Prevalence and Clinical Outcome Associated with Preexisting Malnutrition in Acute Renal Failure: A Prospective Cohort Study ENRICO FIACCADORI, MARIA LOMBARDI, SABINA LEONARDI, CARLO FEDERICO ROTELLI, GIOVANNI TORTORELLA, and ALBERICO BORGHETTI Dipartimento di Clinica Medica, Nefrologia & Scienze della Prevenzione, Universita’ degli Studi di Parma, Italy. Abstract. Malnutrition is a frequent finding in hospitalized patients and is associated with an increased risk of subsequent in-hospital morbidity and mortality. Both prevalence and prog- nostic relevance of preexisting malnutrition in patients referred to nephrology wards for acute renal failure (ARF) are still unknown. This study tests the hypothesis that malnutrition is frequent in such clinical setting, and is associated with excess in-hospital morbidity and mortality. A prospective cohort of 309 patients admitted to a renal intermediate care unit during a 42-mo period with ARF diagnosis was studied. Patients with malnutrition were identified at admission by the Subjective Global Assessment of nutritional status method (SGA); nutri- tional status was also evaluated by anthropometric, biochemi- cal, and immunologic parameters. Outcome measures included in-hospital mortality and morbidity, and use of health care resources. In-hospital mortality was 39% (120 of 309); renal replacement therapies (hemodialysis or continuous hemofiltra- tion) were performed in 67% of patients (206 of 309); APACHE II score was 23.1  8.2 (range, 10 to 52). Severe malnutrition by SGA was found in 42% of patients with ARF; anthropometric, biochemical, and immunologic nutritional in- dexes were significantly reduced in this group compared with patients with normal nutritional status. Severely malnourished patients, as compared to patients with normal nutritional status, had significantly increased morbidity for sepsis (odds ratio [OR] 2.88; 95% confidence interval [CI], 1.53 to 5.42, P  0.001), septic shock (OR 4.05; 95% CI, 1.46 to 11.28, P  0.01), hemorrhage (OR 2.98; 95% CI, 1.45 to 6.13, P  0.01), intestinal occlusion (OR 5.57; 95% CI, 1.57 to 19.74, P  0.01), cardiac dysrhythmia (OR 2.29; 95% CI, 1.36 to 3.85, P  0.01), cardiogenic shock (OR 4.39; 95% CI, 1.83 to 10.55, P  .001), and acute respiratory failure with mechanical ven- tilation need (OR 3.35; 95% CI, 3.35 to 8.74, P  0.0.5). Hospital length of stay was significantly increased (P  0.01), and the presence of severe malnutrition was associated with a significant increase of in-hospital mortality (OR 7.21; 95% CI, 4.08 to 12.73, P  0.001). Preexisting malnutrition was a statistically significant, independent predictor of in-hospital mortality at multivariable logistic regression analysis both with comorbidities (OR 2.02; 95% CI, 1.50 to 2.71, P  0.001), and with comorbidities and complications (OR 2.12; 95% CI, 1.61 to 2.89, P  0.001). Malnutrition is highly prevalent among ARF patients and increases the likelihood of in-hospital death, complications, and use of health care resources. Major advances in the diagnosis and treatment of acute renal failure (ARF) have been made over the past few years, yet prognosis of the syndrome remains poor, as the patients are now increasingly older, more severely ill, have more chronic comorbidities, and an increased number of conditions contrib- uting to ARF development (1– 4). Many factors of potential prognostic value have been identified in ARF patients (under- lying malignancy, previously altered health status, length of hospitalization before the ARF episode, delayed occurrence of ARF, sepsis, oliguria, severity of illness, etc.) (3– 8); although malnutrition is highly prevalent among hospitalized patients (9 –11), and is well known as a negative prognostic factor (12–21), no mention of nutritional status is usually made in studies on ARF patient outcome. Moreover, several controlled studies in the past tried to evaluate the effects of nutritional support on ARF patient mortality, with no clear-cut results (22–26), but again no attention was paid to the presence and possible role of previous malnutrition. We thought that if preexisting malnutrition is a frequent finding in ARF patients, and is associated with an increased risk of morbidity and mortality, nutritional status evaluation in this clinical condition would allow the definition of an important variable for patient risk stratification at the time of referral to specialized units (nephrology units or intensive care units). Thus, we designed the present prospective cohort study to: (1) investigate the Received March 5, 1998. Accepted September 4, 1998. This work was presented in part at the 29th annual meeting of the American Society of Nephrology, November 2 to 5, 1996, and has been published in abstract form (J Am Soc Nephrol 7: A365, 1996). Correspondence to Dr. Enrico Fiaccadori, Dipartimento di Clinica Medica, Nefrologia & Scienze della Prevenzione, Universita’ degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy. Phone: 521 991015; Fax: 521 292627; E-mail: fiaccado@ipruniv.cce.unipr.it 1046-6673/1003-0581$03.00/0 Journal of the American Society of Nephrology Copyright © 1999 by the American Society of Nephrology J Am Soc Nephrol 10: 581–593, 1999