Association between the Malnutrition–Inflammation Score and depressive symptoms in kidney transplanted patients

doi:10.1016/j.genhosppsych.2011.01.012

General Hospital Psychiatry

Volume 33, Issue 2, March–April 2011, Pages 157-165

https://doi.org/10.1016/j.genhosppsych.2011.01.012 Get rights and content

Abstract

Objective

Depressive symptoms and the Malnutrition–Inflammation Complex Syndrome (MICS) are prevalent in patients with chronic kidney disease. The complex relationship between MICS and depression has never been studied in kidney transplanted (Tx) patients. Here we evaluate the association between the Malnutrition–Inflammation Score (MIS) (Kalantar score) and depressive symptoms in Tx patients.

Methods

Cross-sectional data of 973 prevalent Tx patients were analyzed. Sociodemographic and anthropometric characteristics and clinical and laboratory data were collected, and serum levels of inflammatory markers [C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α)] were measured. The Center for Epidemiologic Studies-Depression (CES-D) scale, the MIS and the Charlson Comorbidity Index (CCI) were computed. We used linear regression analysis to examine whether the relationship between MIS and CES-D score is independent from sociodemographic and laboratory parameters.

Results

The CES-D score, corrected for age, gender and estimated glomerular filtration rate weakly but significantly correlated with serum IL-6 and the CCI (0.124 and 0.103, respectively; P<.05 for both) and marginally significantly with CRP (0.06; P=.06). We found a moderate correlation between CES-D score and MIS (0.262; P<.001). In a multivariable linear regression model, the MIS was independently associated with the CES-D score (B=0.110; P<.001).

Conclusions

The MIS was significantly associated with depressive symptoms after adjusting for important covariables in patients after renal transplantation.

Introduction

Depressive symptoms are among the most common psychological disorders in patients with chronic kidney disease (CKD) [1], [2], with a reported prevalence between 20% and 40% [1], [3], [4], [5], [6]. Recently, using the Center for Epidemiologic Studies-Depression (CES-D) scale, we reported that the prevalence of clinically significant depressive symptoms was 22% in kidney transplant recipients [7], [8]. Depression is associated with increased mortality in both dialyzed and kidney transplanted (Tx) patients [9], [10], [11], [12], [13], [14], [15], [16].

A complex relationship exists between depression and inflammation [17], [18]. Proinflammatory cytokines may cause depression-like symptoms [19], [20], [21], [22], [23], [24], and depressive symptoms are often associated with higher levels of inflammatory markers [e.g., C-reactive protein (CRP) and interleukin-6 (IL-6)] both in the general population and also in patients with CKD [25], [26], [27], [28], [29], [30]. Cytokines increase protein catabolism, which may also contribute to the syndrome of protein-energy wasting (PEW) [27], [31]. Furthermore, one of the most common symptoms of depression is poor appetite, which may contribute to undernutrition [32].

The combination of PEW and inflammation, also known as Malnutrition–Inflammation Complex Syndrome (MICS) [33] is very prevalent in patients with CKD [2], [3], [4]. This condition is reportedly associated with atherosclerosis and predicts prospective hospitalization and mortality in patients with CKD [34], [35], [36]. The Malnutrition–Inflammation Score (MIS), also known as Kalantar score, is a semiquantitative instrument for the evaluation of MICS [34]. We have recently demonstrated that the score reliably measures MICS in kidney transplant recipients [37].

Based on the above, a close association between malnutrition, inflammation and depression can be postulated [38]. Depression was associated with the MIS among patients on maintenance dialysis [28], [39], [40], [41]. However, this potential association has not been assessed in Tx patients.

In this study, we tested the hypothesis that markers of malnutrition and inflammation, such as serum albumin, CRP, tumor necrosis factor-alpha (TNF-α), IL-6 and also the MIS are associated with depressive symptoms in Tx patients. We also hypothesized that the association between the MIS and depressive symptoms in kidney transplant recipients is independent of other important clinical and sociodemographic factors.

Section snippets

Patient population and data collection

All prevalent kidney transplant recipients 18 years of age or older (n=1214) who were followed at a single outpatient transplant clinic at the Department of Transplantation and Surgery at the Semmelweis University, Budapest on December 31, 2006, were invited to participate in this observational study. Exclusion criteria were as follows: acute rejection within the last 4 weeks, current hospitalization, transplantation in the previous 3 months, acute infection or bleeding. The assessment was

Basic characteristics of the sample

Of the 1214 eligible patients, 205 (17%) refused to participate, 20 patients (1.6%) did not complete the CES-D scale and 16 patients (1%) were excluded. The study population therefore included 973 participants. There were fewer men among participants compared with nonparticipants (57% vs. 67%; P<.01), but the age of the two groups was similar (51±13 vs. 52±13 years, P=ns).

Baseline sociodemographic characteristics and laboratory values of the sample are shown in Table 2. The average age was

Discussion

In this cross-sectional study of prevalent, stable kidney transplant recipients, the MIS showed a significant association with the CES-D score, even after extensive adjustment for potentially important sociodemographic and clinical covariables.

Depression is associated with increased morbidity and mortality and worse quality of life in patients on maintenance hemodialysis [3], [12], [13], and depressive symptoms are also independently associated with mortality in Tx patients [15]. The potential

Acknowledgments

The authors thank the patients and the staff in the Department of Transplantation and Surgery, Semmelweis University Budapest.

The study was supported by grants from the National Research Fund (F-68841; HUMAN-MB08-A-81231), Scientific Committee of the Hungarian Ministry of Health (ETT 206/09), the Hungarian Kidney Foundation, Hungarian Society of Hypertension, Hungarian Society of Nephrology and the Foundation for Prevention in Medicine. This paper was supported by the János Bolyai Research

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It is possible that differences in health systems or clinical approaches to transplant recipients and other factors such as racial or cultural differences may impact at this level. Nonetheless, PEW features alike in other CKD patient populations, also impact on the outcome of Tx patients, such as mortality risk and allograft rejection,11 presence of anemia,107 risk of depression,108 and poor quality of life.109 Although several lines of evidence suggest that features of PEW exist in the pediatric CKD population, this syndrome seems to be less well characterized in children, and our study could not identify any eligible report.
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The malnutrition-inflammation score (MIS) combines ten components to assess nutritional status. Higher MIS has been associated with higher mortality and poorer health-related quality of life (HRQOL) in maintenance hemodialysis (MHD) patients. It is interesting to investigate associations of each component with mortality and patient-reported outcomes (PROs), that is, HRQOL and depression symptoms, and if MIS associations are generalizable for diverse populations. This study assessed associations of MIS and its components with mortality and PROs in an African descent MHD population.
Prospective cohort for mortality and cross-sectional design for PROs using data of the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO).
A total of 632 MHD patients (92% black or mixed race) treated in Salvador, Brazil.
MIS (range: 0-30, higher worse) and each of its ten components (range: 0-4, higher worse).
Mortality, HRQOL using the KDQOL-SF, and depression symptoms using the 20-item Center for Epidemiological Studies Depression Scale.
Linear regression for comparing scores and Cox regression for mortality.
After extensive adjustments, MIS ≥6 was associated with 52% higher mortality (hazard ratio = 1.52; 95% confidence interval = 1.13-2.05), higher depression symptoms, and poorer HRQOL, including physical, mental, and kidney disease–targeted HRQOL measures. Weight change, comorbidity, muscle wasting, and albumin were the MIS components indicating associations between poor nutrition and higher mortality. By contrast, gastrointestinal symptoms and functional capacity were the MIS components denoting detrimental associations of poorer nutritional status with PROs.
Causal conclusions are not possible.
The PROHEMO results indicate that MIS components associated with mortality are not the same associated with PROs. However, the MIS showed consistent associations with mortality and PROs. These results in a population that were not the target of previous investigations, add support for using tools combining nutritional components, such as MIS, to predict outcomes in MHD populations.

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^☆: Conflict of interest: None.

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Psychiatric–Medical ComorbidityAssociation between the Malnutrition–Inflammation Score and depressive symptoms in kidney transplanted patients☆

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patient population and data collection

Basic characteristics of the sample

Discussion

Acknowledgments

Kidney Int

Am J Med Sci

Kidney Int

Adv Chronic Kidney Dis

Kidney Int

J Psychosom Res

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Kidney Int

Gen Hosp Psychiatry

Neurol Clin

Prog Neuropsychopharmacol Biol Psychiatry

Eur J Pharmacol

Exp Gerontol

Lancet

Trends Immunol

J Psychosom Res

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

J Ren Nutr

J Chronic Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Kidney Int

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Psychiatric–Medical Comorbidity
Association between the Malnutrition–Inflammation Score and depressive symptoms in kidney transplanted patients☆