GLIM标准下三种营养风险筛查工具对350例耐多药肺结核住院患者的适用性分析

doi:10.3877/cma.j.issn.1674-6902.2026.03.015

目的

基于全球营养领导人倡议营养不良诊断(Global Leadership Initiative on Malnutrition, GLIM)标准下探讨营养风险筛查2002(nutritional risk screening, NRS2002)、微型营养评估(mini nutritional assessment, MNA)、营养不良通用筛查工具(malnutrition universal screening tool, MUST)对耐多药肺结核(multidrug-resistant pulmonary tuberculosis, MDR-PTB)住院患者的适用性。

方法

采用描述性研究，连续选取2019年6月至2021年12月在西安市胸科医院确诊为MDR-PTB患者350例，采用3种工具完成营养风险筛查，以GLIM诊断结果为参照，分别计算出3种工具的灵敏度、特异度、阳性预测值(positive predictive value, PPV)、阴性预测值(negative predictive value, NPV)、一致性；绘制受试者工作特征曲线(ROC曲线)并计算曲线下面积(area under curve, AUC)。以2月末痰培养阴转情况和治疗不良结局发生情况为观察指标，通过单因素及多因素Logistic回归分析患者营养状况与临床转归之间的关联性。

结果

350例MDR-PTB患者依据GLIM标准诊断营养不良有204例(58.29%)，营养良好146例(41.71%)。营养筛查工具的营养风险检出率为，MNA 294例(84.00%)、NRS2002 228例(65.14%)、MUST 240例(68.57%)。MNA筛查耗时(3.40±2.07)min长于NRS2002(2.23±0.76)min、MUST(1.54±0.33)min(F＝0.578，P<0.001)。筛查工具性能分析显示，MNA灵敏度99.51%高，但特异度37.67%低；NRS2002和MUST的特异度(66.44% 比63.70%)及AUC值(0.771比0.777)优。多因素二元Logistic回归显示，与营养健康状况良好者比较，GLIM营养不良者(OR＝20.511，95%CI：4.509~93.308)和NRS2002高风险者(OR＝3.492，95%CI：1.147~10.627)2月末痰培养未阴转的风险高；GLIM营养不良者(OR＝2.951，95%CI：1.023~8.509)和MNA高风险者(OR＝17.213，95%CI：1.794~165.179)发生不良结局的风险高。

结论

3种营养筛查工具中，MNA的灵敏度及NRS2002特异度高，适合MUST整体筛查；关注患者短期临床转归时NRS2002和MUST的筛查，关注早期营养风险识别与长期临床转归时MNA具有优势，适合MDR-PTB患者的临床营养管理策略。

关键词: 耐多药肺结核, 营养风险筛查, 全球营养领导人倡议营养不良诊断标准, 痰培养阴转率, 治疗结局

Objective

To evaluate the applicability of Nutritional Risk Screening 2002 (NRS2002), Mini Nutritional Assessment (MNA), and Malnutrition Universal Screening Tool (MUST) in hospitalized patients with multidrug-resistant pulmonary tuberculosis (MDR-PTB), using the Global Leadership Initiative on Malnutrition (GLIM) criteria as the reference standard.

Methods

A descriptive study was conducted, consecutively enrolling 350 patients diagnosed with MDR-PTB at Xi′an Chest Hospital between June 2019 and December 2021. Nutritional risk screening was performed using the 3 toolsSensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and agreement were calculated for each tool. Receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) was computed. Univariate and multivariate logistic regression analyses were conducted to assess the association between nutritional status and clinical outcomes, with sputum culture conversion at 2 months and the occurrence of adverse events as primary endpoints.

Results

Among the 350 MDR-PTB patients, 204 cases (58.29%) were diagnosed with malnutrition according to the GLIM criteria, and 146 cases (41.71%) were well-nourished. The nutritional risk detection rates of various screening tools were as follows: MNA in 294 cases (84.00%), NRS2002 in 228 cases (65.14%), and MUST in 240 cases (68.57%). The screening time required for MNA [(3.40 ± 2.07) minutes] was significantly longer than that for NRS2002 [(2.23±0.76)minutes] and MUST [(1.54±0.33) minutes], with a statistically significant difference (F=0.578, P<0.001). According to GLIM criteria, 58.29% of patients were diagnosed with malnutrition. Performance analysis revealed that MNA had the highest sensitivity (99.51%) but the lowest specificity (37.67%). NRS2002 and MUST demonstrated higher specificity (66.44% vs. 63.70%) and greater AUC values (0.771 vs. 0.777). Multivariate binary logistic regression indicated that, compared with well-nourished patients, those identified as malnourished by GLIM criteria (OR=20.511, 95%CI: 4.509~93.308) and those at high risk by NRS2002 (OR=3.492, 95%CI: 1.147~10.627) had a significantly higher risk of non-conversion in sputum culture at 2 months. Similarly, the GLIM malnutrition group (OR=2.951, 95%CI: 1.023~8.509) and the MNA high-risk group (OR=17.213, 95%CI: 1.794~165.179) were associated with a higher risk of adverse treatment outcomes.

Conclusions

Among the three nutritional screening tools, MNA showed the highest sensitivity, while NRS2002 exhibited the highest specificity, MUST demonstrated better overall screening performance. For focusing on short-term clinical outcomes, NRS2002 and MUST have higher screening efficacy, while MNA is superior for early identification of nutritional risk and assessment of long-term clinical outcomes, and may be more suitable for the clinical nutritional management strategy of MDR-PTB patients.

Key words: Multidrug-resistant pulmonary tuberculosis, Nutritional risk screening, GLIM criteria, Sputum culture conversion rate, Treatment outcome

表1 GLIM标准下MDR-PTB患者的基线特征与营养状况的关系

临床资料	GLIM营养诊断		统计值	P值
临床资料	营养良好(n＝146)	营养不良(n＝204)	统计值	P值
年龄[岁，M(P₂₅~P₇₅)]	33(27~45)	36.5(27~52)	Z＝－2.117	0.034
性别：男/女[n(%)]	91(62.33)/55(37.67)	145(71.08)/59(28.92)	χ²＝2.966	0.105
吸烟史[n(%)]	44(30.14)	79(38.72)	χ²＝2.754	0.097
饮酒史[n(%)]	14(9.59)	39(119.12)	χ²＝6.013	0.014
身高[m，M(P₂₅~P₇₅)]	1.70(1.63~1.75)	1.70(1.64~1.74)	Z＝－0.802	0.423
体重[kg，M(P₂₅~P₇₅)]	62(55~70)	52.25(48~57)	Z＝－8.996	0.001
BMI[kg/m²，M(P₂₅~P₇₅)]	21.6(19.8~23.4)	18.4(17.3~19.7)	Z＝－11.364	0.001
白蛋白[g/L，(±s)]	41.03±3.15	37.38±4.71	t＝8.682	0.001
总蛋白[g/L，(±s)]	66.19±4.79	64.90±5.52	t＝2.272	0.024
血红蛋白[g/L，(±s)]	129.82±16.47	118.99±17.85	t＝5.779	0.001
淋巴细胞计数[×10⁹/L，(±s)]	1.44±0.40	1.23±0.48	t＝4.305	0.001
上臂围[cm，(±s)]	27.27±2.92	22.80±3.11	t＝13.626	0.001
小腿围[cm，(±s)]	34.81±2.32	31.33±2.96	t＝－12.309	0.001
糖尿病[n(%)]	21(14.38)	51(25.00)	χ²＝5.870	0.015
高血压[n(%)]	6(4.11)	9(4.41)	χ²＝0.019	0.891
肝炎[n(%)]	1(0.68)	9(4.41)	χ²＝3.022	0.082
COPD[n(%)]	0(0.00)	12(5.88)		0.020

表1 GLIM标准下MDR-PTB患者的基线特征与营养状况的关系

临床资料	GLIM营养诊断		统计值	P值
临床资料	营养良好(n＝146)	营养不良(n＝204)	统计值	P值
年龄[岁，M(P₂₅~P₇₅)]	33(27~45)	36.5(27~52)	Z＝－2.117	0.034
性别：男/女[n(%)]	91(62.33)/55(37.67)	145(71.08)/59(28.92)	χ²＝2.966	0.105
吸烟史[n(%)]	44(30.14)	79(38.72)	χ²＝2.754	0.097
饮酒史[n(%)]	14(9.59)	39(119.12)	χ²＝6.013	0.014
身高[m，M(P₂₅~P₇₅)]	1.70(1.63~1.75)	1.70(1.64~1.74)	Z＝－0.802	0.423
体重[kg，M(P₂₅~P₇₅)]	62(55~70)	52.25(48~57)	Z＝－8.996	0.001
BMI[kg/m²，M(P₂₅~P₇₅)]	21.6(19.8~23.4)	18.4(17.3~19.7)	Z＝－11.364	0.001
白蛋白[g/L，(±s)]	41.03±3.15	37.38±4.71	t＝8.682	0.001
总蛋白[g/L，(±s)]	66.19±4.79	64.90±5.52	t＝2.272	0.024
血红蛋白[g/L，(±s)]	129.82±16.47	118.99±17.85	t＝5.779	0.001
淋巴细胞计数[×10⁹/L，(±s)]	1.44±0.40	1.23±0.48	t＝4.305	0.001
上臂围[cm，(±s)]	27.27±2.92	22.80±3.11	t＝13.626	0.001
小腿围[cm，(±s)]	34.81±2.32	31.33±2.96	t＝－12.309	0.001
糖尿病[n(%)]	21(14.38)	51(25.00)	χ²＝5.870	0.015
高血压[n(%)]	6(4.11)	9(4.41)	χ²＝0.019	0.891
肝炎[n(%)]	1(0.68)	9(4.41)	χ²＝3.022	0.082
COPD[n(%)]	0(0.00)	12(5.88)		0.020

表2 各营养风险筛查工具在GLIM标准下的诊断表现

评估方法	GLIM营养不良诊断(例)		灵敏度(%)	特异度(%)	PPV(%)	NPV(%)	一致性(%)
评估方法	营养不良(n＝204)	营养良好(n＝146)	灵敏度(%)	特异度(%)	PPV(%)	NPV(%)	一致性(%)
MNA			99.51	37.67	69.05	98.21	73.71
中高风险(>23.5分)	203	91
低风险(≤23.5分)	1	55
NRS2002			87.75	66.44	78.50	79.51	78.86
中高风险(≥3分)	179	49
低风险(<3分)	25	97
MUST			91.67	63.70	77.92	84.55	80.00
中高风险(≥1分)	187	53
低风险(<1分)	17	93

表2 各营养风险筛查工具在GLIM标准下的诊断表现

评估方法	GLIM营养不良诊断(例)		灵敏度(%)	特异度(%)	PPV(%)	NPV(%)	一致性(%)
评估方法	营养不良(n＝204)	营养良好(n＝146)	灵敏度(%)	特异度(%)	PPV(%)	NPV(%)	一致性(%)
MNA			99.51	37.67	69.05	98.21	73.71
中高风险(>23.5分)	203	91
低风险(≤23.5分)	1	55
NRS2002			87.75	66.44	78.50	79.51	78.86
中高风险(≥3分)	179	49
低风险(<3分)	25	97
MUST			91.67	63.70	77.92	84.55	80.00
中高风险(≥1分)	187	53
低风险(<1分)	17	93

图1 MNA、NRS2002、MUST在GLIM标准下营养不良的ROC曲线

表3 不同评估方法下营养状况与短期临床转归的关系

筛查工具	痰未阴转(n＝84)	痰阴转(n＝266)	单变量分析		多变量分析
筛查工具	痰未阴转(n＝84)	痰阴转(n＝266)	OR值(95%CI)	P值	OR值(95%CI)	P值
GLIM
营养良好	2	144	1		1
营养不良	82	122	48.393(11.659~200.868)	0.001	20.511(4.509~93.308)	0.001
MNA
低风险	1	55	1		1
中风险	39	175	12.257(1.646~91.289)	0.014	7.301(0.911~58.488)	0.061
高风险	44	36	67.222(8.863~509.873)	0.001	7.881(0.826~75.168)	0.073
NRS2002
无风险	7	115	1		1
有风险	77	151	8.377(3.724~18.848)	0.001	3.492(1.147~10.627)	0.028
MUST
低风险	6	104	1		1
中风险	5	48	1.806(0.525~6.209)	0.348	1.146(0.265~4.985)	0.855
高风险	73	114	11.099(4.633~26.594)	0.001	4.857(1.641~14.371)	0.004

表3 不同评估方法下营养状况与短期临床转归的关系

筛查工具	痰未阴转(n＝84)	痰阴转(n＝266)	单变量分析		多变量分析
筛查工具	痰未阴转(n＝84)	痰阴转(n＝266)	OR值(95%CI)	P值	OR值(95%CI)	P值
GLIM
营养良好	2	144	1		1
营养不良	82	122	48.393(11.659~200.868)	0.001	20.511(4.509~93.308)	0.001
MNA
低风险	1	55	1		1
中风险	39	175	12.257(1.646~91.289)	0.014	7.301(0.911~58.488)	0.061
高风险	44	36	67.222(8.863~509.873)	0.001	7.881(0.826~75.168)	0.073
NRS2002
无风险	7	115	1		1
有风险	77	151	8.377(3.724~18.848)	0.001	3.492(1.147~10.627)	0.028
MUST
低风险	6	104	1		1
中风险	5	48	1.806(0.525~6.209)	0.348	1.146(0.265~4.985)	0.855
高风险	73	114	11.099(4.633~26.594)	0.001	4.857(1.641~14.371)	0.004

表4 不同评估方法下营养状况与长期临床转归的关系

筛查工具	不良结局(n＝64)	良好结局(n＝286)	单变量分析		多变量分析
筛查工具	不良结局(n＝64)	良好结局(n＝286)	OR值(95%CI)	P值	OR值(95%CI)	P值
GLIM
营养良好	6	140	1		1
营养不良	58	146	9.269(3.876~22.168)	0.001	2.951(1.023~8.509)	0.045
MNA
低风险	1	55	1		1
中风险	27	187	7.941(1.055~59.770)	0.044	6.905(0.851~56.006)	0.070
高风险	36	44	45.000(5.933~341.320)	0.001	17.213(1.794~165.179)	0.014
NRS2002
无风险	9	113	1		1
有风险	55	173	3.992(1.898~8.396)	0.001	1.753(0.601~5.114)	0.304
MUST
低风险	8	102	1		1
中风险	3	50	0.765(0.195~3009)	0.701	0.643(0.142~2.906)	0.566
高风险	53	134	5.043(2.296~11.076)	0.001	2.391(0.857~6.674)	0.096

表4 不同评估方法下营养状况与长期临床转归的关系

筛查工具	不良结局(n＝64)	良好结局(n＝286)	单变量分析		多变量分析
筛查工具	不良结局(n＝64)	良好结局(n＝286)	OR值(95%CI)	P值	OR值(95%CI)	P值
GLIM
营养良好	6	140	1		1
营养不良	58	146	9.269(3.876~22.168)	0.001	2.951(1.023~8.509)	0.045
MNA
低风险	1	55	1		1
中风险	27	187	7.941(1.055~59.770)	0.044	6.905(0.851~56.006)	0.070
高风险	36	44	45.000(5.933~341.320)	0.001	17.213(1.794~165.179)	0.014
NRS2002
无风险	9	113	1		1
有风险	55	173	3.992(1.898~8.396)	0.001	1.753(0.601~5.114)	0.304
MUST
低风险	8	102	1		1
中风险	3	50	0.765(0.195~3009)	0.701	0.643(0.142~2.906)	0.566
高风险	53	134	5.043(2.296~11.076)	0.001	2.391(0.857~6.674)	0.096

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Applicability of three nutritional risk screening tools for 350 in-hospital patients with multidrug-resistant pulmonary tuberculosis based on GLIM criteria

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Applicability of three nutritional risk screening tools for 350 in-hospital patients with multidrug-resistant pulmonary tuberculosis based on GLIM criteria