Impact of malnutrition and frailty on mortality and major amputation in patients with CLTI

Abstract

Objectives To understand the prevalence of malnutrition and its association with chronic limb‐threatening ischemia (CLTI) outcomes; to clarify the differential impact of revascularization methods on outcomes; to assess the ability of the CLTI Frailty Risk Score (CLTI‐FRS) to predict adverse events in patients hospitalized with CLTI. Background Despite advances in the management of CLTI, a majority still undergo major amputation, and a minority heal within 6 months. There is a lack of validated assessment tools for the identification and management of frailty and malnutrition in these patients. Methods Using the National Inpatient Sample from January 2012 to September 2015, we identified all patients with CLTI using International Classification of Diseases Ninth Edition Clinical Modification codes. The cohort was divided into three groups according to nutritional status. Multivariable regression analysis was used to analyze the interaction between malnutrition and outcomes of interest. Results Of 1,414,080 CLTI‐related hospitalizations, 163,835 (11.6%) were malnourished, 332,855 (23.5%) patients were frail, 917,390 (64.9%) were well‐nourished. In‐hospital mortality, major amputation, the average length of stay, and hospital costs were highest among malnourished or frail patients and lowest in well‐nourished patients (p < 0.001). Malnourished and frail patients were observed to have lower rates of mortality with endovascular revascularization as compared to surgical (adjusted odds ratios: 0.675 [0.533–0.854; p = 0.001]). Conclusion Many patients with CLTI are malnourished or frail, and this is associated with mortality and amputation. Both malnourished and frail patients were observed to have a mortality benefit with a less invasive approach to revascularization. Better assessment of nutritional and frailty status of CLTI patients may guide therapy and help prevent amputation and death.

Frailty score and outcomes of patients undergoing vascular surgery and amputation: A systematic review and meta-analysis

“…The included studies were conducted in Australia ( 29 , 50 ), the United States ( 31 , 32 , 35 – 39 , 41 – 43 , 46 , 48 , 49 , 51 ), the United Kingdom ( 30 , 33 , 45 , 47 ), China ( 44 ), Germany ( 40 ), Singapore ( 34 ), and the Netherlands ( 52 ). Among the 24 included studies, five ( 33 , 42 , 43 , 48 , 50 ) investigated in-hospital mortality and provided unbiased data; 12 ( 29 – 31 , 34 , 36 , 38 , 39 , 44 , 49 – 51 , 53 ) investigated postdischarge mortality; nine ( 29 , 30 , 33 , 34 , 36 , 38 , 46 , 48 , 50 ) investigated rehospitalization number; and five ( 32 , 38 , 43 , 46 , 50 ) investigated discharge locations. For additional outcomes, each outcome has multiple studies contributing to data ranging from five to 18 studies.…”

“…Two studies utilized the Rockwood Frailty Index, which defines individuals scoring higher than 0.25 as frail, and used the CFS as a separate assessment ( 45 , 50 ). The remaining nine studies all utilized different frailty score ( 29 , 39 , 40 , 42 , 44 , 47 , 48 , 51 , 52 ). Aitken et al ( 29 ) utilized the HFRS to identify individuals scoring greater than 5 as frail.…”

“…Iliadis et al ( 40 ) utilized the Fried Criteria, which identifies individuals scoring 3 or higher as frail. Karim et al ( 42 ) utilized the Chronic limb-threatening ischemia (CLTI) Frailty Risk Score, which identifies individuals scoring higher than 0.4 as frail. Li et al ( 44 ) utilized the FRAIL scale, which identifies individuals scoring 3 and higher as frail.…”

“…Five studies ( 33 , 42 , 43 , 48 , 50 ) reported in-hospital mortality for both the frail and non-frail groups, with two ( 42 , 43 ) of those studies reporting a significant difference in in-hospital mortality ( p < 0.001). Overall, there was a significant difference in in-hospital mortality between the frail and non-frail groups, with a risk ratio (RR) of 1.832 and a significant I 2 result (CI: 1.724, 1.947, p < 0.001, I 2 = 60.943, p I 2 = 0.025).…”

“…The included studies were conducted in Australia (29,50), the United States (31, 32, 35-39, 41-43, 46, 48, 49, 51), the United Kingdom (30,33,45,47), China (44), Germany (40), Singapore (34), and the Netherlands (52). Among the 24 included studies, five (33,42,43,48,50)…”