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Prognostic Nutritional Index and In-Hospital Mortality After Coronary Artery Bypass Grafting: An Exploratory Analysis
Burak Toprak1, Nihat Söylemez2, Menaf Akın Sert3
1Department of Cardiovascular Surgery, Mersin City Education and Research Hospital, 33240 Mersin, Turkey.
Insights
Postoperative Prognostic Nutritional Index (PNI) is linked to in-hospital mortality after coronary artery bypass grafting (CABG). Early nutritional-immune status may offer insights beyond traditional risk scores, but further validation is needed.
Area of Science:
- Cardiology
- Surgical Risk Assessment
- Nutritional Immunology
Background:
- Coronary anatomical complexity is used for perioperative risk assessment in coronary artery bypass grafting (CABG).
- Systemic biological vulnerability may not be fully captured by anatomical complexity alone.
- The Prognostic Nutritional Index (PNI) is a nutritional-immune marker indicating systemic health.
Purpose of the Study:
- To evaluate the association between the Prognostic Nutritional Index (PNI) and in-hospital mortality after CABG.
- To assess PNI's relationship with coronary anatomical complexity and surgical risk scores.
- To determine if PNI provides additional prognostic information beyond established risk models.
Main Methods:
- A single-center retrospective cohort study of 324 patients undergoing isolated CABG.
- Calculation of preoperative and postoperative PNI using serum albumin and lymphocyte counts.
- Analysis using univariable/multivariable logistic regression, ROC curves, and nested models for prognostic contribution.
Main Results:
- In-hospital mortality occurred in 26 patients, with lower preoperative and postoperative PNI values.
- Postoperative PNI was independently associated with in-hospital mortality; preoperative PNI lost significance after adjustment.
- PNI showed modest discriminative ability and limited incremental prognostic value when added to STS-based models.
Conclusions:
- Postoperative PNI is a stronger predictor of in-hospital mortality post-CABG than preoperative PNI.
- Early postoperative nutritional-immune status may reflect physiological stress and clinical deterioration.
- Further prospective studies are needed to confirm the clinical utility of PNI in CABG risk assessment.
Abstract:
Background: Coronary anatomical complexity is commonly used for perioperative risk assessment in patients undergoing coronary artery bypass grafting (CABG), although it may not fully reflect systemic biological vulnerability. This study aimed to evaluate the association between the Prognostic Nutritional Index (PNI), a nutritional-immune marker derived from serum albumin and lymphocyte counts, and in-hospital mortality after CABG in relation to coronary anatomical complexity and established surgical risk scores. Methods: In this single-center retrospective cohort study, 324 consecutive patients who underwent isolated CABG between April 2024 and April 2025 were analyzed. The PNI was calculated according to the standard Onodera formula using preoperative serum albumin and total lymphocyte count. Associations with in-hospital mortality were evaluated using univariable and multivariable logistic regression analyses. Discriminative performance was assessed using receiver operating characteristic curve analysis, while exploratory analyses evaluating the additional prognostic contribution of the PNI beyond surgical risk scores were performed using nested model comparison and reclassification analyses. Internal validation and calibration analyses were also performed. Results: In-hospital mortality occurred in 26 patients. Preoperative and postoperative PNI values were significantly lower in patients who experienced in-hospital mortality. In multivariable analysis, the postoperative PNI remained independently associated with in-hospital mortality, whereas the preoperative PNI lost statistical significance after adjustment for clinical, renal, and surgical risk parameters. Receiver operating characteristic analysis demonstrated modest discriminative ability for the preoperative PNI (AUC: 0.742, 95% CI: 0.661-0.823). Exploratory analyses suggested a modest improvement in model discrimination and risk classification after the addition of the PNI to STS-based models; however, the overall incremental prognostic contribution remained limited. Calibration and internal validation analyses demonstrated acceptable agreement between predicted and observed mortality risk. Conclusions: The postoperative PNI demonstrated a stronger and independent association with in-hospital mortality than the preoperative PNI, suggesting that early postoperative nutritional-immune deterioration may reflect the magnitude of perioperative physiological stress and evolving clinical deterioration after CABG. Although lower preoperative PNI values were associated with mortality in univariable analyses, this association was no longer statistically significant after adjustment for clinical, renal, and surgical risk parameters. These findings indicate that postoperative nutritional-immune status may provide complementary biological information beyond conventional risk models; however, its clinical utility requires confirmation in larger prospective multicenter studies.
