Elsevier

Annals of Vascular Surgery

Volume 45, November 2017, Pages 10-15
Annals of Vascular Surgery

Clinical Research
Impact of Nutritional State on Critical Limb Ischemia Early Outcomes (DENUCRITICC Study)

https://doi.org/10.1016/j.avsg.2017.04.030Get rights and content

Background

Despite current progress, the prognosis of critical limb ischemia (CLI) remains poor. The ageing of the population, the increasing prevalence of diabetes mellitus, and the stability of tobacco use will increase the prevalence of CLI. CLI patients have risk factors for malnutrition, and the impact of malnutrition on morbidity and mortality has been demonstrated in the general population. However, we have little information on the consequences of undernutrition in the CLI population. The aim of this study is to assess the impact of malnutrition on the early outcomes in CLI patients.

Methods

This is a double-center prospective study that included all consecutive hospitalized patients with CLI. All patients were screened for malnutrition and divided into 2 groups: severe malnourished patients (group A) and moderate malnourished and well-nourished (group B). This distribution was based on age-indexed clinical and biological data and the patient's general condition: the Nutritional Risk Index for patients younger than 75 years, the Mini Nutritional Assessment, or the Geriatric Nutritional Risk Index for those older than 75 years. The primary end point was defined as the rate of 30-day death. Outcomes were compared in a univariate analysis. Stepwise logistic regression was used for the multivariate analysis. Variables with a P value <0.2 in the univariate analysis were introduced in the multivariate model.

Results

We included 106 patients. The prevalence of malnutrition was 75.5%, divided into moderate malnutrition (51.9%) and severe malnutrition (23.6%). Six patients (24%) died in group A compared with 8 in group B (4.9%) (P = 0.01). By univariate analysis, severe malnutrition was the only factor associated with death at 30 days. By stepwise logistic regression, severe malnutrition (odds ratio 6.1, 95% confidence interval 1.6–23.7, P = 0.006) was found to be the significant risk factors for death at 30 days.

Conclusions

This study is the first to demonstrate prospectively the major importance of malnutrition in the early prognosis of CLI patients.

Introduction

Nowadays, endovascular therapies allow more and more procedural approaches to treat increasingly fragile populations, but the overall prognosis of critical limb ischemia (CLI) remains the same, with mortality similar to that of cancer.1 With ageing population, increase in diabetes mellitus, and stable levels of tobacco use, the incidence of CLI is likely to increase dramatically,2, 3 and will force physicians to improve their current results in this field.

Patients with CLI present several risk factors for malnutrition, such as old age, use of analgesics, renal insufficiency, and respiratory or heart failure.4 It has been established that malnutrition is an independent risk factor for complications, increased length of hospital stay and mortality.5 In surgery in particular, the role of malnutrition is significant in terms of wound healing, postoperative infections, morbidity, and mortality.5, 6, 7 Malnutrition has been estimated to range from 20% to 50% in a general population of hospitalized patients.8, 9

However, malnutrition in the context of CLI begins to be now investigated in the literature.10 Vega de Céniga et al.11 found a deficit in iron and vitamins in this population in a retrospective study, while another study12 estimated the prevalence of malnutrition in CLI patients to be above 60%. The methods of evaluation of nutritional status are very different from one study to another, and include anthropomorphic tools, biological parameters, or nutritional indices. Published guidelines now recommend systematic screening in hospitalized populations using specific tools, such as the Mini Nutritional Assessment (MNA) and Nutritional Risk Index (NRI), but they are rarely applied in CLI populations.13 Thus, more widespread systematic screening using these instruments in the CLI population could be of interest, to assess the clinical impact of malnutrition in these patients.

The aim of this study is to assess the impact of malnutrition, as assessed by MNA, NRI and Geriatric (G)-NRI tests, on mortality at 30 days in CLI patients. Secondary objectives were to assess risk factors for malnutrition, prevalence of malnutrition and its impact on mortality and/or major amputation, on major amputation at 30 days, and on the length of hospital stay.

Section snippets

Materials and Methods

The DENUCRITICC study is a 2-center, prospective, observational study. Between February 2011 and April 2012, we included all consecutive patients hospitalized for CLI in the Vascular Surgery Unit of the University Hospital of Besancon (France), and between May and October 2012, in the Vascular Surgery Unit of the University Hospital of Dijon (France). Inclusion criteria were CLI diagnosed in accordance with current consensual definitions.1 CLI was defined as ischemic rest pain, ulcer, or

Results

In total, 106 patients were included. The mean age was 77.3 ± 12.1 years. The majority were men (67%). Overall characteristics were presented in Table I. Initial presentation was ischemic rest pain in 15 patients (14.1%) and a majority of ischemic ulcers: 75 (70.8%) patients Rutherford 5 and 16 (15.1%) Rutherford 6. Initial treatment was presented in Table II.

Overall, 80 of 106 (75.5%) patients had malnutrition: with moderate malnutrition in 55 patients (51.9%) and severe malnutrition in 25

Discussion

This work represents a prospective study assessing the impact of malnutrition, defined by current nutritional recommendations, on the risk of death in a population hospitalized for CLI. Malnutrition has been associated with higher morbidity, mortality, and hospital length of stay in surgical patients.18 Considering the numerous predictive factors of malnutrition observed in the CLI population, we expected a high prevalence, but not as high as that observed, of 75.5% for malnutrition and 23.6%

Conclusion

This study prospectively demonstrates the major impact of malnutrition on early outcomes after hospitalization for CLI. Likewise, it emphasizes that the prevalence of malnutrition in this patient population is clearly underestimated. These results should prompt more effective treatment for CLI and contribute to improving prognosis. Malnutrition should be treated with validated therapeutic strategies, in parallel with the CLI treatment.

References (28)

Cited by (27)

  • A scoping review of malnutrition in patients undergoing interventions for peripheral arterial disease

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    Some of the studies had used more than one nutrition scale. Malnutrition was associated with adverse outcomes, including increased mortality,5,6,9,15,19,24,25,27 reduced overall survival,4,14,16 increased postoperative complications,5,6,24 including major adverse events,7 major adverse cardiac events,7,22 major adverse limb events,7 major adverse cardiac and limb events,18,22 and delayed wound healing.11-13,23,27 Malnutrition was also associated with increased lengths of stay,5,6,8 reduced amputation-free survival,10,14,21,23 and a higher incidence of amputations15,25,26 and major amputations.20

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  • Diet and Nutrition in Peripheral Artery Disease: A Systematic Review

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    We identified 5 studies that assessed the association between diet and complications of PAD in patients with established disease (Table 1). One study24 assessed the role of nutritional state as determined by the Geriatric Nutritional Risk Index (GNRI) or the Nutritional Risk Index on 30-day survival, need for amputation, and length of hospitalisation in admitted patients with critical limb ischemia (CLI). This suggested that malnutrition was associated with poorer survival, with trends toward longer hospitalisation and increased need for amputation.24

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This study was not funded.

The authors have no conflict of interest and no financial disclosure.

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