207 PDI MARCH 2008 – VOL. 28, NO. 2 CORRESPONDENCE Malnutrition–Inflammation Score in Peritoneal Dialysis: Growing Reliability Editor: We read the work by Chan et al. (1) with interest. In their study, the authors concluded that the malnutrition– inflammation score (MIS) is a promising marker for nu- tritional assessment of peritoneal dialysis patients. They suggested that peritoneal dialysis patients with diabe- tes, multiple comorbidities, and limited self-care capa- bility had worse scores with Subjective Global Assessment (SGA) than with MIS, while patients that had been dia- lyzed longer had worse scores with MIS than with SGA. This study is somewhat similar to our recently pub- lished work in which we explored the correlations of SGA and MIS with anemia, nutrition, and inflammation pa- rameters (2). We found that correlations of hospitaliza- tion indices, peritonitis rates, anemia indices, erythropoietin requirements, anthropometric param- eters, and nutritional parameters, including albumin and prealbumin, were stronger with MIS than with SGA. As far as we know, we also were the first to demonstrate that a high MIS is independently associated with a fu- ture increased risk of hospitalization. The study by Chan et al. confirms our previous results in some aspects: In our study group, we found that in- crements in MIS are concordant with SGA groups A to C. Chan et al. also found a linear correlation between SGA score and MIS. They defined arbitrary cutoff MIS values for different stages of malnutrition (≤8: mild to normal malnutrition; 9 – 18: moderate malnutrition; and >18: severe malnutrition), and classification of nutritional status was similar in 80% of patients detected by SGA and MIS. On the other hand, these two studies differed in the following aspects: We used original SGA with three categories (A, B, C), while Chan et al. used a four-item seven-point system. We did not perform a separate analy- sis on diabetic subjects. We analyzed the correlation be- tween peritonitis rates and future hospitalization rates with MIS; however, Chan et al. did not analyze these re- lationships. They found correlations between normalized protein catabolic rate, Kt/V, and residual renal function, which we did not analyze. We found negative correlation with MIS, SGA, and serum albumin. Although Chan et al. found negative correlation between MIS and albumin, they did not find any correlation between SGA and albu- min. We found that MIS and SGA are strongly correlated with ferritin, whereas only MIS was correlated with C-reactive protein. Chan et al. found no difference in fer- ritin between patient groups, without measuring C-reactive protein to quantify the degree of systemic in- flammation. Another explanation for the discrepancy in the two groups’ results may be the presence of severely malnourished patients in our study group. In light of these findings and despite minor discor- dances between the results of two studies, we think that MIS may be incorporated into routine evaluation of nu- tritional status in peritoneal dialysis patients. B. Afsar* S. Sezer R. Elsurer N.F. Ozdemir Department of Nephrology Baskent University Hospital Ankara, Turkey *e-mail: afsarbrs@yahoo.com REFERENCES 1. Chan JY, Che KI, Lam KM, Chow KM, Chung KY, Li PK, et al. Comprehensive malnutrition inflammation score as a marker of nutritional status in Chinese peritoneal dialy- sis patients. Nephrology (Carlton) 2007; 12:130–4. 2. Afsar B, Sezer S, Ozdemir FN, Çelik H, Elsurer R, Haberal M. Malnutrition-inflammation score is a useful tool in peri- toneal dialysis patients. Perit Dial Int 2006; 26:705–11. Severe Peritonitis Due to Pantoea agglomerans in a CCPD Patient Editor: Peritonitis is a common and serious problem, and a significant cause of morbidity and mortality for perito- neal dialysis patients (1). We describe the first case of peritonitis due to Pantoea agglomerans in a patient on continuous cycling peritoneal dialysis (CCPD). A 65-year-old male, receiving CCPD for more than 2 years, with no prior peritonitis, presented at the emer- gency unit with abdominal pain since that morning. He had a history of renal failure secondary to left nephrec- tomy because of congenital hydronephrosis, benign nephroangiosclerosis, and diabetes. He was also suffer- ing from hypertension, obesity, and ischemic cardiopa- thy. On examination, temperature was 35.5°C with tense abdomen, rebound tenderness, and decreased bowel sounds. The peritoneal dialysis catheter’s exit site was clean. Full blood examination showed an elevated white cell count (WCC): 17.7 × 10 6 /L with 80.1% neutrophils. C-reactive protein (CRP) level was normal. The dialysate was pale yellow and cloudy. Analysis of peritoneal efflu- ent demonstrated WCC 2800/μL with 88% neutrophils.