Original Report: Patient-Oriented, Translational Research

American Journal of

Nephrology Am J Nephrol 2008;28:840–846 Received: January 22, 2008

Accepted: April 15, 2008
DOI: 10.1159/000137684
Published online: June 6, 2008

Clinical Utility of Malnutrition-Inflammation

Score in Maintenance Hemodialysis Patients:
Focus on Identifying the Best Cut-Off Point
Li-chun Ho a, e His-Hao Wang a, e Yu-Sen Peng d Chih-Kang Chiang a, b
Jeng-Wen Huang a Kuan-Yu Hung a Fu-Chang Hu c Kwan-Dun Wu a
Departments of a Internal Medicine and b Integrated Diagnostics & Therapeutics, c National Center of Excellence
for General Clinical Trial and Research, National Taiwan University Hospital, School of Medicine, National Taiwan
University, d Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, e Division of Nephrology,
Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan, ROC

Key Words
Hemodialysis ⴢ Malnutrition-inflammation complex
syndrome ⴢ Malnutrition-inflammation score
Abstract
Background: Malnutrition-inflammation score (MIS) is a
comprehensive and quantitative system to assess malnutri-
tion-inflammation complex syndrome, and a strong correla-
tion between MIS and morbidity/mortality in maintenance
hemodialysis (MHD) patients had been demonstrated. How-
ever, there is no cut-off value of MIS to categorize patients
into high risk or low risk patients. Methods: A total of 257
chronic stable and ambulatory adult MHD patients from Far
Eastern Memorial Hospital were enrolled for the study. The
MIS of each patient was recorded at the initiation of study
and the study population was followed up as a 12-month
prospective cohort to evaluate mortality as the primary out-
come. Results: Twelve patients died in the 12-month obser-
vational period. Both multiple logistic regression analyses
and Cox proportional hazards model denoted MIS, alkaline
phosphatase, transferrin saturation, ferritin, and total iron
binding capacity as significant predictors of 1-year mortali-
ty. The conditional effect plot of MIS on 1-year mortality re-
vealed that when fixing the alkaline phosphatase, transferrin
saturation, ferritin, and total iron binding capacity at a mean
value, the probability of death for an MHD patient whose
MIS was 3, 4, and 5 is 10, 40, and 80%, respectively. Conclu-
sions: Our study shows that MHD patients with MIS score of
more than 4–5 had a significant risk of 1-year mortality. Ad-
ditional risk factors associated with short-term mortality be-
sides malnutrition-inflammation complex syndrome were
anemia and renal osteodystrophy. This study proves that MIS
is a useful tool to risk-stratify Asian MHD patients and to
identify those at risk of short-term death. Nutritional inter-
ventions that can improve the MIS may also improve surviv-
al, but this hypothesis needs to be verified in interventional
studies. Copyright © 2008 S. Karger AG, Basel
Introduction
More and more reports disclose the association be-
tween protein-energy malnutrition, inflammation, and
mortality in maintenance hemodialysis (MHD) patients
[1, 2]. The term malnutrition-inflammation complex
syndrome (MICS) was created to denote the important
contribution of malnutrition and inflammation to the
L.H. and H.-H.W. contributed equally to this work.
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Fax +41 61 306 12 34
E-Mail karger@karger.ch
www.karger.com
© 2008 S. Karger AG, Basel
0250–8095/08/0285–0840$24.50/0
Accessible online at:
www.karger.com/ajn
Chih-Kang Chiang, MD, PhD, No. 7 Chung-Shan South Road
Department of Diagnostics and Therapeutics and Internal Medicine
National Taiwan University Hospital, Taipei, Taiwan (ROC)
Tel. +886 2 2312 3456, ext. 980 2381, Fax +886 2 2322 2955
E-Mail ckchiang@ntu.edu.tw
Umea University
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clinical outcome of end-stage renal disease (ESRD) pa-
tients. Many markers, such as tumor necrosis factor-␣,
albumin, C-reactive protein, interleukin-6, normalized
protein nitrogen appearance, and adipocytokines had
been used to represent the severity of MICS, but none of
them had sufficient predictive power. Malnutrition-in-
flammation score (MIS), originally developed by Kalan-
tar-Zadeh et al. [3], is a comprehensive and quantitative
system to assess MICS, and a strong correlation between
MIS and morbidity/mortality in MHD patients had been
demonstrated. However, in their work they did not pro-
vide a cut-off value of MIS to categorize patients into
high-risk or low-risk groups. Besides, the utility of MIS
in Asian MHD patients was not investigated. This study
was conducted to define the predictability of MIS for
clinical outcome in Asian MHD patients and to search
for a cut-off point which best predicts mortality in MHD
patients.
Subjects and Methods
Patients
In June, 2004, a total of 257 chronic stable and ambulatory
adult MHD patients from Far Eastern Memorial Hospital were
enrolled in the study. All the patients had been on maintenance
dialysis for more than 3 months and did not have infection, car-
diovascular events, hospitalization, or surgery in the previous 2
months. The demographic and laboratory data were obtained af-
ter the Far Eastern Memorial Hospital Institutional Review Board
had approved exemption from written consent. The MIS of each
patient was recorded at the initiation of study and the study pop-
ulation was followed up as a 12-month prospective cohort to eval-
uate mortality as the primary outcome.
Malnutrition-Inflammation Score
The MIS consists of four main parts: patient’s related medical
history, physical examination, body mass index (BMI), and labo-
ratory parameters [3]. Patient’s medical history includes weight
changes, dietary intake, gastrointestinal symptoms, functional
capacity, and co-morbidity including number of years on dialysis.
Physical examination is to detect loss of subcutaneous fat and
signs of muscle wasting. Laboratory parameters are serum albu-
min and serum total iron binding capacity (TIBC) levels. Each of
the 10 components has four levels of severity, from 0 (normal) to
3 (severely abnormal). The clinical data of age, sex, duration on
dialysis, body weight and height, underlying renal condition and
presence of co-morbid conditions were obtained by chart review.
One of the investigators (C.-K.C.) interviewed all the patients to
obtain physical morbidity and ability of self-care and to assess the
subcutaneous muscle tissue and muscle mass.
Statistical Analysis
The data were analyzed using SAS/STAT쏐 software, v8.0 (SAS
Institute Inc., Cary, N.C., USA). All the results of descriptive anal-
ysis were expressed in mean 8 standard deviation unless other-
Malnutrition-Inflammation Score and
Maintenance Hemodialysis Patients
wise specified. Comparisons between patients were performed
using Student’s t test (two tailed) for normally distributed data,
Mann-Whitney U test for median data, ␹2 test for categorical data.
The association between MIS and other variables was estimated
by Spearman’s rank correlation.
Multiple logistic regression models and multivariate Cox pro-
portional hazards models were fitted to the collected data for
modeling the probability of 1-year mortality [4]. Model-fitting
techniques for logistic regression analysis including variable se-
lection, assessment of the goodness of fit, and regression diagnos-
tics (e.g. residual analysis, detection of influential cases, and
check for multicollinearity) were used to assure the quality of
analysis results [4]. In variable selection, the stepwise procedure
was applied to logistic regression analysis with both significance
level for entry and significance level for stay set to 0.15. The good-
ness of fit (GOF) measures (e.g. the percentage of concordant
pairs and the adjusted generalized coefficient of determination)
and tests (e.g. deviance, Pearson ␹2 GOF test, and the Hosmer-
Lemeshow GOF test) for logistic regression analysis were com-
puted [4]. In all statistical testing, the type I error ␣ = 0.05 was
taken, and thus p ! 0.05 indicated a statistically significant result.
The variance inflation factors (VIF) were evaluated to uncover
possible collinearity. Parameters in the regression model with
VIF 15 were discarded to avoid biased estimations.
Model-fitting techniques for multivariate Cox proportional
hazards models also included variable selection, assessment of the
goodness of fit, and regression diagnostics [4]. The variable selec-
tion approaches included both Akaike Information Criterion and
the stepwise procedure with both significance level for entry and
significance level for stay set to 0.15. The adjusted R square for
Cox proportional hazards model was computed or conducted. Re-
gression diagnosis included residual analysis, influence analysis,
and check for multicollinearity. Residual analysis was conducted
by checking Martingale residuals, scaled Schoenfeld residuals,
and deviance residuals. Influence diagnosis was made by calcu-
lating DFBETAS of each tested subject. Parameters with VIF !5
were discarded due to remarkable collinearity. We also used c sta-
tistic to evaluate the prediction power of multiple logistic regres-
sion models and multivariate Cox proportional hazards models.
Results
The characteristics of enrolled patients are listed in
table 1. Twelve patients died in the 12-month observa-
tional period. Since the MIS did not show normal distri-
bution, its data are presented as median and quartiles.
Ages ranged from 24 to 87 years (mean 58.8 8 13.5 years),
and dialysis vintage varied from 3.1 to 265.7 months
(mean 48.9 8 51.1 months). One hundred and nine pa-
tients (42.4%) had diabetes mellitus, 42 patients (16.4%)
had coronary artery disease, 25 patients (9.7%) had con-
gestive heart failure, 12 patients (4.7%) had peripheral ar-
terial obstructive disease, and 10 patients (3.9%) had ma-
lignancy. Among patients with malignancy, only 3 were
metastatic. The deceased patients had higher MIS score,
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 Table 1. Characteristics of patients

All patients Survived Deceased p

Patients 257 245 12

Sex
Male 131 124 7
Female 126 121 5
Age, years 58.8813.5 58.5813.5 64.7811.4 0.12
BMI 22.183.5 22.283.5 21.282.7 0.32
Dialysis vintage, months 48.9851.1 48.5849.9 57.5873.1 0.55
Kt/V (Daugirdas) 1.5280.34 1.5380.33 1.4780.28 0.53
Patients with
DM 109 (42.4%) 105 (42.8%) 4 (33.3%) 0.56
CAD 42 (16.4%) 38 (42.8%) 4 (33.3%) 0.11
CHF 25 (9.7%) 23 (9.4%) 2 (16.7%) 0.32
PAOD 12 (4.7%) 10 (4.1%) 2 (16.7%) 0.10
Liver cirrhosis 11 (4.3%) 10 (4.1%) 1 (8.3%) 0.41
Malignancy 10 (3.9%) 9 (3.7%) 1 (8.3%) 0.38
Serum
Albumin, g/dl 3.980.3 4.080.3 3.680.3 0.001
Creatinine, mg/dl 10.782.5 10.782.5 9.781.9 0.17
Cholesterol, mg/dl 178.4845.0 179.0844.9 165.7847.3 0.35
TIBC, ␮g/dl 205.2856.5 203.9842.8 232.48181.3 0.59
Ferritin, ng/ml 693.18332.6 698.38329.9 587.48384.8 0.26
Transferrin saturation, % 38.3813.8 37.9812.8 45.7827.9 0.35
PTH, pg/ml 220.68246.9 220.18250.4 231.38163.5 0.87
Calcium, mg/dl 9.480.8 9.480.8 9.581.0 0.72
Phosphate, mg/dl 5.281.6 5.281.6 5.781.4 0.28
ALK-P, U/l 86.6861.0 84.8860.4 121.9865.2 0.03
Hb, g/dl 10.781.3 10.781.3 9.981.9 0.16
MIS median (25th, 75th percentile) 5 (3, 9) 5 (3, 9) 9.5 (8.5, 15) <0.001

Calcium level had been adjusted by albumin. Kt/V = Dialysis urea clearance; DM = diabetes mellitus;
CAD = coronary artery disease; CHF = congestive heart failure; PAOD = peripheral artery obstructive disease;
Hb = hemoglobin.

higher alkaline phosphatase (ALK-P), and lower albumin
levels. Otherwise, there were no significant differences in
age, duration of dialysis, BMI, comorbidity, dialysis urea
clearance (Kt/V), plasma concentration of creatinine,
cholesterol, TIBC, ferritin, transferring saturation, para-
thyroid hormone (PTH), calcium, phosphate and hemo-
globin level between the survived and the deceased pa-
tients.
Table 2 lists correlation coefficient of MIS and relevant
variables. The MIS was positively and significantly cor-
related with death (r = 0.231, p ! 0.001). It also had posi-
tive correlation with age, gender, dialysis vintage, alka-
line phosphatase, ferritin, fasting blood sugar level, and
Kt/V. Plasma phosphate correlated negatively with the
MIS, but the PTH and serum calcium did not signifi-
cantly correlate with MIS. MIS had mild negative correla-
tion with predialysis creatinine (r = –0.466, p ! 0001) and
hemoglobin (r = –0.315, p ! 0.001). Normalized protein
catabolism rate, plasma concentration of potassium, cho-
lesterol, iron, and uric acid correlated negatively with
MIS but their correlation coefficient was low (r ranged
from 0 to –0.3). It is not surprising that albumin, TIBC,
and BMI had a stronger correlation since they are com-
ponents of MIS.
Multiple logistic regression analyses were conducted
to find important risk factors of 1-year mortality. The re-
sults are shown in table 3. The result of concordant pair
was 94.1% and the adjusted R 2 was 0.4747. According to
the regression model, higher MIS, higher ALK-P, higher
transferrin saturation, lower ferritin, and higher TIBC
were important risk factors of death. Although transfer-
rin (or TIBC) is one of the components of MIS, low VIF
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Table 2. Correlation coefficients of MIS and pertinent laboratory,
anthropometric, and demographic data
1.0

Estimated probability of death

Correlation Correlation
coefficient coefficient 0.8

Death 0.23*** Albumin –0.57*** 0.6

Age 0.36*** TIBC –0.59***
0.4
Gender 0.20*** Ferritin 0.23***
BMI –0.36*** Serum Fe –0.25***
0.2
Vintage (months) 0.22*** Hb –0.31***
ALK-P 0.29*** Creatinine –0.46*** 0
Ca (Alb adjusted) 0.03 Uric acid –0.23***
0 5 10 15 20
P –0.16** Kt/V (Daugirdas) 0.19**
MIS
PTH 0.01 nPCR –0.13*
K –0.22*** Ac sugar 0.12*
Cholesterol –0.15*
Fig. 1. Conditional effect plot of MIS on mortality. Based on mul-
* p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001.
tiple logistic regression model (n = 257). Mean ALK-P, 86.5 U/l;
nPCR = Normalized protein catabolism rate; Ac sugar = fast-
mean transferring saturation, 38.3%; mean ferritin, 693.2 ng/ml;
ing plasma sugar.
mean TIBC, 205.2 ␮g/dl.

Table 3. Hazard ratio for death according to multiple logistic re- Table 4. Hazard ratio for death according to multivariate Cox
gression analysis proportional hazards model

Variable HR (95% CI) p Variable HR (95% CI) p

MIS (per one score increase) 1.51 (1.25–1.83) <0.0001 MIS (per one score increase) 1.437 (1.246–1.657) <0.0001
ALK-P (per 1 U/l increase) 1.01 (1.00–1.02) 0.047 ALK-P (per 1 U/l increase) 1.012 (1.003–1.020) 0.0068
Transferrin saturation Transferrin saturation
(per 1% increase) 1.07 (1.03–1.12) 0.0006 (per 1% increase) 1.069 (1.032–1.106) 0.0002
Ferritin (per 1 ng/ml increase) 0.99 (0.996–0.998) 0.0019 Ferritin (per 1 ng/ml increase) 0.996 (0.993–0.998) 0.0002
TIBC (per 1 ␮g/dl increase) 1.01 (1.00–1.02) 0.0001 TIBC (per 1 ␮g/dl increase) 1.017 (1.011–1.024) <0.0001

(!1.5) indicated no problem of multicollinearity. The c
statistic of this multiple logistic regression model was
0.943, better than MIS alone (c statistic = 0.815). Condi-
tional effect plot of MIS on 1-year mortality was drawn
according to the multiple logistic regression model and
was shown as figure 1. When we fix the ALK-P, transfer-
rin saturation, ferritin, and TIBC at a mean value, the
probability of death for a MHD patient whose MIS was 3,
4, and 5 is 10, 40, and 80%, respectively.
The results of multivariate Cox proportional hazards
model for 1-year mortality are presented in table 4. The
adjusted R 2 for this model was 0.3817, which was good
because the R 2 of Cox proportional hazards models tends
to be low. Although the influence of time had been con-
sidered in Cox proportional hazards model, the risk fac-
tors selected in the model were not different from mul-
tiple logistic regression model. For every one unit in-
crease in MIS, ALK-P, transferrin saturation, ferritin, and
TIBC, the hazard ratio for 1-year mortality was 1.51, 1.01,
1.07, 0.99, and 1.01, respectively.
Discussion
The MIS is a comprehensive scoring system with sig-
nificant strong correlations with prospective hospitaliza-
tion indices and mortality [2]. The easy and reproducible
measure makes it a convenient tool to assess the severity
of MICS. Our study showed that even though the mortal-
ity rate was lower in Asian MHD patients than in white
[5], the higher MIS remained a strong predictor of mor-
tality in Asian patients. Although the association between
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high MIS and poor clinical outcome had been clearly
identified, a cut-off value to categorize patients had never
been defined. In clinical practice, it is important to iden-
tify the ‘high risk’ patients because these patients may
require more aggressive intervention. The value 15 is ob-
viously not a good cut-off point of MIS, which ranged
from 0 to 30, since MIS did not show a normal distribu-
tion. According to multiple logistic regression analysis,
value 4 or 5 is a good candidate for the cut-off value when
the iron profile and ALK-P are around average level. This
result is somewhat consistent with the findings of Kalan-
tar-Zadeh et al. [6]. Their study included 378 MHD pa-
tients, the 25th, 50th, and 75th percentiles of MIS were 4,
5.5, and 8, respectively, and the highest MIS quartile was
associated with a 3- to 4-fold increase in death risk. Since
the majority of MHD patients in their study were Cauca-
sian and Afro-American and our study population was
Asian, the similarities of MIS distribution and its impact
on mortality indicate that MIS is a universal predictor of
death in MHD patients despite different ethnicity.
In this study, the MIS was one of the most powerful
predictors of death in MHD patients. Besides MIS and
the 10 components included in the scoring system, many
other factors had been correlated with ESRD mortality.
Secondary hyperparathyroidism and high calcium-phos-
phate product were associated with high risk of death in
large epidemiologic studies [7, 8]. Correcting ESRD-re-
lated anemia improves clinical outcomes [9, 10]. Suffi-
cient hemodialysis dose (Kt/Vurea) has survival benefits
[11], although some recent studies disagreed with it [12].
In our study, patients who died and those who survived
had the same calcium, phosphate, and PTH levels, but the
higher ALK-P in the patients who died indicated either a
more severe renal osteodystrophy or subclinical liver dis-
ease. The dialysis dose was the same in the two groups.
Thus, from the comparison of patients who survived and
patients who died, we found that only MICS and possibly
renal osteodystrophy, but not dialysis dose, were corre-
lated with 1-year mortality. It is interesting to note that
while MIS was different between patients who died and
survived, only albumin, one of the MIS parameters, was
lower in the deceased group. The other individual com-
ponents of MIS, including BMI, co-morbidity, TIBC, and
dialysis vintage, were the same in the two groups. This
result provides us with the opportunity to discuss the im-
portance of albumin, which was the major determinant
of malnutrition and inflammation status in our study
population.
The reason why MIS has such high predictive power
may be found in the correlation between MIS and other
844 Am J Nephrol 2008;28:840–846
variables. Higher MIS was associated with older age and
male sex, both were risk factors for death. The negative
correlations between MIS and serum iron concentration
and hemoglobin can also explain the clinical outcome
because anemia and iron deficiency are associated with
decreased survival [13, 14]. Ferritin is an inflammatory
marker and the higher ferritin level in the patients with
elevated MIS may suggest more severe inflammatory sta-
tus instead of better iron store. In fact, in a retrospective
study conducted by Kalantar-Zadeh et al. [15], both high
serum ferritin and low serum albumin were significant
markers of dialysis mortality. When interpreting the cor-
relation between MIS and variables, the effect of ‘reverse
epidemiology’ must be kept in mind. The so-called re-
verse epidemiology phenomenon means that markers
predicting a low likelihood of cardiovascular events and
an improved survival in the general population, such as
decreased weight and low serum cholesterol, become par-
adoxically strong risk factors for increased cardiovascu-
lar morbidity and death in MHD patients [16, 17]. Our
study also showed this phenomenon because patients
with higher MIS had lower cholesterol, lower creatinine,
and lower uric acid serum concentration. It is interesting
that the MIS had no significant correlation with calcium
and PTH, and even had a trivial negative correlation with
phosphorus. Renal osteodystrophy is related to poor sur-
vival in MHD patients. Since the high MIS had such
strong correlation with high mortality, the calcium-phos-
phorus product and the PTH level were supposed to rise
along with MIS. There are two possible explanations for
the nonsignificant correlation between MIS, calcium and
PTH: one is that renal osteodystrophy is an independent
risk factor of clinical outcome not correlated with MICS;
the other explanation is reverse epidemiology because
malnutrition tends to result in lower calcium, phospho-
rus, and PTH level [8]. A positive correlation between
MIS and ALK-P implies that the patients with increasing
MIS may actually have more severe renal osteodystrophy,
although a subclinical liver disease should also be consid-
ered. Dialysis treatment and technique were once be-
lieved to be the major factors in clinical outcomes; how-
ever, the HEMO Study [12] failed to show an improve-
ment in mortality or hospitalization by increasing
dialysis dose. Our study also showed a similar result: al-
though dialysis Kt/V was positively correlated with MIS,
it failed to reverse the tendency of poor outcome. The sig-
nificant but trivial correlation between MIS and fasting
plasma glucose makes it hard to tell if malnutrition and
inflammation is associated with worse plasma sugar con-
trol or higher insulin resistance.
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 By using the model fitting technique, MIS, ALK-P,
transferrin saturation, ferritin, and TIBC were demon-
strated to be major risk factors of death both in the mul-
tiple logistic regression analysis and in the Cox propor-
tional hazards model. The c statistic of the multiple lo-
gistic regression model was high (0.943), but the major
determinant of mortality was MIS because even after ex-
cluding all the variables except MIS, the c statistic only
drops from 0.943 to 0.815. It is interesting that transferrin
saturation, ferritin, and TIBC can be included in the
model without causing multicollinearity since TIBC is
one of the components of MIS. As previously discussed,
MIS was associated with lower transferrin saturation,
lower TIBC, and higher ferritin. In contrast, in the logis-
tic regression analysis and the Cox proportional hazards
model, higher transferrin saturation, higher TIBC, and
lower ferritin were related to a higher probability of death.
The association between high transferrin saturation and
mortality could be explained by secondary iron overload
due to parenteral iron therapy, which has long been a de-
batable issue [18]. However, recent large scale studies us-
ing time-varying measures demonstrated that the car-
diovascular and all-cause mortality were not higher or
even lower in hemodialysis patients receiving higher par-
enteral iron load [13, 19]. The alternative explanation is
that these patients may actually have had anemia more
resistant to rEPO and thus received more parenteral iron
therapy. This can also explain the association between
low serum ferritin concentration and poorer clinical out-
comes. The goodness of fit of TIBC in the multiple logis-
tic regression model and Cox proportional hazards mod-
el without significant collinearity implies the require-
ment for adjusting TIBC coding in the MIS system. In
fact, in our preliminary analysis, the correlation between
risk of mortality and TIBC was not linear (data not
shown). This issue needs to be addressed in a further
study. In the multivariate analysis, the ALK-P was also
a major determinant of mortality, which is generally a
novel finding. Since we did not check the bone-specific
ALK-P, the origin of the elevated ALK-P level remained
uncertain, but renal osteodystrophy should be consid-
ered first.
The limitations of this study are relatively small popu-
lation and a short follow-up period. However, even in
such a short period of time the patients with higher MIS
revealed a significant mortality risk. From this result, a
more aggressive and immediate intervention in the high-
risk patients is required. A few studies had reported some
modalities which may possibly work, such as intradia-
lytic parenteral nutrition [20], resistance training [21],
anti-inflammatory and antioxidant nutritional supple-
ment [22], and megesterol acetate [23].
In conclusion, our study shows that MHD patients
with an MIS score of more than 4–5 had a significant risk
of 1-year mortality. Additional risk factors associated
with short-term mortality besides MICS were anemia
and renal osteodystrophy. Although Asian MHD patients
have lower mortality rates than their American counter-
parts, MIS remains a useful tool for risk stratification and
to identify those at risk of short-term death. Nutritional
interventions that can improve the MIS may also improve
survival, but this hypothesis needs to be verified in inter-
ventional studies.
Acknowledgements
We thank the staff of the Second Core Lab, Department of
Medical Research, National Taiwan University Hospital for tech-
nical support during the study. This study was supported by Ta-
Tung Kidney Foundation and the Ms Hsiu-Chin Lee Kidney Re-
search Fund, Taipei.

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