Clinical Nutrition xxx (xxxx) xxx

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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Original article

Controlling Nutritional Status (CONUT) score as immune-nutritional

predictor of outcomes in patients undergoing peritoneal dialysis
Hua Zhou a, 1, Wenying Chao a, 1, Li Cui b, 1, Min Li a, Yun Zou a, Min Yang a, *
a
Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China
b
Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, 213003, China

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: The Controlling Nutritional Status (CONUT) score was designed to assess the
Received 16 June 2019 immune-nutritional status in patients. The aim of this study was to investigate the prognostic value of
Accepted 7 November 2019 the CONUT score at the commencement of peritoneal dialysis (PD) for all-cause mortality, cardiovascular
disease (CVD), and technique failure.
Keywords: Methods: This is a STROBE-compliant, retrospective, observational, single center study. A total of 252
Cardiovascular disease
patients with end stage renal disease initially undergoing PD were enrolled in the study. Baseline data
Immunity
were collected from The Third Affiliated Hospital of Soochow University Peritoneal Dialysis database. The
Malnutrition
Mortality
primary outcome during follow-up was all-cause mortality. The secondary outcomes were CVD and
Peritoneal dialysis technique failure. Univariate and multivariate Cox regression analyses were performed to estimate the
association between confounding factors and outcomes. The area under the curve represented the test
discriminative power of CONUT score and relevant clinical parameters. The KaplaneMeier curve was
used to compare the outcomes of the patients according to the cut-off CONUT score.
Results: During a median follow-up period of 1.9 years, 35 patients (13.9%) died, 38 (15.1%) experienced
CVD events, 58 (23.0%) experienced technique failure. The high CONUT group (CONUT score > 3) had
significantly higher all-cause mortality (p ¼ 0.02), CVD prevalence (p < 0.01), and technique failure rates
(p < 0.01) than the low CONUT group (CONUT score  3). The CONUT score was an independent predictor
of all-cause mortality (hazard ratio [HR]: 1.565; 95% CI: 1.305e1.876; p < 0.001), CVD (HR: 1.346; 95% CI:
1.136e1.594; p ¼ 0.001), and technique failure (HR: 1.144; 95% CI: 1.006e1.302; p ¼ 0.041).
Conclusion: The CONUT score is a straightforward and inexpensive indicator to evaluate the immune-
nutritional status; it could be a reliable prognostic marker of all-cause mortality, CVD, and technique
failure risk in patients undergoing PD.
© 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction patients at greatest risk is critically important because this could

Although overall and technique survival among patients un-
dergoing peritoneal dialysis (PD) have significantly improved dur-
ing the recent decades, reducing PD mortality remains vital and is
important in facilitating the expansion of PD. Cardiovascular dis-
ease (CVD) is the leading cause of mortality among patients un-
dergoing PD [1], and technique failure is a limitation of PD [2].
Death, CVD, hemodialysis (HD) transfer and kidney transplantation,
are all common outcomes for PD patients. The ability to identify
* Corresponding author.
E-mail address: yangmin1516@czfph.com (M. Yang).
1 count, was originally designed to assess perioperative nutritional
Equal contributors.
facilitate the development of targeted preventive strategies. Pre-
dialysis clinical factors associated with a higher risk of mortality,
CVD, and technique failure may help nephrologists to identify pa-
tients who would benefit from initiating PD treatment. In several
cohort studies, predictors of outcome in patients treated with PD
have been investigated [3e6]. The survival of PD patients is asso-
ciated with various clinical factors, such as demographics, comor-
bidities, and nutritional markers [7e10].
Malnutrition is multifactorial in patients undergoing PD and can
be defined using different tools [11,12]. The best marker to identify
patients at a high risk of malnutrition is still to be determined. The
Controlling Nutritional Status (CONUT) score, a variable based on
serum albumin, total cholesterol and total peripheral lymphocyte

https://doi.org/10.1016/j.clnu.2019.11.018
0261-5614/© 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Please cite this article as: Zhou H et al., Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients
undergoing peritoneal dialysis, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.11.018
2 H. Zhou et al. / Clinical Nutrition xxx (xxxx) xxx
and immunological risk in patients undergoing gastrointestinal
surgery [13]. Recently, the prognostic value of the CONUT score has
been validated in a variety of malignant tumors [14,15]. Serum al-
bumin concentration is a major indicator of nutritional status.
Hypoalbuminemia has been reported to be associated with poor
outcome in patients undergoing PD [16]. The total cholesterol level
has also been revealed to correlate with mortality in patients un-
dergoing PD [17]. In addition, lymphocytes play a key role in cell-
mediated immunity and are associated with prevalent atheroscle-
rotic cardiovascular disease in end-stage renal disease (ESRD) [18].
The combination of these three components in the CONUT score
may better reflect the balance of immune-nutritional status and
enhance the ability to accurately predict outcomes than single-
factor markers. However, the prognostic role of the CONUT score
has not been investigated in patients undergoing PD.
We hypothesized that the CONUT score is associated with
prognosis in patients undergoing PD. Therefore, we assessed the
prognostic value of the CONUT score at the commencement of PD
for all-cause mortality, CVD, and technique failure.
2. Materials and methods
2.1. Study design
The present investigation was a STROBE-compliant, retrospec-
tive, observational, single center study. All adult (18 years) pa-
tients with ESRD initially undergoing PD at the Department of
Nephrology of the Third Affiliated Hospital of Soochow University
(Changzhou, China) from August 2010 to August 2018 were eligible
for inclusion in the study. Patients with malignancies (e.g. breast,
lung, gastrointestinal, hematologic cancers) or missing data were
excluded. Finally, we included a total of 252 PD patients in the
study.
2.2. Human subject protection
The study was approved by the Ethics Committee of the Third
Affiliated Hospital of Soochow University, China (registration
number: #27/2013), and written informed consent was obtained
from all participants.
2.3. Data collection
The initiation of PD therapy was defined as the date of first PD
treatment. Data on baseline characteristics, comorbidities, and
laboratory test results were collected from The Third Affiliated
Hospital of Soochow University Peritoneal Dialysis database. Lab-
oratory variables were obtained from clinic records a week before
the first PD treatment, included lymphocyte count, hemoglobin,
serum creatinine, blood urea nitrogen (BUN), uric acid, intact
parathyroid hormone (iPTH), calcium, phosphate, albumin, total
cholesterol, low-density lipoprotein (LDL) cholesterol, high-density
lipoprotein (HDL) cholesterol, triglycerides, C-reactive protein
(CRP), albumin, and prealbumin levels. The CONUT score was
calculated based on 3 laboratory variables: serum albumin con-
centration, total cholesterol concentration, and total peripheral
lymphocyte count [19] (Table S1).
2.4. Clinical outcomes
The primary outcome was all-cause mortality after PD
commencement. The secondary outcomes were CVD and technique
failure during follow-up. CVD was defined as the incidence of cor-
onary heart disease, heart failure, stroke, or peripheral arterial
disease. PD technique failure was defined as a switch to HD for any
Please cite this article as: Zhou H et al., Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients
undergoing peritoneal dialysis, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.11.018
cause, including inadequate dialysis, ultrafiltration failure, re-
fractory peritonitis, fungal peritonitis, exit-site and/or tunnel
infection, catheter malfunction, mechanical problems, and other
reasons, such as patient preference. The end of PD was defined as
death, a switch to HD, kidney transplantation, and recovered renal
function. Patient status was recorded at the end of the study
(December 31, 2018).
2.5. Statistical analysis
Analyses were conducted using SPSS (version 19.0). All data
were first checked for normality of distribution using the
KolmogoroveSmirnov test. Normally distributed data are pre-
sented as the mean ± standard deviation. Non-normally distributed
data are represented as the median (inter-quartile range).
Spearman rank correlation analysis was performed to analyze the
correlation between CONUT score and selected characteristics or
parameters. The independent relationships between CONUT score
and all-cause mortality, CVD, and technique failure in the study
were investigated by univariate and multivariate Cox regression
analyses (confounding factors included all selected characteristics
and parameters). The KaplaneMeier method and the log-rank test
were used to estimate the survival rate of patients. The optimal cut-
off value, based on receiver operating characteristic (ROC) analysis
results, was 3. The area under the curve (AUC) analysis was calcu-
lated and compared for models containing only CONUT score and
joint models containing most relevant clinical parameters in pre-
dicting outcomes. A two-sided p value of <0.05 was considered to
indicate statistical significance.
3. Results
The mean age of 252 enrolled PD patients was 48.3 ± 14.9 years,
and 33 (13.1%) were diabetic. Most patients were men (147 cases,
58.3%), 42 (16.7%) were smokers, and 34 (13.5%) had a history of
CVD. The median CONUT score was 5 (3, 6). The baseline de-
mographic and clinical characteristics of the study population are
listed in Table 1. During the median follow-up period of 1.9 years, 35
patients (13.9%) died, 38 (15.1%) experienced CVD events, 58
(23.0%) experienced technique failure, 26 (10.3%) underwent kid-
ney transplantation, 1 (0.4%) had kidney function recovery, and 3
(1.2%) were lost to follow-up.
According to the cut-off value of 3, the enrolled patients were
divided into two groups: low CONUT group (CONUT score  3; 66
patients, 26.2%) and high CONUT group (CONUT score > 3; 186
patients, 73.8%). Among 35 all-cause deaths, 2 (5.7%) were occurred
in the low CONUT group, and 33 (94.3%) were occurred in the high
CONUT group; among 38 CVD events, 2 (5.3%) were occurred in the
low CONUT group, and 36 (94.7%) were occurred in the high CONUT
group; among 58 technique failure, 5 (8.6%) were occurred in the
low CONUT group, and 53 (91.4%) were occurred in the high CONUT
group. The KaplaneMeier curve comparing the outcomes of the
patients according to the cut-off CONUT score is shown in Fig. 1aec.
The high CONUT group had significantly higher all-cause mortality
(p ¼ 0.02), CVD prevalence (p < 0.01), and technique failure rates
(p < 0.01) than the low CONUT group.
The correlations between CONUT score and selected character-
istics or laboratory variables are shown in Table 2. CONUT scores
were significantly associated with gender, systolic blood pressure
(BP), hemoglobin, BUN, total cholesterol, LDL cholesterol, triglyc-
eride, albumin, lymphocyte count, ejection fraction (EF), and left
ventricular mass index (LVMI) (p < 0.05).
The results of our multivariate Cox analysis showed that the
CONUT score was an independent predictor of all-cause mortality
(hazard ratio [HR]: 1.565; 95% CI: 1.305e1.876; p < 0.001), along
 H. Zhou et al. / Clinical Nutrition xxx (xxxx) xxx 3

Table 1 Table 2
Demographic and baseline characteristics of peritoneal dialysis patients Spearman correlation between CONUT score and variables.
(n ¼ 252).
Variables Correlation p value
Characteristics Values
coefficient
Age (years) 48.3 ± 14.9
Age 0.118 0.061
Male gender (%) 147 (58.3%)
Gender 0.147 0.019*
BMI (kg/m2) 22.5 ± 3.0
BMI 0.053 0.400
Diabetes (%) 33 (13.1%)
Diabetes 0.113 0.073
Current smoking (%) 42 (16.7%)
Systolic BP 0.198 0.002**
ESRD cause
Diastolic BP 0.015 0.818
Glomerulonephritis (%) 135 (53.6%)
Hemoglobin 0.217 0.001**
Hypertension (%) 28 (11.1%)
RRF 0.122 0.053
Diabetes mellitus (%) 24 (9.5%)
Creatinine 0.120 0.057
Other/unknown (%) 65 (25.8%)
BUN 0.137 0.030*
CVD history (%) 34 (13.5%)
Uric acid 0.044 0.487
Systolic BP (mmHg) 155.5 ± 21.5
Corrected calcium 0.067 0.289
Diastolic BP (mmHg)a 90.0 (80.0, 99.8)
Phosphorus 0.028 0.663
Hemoglobin (g/dL) 8.3 ± 1.8
iPTH 0.016 0.795
RRF (ml/min/1.73 m2)a 5.2 (4.1, 6.6)
Total cholesterol 0.276 <0.001***
Creatinine (mg/dL)a 9.6 (7.7, 12.3)
LDL cholesterol 0.252 <0.001***
BUN (mg/dL) 89.3 ± 28.3
HDL cholesterol 0.082 0.196
Uric acid (mg/dL) 8.7 ± 2.2
Triglycerides 0.146 0.020*
Corrected calcium (mg/dL)a 9.3 (8.7, 9.7)
CRP 0.081 0.201
Phosphate (mg/dL)a 6.2 (5.1, 7.7)
Albumin 0.715 <0.001***
iPTH (pg/mL)a 237.4 (100.4, 399.3)
Prealbumin 0.110 0.080
Total cholesterol (mg/dL)a 160.1 (133.2, 184.8)
Lymphocyte count 0.455 <0.001***
LDL cholesterol (mg/dL)a 78.5 (62.3, 92.2)
EF 0.202 0.001**
HDL cholesterol (mg/dL)a 36.0 (29.5, 44.5)
LVMI 0.262 <0.001***
Triglycerides (mg/dL)a 146.6 (99.2, 204.2)
CRP (mg/dL)a 5.4 (4.0, 9.9) * ¼ p < 0.05; ** ¼ p < 0.01; *** ¼ p < 0.001.
Albumin (g/dL) 3.3 ± 0.5
Prealbumin (mg/dL) 25.9 ± 6.2
CONUTa 5 (3, 6)
with age (p < 0.001), body mass index (BMI) (p ¼ 0.005), diabetes
EF (%)a 61.0 (58.0, 63.8)
LVMI (g/m2.7)a 55.4 (46.1, 68.7)
(p < 0.001), and systolic BP (p ¼ 0.022) (Table 3). Furthermore, after
adjustment for confounding factors, age (p < 0.001), diabetes
Characteristics are independent of each other.
a (p ¼ 0.019), LVMI (p ¼ 0.004), and CONUT score (HR: 1.346; 95% CI:
Median with inter-quartile range.
1.136e1.594; p ¼ 0.001) were significantly and independently
associated with new-onset CVD (Table 4).

Fig. 1. KaplaneMeier curves for outcomes in patients undergoing PD. a. all-cause mortality; b. cardiovascular disease; c. technique failure.

Please cite this article as: Zhou H et al., Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients
undergoing peritoneal dialysis, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.11.018
4 H. Zhou et al. / Clinical Nutrition xxx (xxxx) xxx

Table 3
Univariate and multivariate Cox analysis of patient survival in peritoneal dialysis patients (n ¼ 252).

Characteristics Univariate Multivariate

HR (95% CI) p Value HR (95% CI) p Value

Age 1.095 (1.065, 1.127) <0.001*** 1.129 (1.087, 1.172) <0.001***

Gender (male) 1.486 (0.749, 2.950) 0.257 e 0.424
BMI 0.990 (0.874, 1.121) 0.873 0.784 (0.662, 0.928) 0.005**
Diabetes (yes) 4.546 (2.184, 9.464) <0.001*** 5.580 (2.294, 13.569) <0.001***
Current smoking (yes) 0.782 (0.274, 2.235) 0.647 e 0.391
CVD history (yes) 3.072 (1.457, 6.475) 0.003** e 0.296
Systolic BP 0.989 (0.973, 1.005) 0.167 0.976 (0.956, 0.997) 0.022*
Diastolic BP 0.972 (0.949, 0.996) 0.021* e 0.081
Hemoglobin 1.225 (1.015, 1.479) 0.034* e 0.975
RRF 1.084 (0.931, 1.262) 0.300 e 0.399
Phosphate 0.764 (0.622, 0.937) 0.010* e 0.962
iPTH 0.999 (0.998, 1.001) 0.400 e 0.407
CRP 1.021 (1.001, 1.040) 0.036* e 0.590
Prealbumin 0.896 (0.856, 0.938) <0.001*** e 0.719
EF 0.984 (0.932, 1.038) 0.544 e 0.294
LVMI 1.003 (0.985, 1.021) 0.753 e 0.299
CONUT 1.346 (1.149, 1.576) <0.001*** 1.565 (1.305, 1.876) <0.001***

* ¼ p < 0.05; ** ¼ p < 0.01; *** ¼ p < 0.001.

Table 4
Univariate and multivariate Cox analysis of patient with cardiovascular disease undergoing peritoneal dialysis (n ¼ 252).

Characteristics Univariate Multivariate

HR (95% CI) p Value HR (95% CI) p Value

Age 1.057 (1.033, 1.081) <0.001*** 1.065 (1.038, 1.093) <0.001***

Gender (male) 1.079 (0.566, 2.057) 0.816 e 0.404
BMI 0.971 (0.864, 1.091) 0.624 e 0.060
Diabetes (yes) 3.953 (1.980, 7.893) <0.001*** 2.374 (1.149, 4.901) 0.019*
Current smoking (yes) 1.266 (0.556, 2.886) 0.574 e 0.627
CVD history (yes) 1.453 (0.606, 3.484) 0.403 e 0.468
Systolic BP 1.016 (1.001, 1.031) 0.040* e 0.111
Diastolic BP 0.993 (0.973, 1.014) 0.516 e 0.113
Hemoglobin 1.181 (0.989, 1.411) 0.067 e 0.055
RRF 1.054 (0.909, 1.222) 0.486 e 0.508
Phosphate 0.797 (0.663, 0.960) 0.017* e 0.128
iPTH 1.000 (0.998, 1.001) 0.782 e 0.633
CRP 1.022 (1.005, 1.040) 0.010* e 0.230
Prealbumin 0.924 (0.882, 0.967) 0.001** e 0.347
EF 0.971 (0.926, 1.019) 0.234 e 0.407
LVMI 1.022 (1.007, 1.037) 0.004** 1.022 (1.007, 1.037) 0.004**
CONUT 1.322 (1.142, 1.530) <0.001*** 1.346 (1.136, 1.594) 0.001**

* ¼ p < 0.05; ** ¼ p < 0.01; *** ¼ p < 0.001.

Fifty-eight patients (23.0%) experienced technique failure dur- 4. Discussion

ing follow-up. The causes of technique failure were inadequate
dialysis (14 cases, 24.1%), ultrafiltration failure (19 cases, 32.8%),
refractory peritonitis (8 cases, 13.8%), fungal peritonitis (6 cases,
10.4%), catheter malfunction (2 cases, 3.5%), mechanical problems
(6 cases, 10.3%), and other causes (3 cases, 5.2%). The crude and
adjusted HRs for technique failure are presented in Table 5. In the
multi-adjusted model, BMI (p < 0.001), diabetes (p ¼ 0.047), sys-
tolic BP (p ¼ 0.023), and CONUT score (HR: 1.144; 95% CI:
1.006e1.302; p ¼ 0.041) were significantly associated with tech-
nique failure.
The AUC of the joint probability of CONUT score, age, and dia-
betes in predicting all-cause mortality was 0.902 (95% CI:
0.859e0.936), with a sensitivity of 82.86% and a specificity of
86.18% (Fig. 2, Table S2). The AUC of the joint probability of CONUT
score, age, and diabetes in predicting CVD was 0.802 (95% CI:
0.747e0.849), with a sensitivity of 65.79% and a specificity of
84.58% (Fig. 3, Table S3). The AUC of the joint probability of CONUT
score and BMI in predicting technique failure was 0.687 (95% CI:
0.625e0.743), with a sensitivity of 56.90% and a specificity of
72.68% (Fig. 4, Table S4).
To the best of our knowledge, the relationship between the
CONUT score (a well-known immune-nutritional index) and out-
comes has not been investigated previously in patients undergoing
PD. Previous studies have investigated the three parameters with
PD outcomes independently [16,17,20]. Our results indicated that
the CONUT score could be a clinical predictor for all-cause mor-
tality, CVD, and technique failure in patients undergoing PD.
In the present study, a high CONUT score at PD commencement
was associated with a higher risk of mortality. Approximately 74%
patients had high CONUT scores (CONUT score > 3), and patients
with high CONUT score had a risk ratio of 1.57 for mortality
compared with the low CONUT score group. A previous study
showed that approximately 42% of PD patients were malnourished
determined by subjective global assessment (SGA) at dialysis
commencement and survival rates were significantly lower in
malnourished patients [21]. The 2-year patient overall survival rate
was 90.9% and 96.4% for subgroups with malnutrition and normal
nutrition, respectively [21]. Similarly, the 2-year patient overall
survival rate in our study was 92.2% and 96.0% for subgroups with

Please cite this article as: Zhou H et al., Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients
undergoing peritoneal dialysis, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.11.018
 H. Zhou et al. / Clinical Nutrition xxx (xxxx) xxx 5

Table 5
Univariate and multivariate Cox analysis of technique failure in peritoneal dialysis patients (n ¼ 252).

Characteristics Univariate Multivariate

HR (95% CI) p Value HR (95% CI) p Value

Age 1.000 (0.982, 1.017) 0.957 e 0.449

Gender (male) 0.439 (0.243, 0.793) 0.006** e 0.157
BMI 1.183 (1.082, 1.293) <0.001*** 1.181 (1.076, 1.297) <0.001***
Diabetes (yes) 2.532 (1.355, 4.730) 0.004** 1.909 (1.008, 3.613) 0.047*
Current smoking (yes) 1.537 (0.827, 2.855) 0.174 e 0.708
CVD history (yes) 1.542 (0.779, 3.053) 0.214 e 0.952
Systolic BP 1.016 (1.004, 1.028) 0.010* 1.014 (1.002, 1.025) 0.023*
Diastolic BP 1.009 (0.996, 1.022) 0.194 e 0.517
Hemoglobin 1.039 (0.901, 1.199) 0.596 e 0.525
RRF 0.924 (0.809, 1.055) 0.242 e 0.637
Phosphate 0.975 (0.853, 1.114) 0.707 e 0.724
iPTH 1.000 (0.999, 1.001) 0.666 e 0.695
CRP 0.998 (0.975, 1.021) 0.860 e 0.994
Prealbumin 1.015 (0.968, 1.063) 0.541 e 0.451
EF 0.968 (0.932, 1.006) 0.095 e 0.613
LVMI 1.014 (1.001, 1.027) 0.033* e 0.532
CONUT 1.134 (1.003, 1.281) 0.045* 1.144 (1.006, 1.302) 0.041*

* ¼ p < 0.05; ** ¼ p < 0.01; *** ¼ p < 0.001.

Fig. 2. ROC curves of the joint probability of CONUT, age and diabetes in predicting Fig. 3. ROC curves of the joint probability of CONUT, age and diabetes in predicting
mortality. cardiovascular disease.

high CONUT score and low CONUT score, respectively. Although our
patients had higher prevalence of malnutrition based on the
CONUT score, the mean age and the prevalence of co-morbid dis-
ease such as diabetes or CVD history were lower than Chung et al.‘s
study [21]. Serum prealbumin is a more sensitive marker of nutri-
tional status than albumin, and it is a predictor of mortality for HD
and PD patients [22,23]. Although serum prealbumin was a sig-
nificant mortality predictor in patients undergoing PD as a
continuous variable in the univariate Cox model in our study, the
addition of other confounding factors in the multivariate analysis
adjusted the mortality risk of prealbumin. Thus, the CONUT score,
an immune-nutritional index, may be a better predictor of mor-
tality than prealbumin in patients undergoing PD. Routine pre-
dialysis assessment of CONUT may help to improve survival
outcome in patients undergoing PD. However, a further compara-
tive study is needed to make this conclusion.
Our observation that a high CONUT score was related to high
prevalence of CVD during the course of PD. CVD is the most common
cause of deaths in dialysis patients [24,25], and malnutrition is an
established non-traditional cardiovascular risk factor in HD patients
[26]. Precise evaluation of a patient's nutrition status may provide a
valid assessment of the risk for CVD [27]. The mechanism regarding
the association between the CONUT score and CVD has not been fully
investigated. However, each component of the CONUT score has been
reported to be related to CVD in dialysis patients. First, dyslipidemia
is a well-established traditional risk factor for CVD in the general
population, but this relationship is much more complex and even
paradoxical in patients undergoing PD [28]. In our study, a lower total
cholesterol level means a higher CONUT score, and a higher CONUT
score is related to a higher prevalence in CVD. This result supports
the concept of “reverse epidemiology” of dyslipidemia in dialysis
patients [29,30]. Secondly, a lower count of lymphocyte indicates a
higher CONUT score. Lymphocyte count is a novel inflammatory
marker in renal and cardiac disorders. Chronic inflammation is found
to be correlated with coronary and thoracic periaortic calcification in
ESRD patients [31]. The neutrophil-to-lymphocyte ratio (NLR) can

Please cite this article as: Zhou H et al., Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients
undergoing peritoneal dialysis, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.11.018
6 H. Zhou et al. / Clinical Nutrition xxx (xxxx) xxx

Changes in the patient therapy may have occurred and influence

the results of the study. Finally, we did not have information on the
postdialysis and time varying CONUT scores.

6. Conclusion

We conclude that the CONUT score could be useful in clinical

practice as a straightforward, inexpensive biomarker for predicting
outcomes in patients undergoing PD. Patients with high CONUT
scores should receive more effective adjuvant therapy and shorter
follow-up duration. Finally, we suggest that pretreatment nutri-
tional and immunological support based on the CONUT score
should be evaluated in prospective, randomized controlled studies.

Funding

This study was financially supported by Changzhou Sci & Tech

Program (Grant No. CJ20180027).

Availability of data and material

The datasets used and analyzed during the current study are
Fig. 4. ROC curves of the joint probability of CONUT and BMI in predicting technique available from the corresponding author on reasonable request.
failure.
Ethics approval and consent to participate
predict CVD and cardiovascular mortality in ESRD patients [32,33]. In
one study, high NLR is independently associated with arterial stiff- The study was approved by the Ethics Committee of the Third
ness and predicted cardiovascular mortality in patients undergoing Affiliated Hospital of Soochow University, China (registration
PD [34], suggesting that a low lymphocyte count may contribute to number: #27/2013), and written informed consent was obtained
CVD. Finally, serum albumin levels, which are twice the weight of from all participants.
other indicators in CONUT score, can predict CVD mortality in pa-
tients at the initiation of HD therapy [35]. Thus, the CONUT score, an Consent for publication
efficient tool to evaluate protein metabolism, lipid metabolism,
inflammation and immune status, is a reliable biomarker for iden- Not required.
tifying patients with high risk of CVD, which may help clinicians to
improve the clinical management. Moreover, our data suggest that Authors' contributions
the combination of CONUT score, diabetes, and age may provide a
novel tool to facilitate the prediction of mortality and CVD in the MY contributed to the conception and design of the study. WYC
future. and HZ recruited the subjects. LC and HZ analyzed the data and
In our study, the CONUT score was also significantly associated wrote the initial draft of the paper. ML participated in its design and
with technique failure, and CONUT score combined with BMI was a supervised the study. YZ as a professional statistician checked the
better predictor of technique failure according to the AUC analysis. statistical methods and results. All authors contributed to the
One of the major reasons for the low prevalence of PD is the high writing, reviewing, and revising of the manuscript.
withdrawal rate from PD programs because of technique failure
[36]. Inadequate dialysis, ultrafiltration failure and peritonitis were Conflict of interest
the three leading causes of technique failure in our center. Tech-
nique failure shortens the time patients undergo PD and leads to The authors declare that they have no competing interests.
transfer to HD unplanned. In previous studies, the risk of peritonitis
is found to increase with poor nutrition [37,38]. It has been reported Abbreviations
that the initial serum albumin level is a significant predictor of
peritonitis [39], and a higher BMI is associated with a higher risk of AUC area under the curve
technique failure [40]. CONUT score or combined with BMI may BMI body mass index
help to stratify the risk for PD technique failure, and make it BP blood pressure
imperative to implement interventions and strategies that safely BUN blood urea nitrogen
prolong the duration of PD therapy among high CONUT score and CONUT controlling nutritional status
high BMI patients. CRP C-reactive protein
CVD cardiovascular disease
5. Limitations EF ejection fraction
ESRD end stage renal disease
There are several limitations to this study. First, our study did HD hemodialysis
not include information on socioeconomic status and educational HDL high-density lipoprotein
background. Second, it was an observational, retrospective, single- HR hazard ratio
center study with a relatively small sample size. The data were iPTH intact parathyroid hormone
obtained from a single center in China, with a possible selection IQR inter-quartile range
bias and a center-specific effect. The follow-up time was long. LDL low-density lipoprotein

Please cite this article as: Zhou H et al., Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients
undergoing peritoneal dialysis, Clinical Nutrition, https://doi.org/10.1016/j.clnu.2019.11.018
 H. Zhou et al. / Clinical Nutrition xxx (xxxx) xxx
LVMI left ventricular mass index
NLR neutrophil to lymphocyte ratio
PD peritoneal dialysis
ROC receiver operating characteristic
RRF residual renal function
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnu.2019.11.018.
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