DIAGNOSING MALNUTRITION IN DIALYSIS PATIENTS USING THE GLOBAL LEADERSHIP INITIATIVE ON MALNUTRITION (GLIM) CRITERIA

The GLIM criteria refer to a framework for diagnosing malnutrition in adults in a standardized way in diverse health care settings but its role in patients with kidney failure is less well defined. GLIM combines phenotypic measures such as unintentional weight loss, low body mass index (BMI), and low muscle mass, and etiologic factors including inflammation, reduced dietary intake, and disease burden. According to GLIM, individuals on dialysis treatment fulfill the etiological criteria, since kidney failure and the dialysis procedure impose a significant disease burden. However, by assuming that all patients on dialysis meet the etiological criteria, the prevalence of malnutrition might be overestimated. This study aimed to evaluate the performance of GLIM to diagnose malnutrition in patients on dialysis, to examine whether dialysis itself can serve as the sole etiologic criterion, to identify the most prevalent phenotypic criteria, and to evaluate the feasibility of using GLIM in clinical practice.

In this cross-sectional study, adult patients receiving hemodialysis (HD) and peritoneal dialysis (PD) were recruited from six Swedish dialysis centers. Nutritional assessments were conducted by trained renal dietitians; patients on HD were assessed post-dialysis to minimize the confounding effects of fluid overload.  Phenotypic criteria were assessed using unintentional weight loss (>5% within six months or >10% beyond six months), low BMI (<20 kg/m² if <70 years, <22 kg/m² if ≥70 years), and low muscle mass assessed by calf circumference (<32 cm in women, <33 cm in men) or by arm muscle circumference in case of pitting edema. Etiologic criteria were evaluated using two models: (1) reduced dietary intake (assessed by trained renal dietitians) or inflammation (occasional C-reactive protein ≥3.0 mg/L), and (2) dialysis as the sole disease-related burden. Malnutrition was present when at least one phenotypic and one etiologic criterion were present. Ten dietitians who participated in the study completed a survey regarding their perceptions of the feasibility of using GLIM in routine clinical practice.

Ninety-three patients were included (HD n=57, PD n=36; median age 74 (IQR 59–78) years; 60% men; and 43% with diabetes). The most prevalent phenotypic criterion was low muscle mass (49%), followed by low BMI (15%) and unintentional weight loss (5%). For etiologic criteria, inflammation (CRP≥3,0 mg/L) was present in 50%, low energy intake in 22% and low protein intake in 49%. The prevalence of malnutrition based on the model including at least one positive phenotypic criterion and one etiological criterion, malnutrition was present in 41% of patients, while, when dialysis itself was used as the sole etiologic criterion, malnutrition increased to 55%. The main results from the survey among the dietitians are displayed in Figure 1.

Reduced muscle mass was the most prevalent phenotypic GLIM criterion among dialysis patients, highlighting the importance of muscle mass assessment. Despite the chronic inflammatory milieu associated with kidney failure and dialysis, half of the patients displayed normal CRP values. Therefore, dialysis alone may not sufficiently represent the etiologic criteria within the GLIM framework. Moreover, GLIM seemed to be feasible in the dialysis setting as assessed by the dietitians.