MIS SCORE is xxx. xxxxx.
(A) Patient's related medical history:
1. Change in end dialysis dry weight (overall change in past 3-6 months):
0 1 2 3
No decrease in dry
weight or weight
loss < 0.5 kg
Minor weight loss
(≥ 0.5 kg but < 1 kg)
Weight loss more
than 1 kg
but < 5%
weight loss >
2. Dietary Intake:
0 1 2 3
Good appetite and
and no deterioration of
the dietary intake
Somewhat sub-optimal
solid diet intake
Moderate overall
decrease to full
liquid diet
Hypo-caloric liquid
to starvation
3. Gastrointestinal (GI) symptoms:
0 1 2 3
No symptoms with
good appetite
Mild symptoms, poor
appetite or nauseated
Occasional vomiting
or moderate GI
Frequent diarrhea
or vomiting or
severe anorexia
4. Functional capacity (nutritionally related functional impairment)::
0 1 2 3
Normal to improved
functional capacity,
feeling fine
Occasional difficulty
with baseline ambulation,
or feeling tired frequently
Difficulty with
otherwise independent
activities (e.g. going
to bathroom)
or little to no
physical activity
5. Co-morbidity, including number of years on dialysis:
0 1 2 3
On dialysis < 1 year
and healthy otherwise
Dialyzed for 1-4 years,
or mild co-morbidity
(excluding MCC*)
Dialyzed > 4
years, or moderate
(including one MCC*)
Any severe, multiple
(2 or more MCC*)
(B) Physical Exam (according to SGA Crieteria):
6. Decreased fat stores or loss of subcutaneous fat (below eyes, triceps, biceps, chest):
0 1 2 3
Normal (no change)MildModerateSevere
7. Signs of muscle wasting (temple, clavicle, scapula, ribs, quadriceps, knee, interosseous):
0 1 2 3
Normal (no change)MildModerateSevere
(C) Body Mass Index:
8.Body mass index:Input BMI (if known) or leave blank and calculate below
BMI = Wt(kg) / Ht2(m).
Inches: Centimeters:
WEIGHT=wt kg. HEIGHT=ht m. BMI=bmi kg/m2.
0 1 2 3
BMI ≥ 20 kg/m2BMI 18 - 19.99 kg/m2BMI 16 - 17.99 kg/m2 BMI < 16 kg/m2
(D) Laboratory Parameters:
9. Serum albumin
0 1 2 3
Albumin ≥ 4.0 g/dL Albumin 3.5 - 3.9 g/dL Albumin 3.0 - 3.4 g/dL Albumin < 3.0 g/dL
10. Serum TIBC (Total Iron Binding Capacity) OR serum transferrin .
Input value
0 1 2 3
TIBC ≥ 250 mg/dL
Transferrin > 200 mg/dL
TIBC 200 -249 mg/dL
Transferrin 170 -200 mg/dL
TIBC 150 -199 mg/dL
Transferrin 150 -169 mg/dL
TIBC < 150 mg/dL
Transferrin < 150 mg/dL

*MCC (Major Comorbid Conditions): include CHF class III or IV, full blown AIDS
severe CAD, moderate to severe COPD, major neurologic sequelae,
and metastatic malignancies or s/p recent chemotherapy.
NOTES: n = 346 patients x = 6.3 SD = 3.9 25th%=4 50th% (median) = 5.5 75th% = 8
REFERENCE: Kalantar-Zadeh K, Kopple JD, Humphreys MH, Block G.
Comparing outcome predictability of markers of malnutrition-inflammation
complex sydrome in hemodialysis patients. Nephrol Dial Transplant (2004) 19:1507-1519

© 2008-14, Stephen Z. Fadem, M.D., FASN. All rights reserved. No part of this application may be duplicated without written permission from the author.


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