Prognostic nutritional index as a risk factor for diabetic kidney disease and mortality in patients with type 2 diabetes mellitus

Abstract

Aims: Microinflammation and malnutrition are common in individuals with type 2 diabetes mellitus (T2DM). We aimed to validate whether prognostic nutritional index (PNI) may increase the risk of diabetic kidney disease (DKD) and all-cause mortality in T2DM patients.

Methods: This retrospective cohort study was based on the National Health and Nutrition Examination Survey (NHANES) and National Death Index (NDI) 2013-2018 database. A total of 14,349 eligible subjects were included, and 2720 of them were with T2DM. PNI was assessed by the 5 × lymphocyte count (10⁹/L) + serum albumin (g/L). The Logistic and Cox regression analyses were conducted to investigate the risk factors of DKD and mortality in T2DM patients.

Results: For 14,349 participants represented 224.7 million noninstitutionalized residents of the United State, the average PNI was 53.72 ± 0.12, and the prevalence of T2DM was 14.89%. T2DM patients had a lower level of PNI and dietary protein intake, a higher risk of mortality, kidney injury, anemia, arterial hypertension and hyperuricemia, compared with non-T2DM subjects. DKD occurred in 35.06% of diabetic participants and a higher PNI was independently related with a lower risk of DKD (OR 0.64, 95% CI 0.459-0.892, p = 0.01) in T2DM after multivariate adjustment. During a median follow-up of 46 person-months (29-66 months), a total of 233 T2DM individuals died from all causes (mortality rate = 8.17%). Subjects with T2DM who had a higher PNI showed a lower risk of all-cause mortality (HR 0.60, 95% CI 0.37-0.97, p = 0.036).

Conclusions: PNI, as a marker of immunonutrition, correlated with the incidence of DKD, and was an independent predictor for all-cause mortality in participants with T2DM. Thus, PNI may conduce to the risk stratification and timely intervention of T2DM patients.

Keywords: All-cause mortality; Diabetic kidney disease; Immunonutrition; Prognostic nutritional index; Type 2 diabetes.

Fig.1

The flow chart of individual inclusion and exclusion in this study

Fig.2

The cutoff of PNI for the prediction of DKD and mortality. a The spline curve of PNI to predict mortality in all the individuals using cox regression analysis. b The prediction of PNI for mortality in DM subjects evaluated with receiver operating characteristic (ROC) curve. c The prediction of PNI for DKD in DM subjects evaluated with receiver operating characteristic (ROC) curve. HR: hazard ratio

Fig.3

The prediction of PNI for DKD and mortality in DM individuals. a Kaplan–Meier curves of survival rate in DM with different PNI levels. b Kaplan–Meier curves of survival rate in DM subjects without hypoalbuminemia in the two PNI groups.c Kaplan–Meier curves of survival rate in DM subjects without anemia in the two PNI groups. d Kaplan–Meier curves of survival rate in DM subjects with anemia in the two PNI groups