A Predictive Model and Survival Analysis for Tube Feeding in ALS Patients: A Prospective Cohort Study in a Chinese ALS Clinic

Abstract

Objectives. Tube feeding is an effective way to provide nutritional support for amyotrophic lateral sclerosis (ALS) patients with severe dysphagia. Currently, the predictors of tube feeding and the survival affected by tube feeding were poorly studied in Chinese ALS patients. Therefore, we aimed to explore predictive factors and establish a prediction model to quantitatively predict the risk of tube feeding. Furthermore, we explored the survival benefit provided by tube feeding. Methods. In this longitudinal, prospective cohort study, we included patients diagnosed with ALS using the Awaji criteria at the ALS clinic in Huashan Hospital. Follow-up was conducted by telephone interview from January 1, 2019, to December 30, 2021, or until death. All statistical analyses were performed using R software. Results. Overall, 218 patients were recruited for the study. The multivariate Cox regression analysis showed a high ALSFRS-R slope (adjusted hazard ratio $\left(\text{aHR}\right)=4.94$ (95% confidence interval (95% CI: 2.26-10.81), $p<0.001$ ), low bulbar score ( $\text{aHR}=0.81$ (95% CI: 0.69-0.96), $p=0.01$ ), history of ischemic stroke ( $\text{aHR}=5.69$ (95% CI: 1.3-24.82), $p=0.02$ ), and bulbar involvement ( $\text{aHR}=11.87$ (95% CI: 1.42-99.31), $p=0.02$ ) as independent risk factors of tube feeding. The nomogram model was established with moderate discrimination and calibration. Among 71 ALS patients with tube feeding indication, 33.8% accepted gastrostomy suggestion and 14.1% had nasogastric tube (NGT) insertion. However, gastrostomy and NGT did not accelerate disease progression ( $\text{aHR}=0.57$ (95% CI: 0.20-1.67), $p=0.31$ and $\text{aHR}=1.72$ (95% CI: 0.43-6.88), $p=0.43$ , respectively). Conclusions. We developed a nomogram that could be a prediction tool to predict individual timing of tube feeding for ALS patients. In addition, we found that gastrostomy and NGT did not affect ALS patients’ survival.