|Year : 2021 | Volume
| Issue : 5 | Page : 183-190
Geriatric nutritional risk index in screening malnutrition among young adult and elderly trauma patients
Yueh-Wei Liu1, Ching-Hua Tsai2, Sheng-En Chou2, Wei-Ti Su2, Chi Li2, Shiun-Yuan Hsu2, Ching-Hua Hsieh3
1 Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Kaohsiung City, Taiwan
2 Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Kaohsiung City, Taiwan
3 Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Kaohsiung City, Taiwan
|Date of Submission||02-Mar-2021|
|Date of Decision||30-Mar-2021|
|Date of Acceptance||04-Aug-2021|
|Date of Web Publication||12-Oct-2021|
No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City 83301
Source of Support: None, Conflict of Interest: None
Background: The geriatric nutritional risk index (GNRI) calculated as 1.489 × albumin (g/dL) +41.7× (current body weight/ideal body weight) is useful in identifying high-risk for malnutrition in elderly patients with subacute or chronic diseases. Given that trauma patients have sustained injuries in an acute condition, this study is designed to explore the association between GNRI on admission and outcomes in elderly and young adult patients with trauma.
Materials and Methods: From January 01, 2009, to December 31, 2019, a total of 1772 elderly and 2194 young adult trauma patients were categorized into four nutritional risk groups according to GNRI: high-risk group (GNRI <82), moderate-risk group (GNRI 82 to <92), low-risk group (GNRI 92–98), and no-risk group (GNRI >98). Propensity score-matched patient cohorts were created in different nutritional risk groups against the no-risk group to minimize the confounding effects of sex, age, pre-existing comorbidities, Glasgow Coma Scale score, and Injury Severity Score on outcome measurements. Primary outcome was in-hospital mortality, and secondary outcome was the length of hospital stay.
Results: Young adult patients with trauma were comparable in pattern of mortality outcomes and hospital stays to that in elderly patients. Analysis of the selected propensity score-matched patient cohorts revealed that both elderly and young adult patients in the high-risk group had significantly higher odds of mortality (elderly, odds ratio [OR], 6.5; 95% confidence interval [CI], 3.00-14.03; P < 0.009; young adult, OR, 2.7; 95% CI, 1.45-5.11; P = 0.001) and longer hospital stay (elderly, 21.5 days vs. 12.4 days, respectively, P < 0.001; young adults, 22.5 days vs. 14.1 days, respectively, P < 0.001) than those of the no-risk group.
Conclusion: This study demonstrated that the GNRI could serve as a useful screening method to identify high-risk malnutrition in acutely injured trauma patients, including not only the elderly trauma patients but also the young adult trauma patients.
Keywords: Elderly, geriatric nutritional risk index, mortality, nutritional status, trauma, young adults
|How to cite this article:|
Liu YW, Tsai CH, Chou SE, Su WT, Li C, Hsu SY, Hsieh CH. Geriatric nutritional risk index in screening malnutrition among young adult and elderly trauma patients. Formos J Surg 2021;54:183-90
|How to cite this URL:|
Liu YW, Tsai CH, Chou SE, Su WT, Li C, Hsu SY, Hsieh CH. Geriatric nutritional risk index in screening malnutrition among young adult and elderly trauma patients. Formos J Surg [serial online] 2021 [cited 2021 Nov 28];54:183-90. Available from: https://www.e-fjs.org/text.asp?2021/54/5/183/327887
| Introduction|| |
In hospitalized patients, malnutrition is commonly associated with an increased risk of complications, a longer hospital stay, and a higher mortality rate., It has been estimated that, depending on the assessment tool for nutritional status and the study population, the prevalence of malnutrition in severely injured patients ranges from 7% to 76%. Even though there are various nutrition screening and assessment tools for the clinical setting, there is no recommended gold standard for nutritional assessment. Consideration of nutritional status has been particularly important for elderly patients. Therefore, the population selected is often aged and institutionalized or in a nursing home,, and may not represent the hospitalized trauma patients admitted for acute care.
In 2005, the geriatric nutritional risk index (GNRI) was introduced by Bouillanne et al. to assess the nutritional status of elderly patients admitted to a rehabilitation unit. The GNRI was calculated as follows: (1.489× albumin [g/dL] +41.7× [current body weight/ideal body weight]). If the ratio of the current body weight/ideal body weight is >1, then the value input into the equation was set as 1. As proposed by Bouillanne et al., patients were assigned into four groups: high-risk, moderate-risk, low-risk, and no-risk groups according to GNRI values of <82, 82 to <92, 92–98, and > 98. Report showed that in the high-, moderate-, and low-risk groups, the risks of infectious complications and mortality were significantly higher than those in the no-risk group. A strong correlation had been validated for GNRI with handgrip strength, mid-upper arm muscle circumference, and arm muscle area of hospitalized patients. The GNRI could also predict the preoperative sarcopenia status of cancer patients and correlated well with other nutritional scoring tools., GNRI showed a higher prognostic value for predicting mortality than albumin level alone and was reported in a 3-year observational study. This was because the serum albumin level can be altered by inflammation and hydration status and modified by impaired hepatic or renal functions. Although the GNRI was first developed to evaluate the 6-month mid-term nutritional outcomes of elderly patients in rehabilitation units, it had been successfully applied to various medical conditions, including heart failure, chronic obstructive pulmonary disease, sepsis, chronic renal disease, and certain cancers., The GNRI was also useful for assessing long-term postoperative outcomes.,,,,
The GNRI is proposed to be a simple and objective method to evaluate the nutrition-related risk of morbidity and mortality in hospitalized elderly patients., However, no study has evaluated GNRI as a screening method in acutely injured trauma patients, specifically, whether GNRI is suitable for the young adult population, a major population of trauma patients. Therefore, this study aims to investigate whether GNRI on admission correlates with the outcomes of elderly and young adult trauma patients.
| Materials And Methods|| |
The study was approved, with the approval number 202100201B0, by the Institutional Review Board (IRB) of the Chang Gung Memorial Hospital (initiating the study). Due to the retrospective design, the requirement for informed consent in this study was waived according to the IRB regulations. From January 01, 2009, to December 31, 2019, a total of 34,216 patients aged ≥20 years were in the Trauma Registry System [Figure 1]. After exclusion of those patients who had burns (n = 909), lacked albumin data (n = 29,156), and had incomplete data (n = 185), 3,966 trauma patients were enrolled into the study and were further categorized into two groups: Young adult patients (age ≥20 but <65 years, n = 2,194) and elderly patients (age ≥65 years, n = 1772). Both the young adult and elderly patients were subsequently assigned into four nutritional risk groups (high-risk group [Group 1], GNRI <82; moderate-risk group [Group 2], GNRI 82 to <92; low-risk group [Group 3], GNRI 92–98; and no-risk group [Group 4], GNRI >98) according to the original publication by Bouillanne et al.
|Figure 1: Illustration of the flowchart with the inclusion and allocation of elderly and young adult patients into four groups with various nutritional risks according to the value of geriatric nutritional risk index|
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The patients' medical information was collected from the Trauma Registry System database,,, including sex, age, body mass index (BMI), serum albumin levels (g/dL) upon admission, preexisting comorbidities, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), in-hospital mortality, and hospital stay (days). The recorded preexisting comorbidities included diabetes mellitus (DM), hypertension, cerebrovascular accident, congestive heart failure, coronary artery disease, and end-stage renal disease. ISS, which represented the injury severity of the patients, was calculated according to the sum of the squares of the three highest Abbreviated Injury Scale scores in different injured body regions of trauma patients.,
All statistical analyses were performed using IBM SPSS Statistics for Windows (version 23.0; IBM Corp., Armonk, NY, USA). Categorical data were compared using Pearson's Chi-square test or two-sided Fisher's exact test with ORs and 95% CIs. The homogeneity of variance of the continuous variables was estimated using Levene's test. Analysis of variance was used with Bonferroni post hoc correction to analyze continuous data with a normal distribution. Continuous data with non-normaldistribution were analyzed using the Mann–Whitney U test. The results are expressed as mean ± standard deviation or median with interquartile range (Q1–Q3). In this study, the in-hospital mortality and hospital stay of patients were defined as the primary and secondary outcomes, respectively. To minimize the confounding effects of sex, age, pre-existing comorbidities, GCS score, and ISS of patients on outcome measurements, 1:1 propensity score-matched patient cohorts of high-, moderate-, and low-risk groups against the no-risk group of elderly and young adult patients were created using the NCSS 10 software (NCSS statistical software, Kaysville, UT, USA). The propensity score was calculated using the greedy method with a 0.2-caliper width. These matched patient cohorts were used to assess the outcomes of elderly and young adult patients in different nutritional risk groups compared to the no-risk group. Statistical significance was set at P < 0.05.
| Results|| |
Patient and injury characteristics of elderly trauma patients
In the elderly patients, there was no significant difference in the gender predominance and pre-existing comorbidities among these groups with different risks for malnutrition [Table 1]. Patients in the high-, moderate-, and low-risk groups were significantly older and had a significantly lower BMI and albumin level than those in the no-risk group. Compared to the no-risk group, GCS scores were significantly lower in the high-risk and moderate-risk groups but not in the low-risk group. The ISS was significantly higher in the high-risk, moderate-risk, and low-risk groups than in the no-risk group. When stratified by ISS (1–15, 16–24, or ≥25), there were significantly fewer patients with an ISS of 1–15 in the high-, moderate-, and low-risk groups than in the no-risk group, but more patients had an ISS of 16-24 in the low-risk group and an ISS ≥25 in the high-and moderate-risk groups than in the no-risk group. Patients in the high-risk group (19.8%) and moderate-risk groups (9.9%) had a significantly higher mortality rate than patients in the no-risk group (3.9%), excluding the low-risk group (6.3%). Patients in groups of various risks had a significantly longer hospital stay than those in the no-risk group.
|Table 1: Patient and injury characteristics of the elderly trauma patients with various risks of malnutrition|
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Patient and injury characteristics of young adult trauma patients
There was no significant difference in sex predominance and age among the groups with different risks for malnutrition in young adult trauma patients [Table 2]. Patients in groups of various risks had significantly lower BMI and albumin levels than those in the no-risk group. Regarding pre-existing comorbidities, there were fewer patients in the moderate-risk group with hypertension than in the no-risk group. There were fewer patients in the high-risk group, but more patients in the low-risk group had DM than in the no-risk group. There were significantly lower GCS scores in patients of groups of various risks than those in the no-risk group. There was a significantly higher ISS in patients of groups of various risks than in the no-risk group. When stratified by ISS (1–15, 16–24, or ≥25), significantly fewer patients had an ISS of 1–15, but more patients had an ISS of 16–24 and ≥25 in groups of various risks than those in the no-risk group. Patients in the high-risk group (18.1%) and moderate-risk group (6.3%), but not in the low-risk group (4.2%), had a significantly higher mortality rate than patients in the no-risk group (2.5%). Patients in groups of various risks had a significantly longer hospital stay than those in the no-risk group. The pattern of patient and injury characteristics and the outcomes of young adult patients were similar to those of elderly patients.
|Table 2: Patient and injury characteristics of the young adult trauma patients with various risks of malnutrition|
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Comparison of propensity score-matched patient cohorts
A 1:1 propensity score-matched patient cohort was created separately for patients with different risks against those in the no-risk group to attenuate the confounding effects of the patients' baseline characteristics on outcome measurements. As shown in [Table 3], for elderly trauma patients in the selected 287 pairs of propensity score-matched patient populations who did not present with significant differences in sex, age, comorbidities, GCS score, and ISS [Supplemental Table 1]a, the high-risk group patients had significantly higher odds of mortality (OR, 6.5; 95% CI, 3.00–14.03; P < 0.009) and longer hospital stay (21.5 days vs. 12.4 days, respectively, P < 0.001) than the no-risk group. In the selected 295 and 255 pairs of well-balanced matched patient populations [Supplemental Table 1]b and [Supplemental Table 1]c, the moderate-risk and low-risk groups of patients, respectively, did not have significantly different odds of mortality rate than the no-risk group of patients (moderate-risk vs. no-risk, OR, 2.1; 95% CI, 0.87–4.88; P = 0.095; low-risk vs. no-risk, OR, 1.2; 95% CI, 0.50–3.03; P = 0.648). However, patients in the moderate-and low-risk groups had a longer hospital stay than patients of the no-risk group (moderate-risk vs. no-risk, 18.7 days vs. 11.4 days, respectively, P < 0.001; low-risk vs. no-risk, 15.0 days vs. 11.7 days, P = 0.007).
|Table 3: Comparison of outcomes in the propensity score-matched patient cohorts of elderly with various risks versus no-risk group of patients|
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For young adult patients, as shown in [Table 4], in the selected 246 well-balanced pair of propensity score-matched patient populations [Supplemental Table 2]a, the high-risk group had significantly higher odds of mortality (OR, 2.7; 95% CI, 1.45-5.11; P = 0.001) and longer hospital stay (22.5 days vs. 14.1 days, respectively, P < 0.001) than the no-risk group of patients. In the selected well-balanced 424 and 350 pairs of matched patient populations [Supplemental Table 2]b and [Supplemental Table 2]c, moderate-risk and low-risk groups of patients, respectively, did not have significantly different odds of mortality than the no-risk group of patients (moderate-risk vs. no-risk, OR, 1.0; 95% CI, 0.48-2.07; P = 1.000; low-risk vs. no-risk, OR, 0.8; 95% CI, 0.33-1.76; P = 0.525). Patients in moderate-and low-risk groups had a longer hospital stay than the no-risk group of patients (moderate-risk vs. no-risk, 22.5 days vs. 14.1 days, respectively, P < 0.001; low-risk vs. no-risk, 19.0 days vs. 14.2 days, respectively, P = 0.007). The pattern of mortality outcome and hospital stay were similar between young adult patients and elderly patients, except that the magnitude of mortality odds was lower in young adult patients (OR: 2.7) than in elderly patients (OR: 6.5).
|Table 4: Comparison of outcomes in the propensity score-matched patient cohorts of the young adults with various risks versus no-risk group of patients|
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| Discussion|| |
This study demonstrated that the GNRI could be served as a useful screening method to identify high-risk malnutrition in acutely injured trauma patients. In addition, the GNRI could be used both in the elderly and the young adult trauma patients. GNRI has been successfully applied to various illnesses, and in trauma, patients receiving emergent surgeries with hip fracture,, polytrauma, and in critical care. Therefore, as shown in this study, it is not surprising to find that the GNRI could also be applied to patients with all trauma causes. As mortality is the terminal condition that might be a consequence of nutrition-related complications,, the study results demonstrated that the GNRI could only identify a higher mortality outcome in trauma patients with high- or moderate-risk malnutrition, but not in patients with mild-risk malnutrition. In this study, although the low GCS score and ISS of the patients with high-and moderate-risk may contribute to a higher mortality rate and longer hospital stay than those patients in the no-risk group, the comparison in the selected propensity score-matched populations, which had been adjusted by age, sex, comorbidities, GCS, and ISS, also revealed that the high-risk patients still had a higher mortality rate than that of the no-risk patients. This result revealed that low GNRI could be a risk factor for the mortality, independent of the patient characteristics, GCS score and ISS of the trauma patients.
The GNRI is derived from the NRI, calculated based on the serum albumin level as well as the current and usual body weight. However, half of the elderly patients cannot remember their usual body weight in the clinical setting, the NRI is often difficult to acquire. GNRI, which is based only on sex, age, height, weight, and serum albumin levels, can be acquired more easily and objectively. Its advantages are more prominent than some questionnaires, such as the Mini Nutritional Assessment and the subjective global assessment, which can be difficult to acquire for those patients who have conscious disturbance or under intubation. These two scenarios, which lead to difficulties in communication, commonly occur in patients with severe trauma. Therefore, the use of GNRI may be helpful to screen for malnutrition trauma patients who are at risk of mortality.
Although the GNRI was firstly developed for the geriatric patients, the application of GNRI in young patients had been reported by some studies of peripheral artery diseases, pyogenic liver abscess, acute decompensated heart failure, chronic hemodialysis and peritoneal dialysis, and recipients of second allogeneic hematopoietic stem cell transplantation. This study demonstrated that the pattern of mortality outcome and hospital stay were similar between young adult patients and elderly patients, except that the magnitude of mortality odds was lower in young adult patients (OR: 2.7 vs. OR: 6.5). Therefore, the GNRI can be served as a useful screening method to identify high-risk malnutrition in acutely injured trauma patients, regardless the elderly or young patient populations, upon their arrival at the emergency room or at the time of admission.
This study has some limitations. First, owing to the retrospective design of this study, selection bias may have been present. Second, treatments such as operation or resuscitation may lead to a different outcome. However, we can only assume that such outcomes of interventions were uniform in analyzing the data. Third, the registered trauma database only recorded those with in-hospital mortality but not patients who were dead on arrival at the emergency room. Therefore, some selection bias may be encountered in analyzing the outcomes. Furthermore, some selection bias may exist in the fact that this study excluded many patients without albumin level data. However, the lack of albumin measurement in many trauma patients also reflects that the evaluation of the nutritional status of trauma patients is frequently ignored. Finally, the population included in this study is limited to a single trauma center, thus limiting the generalizability of the results.
| Conclusion|| |
This study demonstrated that GNRI could serve as a useful screening method to identify high-risk malnutrition in acutely injured trauma patients, including not only the elderly trauma patients but also the young adult trauma patients.
We appreciate the statistical analyses assisted by the Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital.
Financial support and sponsorship
This research was supported by grants from CMRPG8K0511 and CMRPG8K0512 to Yueh-Wei Liu.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]