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Qin Y, Huang J, Ping X, Zheng H, Zhang K, Xu X, Yu J. No benefit of higher protein dosing in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. PeerJ 2024; 12:e17433. [PMID: 38799065 PMCID: PMC11122048 DOI: 10.7717/peerj.17433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose The optimal range of protein dosage and effect of high-dose protein on critically ill patients remain controversial. We conducted a meta-analysis to compare higher and lower doses of protein supplementation for nutritional support in critically ill patients. Methods We searched the PubMed, Embase, Scopus, and Cochrane Library databases for randomized controlled trials that compared higher (≥1.2 g/kg per day) versus lower (<1.2 g/kg per day) doses of protein supplementation among critically ill adult patients. This search spanned from the inception of relevant databases to November 20, 2023. Our primary endpoint of interest was overall mortality, while secondary endpoints included length of stay in the intensive care unit, length of hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury. Results Seventeen studies including 2,965 critically ill patients were included in our meta-analysis. The pooled analyses showed no significant difference in overall mortality (RR 1.03, 95%CI [0.92-1.15], P = 0.65, I2 = 0%), length of intensive care unit stay (MD 0.19, 95%CI [-0.67 to 1.04], P = 0.66, I2 = 25%), length of hospital stay (MD 0.73, 95%CI [-1.59 to 3.04], P = 0.54, I2 = 27%), duration of mechanical ventilation (MD -0.14, 95%CI [-0.83 to 0.54], P = 0.68, I2 = 8%), and incidence of acute kidney injury (RR 1.11, 95%CI [0.87-1.41], P = 0.38, I2 = 0%) between critically ill patients receiving higher or lower doses of protein supplementation. Conclusions For critically ill patients, the protein supplementation dose had no significant effect on clinical outcomes, including overall mortality, length of intensive care unit and hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury.
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Affiliation(s)
- Yonggen Qin
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Jiuqing Yu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Haines RW, Prowle JR, Day A, Bear DE, Heyland DK, Puthucheary Z. Association between urea trajectory and protein dose in critically ill adults: a secondary exploratory analysis of the effort protein trial (RE-EFFORT). Crit Care 2024; 28:24. [PMID: 38229072 PMCID: PMC10792897 DOI: 10.1186/s13054-024-04799-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Delivering higher doses of protein to mechanically ventilated critically ill patients did not improve patient outcomes and may have caused harm. Longitudinal urea measurements could provide additional information about the treatment effect of higher protein doses. We hypothesised that higher urea values over time could explain the potential harmful treatment effects of higher doses of protein. METHODS We conducted a reanalysis of a randomised controlled trial of higher protein doses in critical illness (EFFORT Protein). We applied Bayesian joint models to estimate the strength of association of urea with 30-day survival and understand the treatment effect of higher protein doses. RESULTS Of the 1301 patients included in EFFORT Protein, 1277 were included in this analysis. There were 344 deaths at 30 days post-randomisation. By day 6, median urea was 2.1 mmol/L higher in the high protein group (95% CI 1.1-3.2), increasing to 3.0 mmol/L (95% CI 1.3-4.7) by day 12. A twofold rise in urea was associated with an increased risk of death at 30 days (hazard ratio 1.34, 95% credible interval 1.21-1.48), following adjustment of baseline characteristics including age, illness severity, renal replacement therapy, and presence of AKI. This association persisted over the duration of 30-day follow-up and in models adjusting for evolution of organ failure over time. CONCLUSIONS The increased risk of death in patients randomised to a higher protein dose in the EFFORT Protein trial was estimated to be mediated by increased urea cycle activity, of which serum urea is a biological signature. Serum urea should be taken into consideration when initiating and continuing protein delivery in critically ill patients. CLINICALTRIALS gov Identifier: NCT03160547 (2017-05-17).
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Affiliation(s)
- Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK.
- William Harvey Research Institute, Queen Mary University of London, London, UK.
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - Andrew Day
- Clinical Evaluation Research Unit, Kingston Health Science Center, Kingston, ON, Canada
| | - Danielle E Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Heyland DK, Patel J, Compher C, Rice TW, Bear DE, Lee ZY, González VC, O'Reilly K, Regala R, Wedemire C, Ibarra-Estrada M, Stoppe C, Ortiz-Reyes L, Jiang X, Day AG. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet 2023; 401:568-576. [PMID: 36708732 DOI: 10.1016/s0140-6736(22)02469-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND On the basis of low-quality evidence, international critical care nutrition guidelines recommend a wide range of protein doses. The effect of delivering high-dose protein during critical illness is unknown. We aimed to test the hypothesis that a higher dose of protein provided to critically ill patients would improve their clinical outcomes. METHODS This international, investigator-initiated, pragmatic, registry-based, single-blinded, randomised trial was undertaken in 85 intensive care units (ICUs) across 16 countries. We enrolled nutritionally high-risk adults (≥18 years) undergoing mechanical ventilation to compare prescribing high-dose protein (≥2·2 g/kg per day) with usual dose protein (≤1·2 g/kg per day) started within 96 h of ICU admission and continued for up to 28 days or death or transition to oral feeding. Participants were randomly allocated (1:1) to high-dose protein or usual dose protein, stratified by site. As site personnel were involved in both prescribing and delivering protein dose, it was not possible to blind clinicians, but patients were not made aware of the treatment assignment. The primary efficacy outcome was time-to-discharge-alive from hospital up to 60 days after ICU admission and the secondary outcome was 60-day morality. Patients were analysed in the group to which they were randomly assigned regardless of study compliance, although patients who dropped out of the study before receiving the study intervention were excluded. This study is registered with ClinicalTrials.gov, NCT03160547. FINDINGS Between Jan 17, 2018, and Dec 3, 2021, 1329 patients were randomised and 1301 (97·9%) were included in the analysis (645 in the high-dose protein group and 656 in usual dose group). By 60 days after randomisation, the cumulative incidence of alive hospital discharge was 46·1% (95 CI 42·0%-50·1%) in the high-dose compared with 50·2% (46·0%-54·3%) in the usual dose protein group (hazard ratio 0·91, 95% CI 0·77-1·07; p=0·27). The 60-day mortality rate was 34·6% (222 of 642) in the high dose protein group compared with 32·1% (208 of 648) in the usual dose protein group (relative risk 1·08, 95% CI 0·92-1·26). There appeared to be a subgroup effect with higher protein provision being particularly harmful in patients with acute kidney injury and higher organ failure scores at baseline. INTERPRETATION Delivery of higher doses of protein to mechanically ventilated critically ill patients did not improve the time-to-discharge-alive from hospital and might have worsened outcomes for patients with acute kidney injury and high organ failure scores. FUNDING None.
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Affiliation(s)
- Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Charlene Compher
- Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; Department of Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Danielle E Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Victoria C González
- Unidad de Soporte Metabólico y Nutricional Sanatorio Allende, Córdoba, Argentina
| | - Kevin O'Reilly
- King's College Hospital NHS Foundation Trust, London, UK
| | - Racquel Regala
- Clinical Nutrition, Legacy Salmon Creek Medical Center, Vancouver, WA, USA
| | - Courtney Wedemire
- Department of Food and Nutrition, Abbotsford Regional Hospital, Abbotsford, BC, Canada
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva Hospital Civil Fray Antonio Alcalde Universidad de Guadalajara, Jalisco, México
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
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Abstract
OBJECTIVES Ongoing risk of death and poor functional outcomes are important consequences of prolonged critical illness. Characterizing the catabolic phenotype of prolonged critical illness could illuminate biological processes and inform strategies to attenuate catabolism. We aimed to examine if urea-to-creatinine ratio, a catabolic signature of prolonged critical illness, was associated with mortality after the first week of ICU stay. DESIGN Reanalysis of multicenter randomized trial of glutamine supplementation in critical illness (REducing Deaths due to OXidative Stress [REDOXS]). SETTING Multiple adult ICUs. PATIENTS Adult patients admitted to ICU with two or more organ failures related to their acute illness and surviving to day 7. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The association between time-varying urea-to-creatinine ratio and 30-day mortality was tested using Bayesian joint models adjusted for prespecified-covariates (age, kidney replacement therapy, baseline Sequential Organ Failure Assessment, dietary protein [g/kg/d], kidney dysfunction, and glutamine-randomization). From 1,021 patients surviving to day 7, 166 (16.3%) died by day 30. After adjustment in a joint model, a higher time-varying urea-to-creatinine ratio was associated with increased mortality (hazard ratio [HR], 2.15; 95% credible interval, 1.66-2.82, for a two-fold greater urea-to-creatinine ratio). This association persisted throughout the 30-day follow-up. Mediation analysis was performed to explore urea-to-creatinine ratio as a mediator-variable for the increased risk of death reported in REDOXS when randomized to glutamine, an exogenous nitrogen load. Urea-to-creatinine ratio closest to day 7 was estimated to mediate the risk of death associated with randomization to glutamine supplementation (HR, 1.20; 95% CI, 1.04-1.38; p = 0.014), with no evidence of a direct effect of glutamine (HR, 0.90; 95% CI, 0.62-1.30; p = 0.566). CONCLUSIONS The catabolic phenotype measured by increased urea-to-creatinine ratio is associated with increased risk of death during prolonged ICU stay and signals the deleterious effects of glutamine administration in the REDOXS study. Urea-to-creatinine ratio is a promising catabolic signature and potential interventional target.
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Lee ZY, Yap CSL, Hasan MS, Engkasan JP, Barakatun-Nisak MY, Day AG, Patel JJ, Heyland DK. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:260. [PMID: 34301303 PMCID: PMC8300989 DOI: 10.1186/s13054-021-03693-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/15/2021] [Indexed: 12/17/2022]
Abstract
Background The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. Methods We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). Results Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75–1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD −3.44% per week, 95% CI −4.99 to −1.90; p < 0.0001). Conclusion In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03693-4.
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Affiliation(s)
- Zheng-Yii Lee
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cindy Sing Ling Yap
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - M Shahnaz Hasan
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Julia Patrick Engkasan
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Yusof Barakatun-Nisak
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,Institute for Social Science Studies, Universiti Putra Malaysia, Serdang, Malaysia
| | - Andrew G Day
- Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | | | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
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Hoffer LJ. Understanding Equipoise. Nutr Clin Pract 2020; 35:495-498. [PMID: 32347586 DOI: 10.1002/ncp.10492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 12/10/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Nutrition in Sepsis: A Bench-to-Bedside Review. Nutrients 2020; 12:nu12020395. [PMID: 32024268 PMCID: PMC7071318 DOI: 10.3390/nu12020395] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 02/06/2023] Open
Abstract
Nutrition therapy in sepsis is challenging and differs from the standard feeding approach in critically ill patients. The dysregulated host response caused by infection induces progressive physiologic alterations, which may limit metabolic capacity by impairing mitochondrial function. Hence, early artificial nutrition should be ramped-up and emphasis laid on the post-acute phase of critical illness. Caloric dosing is ideally guided by indirect calorimetry, and endogenous energy production should be considered. Proteins should initially be delivered at low volume and progressively increased to 1.3 g/kg/day following shock symptoms wane. Both the enteral and parenteral route can be (simultaneously) used to cover caloric and protein targets. Regarding pharmaconutrition, a low dose glutamine seems appropriate in patients receiving parenteral nutrition. Supplementing arginine or selenium is not recommended. High-dose vitamin C administration may offer substantial benefit, but actual evidence is too limited for advocating its routine use in sepsis. Omega-3 polyunsaturated fatty acids to modulate metabolic processes can be safely used, but non-inferiority to other intravenous lipid emulsions remains unproven in septic patients. Nutrition stewardship, defined as the whole of interventions to optimize nutritional approach and treatment, should be pursued in all septic patients but may be difficult to accomplish within a context of profoundly altered cellular metabolic processes and organ dysfunction caused by time-bound excessive inflammation and/or immune suppression. This review aims to provide an overview and practical recommendations of all aspects of nutritional therapy in the setting of sepsis.
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