APPLIED NUTRITIONAL INVESTIGATION
Nutritional Risk Factors for Postoperative
Complications in Brazilian Elderly Patients
Undergoing Major Elective Surgery
Jose´ Carlos dos Santos Junqueira, MD, Elza Cotrim Soares, MD, PhD,
Heleno Rodrigues Correˆa Filho, MD, PhD, Nelci Fenalti Hoehr, PhD,
Daniela Oliveira Magro, BSc, and Miriam Ueno, BSc
From the Intensive Care Unit (Adult), the Department of Clinical Medicine, the Department of
Social and Preventive Medicine, and the Department of Clinical Pathology, Faculty of Medical
Sciences, Hospital das Clı´nicas, State University of Campinas, Campinas, Sa˜o Paulo, Brazil
OBJECTIVE: In this prospective study, we assessed nutritional and immunologic risk factors for infectious
complications and deaths related to infection in elderly patients undergoing major elective surgery.
METHODS: Seventy patients 60 y or older were enrolled in this study. The preoperative variables analyzed
were body mass index, body mass index knee height, triceps skinfold, subscapular skinfold, mid-arm
muscle circumference, mid-arm muscle area, albumin, transferrin, prealbumin, and retinol-binding protein
levels, immunoglobulins G, A, and M, C3, and C4 levels, total lymphocyte counts, and the occurrence of
delayed hypersensitivity reactions (multitest).
RESULTS: Abnormally low levels of prealbumin (P ϭ 0.004), retinol-binding protein (P ϭ 0.05), and
transferrin (P ϭ 0.04) were related to infectious complications. Prealbumin levels (P ϭ 0.02) and
lymphocyte counts below 1500 cells/mm
3
(P ϭ 0.04) were associated with mortality secondary to
infection. Univariate regression analysis showed that levels of prealbumin (P ϭ 0.02, odds ratio ϭ 13.3,
95% confidence limits ϭ 1.6, 110.9), retinol-binding protein (P ϭ 0.03, odds ratio ϭ 4.8, 95% confidence
limits ϭ 1.2, 19.3), and transferrin (P ϭ 0.03; odds ratio ϭ 4.2, 95% confidence limit ϭ 1.2, 15.6) were
associated with infectious complications. Multivariate analysis associated only prealbumin levels with
infectious complications (P ϭ 0.02, odds ratio ϭ 13.3, 95% confidence limit ϭ 1.6, 110.9). Regression
analysis provided no conclusion regarding mortality because of the small number of deaths recorded.
CONCLUSIONS: In patients with a good cardiac index (Goldman I and II) who underwent major elective
surgery, prealbumin protein, retinol-binding protein, and transferrin levels below normal values repre-
sented a significant risk for postoperative infectious complications. Lymphocyte counts lower than
1500/m
3
and abnormal prealbumin values were associated with postoperative mortality secondary to
infection. The anthropometric variables evaluated did not predict postoperative infectious complications
and mortality. Nutrition 2003;19:321–326. ©Elsevier Science Inc. 2003
KEY WORDS: nutritional risk factors, nutrition, nutritional assessment, protein-energy malnutrition,
surgery, elderly
INTRODUCTION
The world population is aging progressively. The projection for
Brazil by the year 2025 is that 15% of the Brazilian population
(approximately 32 million people) will be 60 y or older.
1
Various factors affect the quality of life of the aged, one of the
most important being nutritional status. Compared with the
younger population, the older population has a higher risk of
developing protein-energy malnutrition (PEM). Physiologic and
anatomic modifications, chronic diseases, the habitual use of med-
ication, and dietary and psychosocial habits contribute to this high
risk.
2
Although a high prevalence of PEM has been reported in
hospitals,
3,4
with Corish and Kennedy
5
citing a frequency of 20%
to 50%, the importance of these data are often underestimated.
The usefulness of PEM determined by nutritional assessment is
that it can detect “significant clinical protein-energy malnutri-
tion.”
6,7
An abnormal nutritional variable becomes important only
when its alteration has a direct relation to an increase in morbidity
and mortality.
4,8
Mullen et al.
4
found that only 3% of surgical patients have
normal nutritional and immunologic indices, and that only four
abnormal indices bore a significant relation to an increase in
complications. The influence of age is also important when assess-
ing nutritional variables, especially in the elderly.
9,10
In this study, we examined the nutritional and immunologic
factors involved in the risk of infectious complications and mor-
tality in elderly patients.
MATERIALS AND METHODS
Population Sample and Inclusion Criteria
A prospective study was conducted from February 1994 to Feb-
ruary 1996 on inpatients in the Intensive Care Unit of the Hospital
Correspondence to: Jose´ Carlos dos Santos Junqueira, MD, Rua Angela
Ferraro Menegaldo, 193, Valinhos, SP 13275-442, Brazil. E-mail:
jcsjunqueira@terra.com.br
Nutrition 19:321–326, 2003 0899-9007/03/$30.00
©Elsevier Science Inc., 2003. Printed in the United States. All rights reserved. PII S0899-9007(02)00863-8