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 > 5%
2. Dietary Intake:
	0	1	2	3
	Good appetite and and no deterioration of the dietary intake pattern	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 occasionally	Occasional vomiting or moderate GI symptoms	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)	Bed/chair-ridden, 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 co-morbidity (including one MCC*)	Any severe, multiple co-morbidity (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)	Mild	Moderate	Severe
7. Signs of muscle wasting (temple, clavicle, scapula, ribs, quadriceps, knee, interosseous):
	0	1	2	3
	Normal (no change)	Mild	Moderate	Severe
(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/m²	BMI 18 - 19.99 kg/m²	BMI 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
MIS SCORE: mis
*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

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