Nutritional profile and infection-related hospital admissions in children with chronic kidney disease

doi:10.21203/rs.3.rs-4182304/v1

Protein energy wasting (PEW) and undernutrition are highly prevalent in children with chronic kidney disease (CKD), but their impact on clinical outcomes is not well-described. This prospective longitudinal study in children with CKD assessed the association of nutritional parameters with infection-related hospital admissions (IRHA).

Methods: Children with CKD2-5D aged 2-18years, infection-free for 1 month were recruited over 5 years. Evaluation for undernutrition by subjective global nutritional assessment and for PEW using pediatric criteria were undertaken and categorised as mild (>2criteria), standard (>3criteria) and modified PEW (>3criteria with short stature). The IRHA (severe viral, bacterial or fungal infections) were recorded.

Results: Among 137 children (45 on dialysis; age 123±46 months; 70% males) undernutrition was seen in 60% and PEW in 52%. Over 38±21 months follow-up, 107(78%) required hospital admissions (67% IRHA). The incidence rate of IRHA in days per patient-year was higher in those with undernutrition compared to well-nourished children [1.74(1.27,2.31) vs 0.65(0.44,0.92) p<0.0001] and higher in those with PEW compared to no PEW [1.74(1.30,2.28) vs 0.56(0.36,0.82) p<0.0001] respectively. On adjusted analysis, independent risk factors for IRHA were undernutrition, low BMI, hypoalbuminemia and dialysis status with modified PEW [OR5.34(2.16,13.1) p<0.001] and raised CRP [OR4.66(1.56,13.9) p=0.006] having the highest risk. Additionally, modified PEW and BMI were noted to have a 2-fold risk for recurrent infections.

Conclusion: In children with CKD2-5D, incidence rate of IRHA was significantly high in those with undernutrition and PEW. While dialysis, poor nutritional status, inflammation were risk factors for IRHA, modified PEW and BMI were associated with recurrent infections.

Chronic kidney disease (CKD)

Protein energy wasting (PEW)

Subjective global nutrition assessment

Infection related hospital admission (IRHA)

Undernutrition and growth failure, recognized comorbidities of chronic kidney disease (CKD) are highly prevalent in children, particularly those from low-low middle income countries (LMICs). In these settings, burden of undernutrition ranges from 20–60%, with growth failure observed in approximately 50% [1–3]. The uremic milieu-related immune dysregulation is known to predispose to high risk of infections, leading to repeated hospitalisations, morbidity and mortality. In adults with CKD, infectious events have been shown to increase the risk for adverse cardiovascular events and mortality [4–6]. Despite the common occurrence of infections in children with CKD from LMICs, a potential link between nutritional status and infection-related events has not been systematically studied.

In CKD, nutritional status is influenced by a complex interplay of factors like decreased appetite, increased metabolic rate, increased energy expenditure, inflammation, comorbidities, dialysis therapies and importantly suboptimal response to adequate nutrient intake. There is no single assessment tool to detect nutritional status in CKD. In addition to traditional anthropometry and biochemical parameters, point-of-care assessment tools like subjective global nutritional assessment (SGNA) have been recommended in adult patients but are not well explored in children. The SGNA is a composite tool consisting of nutrition‑focused medical history with physical examination to identify undernutrition and can be used by health workers, nurses and clinicians [7].

To further characterise all pathogenic factors beyond nutrient intake, the entity of protein energy wasting (PEW) was proposed. PEW is characterized by maladaptive responses, including anorexia and high metabolic rate, resulting in weight loss, diminished muscle mass, low serum albumin, and variable fat mass [8]. In 2014, a criterion for PEW adapted from adult criteria was proposed for children by the Chronic Kidney Disease in Children study (CKiD) which included 5 criteria: reduced body mass, reduced muscle mass, biochemical measures, reduced appetite and short stature. Compared to the adult criteria, appetite replaced dietary intake; serum transferrin and C-reactive protein were incorporated into biochemical parameters and short stature was an additional parameter included to reflect status of growth in children [8, 9]. In comparison to the CKiD cohort, we reported a higher burden (47%) of PEW in children with CKD2-5D, affecting 73% of those with kidney failure [10].

In children with CKD, poor nutritional status assessed by anthropometry is shown to be associated with significant morbidity, mortality and suboptimal quality of life [11, 12]. Reduced kidney function and albuminuria increase the risk for infection-related mortality [6]. Hypoalbuminemia and low body mass are associated with increased risk of death in children with kidney failure [13]. The CKiD study highlighted the importance of growth in predicting the risk for hospitalisations in children with CKD stages2-4 [9]. Recent data in children on kidney replacement therapies from the European Society of Pediatric Nephrology/ European Renal Association registry revealed higher mortality risk in those with short stature and undernutrition with infections contributing to death in the majority [14].

There is a lack of information on the clinical consequences of undernutrition assessed by comprehensive tools such as the SGNA and of PEW in children with CKD, particularly from LMICs. This prospective longitudinal study was conducted in children with CKD 2-5D to evaluate the association between undernutrition and PEW with infection-related hospital admissions (IRHA). Additionally, the study aimed to assess the effect of parameters of PEW on recurrent infections in these children over time.

The prospective longitudinal study was conducted at the department of Paediatric Nephrology, St John’s Medical College Hospital, Bangalore, from January 2017 to June 2022. Following approval by the Institution ethics committee and obtaining informed consent, children aged 2–18 years with CKD stages 2–5, and those on dialysis for more than 1 month with no evidence of infection for a month, were recruited for evaluation of undernutrition using SGNA and for PEW. This analysis was undertaken as part of a subset of a cohort study on PEW in children with CKD.

Clinical and demographic profiles were documented. Anthropometry measures of body weight and height were recorded using standard methods and expressed as Z scores. Height for age and BMI (weight in kg/height in m²) expressed as percentile were interpreted using World Health Organization growth charts in children aged 2–5 years, Indian Academy of Pediatrics growth charts in children aged 5–18 years, and Centre for Disease Control and Prevention growth charts for BMI in children below 5 years of age [15–17]. Mid-arm circumference (MAC) for height age was interpreted using reference charts based on centiles with a cut-off of 5th centile being provided [18]. CKD was staged based on Kidney diseases improving global outcome guidelines [19].

Assessment of nutritional status

SGNA, a point-of-care assessment tool was used to diagnose undernutrition (we preferred the term undernutrition to malnutrition for the purpose of this study). SGNA was performed using a specific questionnaire which included nutrition focused medical history (7 features) and physical examination (3 features). Nutrition focused medical history incorporated height, weight for height, change in body weight, and adequacy of dietary intake, gastrointestinal symptoms, functional impairment and metabolic stress of the disease. Physical examination included signs of loss of subcutaneous fat, muscle wasting, and oedema. SGNA scores were finally classified into categories of normal nutrition, moderate and severe undernutrition [20].

PEW was diagnosed using the following 5 criteria [9]. 1. Biochemical: Total cholesterol < 100 mg/dL; serum albumin < 3.8 g/dL, approximately the 5th percentile of the data; serum transferrin < 140 mg/dL; CRP > 3 mg/L. 2. Reduced body mass: defined by a BMI for height-age and sex of less than 5th percentile at recruitment or decrease of ≥ 10% (from initial BMI of < 80th percentile) between the first and second annual visits. 3. Reduced muscle mass: MAC for height-age and sex of < 5th percentile at recruitment or decrease of ≥ 10% between the first and second annual visits. 4. Decreased appetite as a surrogate for dietary protein intake: fair, poor, or very poor appetite reported by the parent over the week prior to the study visit and 5. Poor growth: defined as either short stature (a height for age and sex percentile of < 3%) or poor growth velocity (a decrease in height for age and sex percentile of ≥ 10% between the first and second annual visits. PEW was further categorized as Mild: ≥2criteria, (1 to 4); Standard: ≥3criteria (1 to 4) and Modified: ≥3criteria (1 to 4 with criteria 5 mandatory).

Biochemical analysis

Serum creatinine was estimated using picrate enzymatic method and equated to the Isotope dilution mass spectrometry method. The estimated glomerular filtration rate (eGFR) was calculated using modified Schwartz formula. Metabolic acidosis was defined as serum bicarbonate < 22meq/L. In addition serum total cholesterol (mg/dL) by enzymatic method, serum albumin (g/dL) by bromocresol purple dye binding method, serum transferrin (mg/dL) by Siemens Dimension Xp and plus machine, C-reactive protein (mg/dL) by particle-enhanced immunoturbidometric assay were measured and systemic inflammation was defined as CRP > 3 mg/L[9].

The numbers of IRHA secondary to severe viral, bacterial, and fungal infections were documented. The association of undernutrition, PEW and individual parameters of PEW with IRHA was analyzed. Recurrent infection was considered if there was more than one episode of infection per patient. The effect of PEW on recurrent infections was also explored over a 5-year period.

Statistical analysis:

All categorical data were summarized using frequency and percentages, and continuous data described using mean and standard deviation or median and interquartile ranges as appropriate. To assess the difference of clinical parameters between groups, independent sample t-test or Mann-Whitney test was applied and between PEW categories, analysis of variance or Kruskal-Wallis test was applied. To study the association between undernutrition, PEW and IRHA, chi-square test or Fisher’s exact test was used. Risk factors associated with IRHA was performed using logistic regression. Variables examined for univariate analysis included age, sex, aetiology and stages of CKD, weight and height, presence of systemic inflammation. The overall incidence rate of hospitalisation and IRHA per patient-year and rates by nutritional status were reported along with 95% confidence interval. Factors significantly associated with IRHA in the univariate analysis were considered for multivariable analysis. Adjusted analysis was conducted in 4 models. In model 1, the independent effect of the presence of PEW was considered. In model 2, effect of SGNA on IHRA was performed. In model 3, association between PEW categories with IRHA was done, and in the model 4, individual parameters of PEW were added. The effect of PEW and its parameters on recurrent infection over time was analysed using marginal approach of recurrent event data. The p-value was considered significant at 5% level of significance for all comparisons. Data was analysed using STATA 15.0.

Among 176 children screened, 137 children (mean age 123+46 months, 70% males) meeting the inclusion criteria were recruited. The proportion of children with CKD stages 2, 3, 4 and 5/5D were 31 (22%), 27 (20%), 26 (19%), 53 (39%) respectively [37 (27%) on peritoneal dialysis (PD), 8 (6%) on hemodialysis (HD) and 8 not dialysis]. The most common etiology for CKD was CAKUT (32%). Over 5 years, the in-hospital death in these children was 2% while 12% received kidney transplantation. Table 1 depicts the clinical and nutritional characteristics of the cohort.

Profile of undernutrition and PEW: Nutritional status as assessed by SGNA revealed 72 (53%) to be well nourished, 47 (35%) with moderate undernutrition, and 18 (13%) with severe undernutrition (Table 1). The proportion of children with undernutrition (moderate and severe combined) was 39% in those with CKD 2-5, and 64% in those on dialysis (p=0.005). The burden of PEW was observed in 72 (53%) children [CKD 2-5: 41 (45%); dialysis: 31 (69%), p=0.007]. The proportion of children with PEW did not vary with age, gender or etiology of CKD. Among the individual parameters of PEW, low serum cholesterol and low transferrin were seen in less than 8%. With regard to categories of PEW, 12 (8.8%), 17 (12.4) and 43 (31.4%) belonged to mild PEW, standard PEW and modified PEW categories respectively (Table 1).

Nutritional status and IRHA: Over a mean follow up of 38+21 months, 107 (78%) children required hospital admissions for infectious and non-infectious events. Among them 72 (67%) were due to IRHA (57% bacterial infections including urinary tract infections, PD peritonitis, catheter related blood stream infections and pneumonia, 38% with viral infections, and 5% due to fungal infections). Table 1 also presents the comparison of clinical and nutritional profiles of those with and without IRHA. The incidence rates of hospital admissions and IRHA were 0.68 (95% CI: 0.56, 0.82) days per patient-year and 1.03 (95% CI: 0.81, 1.28) days per patient-year respectively. The incidence of IRHA in those with and without PEW was 1.74 (1.30, 2.28) and 0.56 (0.36, 0.82) days per patient-year respectively (p=<0.0001). Similarly the incidence rates for IRHA were higher in those with undernutrition compared to well-nourished children [1.74 (1.27, 2.31) vs 0.65 (0.44, 0.92) p<0.0001] respectively.

The mean age, sex, weight for age z score of the children were comparable between those with and without IRHA. Height for age z score and mean MAC were significantly lower in children with IRHA. Significantly higher proportions of IRHA were observed in children with CKD stage 5 and in those on PD. The proportion of IRHA was significantly higher in those with undernutrition as compared to well-nourished children [60% vs. 34%, p=0.008 respectively]. Higher proportion of hospital admissions were noted in those with PEW compared to those without PEW [85% vs. 66%, p=0.011 respectively]. IRHA was observed in 68% of children with PEW compared to 35% in those without PEW (p<0.001). In both groups of CKD 2-5 and dialysis, the proportion of IRHA was significantly higher in those with PEW compared to without PEW (CKD2-5: 58% vs. 35%, p=0.03; dialysis: 79% vs. 36%, p=0.007). Among the categories of PEW, the proportion of IRHA was significantly higher with modified PEW compared to mild and standard PEW [44% vs 9.7% vs 14% respectively].

Risk Factors associated with IRHA: On univariate analysis, presence of undernutrition, PEW and the individual parameters of PEW namely low MAC, low BMI, short stature, hypoalbuminemia, systemic inflammation were significant risk factors for IRHA. On adjusted analysis in model 1 (Table 2), the presence of PEW [OR 3.59 (1.7, 7.56) p<0.001] had a higher odds of IRHA. In model 2, children with undernutrition had 2.78 times higher odds of IRHA [OR 2.78 (1.33, 2.8) p=0.007]. Model 3 with categories of PEW showed modified PEW to have the highest odds of IRHA [OR 5.34 (2.16, 13.1) p<0.001] compared to standard PEW mild PEW. Among parameters of PEW as undertaken in model 4, systemic inflammation (CRP) [OR 4.66 (1.56, 13.9) p=0.006], low BMI and hypoalbuminemia were independent risk factors for IRHA. In univariate and adjusted analyses, dialysis status in itself was an independent risk factor with more than 2-fold risk for IRHA in all the models. Short stature, though significantly associated with IRHA in univariate analysis lost significance in the adjusted analysis.

Nutritional parameters and recurrent infection rate: In this cohort, 56% of children had recurrent infections. After adjusting for age, sex, and dialysis status, the modified PEW category had a higher risk for recurrent infections [HR 2.36 (1.26, 4.42) p=0.007] compared to mild and standard categories. Among individual parameters of PEW, low BMI had a higher risk for recurrent infections [2.23 (1.41, 3.53) p=0.001] compared to hypoalbuminemia [1.78 (1.06, 3.00) p=0.031] and raised CRP [1.84 (1.09, 3.11) p=0.021] (Figure 1).

This prospective longitudinal study, conducted over five years in children with CKD2-5D in a LMIC, revealed a significant burden of undernutrition and PEW, particularly associated with IRHA in the majority of cases. The study identified independent risk factors for IRHA, including undernutrition, modified PEW category, low BMI, systemic inflammation, and hypoalbuminemia. Additionally, children undergoing dialysis faced a higher risk of IRHA compared to the pre-dialysis group. The modified PEW category, which includes short stature as a criterion and low BMI demonstrated a higher risk for both IRHA and recurrent infections.

The prevalence of undernutrition in children with CKD varies depending on the assessment tool used for diagnosis and is reported to be as high as 60–73% in LMICs [3, 7]. Despite its time-consuming nature, SGNA for undernutrition is a comprehensive tool, encompassing both nutrition-related medical history and physical examination. In the current study, undernutrition was diagnosed by SGNA in 48%, while a previous report observed undernutrition in 73% of children on dialysis [7]. The outcomes of undernutrition based on SGNA are not reported in children. The current study reveals presence of undernutrition by SGNA to be an independent risk factor for IRHA and therefore provides a rationale for the use of this tool in clinical practice.

PEW, an extreme form of undernutrition in CKD, includes a specific component of systemic inflammation in the pediatric diagnostic criteria [21]. The current study notes a significant burden of PEW, that has been reported previously from the region [10].

As multiple parameters are utilized to assess nutritional status, establishing a systematic link between nutritional parameters and outcomes is crucial in the uremic milieu, providing opportunities for preventive and therapeutic interventions. Numerous clinical outcomes have been studied concerning nutritional markers in CKD. However, as nutritional and inflammatory parameters are often interlinked, the interpretation of outcomes becomes complex and challenging. Among studies in adults, hypoalbuminemia and undernutrition are proven independent risk factors for infections, fatal and non-fatal cardiovascular morbidities. Additionally, undernutrition correlates with early hospital admissions, increased admission rates, prolonged hospital stay, and diminished quality of life in this population [22–27]. A recent study in 682 adult patients with CKD stages 1–5 highlighted a higher proportion of infectious complications in patients with undernutrition (62.3%) compared to well-nourished counterparts (29%). Patients with CKD and undernutrition had a 2.4 times higher risk of infectious complications, lengthier hospital stay, and increased hospitalisation costs compared to those who were well-nourished [28]. Among adults with CKD, nutritional status assessed through SGNA was associated with kidney failure, mortality, poor physical function and gastrointestinal symptoms [29, 30]. In adults on maintenance hemodialysis, individual measures of PEW, such as low BMI, hypoalbuminemia, and normalized protein catabolic rate, have been shown to be associated with infection-related mortality [31].

In children with kidney failure, key outcomes of nutritional parameters (BMI and linear growth) include mortality, hospitalisation, infection related death, health-related quality of life, access to transplantation, graft failure, and time to reduced graft function post-transplant [32–36]. Extremes of BMI and growth failure have consistently been associated with adverse outcomes. In children with early stages of CKD, malnutrition as defined by weight for height, BMI for age and height for age has shown to be associated with worse glomerular filtration rate and declining kidney function [37].

Research on the clinical ramifications of PEW in pediatric CKD remains scarce [9, 14, 37]. The primary hurdle stems from the absence of universally validated criteria for diagnosing PEW in children. Consequently, there is a pressing need to reassess current PEW diagnostic criteria [38]. To address this gap, it is imperative to furnish evidence regarding the association between existing PEW criteria and clinical outcomes.

The current study reveals a notable higher incidence of hospitalisation rates and IRHA in those with undernutrition and PEW. In those with modified PEW, where short stature was incorporated as a criterion, a five-fold higher risk for IRHA and a two-fold risk for recurrent infections were observed. The CKiD study indicated a two-fold increase in hospitalisation among children with modified PEW but did not report incidence of IRHA in particular [9]. Compared to the CKiD cohort, we report a larger proportion of children with short stature that contributes to the category of modified PEW [2, 9, 10].

Severity of CKD was a predictor of hospitalisation in pre-dialysis patients under the CKiD study and the current study underscores dialysis status to be an independent risk factor for IRHA. Within a cohort of 1,112 pediatric dialysis patients, those experiencing growth failure exhibited a 1.1-fold higher likelihood of hospitalisation, with infections constituting approximately 40% of these cases [33]. In the current study, adjusted analysis did not reveal short stature as an independent risk factor for IRHA probably due to the overbearing impact of other risk factors. Interestingly, modified PEW that mandates the inclusion of short stature did stand out as an independent risk factor for both IRHA and recurrent infections. Studies conducted in children undergoing dialysis have highlighted the significant impact of hypoalbuminemia, linking it to elevated mortality and hospitalisation rates [12, 39]. A study tracking 416 children new to dialysis over a span of 4 years revealed a hospitalisation incidence rate of 2.2 (95% CI: 1.9, 2.4) days per patient year, with 16% of these hospitalisations attributed to IRHA [40]. Those with serum albumin levels below 3 g/dl faced a 1.6-fold increased odds of hospitalisation, while those with levels below 3.5 g/dl experienced a 1.2-fold increased odds. The current study, with more than a quarter of the cohort on chronic peritoneal dialysis identified a 2.4-fold risk of IRHA with hypoalbuminemia with a cut-off of serum albumin < 3.8g/dl. There are no prospective studies on the impact of systemic inflammation on outcomes in these children. The current study highlights CRP to be an independent risk factor for IRHA. Nutritional status and growth were shown to be associated with systemic inflammation in 29 pre-dialysis CKD children where CRP predicted one fifth of the variance in height for age [41].

The strength of this study lies in its prospective design, offering insights into the relationship between nutritional parameters and both IRHA and recurrent infections among children with CKD 2-5D in a LMIC setting. Recurring infections constitute a significant cause of morbidity and mortality and it is imperative to identify specific risk factors for their occurrence. The stringent exclusion criterion, particularly the requirement for absence of active infection at recruitment, enhances the reliability of the findings. However, the substantial loss to follow-up among patients may have introduced a potential bias, and possibly led to an underestimation of the true mortality rate. The study did not analyse the length of hospital stay, as patients traveling from distant areas often prefer extended hospital stays for follow-up on recovery. Furthermore, the absence of consideration for confounding factors such as dietary intake, dialysis adequacy, and fluid overload status in the analysis warrants acknowledgment, as these variables could have influenced the observed outcomes.

In conclusion, this study sheds light on the intricate relationship between nutritional status and IRHA in pediatric CKD within an LMIC. With the prevalence of poor nutritional status and infection-related events being notably high in this population, understanding specific nutrition-related risk factors for IRHA is crucial. In the absence of a standardized tool for nutrition assessment, studying the effects of specific nutritional parameters on clinical outcomes becomes paramount. Among children with CKD stages 2-5D, it is evident that poor nutrition, along with factors such as dialysis therapy and inflammation, contributes significantly to the risk of IRHA. Furthermore, the study highlights modified PEW and low BMI as notable risk factors for recurrent infections in this cohort. As a consequence, these findings emphasize the importance of reassessing and potentially refining the diagnostic criteria and categorization of PEW in children with CKD.

This manuscript has not been published elsewhere and has not been submitted simultaneously for publication elsewhere.

Conflict of Interest: None

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Table 1: Clinical and nutritional profiles between children with and without IRHA

Clinical and nutritional parameters	Value (n=137)	IRHA Yes: n=72	IRHA No: n=65	P value
Age (months)*	122±46	123.5±46.4	120.9±46.9	0.755
Male ^	96 (70)	49 (75.4)	48 (66.7)	0.262
Anthropometry
Weight* (kg) Weight Z score* Height* (cm) Height Z score* MAC* cm BMI* Kg/m²	25.13±11.99 -2.86±2.44 122.99±21.67 -2.64±1.89 17.14±3.95 15.66±2.83	24.0±12.1 -3.20±2.32 120.9±21.9 -2.98±1.57 16.5±3.99 15.4±3.01	26.9±12.5 -2.43±2.53 126.0±21.8 -2.21± 2.15 17.9±4.00 16.0±2.70	0.168 0.172 0.066 0.019 0.045 0.231
Stage of CKD: ^ Stage 2 Stage 3 Stage 4 Stage 5	31 (22.6) 27 (19.7) 26 (19.0) 53 (38.7)	9 (12.5) 12 (16.7) 15 (20.8) 36 (50.0)	22 (33.8) 15 (23.1) 11 (16,9) 17 (26.2)	0.007
Dialysis status^ Non-dialysis Peritoneal Dialysis Hemodialysis	92 (67.2) 37 (27.0) 8 (5.8)	38 (52.8) 30 (41.7) 4 (5.6)	54 (83.1) 7 (10.8) 4 (6.2)	0.001
SGNA^ Well nourished Moderate undernutrition Severe undernutrition	72(52.6) 47(34.3) 18(13.1)	29 (40.3) 30 (41.7) 13 (18.1)	43 (66.2) 17 (26.2) 5 (7.7)	0.008
PEW ^ No PEW Minimal PEW Standard PEW Modified PEW	72 (53) 65 (47.4) 12 (8.8) 17 (12.4) 43 (31.4)	23 (31.9) 7 (9.7) 10 (13.9) 32 (44.4)	42 (64.6) 5 (7.7) 7 (10.8) 11 (16.9)	<0.001
Biochemical parameters
Total cholesterol <100 mg/dL ^	2 (2)	0	2 (3.2)	0.128
Serum albumin <3.8 g/dL ^	77 (56)	30 (41.7)	47 (72.3)	<0.0001
Serum Transferrin <140 mg/dL ^	6 (4)	5 (7.5)	1 (1.7)	0.134
C- reactive protein > 3 mg/dL ^	32 (23)	25 (34.7)	7 (10.8)	0.001
Reduced body mass
BMI for height age <5^th percentile ^	48 (35)	33 (45.8)	15 (23.1)	0.005
Reduced muscle mass
MAC <5^th percentile ^	75 (54)	47 (63.4)	28 (45.2)	0.035
Appetite ^	35 (26)	22 (30.0)	13 (20.6)	0.255
Short stature ^	57 (42.2)	37 (51.4)	20 (31.7)	0.021

MAC: Mid arm circumference; BMI: Body mass index; PEW: Protein energy wasting; SGNA: Subjective global nutrition assessment. *Mean (SD), ^ n (%)

Table 2: Adjusted analysis showing factors associated with IRHA.

	Adjusted Odds Ratio	95% C.I.	P value
Model 1
Dialysis	2.73	1.37, 5.41	0.004
PEW	3.59	1.70, 7.56	0.001

Model 2
Dialysis	2.77	1.38, 5.57	0.004
Undernutrition	2.78	1.33, 2.80	0.007

Model 3
Dialysis	2.85	1.42, 5.73	0.003
No PEW
Mild PEW	2.47	0.67,9.02	0.171
Standard PEW	1.95	0.62,6.19	0.253
Modified PEW	5.34	2.16,13.1	<0.001

Model 4
Dialysis	2.28	1.08, 4.86	0.031
S. CRP	4.66	1.56, 13.9	0.006
S. Albumin	2.43	1.02, 5.80	0.045
BMI	2.61	1.14, 6.00	0.024

95% C.I: Confidence interval; PEW: Protein energy wasting; BMI: Body mass index

Nutritional profile and infection-related hospital admissions in children with chronic kidney disease

Status:

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Abstract

Figures

Introduction

Methodology

Statistical analysis:

Results

Discussion

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References

Tables

Status:

Journal Publication

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