Prealbumin Is Associated With In-Hospital Mortality in Critically Ill Patients

Transthyretin and Nutritional Status in Critically Ill Adults on Parenteral Nutrition: A Prospective Cohort Study

BACKGROUND AND AIMS

Correctly characterizing malnutrition is a challenge. Transthyretin (TTR) rapidly responds to adequate protein intake/infusion, which could be used as a marker to identify malnutrition. Nutritional therapy is used to prevent malnutrition. Parenteral nutrition (PN) requires daily monitoring to determine whether what is being offered is adequate. This article aims to investigate whether the practice of measuring TTR is justified.

METHODS

Data from patients admitted to the ward or intensive care unit (ICU) were collected at three different times: within the first 72 h (T1) of PN use, on the 7th day (T2), and the 14th day (T3) after the initial assessment.

RESULTS

302 patients were included; the average age was 48.3 years old; the prevalence of death was 22.2%, and 61.6% of the sample were male. TTR values and the effectiveness of nutritional support in these patients were not associated with the outcome; however, meeting caloric needs was related to the outcome (p = 0.047). No association was found when TTR values were compared to the nutritional status. Thus, TTR was not a good indicator of nutritional risk or nutritional status in hospitalized patients.

CONCLUSIONS

Undoubtedly, the TTR measurement was inversely proportional to CRP measurements. It was possible to conclude in this follow-up cohort of hospitalized patients that TTR values were not useful for determining whether the patient was malnourished, predicting death or effectiveness of nutritional support, yet based upon our analyses, a decrease in TTR greater than 0.024 units for every 1 unit increase in CRP might be due to ineffective nutritional supply.

Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients

BACKGROUND & AIMS

Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.

METHODS

This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.

RESULTS

We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047).

CONCLUSION

Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.

Predictors of acute muscle loss in the intensive care unit: A secondary analysis of an in-bed cycling trial for critically ill patients

PURPOSE

The purpose of this study was to assist clinicians to identify critically ill patients at greatest risk of acute muscle loss and to analyse the associations between protein intake and exercise on acute muscle loss.

MATERIALS AND METHODS

Secondary analysis of a single-centre randomised clinical trial of in-bed cycling using a mixed effects model was undertaken to examine the association between key variables and rectus femoris cross-sectional area (RFCSA). Groups were combined, and key variables for the cohort were modified Nutrition Risk in the Critically Ill (mNUTRIC) scores within the first days following intensive care unit admission, longitudinal RFCSA measurements, percent of daily recommended protein intake, and group allocation (usual care, in-bed cycling). RFCSA ultrasound measurements were taken at baseline and days 3, 7, and 10 to quantify acute muscle loss. All patients received usual care nutritional intake while in the intensive care unit. Patients allocated to the cycling group commenced in-bed cycling once safety criteria were met.

RESULTS

Analysis included all 72 participants, of which 69% were male, with a mean (standard deviation) age of 56 (17) years. Patients received a mean (standard deviation) of 59% (26%) of the minimum protein dose recommended for critically ill patients. Mixed-effects model results indicated that patients with higher mNUTRIC scores experienced greater RFCSA loss (estimate = -0.41; 95% confidence interval [CI] = -0.59 to -0.23). RFCSA did not share a statistically significant association with cycling group allocation (estimate = -0.59, 95% CI = -1.53 to 0.34), the percentage of protein requirements received (estimate = -0.48; 95% CI = -1.16 to 0.19), or a combination of cycling group allocation and higher protein intake (estimate = 0.33, 95% CI = -0.76 to 1.43).

CONCLUSIONS AND RELEVANCE

We found that a higher mNUTRIC score was associated with greater muscle loss, but we did not observe a relationship between combined protein delivery and in-bed cycling and muscle loss. The low protein doses achieved may have impacted the potential for exercise or nutrition strategies to reduce acute muscle loss.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN 12616000948493).

Using a Decision Tree Approach to Analyze Key Factors Influencing Intraoperative-Acquired Pressure Injury

OBJECTIVE

To determine the key factors influencing intraoperative-acquired pressure injury (IAPI).

METHODS

Researchers assessed 413 surgical patients in a Shanghai tertiary hospital using an information collection form and an IAPI occurrence record form. Analysis took place using the classification and regression tree algorithm and multiple logistic regression.

RESULTS

A total of 43 surgical patients (10.4%) had IAPI, including 32 stage 1 cases (74.4%), and 11 stage 2 cases (25.6%). The multiple logistic regression analysis indicated that operation duration, surgical position, preoperative hypertension, and preoperative Braden Scale risk score were independently associated with IAPI development. The decision tree showed that preoperative Braden Scale score, surgical position, operation grade, operation duration, age, prealbumin level, and body mass index were important factors and that preoperative Braden Scale score was the most critical decision variable. The cross-validation method was used to indicate a model accuracy of 91.8%.

CONCLUSIONS

The decision tree effectively identified key factors for IAPI, complementing the logistic regression analysis and providing a scientific basis for the further development of structural risk assessment, prevention, and treatment strategies for IAPI.

Nutritional indices may have prognostic value in elderly critically ill patients with sepsis

Aim: Nutritional indicators are associated with adverse outcomes in critically ill elderly patients. In this study, we aimed to evaluate the prognostic potential of prealbumin and albumin in the prediction of mortality in elderly patients with sepsis. Material and Method: A total of 108 patients who developed intensive care unit-acquired sepsis were divided into two groups: Survivors (n=72) and Non-survivors (n=36). Results: Patients in the Non-survivors group were often older (68 vs 74) and presented lower prealbumin (15.1 vs 11), and higher Charlson index (4 vs 6), Sequential Organ Failure Assessment (SOFA) score (8.5 vs 10), C-reactive protein (CRP) (68.8 vs 91) and procalcitonin (PCT) (6 vs 8.4) (p< 0.05). The area under the curve of PCT was the highest at 0.74. Prealbumin presented the best sensitivity (75%) and 12 mg/dL cut-off value, while PCT had the best specificity (75%) and a cut-off value of 7 ng/mL. Although prealbumin was negatively correlated to SOFA score in a significant way (r=-0.226, p=0.019), White blood cells, CRP, and PCT were positively correlated to SOFA score (r=0.198, p=0.040; r=0.233, p=0.015; r=0.286, p=0.003, respectively). In addition, a weak negative correlation was observed between prealbumin and CRP and PCT (r=-0.203, p=0.037; r=-0.215, p=0.026, respectively). Multivariate analysis showed that a reduction in serum prealbumin levels compared to steady prealbumin greater than 4 mg/dL increased the risk of death by 85% (aHR: 1.85, 95% CI: 1.05-2.56, p=0.029). Conclusion: Changes in serum prealbumin in the acute phase of sepsis may assist in determining the risk of mortality and in the administration of specific treatment in critically ill elderly patients.

Effect of Whey Proteins on Malnutrition and Extubating Time of Critically Ill COVID-19 Patients

The novel SARS-CoV-2 virus has led to a severe pandemic, starting from early 2020. Intensive care (ICU) management of the COVID-19 disease is difficult with high morbidity and mortality. Early nutritional support, especially with whey protein, seems to be crucial in this medical case. Thus, we aimed to assess the effects of an adequate nutritional protocol rich in whey protein on nutritional and inflammatory status, extubating time, and mortality of critically ill COVID-19 patients (CICP). Methods: A prospective single-center exploratory observational study was undertaken on 32 consecutive CICP admitted to the ICU of Santa Maria Hospital, Terni, Italy, and treated with whey protein-enriched formula. Patients’ demographics, nutritional status, indexes of inflammation, daily pre-albumin serum levels, duration of mechanical ventilation, and mortality were recorded. Results: Thirty-two patients were enrolled. Ninety-five percent of them showed a gradual reduction in C-reactive protein (CRP) values and increase in pre-albumin levels after the whey protein-enriched formula. Prealbumin levels were not correlated with a better nutritional status but with a shorter extubating time and better survival. Conclusions: An adequate administration of whey protein during COVID-19 patients’ ICU stays can provide fast achievement of protein targets, reducing the duration of mechanical ventilation, and improving inflammatory status and ICU survival. Further prospective and large-scale, controlled studies are needed to confirm these results.

Pre-albumin is a strong prognostic marker in elderly intensive care unit patients

Objectives

Pre-albumin (PAB) can be used to evaluate the association between nutrition status and in-hospital mortality. However, there is no literature to compare if PAB is the best indicator to predict in-hospital mortality among the nutrition indexes in a study.

Methods

We operated a retrospective study including 145 patients admitted to our institution’s elderly intensive care unit (ICU) from January, 2017 to December, 2019. Admission laboratory results were collected. Regression analysis and receiver operating curve (ROC) were analyzed to explore the performance of different nutrition indexes.

Results

The levels of PAB were significantly different between the survivor and non-survivor group (p=0.001). Univariate analysis showed nutrition indexes (lymphocytes, albumin, body mass index [BMI], geriatric nutritional risk index (GNRI), prognostic nutritional index [PNI] and PAB) were associated with in-hospital mortality (all p<0.1). Following adjustment for age, platelets and creatinine (CREA), only BMI and PAB remained statistically significant (BMI: HR 2.799, 95% CI 1.167–6.715, p=0.021; PAB: HR 6.329, 95% CI 2.660–15.151, p<0.001). In addition, PAB had the highest area under the curve (AUC) for predicting in-hospital mortality (AUC = 0.696) followed by BMI (AUC = 0.561) and other factors.

Conclusions

PAB is a better predictor of in-hospital mortality than other nutrition indexes in elderly ICU patients.