Importance of prognostic nutritional index in on-pump coronary artery bypass graft surgery

Abstract

Objectives: A simple and appropriate risk index is still required to show the patient's nutritional status undergoing coronary artery bypass graft (CABG) surgery. This study aimed to evaluate the Prognostic Nutritional Index (PNI) value as a predictor of in-hospital mortality in patients undergoing CABG surgery.

Methods: In this study, we scanned the medical data of 742 patients’ who underwent on-pump CABG surgery retrospectively. Patients' were divided into two groups based on the PNI cut-off value (high-risk group, PNI < 45.85, n = 230; low-risk group, PNI ≥ 45.85, n = 512).

Results: To analyze the factors affecting in-hospital mortality in the postoperative period, univariate and multivariate logistic regression analysis was performed. In univariate analysis, advanced age (Odds ratio (OR): 1.219, 95% confidence interval (CI): 1.194-2.669, p < 0.001), left ventricular ejection fraction (LVEF) (OR: 3.471, 95% CI: 2.854-6.927, p < 0.001), total perfusion time (OR: 0.876, 95% CI: 0.690-0.954, p = 0.012), intra-aortic balloon pump (IABP) use (OR: 2.148, 95% CI: 1.394-2.889, p = 0.002), preoperative high creatinine (OR: 1.229, 95% CI: 1.066-2.118, p = 0.019), low lymphocyte count (OR: 0.879, 95% CI: 0.789-0.945, p = 0.017), low albumin (OR: 1.682, 95% CI: 1.433-2.765, p = 0.003), high C-reactive protein (CRP) (OR: 1.0.790, 95% CI: 0.678-0.927, p = 0.042) and low PNI (OR: 1.290, 95% CI: 1.119-1.654, p < 0.001) were correlated with the postoperative mortality. In multivariate logistic regression analysis, advanced age (OR: 1.145, 95% CI: 1.110-1.938, p = 0.017), LVEF (OR: 2.916, 95% CI: 1.768-4.928, p < 0.001), IABP use (OR: 1.880, 95% CI: 1.350-2.554, p = 0.032) and PNI (OR: 0.932, 95% CI: 0.889-0.978, p = 0.004) were independent predictors of mortality.

Conclusions: In on-pump CABG surgery, postoperative mortality is associated with low preoperative PNI, and can be a useful and suitable parameter for preoperative risk evaluation.

Keywords

• Prognostic nutritional index
• Nutritional status
• CABG surgery
• Cardiopulmonary bypass
• Risk factors

References

1. 1. Yalcin M, Ay D, Turk T, Yavuz S, Ozyazicioglu AF. Impact of previous percutaneous coronary intervention on postoperative outcomes of coronary artery bypass grafting. Eur Res J 2016;2:170-6.
2. 2. Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med. 2005;352:2174-83.
3. 3. Engin M, Aydın C. Investigation of the Effect of HATCH score and coronary artery disease complexity on atrial fibrillation after on-pump coronary artery bypass graft surgery. Med Princ Pract 2021;30:45-51.
4. 4. Weymann A, Ali-Hasan-Al-Saegh S, Popov AF, Sabashnikov A, Mirhosseini SJ, Liu T, et al. Haematological indices as predictors of atrial fibrillation following isolated coronary artery bypass grafting, valvular surgery, or combined procedures: a systematic review with meta-analysis. Kardiol Pol 2018;76:107-18.
5. 5. Abanoz M, Engin M. The effect of the relationship between post-cardiotomy neutrophil/lymphocyte ratio and platelet counts on early major adverse events after isolated coronary artery bypass grafting. Turk Gogus Kalp Dama 2021;29:36-44.
6. 6. Eriş C, Sanrı US, Engin M, Yavuz Ş. Early postoperative results of on-pump coronary endarterectomy: is it still a controversy? Eur Res J 2021;7:248-55.
7. 7. Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF. Prognostic nutritional index in gastrointestinal surgery. Am J Surg 1980;139:160-7.
8. 8. Caputo F, Dadduzio V, Tovoli F, Bertolini G, Cabibbo G, Cerma K, et al. The role of PNI to predict survival in advanced hepatocellular carcinoma treated with Sorafenib. PLoS One 2020;15:e0232449.

9. 9. Yang Y, Gao P, Song Y, Sun J, Chen X, Zhao J, et al. The prognostic nutritional index is a predictive indicator of prognosis and postoperative complications in gastric cancer: a meta-analysis. Eur J Surg Oncol 2016;42:1176-82.
10. 10. Okada S, Shimada J, Kato D, Tsunezuka H, Teramukai S, Inoue M. Clinical significance of prognostic nutritional index after surgical treatment in lung cancer. Ann Thorac Surg 2017;104:296-302.
11. 11. Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai Zasshi 1984;85:1001-5.
12. 12. Engin M, Ozsin KK, Savran M, Guvenc O, Yavuz S, Ozyazicioglu AF. Visceral adiposity index and prognostic nutritional index in predicting atrial fibrillation after on-pump coronary artery bypass operations: a prospective study. Braz J Cardiovasc Surg. 2020 Dec 23. doi: 10.21470/1678-9741-2020-0044.
13. 13. Sanrı U , Özsin K , Duman B , Toktaş F , Yavuz S . The relationship between prognostic nutritional index and carotid artery stenosis in patients with diagnosed carotid artery disease. CBU-SBED. 2020;8:129-34.
14. 14. O'Keefe S, Williams K, Legare JF. Hospital-Acquired Infections After Cardiac Surgery and Current Physician Practices: A Retrospective Cohort Study. J Clin Med Res. 2017;9:10-16.
15. 15. Budczies J, Klauschen F, Sinn BV, Győrffy B, Schmitt WD, Darb-Esfahani S, et al. Cutoff finder: a comprehensive and straight forward Web application enabling rapid biomarker cutoff optimization. PLoS One 2012;7:e51862.
16. 16. Chermesh I, Hajos J, Mashiach T, Bozhko M, Shani L, Nir RR, et al. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol 2014;21:475-83.
17. 17. Sanchez JA, Sanchez LL, Dudrick SJ. Nutritional considerations in adult cardiothoracic surgical patients. Surg Clin North Am 2011;91:857-75.
18. 18. Lomivorotov VV, Efremov SM, Boboshko VA, Nikolaev DA, Vedernikov PE, Lomivorotov VN, et al. Evaluation of nutritional screening tools for patients scheduled for cardiac surgery. Nutrition 2013;29:436-42.
19. 19. Tepaske R, Velthuis H, Oudemans-van Straaten HM, Heisterkamp SH, van Deventer SJ, Ince C, et al. Effect of preoperative oral immune-enhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomized placebo-controlled trial. Lancet 2001;358:696-701.
20. 20. vanVenrooij LM, vanLeeuwen PA, Hopmans W, Borgmeijer-Hoelen MM, de Vos R, De Mol BA. Accuracy of quick and easy undernutrition screening tool short Nutritional Assessment Questionnaire, Malnutrition Universal Screening Tool, and modified Malnutrition Universal Screening Tool--in patients undergoing cardiac surgery. J Am Diet Assoc 2011;111:1924-30.
21. 21. van Venrooij LM, de Vos R, Borgmeijer-Hoelen MM, Haaring C, de Mol BA. Preoperative unintended weight loss and low body mass index in relation to complications and length of stay after cardiac surgery. Am J Clin Nutr 2008;87:1656-61.
22. 22. Stoppe C, Goetzenich A, Whitman G, Ohkuma R, Brown T, Hatzakorzian R, et al. Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery. Crit Care 2017;21:131.
23. 23. Bhamidipati CM, LaPar DJ, Mehta GS, Kern JA, Upchurch GR Jr, Kron IL, et al. Albumin is a better predictor of outcomes than body mass index following coronary artery bypass grafting. Surgery 2011;150:626-34.
24. 24. Thourani VH, Keeling WB, Kilgo PD, Puskas JD, Lattouf OM, Chen EP, et al. The impact of body mass index on morbidity and short and long term mortality in cardiac valvular surgery. J Thorac Cardiovasc Surg 2011;142:1052-61.
25. 25. Bian C, Wu Y, Shi Y, Xu G, Wang J, Xiang M, et al. Predictive value of the relative lymphocyte count in coronary heart disease. Heart Vessels. 2010;25:469-73.
26. 26. Korkmaz L, Kul S, Korkmaz AA, Akyüz AR, Ağaç MT, Erkan H, et al. Increased leucocyte count could predict coronary artery calcification in patients free of clinically apparent cardiovascular disease. Turk Kardiyol Dern Ars 2012;40:223-8.
27. 27. Sun XP, Li J, Zhu WW, Li DB, Chen H, Li HW, et al. Platelet to lymphocyte ratio predicts contrast-induced nephropathy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Angiology 2018;69:71-8.
28. 28. Bagger JP, Zindrou D, Taylor KM. Leukocyte count: a risk factor for coronary artery bypass graft mortality. Am J Med.2003;115:660-3.
29. 29. Wiedermann CJ, Wiedermann W, Joannidis M. Hypoalbuminemia and acute kidney injury: a meta-analysis of observational clinical studies. Intensive Care Med. 2010;36:1657-65.
30. 30. de la Cruz KI, Bakaeen FG, Wang XL, Huh J, LeMaire SA, Coselli JS, et al. Hypoalbuminemia and long-term survival after coronary artery bypass: a propensity score analysis. Ann Thorac Surg 2011;91:671-5.
31. 31. Nozoe T, Kimura Y, Ishida M, Saeki H, Korenaga D, Sugimachi K. Correlation of pre-operative nutritional condition with post-operative complications in surgical treatment for oesophageal carcinoma. Eur J Surg Oncol 2002;28:396-400.
32. 32. Keskin M, Hayıroğlu MI, Keskin T, Kaya A, Tatlısu MA, Altay S, et al. A novel and useful predictive indicator of prognosis in ST-segment elevation myocardial infarction, the prognostic nutritional index. Nutr Metab Cardiovasc Dis 2017;27:438-46.
33. 33. Lee SI, Ko KP, Choi CH, Park CH, Park KY, Son KH. Does the prognostic nutritional index have a predictive role in the outcomes of adult cardiac surgery? J Thorac Cardiovasc Surg 2020;160:145-53.e3.
34. 34. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, et al. American Heart Association Council on Clinical Cardiology; Society of Geriatric Cardiology. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for health care professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115:2549-69.