021^† † Pearson's Chi-square test;	47.5	51.6	0.708^† † Pearson's Chi-square test;
Mechanical ventilation	60.6	51.6	83.8	0.005^† † Pearson's Chi-square test;	57.6	87.1	0.005^† † Pearson's Chi-square test;
Days of hospital stay prior to ICU admission	5.0 (1.0 - 17.5)	6.0 (1.0 - 18.0)	5.0 (1.0 - 16.0)	0.858^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).	10.0 (2.0 - 26.0)	3.0 (1.0 - 13.0)	0.016^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).
Days of ICU stay	8.0 (3.0 - 16.0)	7.0 (3.0 - 14.0)	9.0 (5.0 - 22.0)	0.042^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).	10.0 (5.0 - 16.0)	8.0 (5.0 - 22.0)	0.51^‡ ‡ Wilcoxon-Mann-Whitney test. Results expressed as mean ± standard deviation, %, median (interquartile range) or n (%).
Death in the ICU	38.9	29.0	64.9	< 0.001^† † Pearson's Chi-square test;	23 (39.0)	21 (67.7)	0.009^† † Pearson's Chi-square test;
Death within 28 days	34.8	28.9	54.1	0.007^† † Pearson's Chi-square test;	21 (36.2)	18 (58.1)	0.048^† † Pearson's Chi-square test;

Category	HR (95%CI)
Low mNUTRIC score and well-nourished (SGA A)	Reference
Low mNUTRIC score and malnourished (SGA B or C)	1.429 (0.643 - 3.178)
High mNUTRIC score well-nourished (SGA A)	1.750 (0.727 - 4.215)
High mNUTRIC score and malnourished (SGA B or C)	2.167 (1.029 - 4.563)

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[1] Corresponding author: Aline Marcadenti, Instituto de Pesquisa, HCor-Hospital do Coração, Rua Abílio Soares, 250 - Paraíso, Zip code: 04004-030 - São Paulo (SP), Brazil, E-mail: marcadenti.aline@gmail.com