Geriatric nutritional risk index as a predictor of 28-day and 365-day mortality in patients with heart failure complicated by sepsis: A retrospective cohort study using the MIMIC-Ⅳ database

Abstract

Objective: To evaluate the association between the Geriatric Nutritional Risk Index (GNRI) at ICU admission and mortality in patients with heart failure complicated by sepsis, a high-risk population in which the prognostic value of this validated malnutrition risk assessment tool remains underexplored. Methods: Patients with heart failure and sepsis were identified from the Medical Information Mart for Intensive Care (MIMIC-Ⅳ) database and stratified into four GNRI groups. The primary endpoints were 28-day and 365-day all-cause mortality. Survival analysis used Kaplan-Meier curves and Cox proportional hazards models. Linearity was assessed using restricted cubic splines (RCS), while GNRI’s predictive performance was evaluated using receiver operating characteristic (ROC) curves. Results: Altogether, 1 713 patients with heart failure complicated by sepsis were identified in the present study. Kaplan-Meier analysis revealed 28-day mortality rates of 40.44% (high-risk) vs. 25.27% (no-risk) (P<.001), with a similar trend for 365-day mortality (63.75% vs. 43.96%, P<.001). RCS confirmed a linear inverse relationship between GNRI and mortality. Cox regression demonstrated that each unit GNRI increase reduced 28-day (hazard ratio [HR], 0.99; 95% confidence interval [ CI] 0.98–1.00) and 365-day mortality risk (HR, 0.98; 95% CI 0.98–0.99). ROC analysis indicated a moderate predictive value of GNRI for 28-day all-cause mortality (AUC=0.58, sensitivity=66.61%, specificity=45.62%, P<.001) and 365-day all-cause mortality (AUC=0.60, sensitivity=66.52%, specificity=51.28%, P<.001). Furthermore, the addition of GNRI significantly enhanced the predictive performance of the SAPSⅡ (AUC increased from 0.69 to 0.70, P=.02), SOFA (AUC increased from 0.73 to 0.74, P=.02), and LODS (AUC increased from 0.67 to 0.68, P=.03) scores, with these improvements achieving statistical significance. Conclusions: Admission GNRI is an independent risk factor for in-hospital mortality in ICU patients with heart failure complicated by sepsis. GNRI scores serve as a valuable prognostic indicator for assessing mortality risk in this patient population.

Keywords

Geriatric nutritional risk index / MIMIC-Ⅳ database / Heart failure / Sepsis

Conflict of interest statement

The authors report no conflict of interest.

Funding

This work was supported by the Guangdong Provincial Second Hospital of Traditional Chinese Medicine Scientific Research Innovation Foundation (SEZYY2023B18); the University-Institute Joint Science and Technology Innovation Fund of Guangzhou University of Chinese Medicine (GZYSE2024G04); the Chinese Traditional Medicine Foundation of Guangdong (20251464); Medical Scientific Research Foundation of Guangdong (B2025323, A2024635); the Science and Technology Innovation Project of Maoming Municipality (2023SZY002; 2023SZY022); Sanming Project of Medicine in Shenzhen (No.SZZYSM202411012), and the Open Fund of the Key Laboratory of Traditional Chinese Medicine Research and Development of Guangdong Province (KFKT25001).

Data availability statement

The data supporting this bibliometric analysis are publicly available from the Web of Science Core Collection. Any additional details can be obtained from the corresponding authors upon reasonable request.

Authors’ contributions

WYM: Data curation, Formal analysis, Writing and original draft. WMS: Methodology, Software, Writing and original draft. WL: Resources, Software, Methodology and original draft. TQ: Conceptualization, Data curation, Writing and original draft. WYP: Supervision, Project administration, Writing and original draft. TYX: Investigation, Supervision, Writing and review. JLL: Conceptualization, Supervision, Writing review and editing.

Publisher’s note

The Publisher of the Journal remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

[1] Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. Eur J Heart Fail 2020; 22(8): 1342-1356.

[2] Shahim B, Kapelios CJ, Savarese G, Lund LH. Global public health burden of heart failure: An updated Review. Card Fail Rev 2023; 9: e11.

[3] Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the management of heart failure: A report of the american college of cardiology/american heart association joint committee on clinical practice guidelines. Circulation 2022; 79(17): e263-e421.

[4] Walker AMN, Drozd M, Hall M, Patel PA, Paton M, Lowry J, et al. Prevalence and predictors of sepsis death in patients with chronic heart failure and reduced left ventricular ejection fraction. J Am Heart Assoc 2018; 7(20): e009684.

[5] Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990—2017: Analysis for the global burden of disease study. Lancet 2020; 395(10219): 200-211.

[6] Jentzer JC, Lawler PR, Van Houten HK, Yao X, Kashani KB, Dunlay SM. Cardiovascular events among survivors of sepsis hospitalization: A retrospective cohort analysis. J Am Heart Assoc 2023; 12(3): e027813.

[7] Zhu M, Tang X, Gao Y, Xu J, Gong Y. Impact of heart failure on outcomes in patients with sepsis: A systematic review and meta—analysis. World J Clin Cases 2023; 11(15): 3511-3521.

[8] Lv S, Ru S. The prevalence of malnutrition and its effects on the all—cause mortality among patients with heart failure: A systematic review and meta—analysis. PLoS One 2021; 16(10): e0259300.

[9] Lin H, Zhang H, Lin Z, Li X, Kong X, Sun G. Review of nutritional screening and assessment tools and clinical outcomes in heart failure. Heart Fail Rev 2016; 21(5): 549-565.

[10] Driggin E, Cohen LP, Gallagher D, Karmally W, Maddox T, Hummel SL, et al. Nutrition assessment and dietary interventions in heart failure: JACC review topic of the week. J Am Coll Cardiol 2022; 79(16): 1623-1635.

[11] Scotti A, Coisne A, Granada JF, Driggin E, Madhavan MV, Zhou Z, et al. Impact of malnutrition in patients with heart failure and secondary mitral regurgitation: The COAPT trial. J Am Coll Cardiol 2023; 82(2): 128-138.

[12] Hao X, Li D, Zhang N. Geriatric nutritional risk index as a predictor for mortality: A meta—analysis of observational studies. Nutr Res 2019; 71: 8-20.

[13] Bouillanne O, Morineau G, Dupont C, Coulombel I, Vincent J, Nicolis I et al. Geriatric nutritional risk index: A new index for evaluating at—risk elderly medical patients. Am J Clin Nutr 2005; 82(4): 777-783.

[14] Li H, Cen K, Sun W, Feng B. Prognostic value of geriatric nutritional risk index in elderly patients with heart failure: A meta—analysis. Aging Clin Exp Res 2021; 33(6): 1477-1486.

[15] Daud M, Ullah F, Uzair M, Siddiq A, Siddiq U, Riaz FB, et al. Malnutrition and its influence on sepsis outcomes in elderly patients. Cureus 2024; 16(6): e63433.

[16] Johnson AEW, Bulgarelli L, Shen L, Gayles A, Shammout A, Horng S, et al. MIMIC—Ⅳ, a freely accessible electronic health record dataset. Sci Data 2023; 10(1): 1.

[17] Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019; 13(Suppl 1): S31-S34.

[18] Singer M, Deutschman CS, Seymour CW, Shankar—Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis—3). JAMA 2016; 315(8): 801-810.

[19] MIT—LCP. MIMIC code repository: Code shared by the research community for the MIMIC family of databases. [Online] Available from: https://github.com/MIT—LCP/mimic—code [Accessed on December 28, 2025].

[20] Cereda E, Pedrolli C. The geriatric nutritional risk index. Curr Opin Clin Nutr Metab Care 2009; 12(1): 1-7.

[21] Zhao D, Zhou D, Li T, Wang C, Fei S. The relationship between geriatric nutritional risk index (GNRI) and in—hospital mortality in critically ill patients with acute kidney injury (AKI). BMC Anesthesiol 2024; 24(1): 313.

[22] Zheng X, Zheng X, Zhang C, Liu M. Geriatric nutritional risk index as a predictor of 30—day and 365—day mortality in patients with acute myocardial infarction: A retrospective cohort study using the MIMIC—Ⅳ database. Front Nutr 2025; 12: 1544382.

[23] Li Y, Wang Z, Sun T, Zhang B, Liang X. Geriatric nutritional risk index was associated with in—hospital mortality among cardiac intensive care unit patients. Front Nutr 2023; 10: 1218738.

[24] Dong C, Chen S, Zeng H, Yang B, Pan J. Geriatric nutritional risk index predicts all—cause mortality in patients with heart failure: A systematic review and meta—analysis. Clinics (Sao Paulo) 2021; 76: e2258.

[25] Dong G, Li Z. The association between geriatric nutritional risk index and readmission within six months in elderly heart failure patients: A retrospective cohort study: Geriatric nutritional risk index for heart failure readmission within 6 months. Cardiol Res Pract 2024; 2024: 5692215.

[26] Wi Toniowska—Lonc N, Mak MA, Klausa F, Ciborski K, Banasiak W, Doroszko A. The nutritional status of patients with heart failure and its impact on patient' outcomes—the center's own experience. Nutrients 2025; 17(5): 761.

[27] Baek MS, Kwon YS, Kang SS, Shim D, Yoon Y, Kim JH. Association of malnutrition status with 30—day mortality in patients with sepsis using objective nutritional indices: A multicenter retrospective study in South Korea. Acute Crit Care 2024; 39(1): 127-137.

[28] Albar Z, Albakri M, Hajjari J, Karnib M, Janus SE, Al—Kindi SG. Inflammatory markers and risk of heart failure with reduced to preserved ejection fraction. Am J Cardiol 2022; 167: 68-75.

[29] Abugroun A, Nayyar A, Abdel—Rahman M, Patel P. Impact of malnutrition on hospitalization outcomes for older adults admitted for sepsis. Am J Med 2021; 134(2): 221-226.e1.

[30] Bansal N, Alharbi A, Shah M, Altorok I, Assaly R, Altorok N. Impact of malnutrition on the outcomes in patients admitted with heart failure. J Clin Med 2024; 13(14): 4215.

[31] Chander S, Luhana S, Sadarat F, Parkash O, Rahaman Z, Wang HY, et al. Mortality and mode of dialysis: meta—analysis and systematic review. BMC Nephrol 2024; 25(1): 1.

[32] Targher G, Byrne CD, Tilg H. MASLD: A systemic metabolic disorder with cardiovascular and malignant complications. Gut 2024; 73(4): 691-670.