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Keywords:

  • haemodialysis;
  • malnutrition;
  • mini-nutritional assessment;
  • nutritional risk screening

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Aims and objectives

To improve the short-form Mini-Nutritional Assessment (MNA) to ameliorate under-rating the risk of malnutrition in patients on haemodialysis.

Background

The full MNA was found to be appropriate for rating the risk of malnutrition in persons undergoing haemodialysis but the short-form under-rated the risk.

Design

A cross-sectional study with purposive sampling.

Methods

The study recruited 152 adult ambulatory patients on maintenance haemodialysis from one dialysis centre in Taiwan. Each subject was rated with the Subjective Global Assessment (SGA), the original and selected alternative short-forms (by replacing better performing nonshort-form items for lesser performing short-form items) of a Taiwanese-specific MNA (T1). Serum albumin and creatinine concentrations and the SGA were also used as referents. Results were evaluated with Pearson's correlation analysis, binary classification test and receiver operating characteristic (ROC) curves.

Results

The full MNA showed good consistency with the SGA, but the original short-form rated fewer patients at risk of malnutrition compared with the full MNA. Exchanging item O (self-rated nutritional status) with item E (neuropsychological problems) produced the best results and restored the predictive ability of the short-form. Replacing item P for E produced the next best results.

Conclusion

Results suggest that the predictive ability of the short-form can be greatly restored by rearranging the component items of the short-form without affecting the performance of the full MNA. The study is probably the first example of a disease-specific version of the MNA.

Relevance to clinical practice

The revision makes short-form MNA suitable for rating the risk of malnutrition in patients on haemodialysis in clinical practice.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Persons on haemodialysis (HD) are at an increased risk of developing protein-energy malnutrition. Routine screening and timely intervention is a necessary strategy to avoid developing severe nutritional problems. The Mini-Nutritional Assessment (MNA) is a popular tool for rating the risk of malnutrition in elderly individuals. The scale is well known for its simplicity, portability, noninvasiveness and wide application (Guigoz et al. 1994, Vellas et al. 1999). It has been shown to be effective for screening/assessing the risk of malnutrition in elderly living in a variety of settings (community, nursing homes or institutions) or with a variety of health conditions (mental disorder, cognitive impairment, dementia, undergoing stroke rehabilitation, cancer patients or on haemodialysis treatment; Guigoz et al. 2002, Kuzuya et al. 2005, Read et al. 2005, Cabrera et al. 2007, Tsai & Shih 2007, Bauer et al. 2008, Tsai et al. 2009a,b, 2010a,b).

The MNA has a full scale and a short-form (SF). The full scale consists of 18 items and evaluates four aspects of nutritional/health status including diet, anthropometrics, global and self-rated status (Guigoz et al. 2002). The first six items of the full scale constitute the short-form. The short-form can function either as a stand-alone unit or as the first part of a two-stage screening process of the full MNA. In a two-stage process, individuals who are rated as ‘at risk of malnutrition’ are further evaluated with the rest of the full scale to confirm the diagnosis. The long-form has a maximum score of 30. A score of ≤16·5 suggests malnourishment; 17–23·5, at risk of malnutrition; and 24–30, normal (Guigoz et al. 2002). The short-form has a maximum score of 14. A score ≤ 11 suggests possible malnutrition; ≥12, normal (Rubenstein et al. 2001). Recently, a revised three-category scoring classification (a score ≤ 7 as malnourished; 8–11 as at risk; and ≥ 12 as normal) comparable with the full MNA has been validated by Kaiser et al. (2009).

The MNA was developed based on clinical data of western populations. Thus, the scale is not directly applicable to the Taiwanese because of anthropometric and dietary differences from the Western populations (Chumlea 2006). Thus, we adopted the Taiwanese-specific anthropometric cut-offs to correct for these differences, and the version is named MNA-Taiwan version 1 (MNA-T1; Tsai et al. 2007, 2008).

We have recently shown that the full MNA-T1 is appropriate for assessing/screening the risk of malnutrition of elderly Taiwanese living in a variety of settings (Tsai et al. 2007, 2008, 2009b, 2010b, Tsai & Shih 2008) including patients on haemodialysis (Tsai et al. 2009a). But recently we have also found the short-form rates a smaller proportion of HD patients as possible malnutrition (Tsai & Chang 2011). This is not acceptable because in a two-stage rating process, those who are not identified as at risk by the short-form are presumed normal. This is a matter of concern because some HD patients who are indeed at risk of malnutrition would be missed for early intervention. Hence, the present study was aimed to improve the short-form MNA so that the tool can function properly in patients on haemodialysis.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Setting and subjects

We conducted a cross-sectional study and recruited patients on haemodialysis from a hospital-managed haemodialysis centre in central Taiwan. Adult patients who were without acute disease or infection and agreed to sign an informed consent were recruited to participate. Among 160 eligible patients, 152 (78 men and 74 women) qualified and agreed to participate in the study that took place during September 2009 to March 2010 (Table 1). The study followed the guidelines laid down in the Declaration of Helsinki. All procedures involving human subjects were approved by the ethics review board of the hospital.

Measurements

A clinical nurse interviewed each participant with a structured questionnaire to elicit personal data and answers to items in the MNA during a routine dialysis session. Weight, height and mid-arm and calf circumferences were measured according to methods described by Lee and Nieman (2003). The risk of malnutrition was rated with the SGA (Detsky et al. 1987), the original MNA (Rubenstein et al. 2001) and an alternative short-form MNA-T1 (Tsai et al. 2010a) using the full MNA-T1 (Tsai et al. 2007) as a criterion version.

Alternative short-form MNAs

We took the following approaches in selecting the most appropriate short-form version: (1) using the full MNA-T1 as a criterion version, because it is a validated scale and it agrees with the SGA well, (2) limiting the revision to exchanging selected short-form items with nonshort-form items, and (3) keeping all other criteria such as content items and cut-points intact. We then performed item-to-item and score-to-score exchange between the short-form and nonshort-form items (replacing the short-form item D or E that poorly reflected the nutritional status of HD patients with a nonshort-form item O or P that reflected the nutritional status of HD patients well) and evaluated the predictive ability of each alternative version using the full MNA-T1 as the criterion version.

Results were analysed with spss for Windows, version 15.0 (SPSS Inc., Chicago, IL, USA). Wilcoxon signed-rank test was used to evaluate the significance of differences of rated results among the versions. The performance of the short-form versions were evaluated with Pearson's correlation analysis, binary classification test and receiver operating characteristic (ROC) curves. Statistical significance was accepted at alpha = 0·05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Table 1 shows the basic characteristics of subjects. There were roughly equal number of men and women in the study, and the average age was 61·7 years. Seventeen per cent were on haemodialysis for <one year, 43% between two and five years and 34% over 6 years. Average BMI was 22·6 kg/m2; albumin was 3·8 g/dl; and creatinine was 10·0 mg/dl.

Table 1. Characteristics of subjects (n = 152)
Itemn (%)Mean ± SD
  1. BMI, body mass index; MAC, mid-arm circumference; CC, calf circumference.

Sex
Men78 (51·3) 
Women74 (48·7) 
Haemodialysis history (year)
≤134 (22·4) 
2–337 (24·3) 
4–529 (19·1) 
>652 (34·2) 
Age (year) 61·7 ± 12·9
BMI (kg/m2) 22·6 ± 3·5
MAC (cm) 27·4 ± 3·4
CC (cm) 31·3 ± 3·7
Serum albumin (g/dl) 3·8 ± 0·3
Serum creatinine (mg/dl) 10·0 ± 2·2
image

Figure 1. Receiving operating characteristic curves for the original and two best alternative short-forms using the full Mini-Nutritional Assessment (MNA) as referent (cut-point 23·5). Areas under the curve are 0·912 (0·868–0·955), 0·965 (0·934–0·989) and 0·948 (0·910–0·979); Youden indices are 0·628, 0·839 and 0·729; and the best-fit points are 12·50, 11·50 and 10·75 for the original (MNA-T1-SF), the best alternative (O/E) and the second best alternative (P/E), respectively.

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Table 2 shows the scoring patterns of the MNA items. Approximately 26% of subjects reported poor appetite; 14% lost >1 kg body weight during the last three months; 31% had mobility impairment; 16% had psychological stress; 34% had BMI < 21 kg/m2; 18% could not live independently; 78% took >3 prescribed drugs; 20% had less than desired protein–marker foods; 20% consumed less than two servings of fruits or vegetables; 47% consumed <5 cups of fluid a day; 55% self-viewed malnourished or were unsure about nutritional state and 61% viewed own health not as good as peers or unsure about own health status.

Table 2. Scoring pattern on the MNA-T1 items by study subjects (n = 152)
Item (item score)n (%)
  1. MNA, Mini-Nutrition Assessment; T1, Taiwan version 1. Short-form MNA includes items A-F, and it has a maximum score of 14. Individuals who score ≤ 11 should continue the assessment. The full MNA has a maximum score of 30. A score of 24–30 suggests normal nutrition; 17–23·5, at risk of malnutrition; and ≤16·5, malnourishment.

  2. a

    Cut-offs for men/women, respectively.

Screening
A. Appetite status over the past three months (2)
0 = severe loss of appetite5 (3·3)
1 = moderate loss of appetite34 (22·4)
2 = no loss of appetite113 (74·3)
B. Weight loss during last three months (3)
0 = weight loss > 3 kg2 (1·3)
1 = does not know1 (0·7)
2 = weight loss between 1–3 kg19 (12·5)
3 = no weight loss130 (85·5)
C. Mobility (2)
0 = bed or chair bound13 (8·6)
1 = able to get out of bed/chair but does not go out34 (22·4)
2 = goes out105 (69·0)
D. Suffered psychological stress or acute disease (2)
0 = yes25 (16·4)
2 = no127 (83·6)
E. Neuropsychological problems (2)
0 = severe dementia or depression8 (5·3)
1 = moderate dementia4 (2·6)
2 = mild dementia140 (92·1)
F. Body mass index (kg/m2) (3)
0 = BMI < 174 (2·6)
1 = BMI 17 to <1917 (11·2)
2 = BMI 19 to <2131 (20·4)
3 = BMI 21 or greater100 (65·8)
Assessment
G. Lives independently (not in a nursing home or hospital) (1)
0 = no27 (17·8)
1 = yes125 (82·2)
H. Takes more than 3 prescription drugs per day (1)
0 = yes119 (78·3)
1 = no33 (21·7)
I. Pressure sores or skin ulcers (1)
0 = yes3 (2·0)
1 = no149 (98·0)
J. How many full meals does the patient eat daily? (2)
0 = 1 meal0 (0·0)
1 = 2 meal16 (10·5)
2 = 3 meal136 (89·5)
K. Selected consumption markers for protein intake (1)
0 = 0 or 1 ‘yes’2 (1·3)
0·5 = 2 ‘yes’28 (18·4)
1·0 = 3 ‘yes’122 (80·3)
L. Consumes two or more servings of fruits or vegetable/day (1)
0 = no30 (19·7)
1 = yes122 (80·3)
M. How much fluid consumed/day (1)
0 = <3 cups7 (4·6)
0·5 = 3–5 cups64 (42·1)
1 = >5 cups81 (53·3)
N. Mode of feeding (2)
0 = unable to eat without assistance3 (2·0)
1 = self-fed with some difficulty14 (9·2)
2 = self-fed without any problem135 (88·8)
O. Self-view of nutritional status (2)
0 = view self as being malnourished58 (38·2)
1 = is uncertain of nutritional state26 (17·1)
2 = views self as having no nutritional problem68 (44·7)
P. Self-view of health status compared to peers (2)
0·0 = not as good33 (21·7)
0·5 = does not know58 (38·1)
1·0 = as good22 (14·5)
2·0 = better39 (25·7)
Q. Mid-arm circumference (cm) (1)
0 = <22·5/21a1 (0·7)
0·5 = 22·5–23·5/21–227 (4·6)
1 = ≥23·5/22144 (94·7)
R. Calf circumference (cm) (1)
0 = <28/25a7 (4·6)
1 = ≥28/25145 (95·4)

Table 3 shows the results rated with the SGA and various versions of the MNA. The SGA rated 1 (0·7%) person malnourished, 71 persons (46·7%) at risk of malnutrition and 80 persons (52·6%) normal; the full MNA (T1) rated 62 (40·8%) persons possible malnutrition (10 malnourished + 52 at risk of malnutrition) and 59·2% normal, while the altered MNA-SF (T1) rated 49 persons (32·2%) possible malnutrition and 67·8% normal (significantly different from the full MNA, p < 0·05). Among the alternative short-forms examined, exchanging item O (self-rated nutritional status) with E produced the best result and exchanging item P (self-rated health status) with E produced the second best result and rated 48·7% and 47·4% of patients on haemodialysis at risk of malnutrition, respectively, compared with 40·8% by the full MNA or 47·4% by the SGA (p > 0·05). Other replacements such as replacing item O or P for D or replacing both items (O and P) for D and E resulted in less satisfactory results (either inadequate or over-rating of nutritional risk; data not shown).

Table 3. Grading the nutritional status of patients on haemodialysis with the SGA, full Mini-Nutritional Assessment (MNA), unaltered short-form-MNA and alternative short-forms of MNA-T1 (n, %)
ToolAt risk of malnutritionbNormal
  1. SGA, Subjective Global Assessment; MNA, Mini-Nutrition Assessment; T1, Taiwan version 1; NA, not applicable.

  2. a

    The distribution rated by the unaltered short-form was significantly less than that rated with the full MNA-T1 or the SGA on the basis of Wilcoxon signed-rank test (p < 0·01). Results rated with the alternative short-form scales were not significantly different from that rated with the SGA or full MNA-T1.

  3. b

    Including those rated as malnourished and at risk of malnutrition by the SGA or full MNA.

  4. c

    Exchanging the position of item O or P with E (neurological problems), respectively. Alternative O/E and P/E are the two best performing alternatives.

SGA72 (47·4)80 (52·6)
Full MNA62 (40·8)90 (59·2)
Short-form MNA
unaltered49 (32·2)103 (67·8)a
Alternative versionsc
Replacing item O for E74 (48·7)78 (51·3)
Replacing item P for E72 (47·4)80 (52·6)

Table 4 shows the results of cross-tabulation tests. Among the short-forms examined, exchanging item O with E produced the best result according to the strength of correlation with serum albumin and creatinine concentrations (both indicators are known to reflect protein-energy nutritional status in maintenance dialysis patients; National Kidney Foundation 2000) and with the criterion version (full MNA) or the SGA. Alternative O/E was comparable with the full MNA or the SGA in predicting serum albumin and creatinine status and showed the best consistency with the full MNA and the SGA.

Table 4. Cross-tabulation tests of nutritional assessment/screening scales with reference standards (n = 152)
MNA scaleSerum albuminaCreatinineaFull MNA-T1SGA
At riskNormalAt riskNormalAt riskNormalAt riskNormal
  1. SGA, Subjective Global Assessment; MNA, Mini-Nutrition Assessment; T1, Taiwan version 1; LF, long-form; SF, short-form.

  2. a

    At risk: Cut-off for serum albumin is <3·8 mg/dl; for creatinine is <10·0 mg/dl.

  3. b

    Only two best performing alternative short-form are shown. O/E, Replacing item O for item E; P/E, Replacing item P for item E.

  4. c

    **p < 0·01; ***p < 0·001.

SGA
At risk432956165715 
Normal15652555575  
Kappa  0·414c  0·462c  0·734c  
Full-MNA-T1
At risk40224814  57 5
Normal18723357  1575
Kappa  0·450c  0·389c    0·734c
MNA-T1-SF
At risk2821381143640 9
Normal3073436019843271
Kappa  0·267c  0·306c  0·648c  0·450c
MNA-T1-SF-O/Eb
At risk4430561861136212
Normal146425531771068
Kappa  0·417c  0·435c  0·815c  0·710c
MNA-T1-SF-P/Eb
At risk3933502256165715
Normal196131496741565
Kappa  0·307c  0·305c  0·708c  0·604c

Table 5 shows the summary of (1) Pearson's correlation analysis, (2) binary classification test, and (3) the ROC analysis for short-form versions against the full MNA. Exchanging item O with E produced the best result in all indicators examined.

Table 5. Pearson's correlation coefficients (r), binary classification tests, areas under the curves (AUC) of the receiver operating characteristics (ROC), Youden indices and best-fit points of short-form versions using the long-form as referent (n = 152)
Short-form versions (items)Pearson's r valueaCross-tabulation Sn/Sp/(kappa)bReceiver operating characteristics
Sn/SpAUC (95% CI)cYICut-offd
  1. ROC, receiver operating characteristics; AUC, area under the curve; YI, Youden index; Sn/Sp, sensitivity/specificity; MNA, Mini-Nutritional Assessment; SF, short-form.

  2. a

    Pearsons's correlation coefficients between the scores rated with the long-form and the short-forms. All p < 0·001.

  3. b

    Sensitivity/specificity and kappa for the short-forms (cut-point 11) vs. results predicted with the long-form (cut-point ≤ 23·5). All p < 0·001.

  4. c

    AUC for each of the short-form versions tested against the long-form at cut-off 23·5.

  5. d

    The best-fit MNA-SF cut-off point according to the Youden index.

  6. e

    Only two alternative short-forms showed stronger Pearson's correlation with the full MNA than the unaltered short-form.

MNA-T1-SF0·8669·4/93·3 (0·648)78·9/83·90·912 (0·868–0·955)0·62812·5
Alternative short-formse
Replacing item O for E0·9398·4/85·6 (0·815)85·6/98·40·965 (0·940–0·989)0·83911·5
Replacing item P with E0·9190·3/82·2 (0·708)92·2/80·60·948 (0·918–0·979)0·72910·75

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Comparing the predictive abilities of the full MNA, MNA-SF and the SGA

As we have shown in a recent publication (Tsai & Chang 2011) that short-form MNA rates a significantly smaller proportion of HD patients as possible malnutrition compared with that rated by the full MNA. This phenomenon is inconsistent with the functioning principle of the MNA. Whether the short-form functions as a prescreening scale in a two-stage rating process of the MNA or as an independent screening unit, it will miss to identify a fraction of patients who are actually at risk of malnutrition. Some patients at risk would be assumed normal and miss the chance of getting a timely intervention.

Our results indicate that the full MNA (T1 version) performs well against the SGA (kappa = 0·734) which is a tool recommended by the by the U.S. National Kidney Foundation (2000) and the Taiwan Society of Nephrology (2010). Our results also show that the full MNA compares very favourably with the SGA based on its ability to rate serum albumin (kappa = 0·450 vs. 0·414) and creatinine (kappa = 0·389 vs. 0·462) status in HD patients. These results suggest that the full MNA is as effective as the SGA in rating the risk of malnutrition in HD patients.

Short-form MNA predicts the full-scale well in elderly under a variety of living settings and health conditions (Tsai et al. 2010a), suggesting that the 6-item short-form is generally adequate to reflect the health/nutritional conditions of the elderly adults. However, unlike the 18-item full scale, the 6-item short-form is inadequate to fully reflect the metabolic derangement and anorexic effects that occur in ESRD patients. As a result, the full scale but not the short-form can fully rate the risk of malnutrition in these patients. Theoretically, such a shortcoming could be ameliorated by exchanging the less performing short-form items with nonshort-form items that better reflect the nutritional status of HD patients.

Evaluating the alternative short-forms

Our results show that a simple exchange of the component items in the MNA can markedly improve the predictive ability of the short-form without affecting the performance of the full MNA. It also improves the consistency of the short-form with the full scale. Exchanging item O (self-rated nutritional status) with item E (neurological problems) produced the best result, while exchanging P with E produced the next best result. The O/E exchange fully restored the expected performance of MNA-SF without affecting the performance of the full MNA. Item E evaluates neurological disorders that are not common problems in HD patients. So the item would not reflect nutritional status of HD patients well. On the other hand, self-rated nutritional status (item O) and self-rated health status (item P) are known to be good indicators of overall nutritional/health status in HD patients (Miilunpalo et al. 1997). Of the two exchanges, exchanging item O with item E produces better results than P with E.

The exchange not only makes the MNA a better functional scale for screening/assessing nutritional risk of HD patients, it also enables the short-form to function independently (because it no longer under-rates the nutritional risk) as a stand-alone unit. Based on results of the present study, a short-form that consists of items ABCDFO is the most appropriate for screening/assessing the risk of malnutrition in patients on HD. Although the revision was tested in a nonWestern population (the Taiwanese), we believe the exchange should probably be applicable to other populations. However, the applicability of the revised scale to patients on peritoneal dialysis remains to be examined.

Limitations of the study

This study has some limitations: (1) The study uses the full MNA as a criterion version, as it shows good consistency with the SGA. However, it is not known at the present time whether it is the best gold standard for the HD patients, (2) Subjects were purposely drawn from one typical HD centre that may not totally represent the entire spectrum of HD patients in Taiwan, (3) Lastly, the study limited the revision to exchanging between the short-form and nonshort-form items of the MNA. It is possible that other variables outside of the MNA might reflect the conditions better than Item O or P in MNA.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Results suggest that exchanging item O with E in the MNA scale corrects the shortcomings of the MNA-SF in rating the risk of malnutrition in patients on haemodialysis. The revised version would probably be the first example of a disease-specific version of the MNA.

The revision increases the usefulness of the MNA in clinical and community settings. It also enables the short-form MNA to function as a stand-alone unit to rate the risk of malnutrition in patients on haemodialysis.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

The authors wish to thank the haemodialysis centres for permitting the study, and the cooperation of the participants.

Contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References

Study design: ACT, MZC; data collection and analysis: TLC and manuscript preparation: TLC, MZC.

References

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. References
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The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:

High-impact forum: one of the world's most cited nursing journals, with an impact factor of 1·316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reports® (Thomson Reuters, 2012).

One of the most read nursing journals in the world: over 1·9 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access).

Early View: fully citable online publication ahead of inclusion in an issue.

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.