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Ferguson CE, Hayes K, Tatucu-Babet OA, Lambell KJ, Paul E, Hodgson CL, Ridley EJ. Nutrition delivery and the relationship with changes in muscle mass in adult patients receiving extracorporeal membrane oxygenation: A retrospective observational study. Aust Crit Care 2024; 37:727-733. [PMID: 38637220 DOI: 10.1016/j.aucc.2024.02.008] [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: 11/27/2023] [Revised: 02/12/2024] [Accepted: 02/23/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Adverse changes in muscle health (size and quality) are common in patients receiving extracorporeal membrane oxygenation (ECMO). Nutrition delivery may attenuate such changes, yet the relationship with muscle health remains poorly understood. This study explored the association between energy and protein delivery and changes in muscle health measured using ultrasound from baseline to day 10 and 20 in patients receiving ECMO. METHODS A secondary analysis of data from a prospective study quantifying changes in muscle health using ultrasound in adults receiving ECMO was completed. Patients were eligible for inclusion if they were prescribed artificial nutrition within 3 days of enrolment and had >1 ultrasound measurement. The primary outcome was the association between protein delivery (grams delivered and percentage of targets received) and change in rectus femoris cross-sectional area (RF-CSA) till day 20. Secondary outcomes were the association between energy and protein delivery and change in RF-CSA till day 10, RF-echogenicity, and quadriceps muscle layer thickness to day 10 and 20. Associations were assessed using Spearman's rank correlation. RESULTS Twenty-three patients (age: 48 [standard deviation {SD}: 14], 44% male) were included. Mean energy and protein delivery were 1633 kcal (SD: 374 kcal) and 70 g (SD: 17 g) equating to 79% (SD: 19%) of energy and 73% (SD: 17%) of protein targets. No association was observed between protein delivery (r = 0.167; p = 0.495) or the percentage of targets received (r = 0.096; p = 0.694) and change in RF-CSA till day 20. No other significant associations were found between energy or protein delivery and change in RF-CSA, echogenicity, or quadriceps muscle layer thickness at any time point. CONCLUSIONS This exploratory study observed no association between nutrition delivery and changes in muscle health measured using ultrasound in patients receiving ECMO. Larger prospective studies are required to investigate the association between nutrition delivery and changes in muscle health in patients receiving ECMO.
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Affiliation(s)
- Clare E Ferguson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Dietetics and Nutrition Department, Alfred Health, Melbourne, Victoria, Australia
| | - Kate Hayes
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Dietetics and Nutrition Department, Alfred Health, Melbourne, Victoria, Australia
| | - Kate J Lambell
- Dietetics and Nutrition Department, Alfred Health, Melbourne, Victoria, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia; Division of Clinical Trial and Cohort Studies, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia; The George Institute for Global Health, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Dietetics and Nutrition Department, Alfred Health, Melbourne, Victoria, Australia.
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Sabatino A, Fiaccadori E, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Cuerda C, Bischoff SC. ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2024; 43:2238-2254. [PMID: 39178492 DOI: 10.1016/j.clnu.2024.08.002] [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: 07/15/2024] [Accepted: 08/02/2024] [Indexed: 08/25/2024]
Abstract
BACKGROUND AND AIMS Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD. METHODS The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process. RESULTS The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements. CONCLUSION The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.
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Affiliation(s)
- Alice Sabatino
- Division of Renal Medicine, Baxter Novum. Department of Clinical Science, Intervention and Technology. Karolinska Institute, Stockholm, Sweden.
| | - Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Department of Intensive Care Medicine, Universitair Ziekenhuis Brussel, Department of Clinical Nutrition, Vitality Research Group, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Brussels, Belgium
| | - Joop Jonckheer
- Department of intensive Care Medicine, University Hospital Brussel (UZB), Brussels, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine. Universidad Complutense. Madrid, Spain
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Yébenes JC, Bordeje-Laguna ML, Lopez-Delgado JC, Lorencio-Cardenas C, Martinez De Lagran Zurbano I, Navas-Moya E, Servia-Goixart L. Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC). Nutrients 2024; 16:1157. [PMID: 38674847 PMCID: PMC11054493 DOI: 10.3390/nu16081157] [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: 03/01/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.
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Affiliation(s)
- Juan Carlos Yébenes
- Institut d’Assistència Sanitària (IAS)—Hospital Santa Caterina, 17007 Girona, Spain
| | | | - Juan Carlos Lopez-Delgado
- Hospital Clinic, Medical ICU, Clinical Institute of Internal Medicine & Dermatology (ICMiD), 08036 Barcelona, Spain;
| | | | | | | | - Lluis Servia-Goixart
- Intensive Care Department, Hospital Universitari Arnau de Vilanova, LLeida, 25198 Lleida, Spain;
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Abe R, Shimazui T, Sugo M, Ogawa A, Namekawa M, Kitamura N, Kido S. Achievement of adequate nutrition contributes to maintaining the skeletal muscle area in patients with sepsis undergoing early mobilization: a retrospective observational study. BMC Nutr 2024; 10:32. [PMID: 38395891 PMCID: PMC10893714 DOI: 10.1186/s40795-024-00846-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The onset of muscle loss in critically ill patients, known as intensive care unit-acquired weakness (ICU-AW), worsens their outcomes. Preventing muscle loss, which begins in the early phase of critical illness, is crucial in patient care. Adequate nutrition management may contribute to maintaining muscles; however, its evidence in patients with sepsis is insufficient. This study aimed to analyze the association between energy achievement rate in the first 7-days of critical care and muscle area changes evaluated by computed tomography (CT). METHODS This was a retrospective observational study. Patients with sepsis admitted to the intensive care (ICU) of a tertiary care hospital in Japan were included. They were divided into three groups according to tertiles of the first 7-day energy achievement rate calculated using administered energy doses and basement energy expenditure. Skeletal muscle area (SMA) and changes in SMA were determined by CT on ICU admission and within days 7-10 of ICU admission. SMA maintenance was defined as SMA change ≥ 100%. Logistic regression analyses were performed to analyze the association of energy achievement rate with SMA changes (primary outcome) and in-hospital 28-day mortality (secondary outcome). RESULTS Patients (n = 93) were classified into low, middle, and high groups according to their 7-day energy achievement rate (median rates, 16.8%, 38.8%, and 73.4%, respectively). The CT scans showed that SMA decreased between the CT scans in the low and middle groups, whereas it was maintained in the high group (median changes, -8.5%, -11.7%, and 2.8%, respectively). Univariate and multivariate logistic regression analyses showed that high energy achievement rate was significantly associated with SMA maintenance (reference, middle energy achieved group; univariate, odds ratio [95% confidence interval] 6.23 [2.04-19.10], P = 0.0013; multivariate, odds ratio [95% confidence interval] 5.92 [1.90-18.40], P = 0.0021). There was no significant difference in the association between energy achievement rate and mortality among the three groups. CONCLUSIONS Our study found that a fulfillment of energy achievement in the first 7 days of hospitalization was associated with maintenance of muscle area. Thus, satisfying adequate energy should be considered even in patients with sepsis.
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Affiliation(s)
- Ryo Abe
- Department of Rehabilitation, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba, 292-0822, Japan.
- Department of Health and Social Services, Graduate School of Saitama Prefectural University, Koshigaya, Saitama, Japan.
| | - Takashi Shimazui
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Japan
| | - Masayuki Sugo
- Department of Health and Social Services, Graduate School of Saitama Prefectural University, Koshigaya, Saitama, Japan
| | - Akihiro Ogawa
- Department of Health and Social Services, Graduate School of Saitama Prefectural University, Koshigaya, Saitama, Japan
| | - Michito Namekawa
- Department of Health and Social Services, Graduate School of Saitama Prefectural University, Koshigaya, Saitama, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Japan
| | - Satoshi Kido
- Department of Health and Social Services, Graduate School of Saitama Prefectural University, Koshigaya, Saitama, Japan
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Clouse JW, Mangus RS, Vega CA, Cabrales AE, Bush WJ, Clouse IT, Ekser B, Mihaylov P, Kubal CA. Pleural Effusion and Malnutrition Are Associated With Worse Early Outcomes After Liver Transplant. Am Surg 2023; 89:5881-5890. [PMID: 37220891 DOI: 10.1177/00031348221126962] [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] [Indexed: 05/25/2023]
Abstract
INTRODUCTION Pulmonary complications after liver transplantation (LT) have previously been associated with longer hospital stays and ventilator time, and higher mortality. This study reports the outcomes for a specific pulmonary complication, pleural effusion, in LT recipients. METHODS Records from a single transplant center were analyzed retrospectively for all adult LT patients. Patients with documented pleural effusion by radiographic imaging within 30 days pre- or post-transplant were considered as cases. Outcomes included length of hospital stay, discharge disposition, hospital readmission, discharge with home oxygen, and 1-year survival. RESULTS During the 4-year study period, 512 LTs were performed, with 107 patients (21%) developing a peri-transplant pleural effusion. In total, 49 patients (10%) had a pre-transplant effusion, 91 (18%) had a post-transplant effusion, and 32 (6%) had both. Characteristics associated with the presence of any pleural effusion included an increasing model for end-stage liver disease score, re-transplantation, diagnosis of alcoholic liver disease, low protein levels, and sarcopenia. Effusion patients had longer hospital stays (17 vs 9 days, P < .001) and higher likelihood of discharge to a care facility (48% vs 21%, P < .001). Ninety-day readmission occurred in 69% of effusion patients (vs 44%, P < .001). One-year patient survival with any effusion was 86% (vs 94%, P < .01). CONCLUSIONS Overall, 21% of recipients developed a clinically significant peri-transplant pleural effusion. Pleural effusion was associated with worse outcomes for all clinical measures. Risk factors for the development of pleural effusion included higher MELD score (>20), re-transplantation, alcoholic liver disease, and poor nutrition status, including poor muscle mass.
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Affiliation(s)
- Jared W Clouse
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carlos A Vega
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arianna E Cabrales
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Weston J Bush
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Isaac T Clouse
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Burcin Ekser
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Plamen Mihaylov
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Singer P, Blaser AR, Berger MM, Calder PC, Casaer M, Hiesmayr M, Mayer K, Montejo-Gonzalez JC, Pichard C, Preiser JC, Szczeklik W, van Zanten ARH, Bischoff SC. ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clin Nutr 2023; 42:1671-1689. [PMID: 37517372 DOI: 10.1016/j.clnu.2023.07.011] [Citation(s) in RCA: 83] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.
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Affiliation(s)
- Pierre Singer
- Intensive Care Unit, Herzlia Medical Center and Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, and Intensive Care Unit, Herzlia Medical Center, Israel.
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Mette M Berger
- Faculty of Biology and Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Michael Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Catholic University Hospitals (UZLeuven) and Catholic University Leuven, Leuven, Belgium
| | - Michael Hiesmayr
- Division Cardiac-, Thoracic-, Vascular Anaesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Konstantin Mayer
- Department of Pneumonology, Infectious Diseases and Sleep Medicine, St. Vincentius Kliniken gAG, Karlsruhe, Germany
| | | | - Claude Pichard
- Department of Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Charles Preiser
- Medical Direction, Hopital Universitaire de Bruxelles, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College & Anesthesia and Intensive Care Department, 5th Military Hospital, Krakow, Poland
| | - Arthur R H van Zanten
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands & Wageningen University & Research, Wageningen, the Netherlands
| | - Stephan C Bischoff
- Department of Nutritional Medicine/Prevention, University of Hohenheim, Stuttgart, Germany
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7
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de Heer G, Erley J, Kemper M, Ogica A, Weber T, Molwitz I. [Routine computed tomography body composition analysis-experience in intensive care patients]. Med Klin Intensivmed Notfmed 2023; 118:99-106. [PMID: 36692582 PMCID: PMC9874172 DOI: 10.1007/s00063-022-00985-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 01/25/2023]
Abstract
The assessment of the nutritional status of patients in the intensive care unit is recommended in current guidelines and should include the assessment of muscle status. A suitable method is the analysis of routine computed tomography (CT) scans, which are frequently performed in critically ill patients. With the help of special software, individual CT slices are processed and various parameters such as muscle area, muscle density or even the percentage of adipose tissue are displayed and quantified. It has been shown that cross-sectional acquisition of skeletal muscle in the lumbar spine correlates very well with total body muscle. There are defined, albeit population-based, cut-off values that can be used to establish diagnosis of sarcopenia. Monitoring of individualized nutritional therapy can be accomplished by assessment of repetitive CT examinations. The steadily growing body of data confirms that the method can make a valuable contribution to the assessment of body composition in intensive care medicine. Most of the currently available software requires time-consuming processing of the CT. Automated programs, which are now occasionally available and eliminate the need for most manual processing, may make the method even more attractive in the future. Ultimately, the risk of intensive transport to the CT or radiation exposure may be only justified for medical indications. Nevertheless, whenever CT is available for medical reasons, it should also be exploited for composition analysis.
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Affiliation(s)
- Geraldine de Heer
- Klinik für Intensivmedizin, Zentrum für Anästhesie und Intensivmedizin, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland. .,Klinik für Intensivmedizin, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Jennifer Erley
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
| | - Marius Kemper
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
| | | | - Theresa Weber
- Klinik für Intensivmedizin, Zentrum für Anästhesie und Intensivmedizin, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
| | - Isabel Molwitz
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
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Muscle size, strength, and physical function in response to augmented calorie delivery: A TARGET sub-study. J Crit Care 2022; 72:154140. [PMID: 36058058 DOI: 10.1016/j.jcrc.2022.154140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/06/2022] [Accepted: 08/18/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Augmented calories may attenuate muscle loss experienced in critical illness. This exploratory sub-study assessed the effect of augmented calorie delivery on muscle mass, strength, and function. MATERIALS AND METHODS Patients in The Augmented versus Routine approach to Giving Energy Trial (TARGET) randomised to 1.5 kcal/ml or 1.0 kcal/ml enteral formulae at a single-centre were included. Ultrasound-derived muscle layer thickness (MLT) at quadriceps, forearm and mid-upper arm, and handgrip strength, were measured weekly from baseline to hospital discharge, and 3- and 6-months. Physical function was assessed at 3- and 6-months using the 'get up and go' and 6-min walk tests. Data are mean ± SD. RESULTS Eighty patients were recruited (1.5 kcal: n = 38, 58 ± 14y, 60%M, APACHE II 20 ± 7; 1.0 kcal: n = 42, 54 ± 18y, 66%M, APACHE II 22 ± 10). The 1.5 kcal/ml group received more calories with no difference in quadriceps MLT at any timepoint including ICU discharge (primary outcome) (2.90 ± 1.27 vs 2.39 ± 1.06 cm; P = 0.141). Relationships were similar for all MLT measures, handgrip strength, and 6-min walk test. Patients in the 1.5 kcal/ml group had improved 'get up and go' test at 3-months (6.66 ± 1.33 vs. 9.11 ± 2.94 s; P = 0.014). CONCLUSION Augmented calorie delivery may not attenuate muscle loss or recovery of strength or function 6-months post-ICU, but this requires exploration in a larger trial.
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9
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Mortality and Length of Stay in Critically Ill Patients With Low Muscle Mass. TOP CLIN NUTR 2022. [DOI: 10.1097/tin.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Dreizin D, Rosales R, Li G, Syed H, Chen R. Volumetric Markers of Body Composition May Improve Personalized Prediction of Major Arterial Bleeding After Pelvic Fracture: A Secondary Analysis of the Baltimore CT Prediction Model Cohort. Can Assoc Radiol J 2021; 72:854-861. [PMID: 32910695 PMCID: PMC8011455 DOI: 10.1177/0846537120952508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
METHODS This work is a retrospective secondary analysis of a single institution cohort used in the development of the Baltimore CT prediction model. The cohort includes 115 consecutive patients that underwent admission contrast-enhanced CT of the abdomen and pelvis for blunt trauma with pelvic ring disruption followed by conventional angiography. Major arterial injury requiring angioembolization served as the outcome variable. Angioembolization was required in 73/115 patients (63% of the cohort). Average age was 46.9 years (±SD 20.4). Body composition measurements were determined as 2-dimensional (2D) or 3-dimensional (3D) parameters and included mid-L3 trabecular bone attenuation, abdominal visceral fat area or volume, and percent muscle fat fraction (as a marker of sarcopenia) measured using segmentation and histogram analysis. RESULTS Models incorporating 2D (Model B) or 3D markers (model C) of body composition showed improvement over the original Baltimore model (model A) in all parameters of performance, quality, and fit (area under the receiver-operating curve [AUC], Akaike information criterion, Brier score, Hosmer-Lemeshow test, and adjusted-R2). Area under the receiver-operating curve increased from 0.83 (A), to 0.86 (B), and 0.88 (C). The greatest improvement was seen with 3D parameters. CONCLUSION Once automated, quantitative visualization tools providing "free" 3D body composition information can be expected to improve personalized precision diagnostics, outcome prediction, and decision support in patients with bleeding pelvic fractures.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Remberto Rosales
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hassan Syed
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rong Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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11
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Sabatino A, Regolisti G, Benigno G, Di Mario F, Avesani CM, Fiaccadori E. Low skeletal muscle mass by computerized tomography is associated with increased mortality risk in end-stage kidney disease patients on hemodialysis. J Nephrol 2021; 35:545-557. [PMID: 34622417 DOI: 10.1007/s40620-021-01167-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/17/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Skeletal muscle (SM) area, as measured by abdominal CT at the level of the third lumbar vertebra (L3), has been proposed as a proxy of whole body muscle mass. However, population-specific reference values are lacking. In the present study we aimed at: (1) detecting low SM area on abdominal CT images in patients on hemodialysis by applying cut-offs derived from a group of healthy subjects, and (2) estimating the independent risk of all-cause mortality associated with low SM area. METHODS We retrospectively enrolled 212 adult patients on hemodialysis, undergoing abdominal CT scan (study group), and 87 healthy kidney donors (reference group). We obtained the gender-specific 5th percentile values of the abdominal SM area distribution from both the whole control group and the subgroup of younger (29-60 years) subjects, which we used as reference cut-offs. Then we applied those cut-offs in the study group to identify patients with low SM area. We used survival and Cox regression analysis to evaluate the risk of all-cause mortality associated with low abdominal SM area. RESULTS In the fully adjusted Cox regression analysis, the patients with low abdominal SM area had a higher risk of death than the patients with values above the reference cut-off derived in the subgroup of younger controls (adjHR = 1.79 (1.21; 2.67), P = 0.004). CONCLUSIONS Abdominal CT imaging can be used to detect low abdominal SM area in patients on hemodialysis by applying cut-offs derived from healthy subjects sharing a similar ethnic background. Low SM area as assessed by CT is independently associated with all-cause mortality in ESKD patients on hemodialysis.
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Affiliation(s)
- Alice Sabatino
- UO Nefrologia, Azienda Ospedaliera- Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy. .,Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.
| | - Giuseppe Regolisti
- UO Nefrologia, Azienda Ospedaliera- Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.,Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Giuseppe Benigno
- UO Nefrologia, Azienda Ospedaliera- Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.,Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliera- Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.,Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Carla Maria Avesani
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliera- Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy.,Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
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12
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Relationship Between Skeletal Muscle Area and Density and Clinical Outcome in Adults Receiving Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 49:e350-e359. [PMID: 33497166 DOI: 10.1097/ccm.0000000000004827] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To investigate the prevalence of low skeletal muscle index (area normalized for height) and density, their trajectory of change, and to determine associations with clinical outcome in adults with severe respiratory failure requiring venovenous extracorporeal membrane oxygenation. DESIGN Prospective observational study. PATIENTS Adults receiving venovenous extracorporeal membrane oxygenation for a minimum of 72 hours and a maximum of 6 months between September 2010 and June 2017, who had a CT scan which included the third lumbar vertebra. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Skeletal muscle index and density was determined using Slice-O-Matic V5.0 (TomoVision, Montreal, QC, Canada). Low skeletal muscle index and density were defined using published criteria. Regression models were used to assess for associations between muscle index and density and clinical outcome. Two-hundred fifteen patients, median (interquartile range) age 46 years (35.0-57.0 yr) were included. Forty-five patients (21.1%) had low skeletal muscle index, and 48 (22.3%) had low skeletal muscle density on commencement of venovenous extracorporeal membrane oxygenation. Low skeletal muscle index was more prevalent in males (28.8% vs 11.6%; χ2 = 9.4; p = 0.002) and was associated with a longer duration of venovenous extracorporeal membrane oxygenation (B = 5.0; 95% CI, 0.2-9.9; p = 0.042). Higher skeletal muscle density was independently associated with ICU survival (odds ratio 1.6 per 10 Hounsfield units; 95% CI, 1.1-2.5; p = 0.025). No relationship was observed between skeletal muscle index nor density and physical function. Adequacy of energy and protein did not influence change in skeletal muscle index or density. CONCLUSIONS Low skeletal muscle index at the commencement of venovenous extracorporeal membrane oxygenation was associated with a longer duration of venovenous extracorporeal membrane oxygenation, whereas preserved skeletal muscle density was associated with improved survival.
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13
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Shi X, Shen Y, Yang J, Du W, Yang J. The relationship of the geriatric nutritional risk index to mortality and length of stay in elderly patients with acute respiratory failure: A retrospective cohort study. Heart Lung 2021; 50:898-905. [PMID: 34411871 DOI: 10.1016/j.hrtlng.2021.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/26/2021] [Accepted: 07/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Elderly people with acute respiratory failure (ARF) have prolonged length of hospital stay (LOS) and high mortality rates. Malnutrition is negatively correlated with these LOS and mortality. However, no tools have been used to detect the risk of malnutrition and assist in designing nutritional support for these patients. The geriatric nutritional risk index (GNRI) is reported as a novel tool for evaluating the risk of malnutrition. The aim of this study is to explore the relationship of the GNRI score with mortality and LOS in elderly patients with ARF. METHODS Data of elderly patients diagnosed with ARF were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. A total of 1250 patients were divided into two groups based on their GNRI score: the malnutrition risk group (GNRI ≤ 98) and no risk group (GNRI > 98). The primary endpoints of this study were hospital mortality and hospital LOS. RESULTS The higher GNRI score was associated with lower hospital mortality and shorter hospital LOS. Odds ratio (OR) for hospital mortality of patients with nutritional risk (GNRI ≤ 98) was 1.264 (95% CI:1.067-1.497) in the adjusted model. Patients with GNRI ≤98 had longer hospital LOS (adjusted OR: 1.142, 95%CI: 1.044-1.250) compared with those with GNRI > 98. Subgroup analysis showed that higher GNRI was only significantly associated with lower hospital mortality in the patients that did not undergo mechanical ventilator (MV) treatment (adjusted OR: 0.985, 95% CI: 0.977-0.992, P < 0.01). Kaplan-Meier curve analysis showed that the 90-day survival was significantly lower in the group with nutrition risk (GNRI≤98) compared with the no risk group (GNRI > 98, p < 0.05). CONCLUSION These findings imply that GNRI is a useful prognostic tool in elderly patients with ARF.
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Affiliation(s)
- Xiawei Shi
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Yueqian Shen
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Yang
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Wurong Du
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Junchao Yang
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang Chinese Medical University, No.54 Youdian Road, Shangcheng District, Hangzhou, Zhejiang 310006, China.
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14
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Zhang Q, Zhou J, Zhu D, Zhou S. Evaluation of the effect of high protein supply on diaphragm atrophy in critically ill patients receiving prolonged mechanical ventilation. Nutr Clin Pract 2021; 37:402-412. [PMID: 34101252 DOI: 10.1002/ncp.10672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Our aim was to evaluate the effect of high protein to the target of 2.0 g/kg/d on diaphragm atrophy and clinical prognosis of patients receiving prolonged mechanical ventilation (MV). METHODS This prospective, randomized, controlled, single-center study included 41 patients who were treated with ≥7 days' MV. The patients were randomly divided into a standard nutrition treatment (SNT) group and intensive nutrition treatment (INT) group, followed by evaluation of computer tomography-analyzed diaphragm volume, the level of butyrylcholinesterase (BChE) as a muscle mass indicator, and respiratory mechanics indices weekly to observe and compare the differences between the groups. RESULTS In the INT group, the actual protein (1.70 ± 0.21 vs 1.06 ± 0.21 g/kg/d, P < .001) and calorie intake (33.46 ± 2.78 vs 25.75 ± 4.81 kcal/kg/d, P < .001) were significantly different from those of the SNT group. Compared with the SNT group, the INT group's diaphragm atrophy improved in the fourth and fifth weeks (all P < .05). The BChE after the third week was higher (all P < .05). No significant differences in respiratory mechanical indices and clinical outcomes were found in the surviving patients between the groups. CONCLUSION INT improved the diaphragm atrophy and muscle mass of critically ill patients receiving prolonged MV. There was no evidence that increasing protein to the target amount of 2.0 g/kg/d is related to improvement in clinical prognosis for patients receiving prolonged MV.
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Affiliation(s)
- Qian Zhang
- Department of Geriatrics ICU, the First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
| | - Jing Zhou
- Department of Geriatrics ICU, the First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
| | - Dongmei Zhu
- Department of Geriatrics ICU, the First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
| | - Suming Zhou
- Department of Geriatrics ICU, the First Affiliated Hospital with Nanjing Medical University, Nanjing, People's Republic of China
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15
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Marasco G, Dajti E, Ravaioli F, Brocchi S, Rossini B, Alemanni LV, Peta G, Bartalena L, Golfieri R, Festi D, Colecchia A, Renzulli M. Clinical impact of sarcopenia assessment in patients with liver cirrhosis. Expert Rev Gastroenterol Hepatol 2021; 15:377-388. [PMID: 33196344 DOI: 10.1080/17474124.2021.1848542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Sarcopenia is defined as loss of skeletal muscle mass, strength, and function, and it is associated with increased morbidity and mortality in patients with chronic liver disease.Areas covered: The aim of this review is to provide a detailed report on the pathophysiological mechanisms underlying sarcopenia in cirrhotic patients, the several imaging methods available for the assessment of sarcopenia and the clinical studies evaluating the prognostic role of sarcopenia presence in cirrhotic patients.Expert opinion: Sarcopenia pathogenesis is complex and multifaceted, as chronic catabolic conditions, increased energy expenditure, reduced appetite, side effects of multiple therapies, alterations in circulating levels of hormones, low protein synthesis, presence of ascites or portosystemic shunts are all factors contributing to muscle atrophy in cirrhotic patients. Computed tomography scan is the most validated method to evaluate muscle mass and quality. Sarcopenia is associated with a higher rate waitlist mortality, hepatic encephalopathy, and lower quality of life in patients with liver cirrhosis. Future studies should make an effort to unify and validate liver disease-specific cutoffs for the definition of sarcopenia.
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Affiliation(s)
- Giovanni Marasco
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Elton Dajti
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Stefano Brocchi
- Radiology Unit, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | - Benedetta Rossini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | | | - Giuliano Peta
- Radiology Unit, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | - Laura Bartalena
- Radiology Unit, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Matteo Renzulli
- Radiology Unit, Sant'Orsola Malpighi Hospital, Bologna, Italy
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16
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Baggerman MR, van Dijk DPJ, Winkens B, Schnabel RM, van Gassel RJJ, Bol ME, Bakers FC, Olde Damink SWM, van de Poll MCG. Edema in critically ill patients leads to overestimation of skeletal muscle mass measurements using computed tomography scans. Nutrition 2021; 89:111238. [PMID: 33895558 DOI: 10.1016/j.nut.2021.111238] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/28/2021] [Accepted: 02/28/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Changes in muscle mass and quality are important targets for nutritional intervention in critical illness. Effects of such interventions may be assessed using sequential computed tomography (CT) scans. However, fluid and lipid infiltration potentially affects muscle area measurements. The aim of this study was to evaluate changes in muscle mass and quality in critical illness with special emphasis on the influence of edema on this assessment. METHODS Changes in skeletal muscle area index (SMI) and radiation attenuation (RA) at the level of vertebra L3 were analyzed using sequential CT scans of 77 patients with abdominal sepsis. Additionally, the relation between these changes and disease severity using the maximum Sequential Organ Failure Assessment (SOFA) score and change in edema were studied. RESULTS SMI declined on average 0.35%/d (±1.22%; P = 0.013). However, SMI increased in 41.6% of the study population. Increasing edema formation was significantly associated with increased SMI and with a higher SOFA score. Muscle RA decreased during critical illness, but was not significantly associated with changes in SMI or changes in edema. CONCLUSION In critically ill patients, edema affects skeletal muscle area measurements, which leads to an overestimation of skeletal muscle area. A higher SOFA score was associated with edema formation. Because both edema and fat infiltration may affect muscle RA, the separate effects of these on muscle quality are difficult to distinguish. When using abdominal CT scans to changes in muscle mass and quality in critically ill patients, researchers must be aware and careful with the interpretation of the results.
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Affiliation(s)
- Michelle R Baggerman
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Intensive Care Medicine, Laurentius hospital, Roermond, the Netherlands.
| | - David P J van Dijk
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rob J J van Gassel
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martine E Bol
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Frans C Bakers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
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17
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Fiaccadori E, Sabatino A, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Singer P, Cuerda C. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2021; 40:1644-1668. [PMID: 33640205 DOI: 10.1016/j.clnu.2021.01.028] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.
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Affiliation(s)
- Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alice Sabatino
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Adamasco Cupisti
- Nephrology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Intensive Care, University Hospital Brussels (UZB), Department of Nutrition, UZ Brussel, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Bruxelles, Belgium
| | | | - Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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18
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Imaging Software-Based Sarcopenia Assessment in Gastroenterology: Evolution and Clinical Meaning. Can J Gastroenterol Hepatol 2021; 2021:6669480. [PMID: 33505942 PMCID: PMC7806369 DOI: 10.1155/2021/6669480] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
Sarcopenia is gaining attention as a negative prognostic factor in different fields of medicine, including chronic liver failure. However, the assessment of sarcopenia in patients with liver diseases is often neglected due to unawareness of reliable tools and methods and thus is limited to research studies. Cross-sectional imaging is a diffuse diagnostic tool and is commonly performed in patients with chronic liver failure. The last advancements in radiology image analysis using dedicated software allow an easy and standardized method to assess skeletal muscle volume. Several measures can be obtained from cross-sectional imaging analysis to evaluate sarcopenia in patients affected by chronic liver disease. We aimed to review the recent advances in imaging-based sarcopenia assessment, in particular in patients with chronic liver diseases. As a result, we found that the skeletal muscle index (SMI) seems to be a reliable method to assess sarcopenia in cirrhotic patients. Even if further studies are needed to validate proper cut-offs for each clinical endpoint, physicians are invited to consider the assessment of sarcopenia in the work-up of patients with chronic liver disease.
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19
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Lambell KJ, Goh GS, Tierney AC, Forsyth A, Nanjayya V, Nyulasi I, King SJ. Marked losses of computed tomography-derived skeletal muscle area and density over the first month of a critical illness are not associated with energy and protein delivery. Nutrition 2020; 82:111061. [PMID: 33341597 DOI: 10.1016/j.nut.2020.111061] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Changes in muscularity during different phases of critical illness are not well described. This retrospective study aimed to describe changes in computed tomography (CT)-derived skeletal muscle area (SMA) and density (SMD) across different weeks of critical illness and investigate associations between changes in these parameters and energy and protein delivery. METHODS Thirty-two adults admitted to the intensive care unit (ICU) who had ≥2 CT scans at the third lumbar area performed ≥7 d apart were included in the study. CT-derived SMA (cm2) and SMD (Hounsfield units) were determined using specialized software. A range of clinical and nutrition variables were collected for each day between comparator scans. Associations were assessed by Pearson or Spearman correlations. RESULTS There was a significant decrease in SMA between the two comparator scans where the first CT scan was performed in ICU wk 1 (n = 20; P < .001), wk 2 (n = 11; P < .007), and wk 3 to 4 (n = 7; P = .012). There was no significant change in SMA beyond ICU wk 5 to 7 (P = .943). A significant decline in SMD was observed across the first 3 wk of ICU admission (P < .001). Overall, patients received a mean 24 ± 6 kcal energy/kg and 1.1 ± 0.4 g protein/kg per study day and 83% of energy and protein requirements according to dietitian estimates. No association between SMA or SMD changes and nutrition delivery were found. CONCLUSIONS Critically ill patients experience marked losses of SMA over the first month of critical illness, attenuated after wk 5 to 7. Energy and protein delivery were not associated with degree of muscle loss.
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Affiliation(s)
- Kate J Lambell
- Nutrition Department, Alfred Health, Melbourne, Australia; Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, Australia.
| | - Gerard S Goh
- Department of Radiology, The Alfred, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia; National Trauma Research Institute, Melbourne, Australia
| | - Audrey C Tierney
- Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, Australia; School of Allied Health and Health Implementation Science and Technology Cluster, Health Research Institute, University of Limerick, Ireland
| | - Adrienne Forsyth
- Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, Australia
| | - Vinodh Nanjayya
- Intensive Care Unit, The Alfred, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Ibolya Nyulasi
- Nutrition Department, Alfred Health, Melbourne, Australia
| | - Susannah J King
- Nutrition Department, Alfred Health, Melbourne, Australia; Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, Australia
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20
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Sabatino A, D'Alessandro C, Regolisti G, di Mario F, Guglielmi G, Bazzocchi A, Fiaccadori E. Muscle mass assessment in renal disease: the role of imaging techniques. Quant Imaging Med Surg 2020; 10:1672-1686. [PMID: 32742960 DOI: 10.21037/qims.2020.03.05] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Muscle wasting is a frequent finding in patients with chronic kidney disease (CKD), especially in those with end-stage kidney disease (ESKD) on chronic dialysis. Muscle wasting in CKD is a main feature of malnutrition, and results principally from a vast array of metabolic derangements typical of the syndrome, that converge in determining reduced protein synthesis and accelerated protein catabolism. In this clinical setting, muscle wasting is also frequently associated with disability, frailty, infections, depression, worsened quality of life and increased mortality. On these grounds, the evaluation of nutritional status is crucial for an adequate management of renal patients, and consists of a comprehensive assessment allowing for the identification of malnourished patients and patients at nutritional risk. It is based essentially on the assessment of the extent and trend of body weight loss, as well as of spontaneous dietary intake. Another key component of this evaluation is the determination of body composition, which, depending on the selected method among several ones available, can identify accurately patients with decreased muscle mass. The choice will depend on the availability and ease of application of a specific technique in clinical practice based on local experience, staff resources and good repeatability over time. Surrogate methods, such as anthropometry and bioimpedance analysis (BIA), represent the most readily available techniques. Other methods based on imaging modalities [dual-energy X-ray absorptiometry (DXA), magnetic resonance imaging (MRI), and whole body computed tomography (CT)] are considered to be the "gold standard" reference methods for muscle mass evaluation, but their use is mainly confined to research purposes. New imaging modalities, such as segmental CT scan and muscle ultrasound have been proposed in recent years. Particularly, ultrasound is a promising technique in this field, as it is commonly available for bedside evaluation of renal patients in nephrology wards. However, more data are needed before a routine use of ultrasound for muscle mass evaluation can be recommended in clinical practice.
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Affiliation(s)
- Alice Sabatino
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Claudia D'Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Regolisti
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Francesca di Mario
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giuseppe Guglielmi
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Enrico Fiaccadori
- Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.,UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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21
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Duan K, Gao X, Zhu D. The clinical relevance and mechanism of skeletal muscle wasting. Clin Nutr 2020; 40:27-37. [PMID: 32788088 DOI: 10.1016/j.clnu.2020.07.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/15/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023]
Abstract
Skeletal muscle wasting occurs in both chronic and acute diseases. Increasing evidence has shown this debilitating process is associated with short- and long-term outcomes in critical, cancer and surgical patients. Both muscle quantity and quality, as reflected by the area and density of a given range of attenuation in CT scan, impact the patient prognosis. In addition, ultrasound and bioelectrical impedance analysis (BIA) are also widely used in the assessment of body composition due to their bedside viability and no radioactivity. Mechanism researches have revealed complicated pathways are involved in muscle wasting, which include altered IGF1-Akt-FoxO signaling, elevated levels of myostatin and activin A, activation of NF-κB pathway and glucocorticoid effects. Particularly, central nervous system (CNS) has been proven to participate in regulating muscle wasting in various conditions, such as infection and tumor. Several promising therapeutic agents have been under developing in the treatment of muscle atrophy, such as myostatin antagonist, ghrelin analog, non-steroidal selective androgen receptor modulators (SARMs). Notably, nutritional therapy is still the fundamental support in combating muscle wasting. However, the optimizing and tailored nutrition regimen relies on accurate metabolism measurement and large clinical trials in the future. Here, we will discuss the current understanding of muscle wasting and potential treatment in clinical practice.
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Affiliation(s)
- Kaipeng Duan
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, PR China
| | - Xin Gao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, PR China
| | - Dongming Zhu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, PR China.
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22
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Fetterplace K, Ridley EJ, Beach L, Abdelhamid YA, Presneill JJ, MacIsaac CM, Deane AM. Quantifying Response to Nutrition Therapy During Critical Illness: Implications for Clinical Practice and Research? A Narrative Review. JPEN J Parenter Enteral Nutr 2020; 45:251-266. [PMID: 32583880 DOI: 10.1002/jpen.1949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/17/2020] [Indexed: 11/09/2022]
Abstract
Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.
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Affiliation(s)
- Kate Fetterplace
- Department of Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Emma J Ridley
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Nutrition Department, The Alfred Hospital, Commercial Road, Melbourne, Australia
| | - Lisa Beach
- Department of Allied Health (Physiotherapy), Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jeffrey J Presneill
- Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christopher M MacIsaac
- Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam M Deane
- Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
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23
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Singer P. Protein metabolism and requirements in the ICU. Clin Nutr ESPEN 2020; 38:3-8. [PMID: 32690175 DOI: 10.1016/j.clnesp.2020.03.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/03/2020] [Accepted: 03/09/2020] [Indexed: 11/26/2022]
Abstract
The critically ill patient is highly catabolic, loosing significant amounts of protein and muscle. This proteolysis may induce a loss of 20% of the muscle mass in 10 days of hospitalization. Muscle loss may be assessed measuring urinary nitrogen excretion, muscle mass by ultrasound, bioimpedance, computerized tomography or MRI. To reduce the negative nitrogen balance, protein can be administrated enterally, or parenterally through amino acids as a part of parenteral nutrition. ESPEN guidelines recommend to administer 1.3 g/kg/day of protein to critically ill patients but this recommendation should be adapted according to clinical conditions. Elderly, obese, trauma, burn, acute kidney injury patients should receive larger amount of protein.
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Affiliation(s)
- Pierre Singer
- Department of Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tiqva, 49100, Israel.
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24
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Dusseaux MM, Antoun S, Grigioni S, Béduneau G, Carpentier D, Girault C, Grange S, Tamion F. Skeletal muscle mass and adipose tissue alteration in critically ill patients. PLoS One 2019; 14:e0216991. [PMID: 31194755 PMCID: PMC6563951 DOI: 10.1371/journal.pone.0216991] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 05/02/2019] [Indexed: 12/13/2022] Open
Abstract
Background Increasing numbers of studies in chronic diseases have been published showing the relationship between body composition (BC) parameters (i.e. skeletal muscle mass (SMM) and adipose tissue (AT)) and outcomes. For patients admitted to intensive care unit (ICU), BC parameters have rarely been described as a prognostic marker of outcome. The primary objective was to evaluate the relationship between body composition at ICU admission and major clinical outcomes. Secondary objectives were to assess the relationship between BC parameters and other parameters (systemic inflammatory markers, Sequential Organ Failure Assessment (SOFA) score, albumin level) at ICU admission, and between BC alterations during ICU stay and outcomes. Patients and methods This retrospective study enrolled 25 adult patients who had two abdominal CT scans for clinical indication: first, within 48 hours of ICU admission (initial assessment), and second, 7 to 14 days later (late assessment). Skeletal Muscle radiodensity (SMD), cross-sectional area of SMM, Visceral Adipose Tissue (VAT) and Subcutaneous Adipose Tissue (SAT) were measured at the third lumbar vertebra. Cox regression analysis was used to determine the association between these parameters and mortality. Results Patients’ mean age was 64.6 years. Their mean BMI was 27.7 kg/m2 (SD = 6.0). ICU mortality was 36%. There was no correlation between BC parameters at initial assessment and ICU outcomes. We observed a negative correlation between SMM index and SOFA score at initial assessment (r = -0.458, p = 0.037). There was a significant loss of VAT between two CT assessments which was associated with mortality (-22.34cm2 / m2 in non-survivors versus -6.22 cm2 / m2 in survivors, p = 0.039). Loss of SMD was greater with the occurrence of an infection than without (Delta SMD = -5.642 vs +1.957, p = 0.04). Conclusions Our results show alterations in body composition during ICU stay with a loss of muscle quality (decreased SMD) and adipose tissue. These findings require confirmation in future studies but already show that BC assessments at ICU admission and BC alterations during ICU stay are important factors for outcome in critically ill patients.
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Affiliation(s)
| | - Sami Antoun
- Gustave Roussy Institute, Emergency Unit, Villejuif, France
| | - Sébastien Grigioni
- Normandie University, UNIROUEN, Inserm U 1073, Rouen University Hospital, Rouen, France
| | - Gaétan Béduneau
- Department of Intensive Care, Rouen University Hospital, Rouen, France
| | | | | | - Steven Grange
- Department of Intensive Care, Rouen University Hospital, Rouen, France
| | - Fabienne Tamion
- Normandie University, UNIROUEN, Inserm U 1096, Rouen University Hospital, Rouen, France
- * E-mail:
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25
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Fetterplace K, Beach LJ, MacIsaac C, Presneill J, Edbrooke L, Parry SM, Rechnitzer T, Curtis R, Berney S, Deane AM, Denehy L. Associations between nutritional energy delivery, bioimpedance spectroscopy and functional outcomes in survivors of critical illness. J Hum Nutr Diet 2019; 32:702-712. [PMID: 31034122 DOI: 10.1111/jhn.12659] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life; nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes. METHODS A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48 h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C); (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SS score of less than 48/60. RESULTS The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650) kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000 kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.4-3.3, P = 0.001] and malnutrition (OR = 1.9, 95% CI = 1.1-3.2, P = 0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3 kg; 95% CI = -2.4 to -0.2, P = 0.02) and physical function scores (-0.6 points; 95% CI = -0.9 to -0.3, P = 0.001). CONCLUSIONS Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.
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Affiliation(s)
- K Fetterplace
- Department of Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - L J Beach
- Department of Allied Health (Physiotherapy), Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - C MacIsaac
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - J Presneill
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - L Edbrooke
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia
| | - S M Parry
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia
| | - T Rechnitzer
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - R Curtis
- Department of Allied Health (Physiotherapy), Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - S Berney
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - A M Deane
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - L Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia
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Abstract
Malnutrition continues to be highly prevalent in hospitalized and critically ill patients and is associated with significant morbidity and mortality. Additionally, survivors of critical illness have an increased risk for sarcopenia, which leads to weakness and physical debilitation that can persist for years. Nutrition risk assessment tools have been developed and validated in critically ill patients but have limitations. Variables such as body weight, body mass index, weight change, or percentage of food intake can be difficult to obtain in critically ill patients and may be misleading given changes in body composition, such as an increase in body water. Assessment of body composition through new techniques provides a unique opportunity to counter some of these limitations and develop improved methods of nutrition risk assessment based on objective data. The present manuscript provides a review of the most commonly available clinical technology for assessment of body composition (bioimpedance, computed tomography, and ultrasound), including data from trials in critically ill patients highlighting the benefits and weaknesses of each modality.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert Martindale
- Department of General Surgery, Oregon Health & Science University, Portland, Oregon, USA
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27
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Price KL, Earthman CP. Update on body composition tools in clinical settings: computed tomography, ultrasound, and bioimpedance applications for assessment and monitoring. Eur J Clin Nutr 2018; 73:187-193. [DOI: 10.1038/s41430-018-0360-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 12/31/2022]
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28
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ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2018; 38:48-79. [PMID: 30348463 DOI: 10.1016/j.clnu.2018.08.037] [Citation(s) in RCA: 1319] [Impact Index Per Article: 219.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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29
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Bush WJ, Davis JP, Maluccio MA, Kubal CA, Salisbury JB, Mangus RS. Computed Tomography Measures of Nutrition in Patients With End-Stage Liver Disease Provide a Novel Approach to Characterize Deficits. Transplant Proc 2018; 50:3501-3507. [PMID: 30586837 DOI: 10.1016/j.transproceed.2018.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/19/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with cirrhosis and end-stage liver disease (ESLD) develop severe nutrition deficits that affect morbidity and mortality. Laboratory measures of nutrition fail to fully assess clinical deficits in muscle mass and fat stores. This study employs computed tomography imaging to assess muscle mass and subcutaneous and visceral fat stores in patients with ESLD. METHODS This 1:1 case-control study design compares ESLD patients with healthy controls. Study patients were selected from a database of ESLD patients using a stratified method to assure a representative sample based on age, body mass index (BMI), sex, and model for end-stage liver disease score (MELD). Control patients were trauma patients with a low injury severity score (<10) who had a computed tomography scan during evaluation. Cases and controls were matched for age ± 5 years, sex, and BMI ± 2. RESULTS There were 90 subjects and 90 controls. ESLD patients had lower albumin levels (P < .001), but similar total protein levels (P = .72). ESLD patients had a deficit in muscle mass (-19%, P < .001) and visceral fat (-13%, P < .001), but similar subcutaneous fat (-1%, P = .35). ESLD patients at highest risk for sarcopenia included those over age 60, BMI<25.0, and female sex. We found degree of sarcopenia to be independent of model for end-stage liver disease score. CONCLUSIONS These results support previous research demonstrating substantial nutrition deficits in ESLD patients that are not adequately measured by laboratory testing. Patients with ESLD have significant deficits of muscle and visceral fat stores, but a similar amount of subcutaneous fat.
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Affiliation(s)
- W J Bush
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN
| | - J P Davis
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN
| | - M A Maluccio
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN
| | - C A Kubal
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN
| | - J B Salisbury
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN
| | - R S Mangus
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN.
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30
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Abstract
With the emerging interest in documenting and understanding muscle atrophy and function in critically ill patients and survivors, ultrasonography has transformational potential for measurement of muscle quantity and quality. We discuss the importance of quantifying skeletal muscle in the intensive care unit setting. We also identify the merits and limitations of various modalities that are capable of accurately and precisely measuring muscularity. Ultrasound is emerging as a potentially powerful tool for skeletal muscle quantification; however, there are key challenges that need to be addressed in future work to ensure useful interpretation and comparability of results across diverse observational and interventional studies. Ultrasound presents several methodological challenges, and ultimately muscle quantification combined with metabolic, nutritional, and functional markers will allow optimal patient assessment and prognosis. Moving forward, we recommend that publications include greater detail on landmarking, repeated measures, identification of muscle that was not assessable, and reproducible protocols to more effectively compare results across different studies.
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31
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Combination of APACHE Scoring Systems with Adductor Pollicis Muscle Thickness for the Prediction of Mortality in Patients Who Spend More Than One Day in the Intensive Care Unit. Crit Care Res Pract 2018; 2018:5490346. [PMID: 29973987 PMCID: PMC6008737 DOI: 10.1155/2018/5490346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/17/2018] [Accepted: 04/22/2018] [Indexed: 11/17/2022] Open
Abstract
Background The objective of the present study was to compare the ability of Acute Physiology and Chronic Health Evaluation (APACHE) scoring systems with the combination of an anthropometric variable score “adductor pollicis muscle (APM) thickness” to the APACHE systems in predicting mortality in the intensive care unit. Methods A prospective observational study was conducted with the APM thickness in the dominant hand, and APACHE II and III scores were measured for each patient upon admission. Given scores for the APM thickness were added to APACHE score systems to make two composite scores of APACHE II-APM and APACHE III-APM. The accuracy of the two composite models and APACHE II and III systems in predicting mortality of patients was compared using the area under the ROC curve. Results Three hundred and four patients with the mean age of 54.75 ± 18.28 years were studied, of which 96 (31.57%) patients died. Median (interquartile range) of APACHE II and III scores was 15 (12–20) and 47 (33–66), respectively. Median (interquartile range) of APM thickness was 15 (12–17) mm, respectively. The area under the ROC curves for the prediction of mortality was 0.771 (95% CI: 0.715–0.827), 0.802 (95% CI: 0.751–0.854), 0.851 (95% CI: 0.807–0.896), and 0.865 (95% CI: 0.822–0.908) for APACHE II, APACHE III, APACHE II-APM, and APACHE III-APM, respectively. Conclusion Although improvements in the area under ROC curves were not statistically significant when the APM thickness added to the APACHE systems, but the numerical value added to AUCs are considerable.
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32
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Lambell KJ, King SJ, Forsyth AK, Tierney AC. Association of Energy and Protein Delivery on Skeletal Muscle Mass Changes in Critically Ill Adults: A Systematic Review. JPEN J Parenter Enteral Nutr 2018; 42:1112-1122. [PMID: 29603281 DOI: 10.1002/jpen.1151] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 01/10/2018] [Indexed: 12/15/2022]
Abstract
Critically ill patients experience significant and rapid loss of skeletal muscle mass, which has been associated with negative clinical outcomes. The aetiology of muscle wasting is multifactorial and nutrition delivery may play a role. A systematic literature review was conducted to examine the association of energy and/or protein provision on changes in skeletal muscle mass in critically ill patients. Key databases were searched up until March 2016 to identify studies that measured skeletal muscle mass and/or total body protein (TBP) at 2 or more time points during acute critical illness (up to 2 weeks after an intensive care unit [ICU] stay). Studies were included if there was documentation of participant energy balance or mean energy delivered to participants during the time period between body composition measurements. Six studies met inclusion criteria. A variety of methods were used to assess skeletal muscle mass or TBP. Participants in included studies experienced differing levels of muscle loss (0%-22.5%) during the first 2 weeks of ICU admission. No association between energy and protein delivery and changes in skeletal muscle mass were observed. This review highlights that there is currently limited high-quality evidence to clearly define the association between energy and/or protein delivery and skeletal muscle mass changes in acute critical illness. Future studies in this area should be adequately powered, account for all potential confounding factors to changes in skeletal muscle mass, and detail all sources and quantities of energy and protein delivered to participants.
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Affiliation(s)
- Kate J Lambell
- Nutrition Department, The Alfred, Melbourne, Victoria, Australia.,Department of Rehabilitation, Nutrition and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Susannah J King
- Nutrition Department, The Alfred, Melbourne, Victoria, Australia.,Department of Rehabilitation, Nutrition and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Adrienne K Forsyth
- Department of Rehabilitation, Nutrition and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Audrey C Tierney
- Nutrition Department, The Alfred, Melbourne, Victoria, Australia.,Department of Rehabilitation, Nutrition and Sport, La Trobe University, Bundoora, Victoria, Australia.,Department of Clinical Therapies, University of Limerick, Ireland
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33
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Irlbeck T, Janitza S, Poros B, Golebiewski M, Frey L, Paprottka PM, da Silva T, Irlbeck M, Böcker W, Weig T. Quantification of Adipose Tissue and Muscle Mass Based on Computed Tomography Scans: Comparison of Eight Planimetric and Diametric Techniques Including a Step-By-Step Guide. Eur Surg Res 2018; 59:23-34. [PMID: 29393202 DOI: 10.1159/000486173] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 12/08/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent scientific work proved that knowledge about body composition beyond the body mass index is essential. Both adipose tissue and muscular status are determining risk factors of morbidity and mortality. Analysis of single cross-sectional computed tomography (CT) images, acquired during routine care only to prevent additional radiation exposure, provide a detailed insight into the body composition of chronically and critically ill patients. METHODS This retrospective study included 490 trauma patients of whom a whole-body multiple detector CT scan was acquired at admission. From a single cross-sectional CT, we compared eight diametric and planimetric techniques for the assessment of core muscle mass as well as visceral and subcutaneous adipose tissue. Furthermore, we derived formulas for converting the measurement results of various techniques into each other. RESULTS For intra- and interobserver reliability, we obtained intraclass correlation coefficients (ICCs) ranging from 0.947 to 0.997 (intraobserver reliability) and from 0.850 to 0.998 (interobserver reliability) for planimetric measurements. Diametric techniques conferred lower ICCs with 0.851-0.995 and 0.833-0.971, respectively. Overall, area-based measurements of abdominal adipose tissue yielded highly correlated results with diametric measures of obesity. For example, the Pearson correlation of visceral adipose tissue and sagittal abdominal diameter was 0.87 for male and 0.82 for female patients. Planimetric and diametric muscle measurements correlated best for lean psoas area and bilateral diametric measurement of the psoas with a Pearson correlation of 0.90 and 0.93 for male and female patients, respectively. CONCLUSION Planimetric measurements should remain the gold standard to describe fat and muscle compartments. Diametric measurements could however serve as a surrogate if planimetric techniques are not readily available or feasible as for example in large registries.
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Affiliation(s)
- Thomas Irlbeck
- Department of Anesthesiology, University Hospital Munich (LMU), Munich, Germany
| | - Silke Janitza
- Department of Medical Informatics, Biometry and Epidemiology, Ludwig Maximilians University Munich (LMU), Munich, Germany
| | - Balázs Poros
- Department of Anesthesiology, University Hospital Munich (LMU), Munich, Germany
| | - Monika Golebiewski
- Department of Anesthesiology, University Hospital Munich (LMU), Munich, Germany
| | - Lorenz Frey
- Department of Anesthesiology, University Hospital Munich (LMU), Munich, Germany
| | - Philipp M Paprottka
- Department of Clinical Radiology, University Hospital Munich (LMU), Munich, Germany
| | - Teresa da Silva
- Department of Clinical Radiology, University Hospital Munich (LMU), Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital Munich (LMU), Munich, Germany
| | - Wolfgang Böcker
- Department of Trauma Surgery, University Hospital Munich (LMU), Munich, Germany
| | - Thomas Weig
- Department of Anesthesiology, University Hospital Munich (LMU), Munich, Germany
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34
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López JJ, Cooper JN, Albert B, Adler B, King D, Minneci PC. Sarcopenia in children with perforated appendicitis. J Surg Res 2017; 220:1-5. [PMID: 29180169 DOI: 10.1016/j.jss.2017.05.059] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/20/2017] [Accepted: 05/18/2017] [Indexed: 12/29/2022]
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35
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Severe Sarcopenia and Increased Fat Stores in Pediatric Patients With Liver, Kidney, or Intestine Failure. J Pediatr Gastroenterol Nutr 2017; 65:579-583. [PMID: 28604513 DOI: 10.1097/mpg.0000000000001651] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Malnutrition and wasting predict clinical outcomes in children with severe chronic illness. Objectively calculated malnutrition in children with end-stage organ failure has not been well studied. This analysis compares children with kidney, liver or intestine failure to healthy controls to quantitate the disparity in muscle and fat stores. METHODS Children younger than 19 years with end-stage liver, kidney, or intestine failure and with pretransplant computed tomography (CT) imaging were selected from the transplant database. Age- and sex-matched healthy controls were selected from the trauma database. Measures of nutrition status included a scaled scoring of core muscle mass, and visceral and subcutaneous fat stores. Analysis was conducted using the pooled and individually matched subject-control differences. RESULTS There were 81 subjects included in the final analysis (liver [n = 35], kidney [n = 20], and intestine [n = 26]). Children with end-stage liver disease had a 23% reduction in muscle mass, a 69% increase in visceral fat, and a 29% increase in subcutaneous fat. End-stage renal disease patients had a 19% reduction in muscle mass and a 258% increase in subcutaneous fat. Intestine failure patients had a 24% reduction in muscle mass, a 30% increase in visceral fat, and a 46% increase in subcutaneous fat. CONCLUSIONS These results demonstrate significant sarcopenia and increased fat stores in end-stage organ failure patients, which supports the idea of an active physiologic mechanism to store fat while losing muscle mass. Sarcopenia may be related to total protein loss from a catabolic state, or from decreased synthesis (liver), wasting (kidney), or malabsorption (intestine).
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36
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[Above and beyond BMI : Alternative methods of measuring body fat and muscle mass in critically ill patients and their clinical significance]. Anaesthesist 2017; 65:655-62. [PMID: 27411524 DOI: 10.1007/s00101-016-0205-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Obesity leads to better survival in critically ill patients. Although there are several studies confirming this thesis, the "obesity paradox" is still surprising from the clinician's perspective. One explanation for the "obesity paradox" is the fact that the body mass index (BMI), which is used in almost all clinical evaluations to determine weight categories, is not an appropriate measure of fat and skeletal muscle mass and its distribution in critically ill patients. In addition, height and weight are frequently estimated rather than measured. Central obesity has been identified in many disorders as an independent risk factor for an unfavourable outcome. The first clues are to be found in intensive care. Along with obesity, an individual's entire muscle mass is a variable that has an influence on outcome. Central obesity can be measured relatively easily with an abdominal calliper, but the calculation of muscle mass is more complex. A valid and detailed measurement of this can be obtained using computed tomography (CT) images, acquired during routine care. For future clinical observation or interventional studies, single cross-sectional CT is a more sophisticated tool for measuring patients' anthropometry than a measuring tape and callipers. Patients with sarcopenic obesity, for example, who may be at a particular risk, can only be identified using imaging procedures such as single cross-sectional CT. Thus, BMI should take a back seat as an anthropometric tool, both in the clinic and in research.
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37
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Thongprayoon C, Cheungpasitporn W, Kashani K. Serum creatinine level, a surrogate of muscle mass, predicts mortality in critically ill patients. J Thorac Dis 2016; 8:E305-11. [PMID: 27162688 DOI: 10.21037/jtd.2016.03.62] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Serum creatinine (SCr) has been widely used to estimate glomerular filtration rate (GFR). Creatinine generation could be reduced in the setting of low skeletal muscle mass. Thus, SCr has also been used as a surrogate of muscle mass. Low muscle mass is associated with reduced survival in hospitalized patients, especially in the intensive care unit (ICU) settings. Recently, studies have demonstrated high mortality in ICU patients with low admission SCr levels, reflecting that low muscle mass or malnutrition, are associated with increased mortality. However, SCr levels can also be influenced by multiple GFR- and non-GFR-related factors including age, diet, exercise, stress, pregnancy, and kidney disease. Imaging techniques, such as computed tomography (CT) and ultrasound, have recently been studied for muscle mass assessment and demonstrated promising data. This article aims to present the perspectives of the uses of SCr and other methods for prediction of muscle mass and outcomes of ICU patients.
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Affiliation(s)
- Charat Thongprayoon
- 1 Division of Nephrology and Hypertension, 2 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wisit Cheungpasitporn
- 1 Division of Nephrology and Hypertension, 2 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush Kashani
- 1 Division of Nephrology and Hypertension, 2 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Smith S, Madden AM. Body composition and functional assessment of nutritional status in adults: a narrative review of imaging, impedance, strength and functional techniques. J Hum Nutr Diet 2016; 29:714-732. [PMID: 27137882 DOI: 10.1111/jhn.12372] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The accurate and valid assessment of body composition is essential for the diagnostic evaluation of nutritional status, identifying relevant outcome measures, and determining the effectiveness of current and future nutritional interventions. Developments in technology and our understanding of the influences of body composition on risk and outcome will provide practitioners with new opportunities to enhance current practice and to lead future improvements in practice. This is the second of a two-part narrative review that aims to critically evaluate body composition methodology in diverse adult populations, with a primary focus on its use in the assessment and monitoring of under-nutrition. Part one focused on anthropometric variables [Madden and Smith (2016) J Hum Nutr Diet 29: 7-25] and part two focuses on the use of imaging techniques, bioelectrical impedance analysis, markers of muscle strength and functional status, with particular reference to developments relevant to practice.
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Affiliation(s)
- S Smith
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - A M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Gomez-Perez SL, Haus JM, Sheean P, Patel B, Mar W, Chaudhry V, McKeever L, Braunschweig C. Measuring Abdominal Circumference and Skeletal Muscle From a Single Cross-Sectional Computed Tomography Image: A Step-by-Step Guide for Clinicians Using National Institutes of Health ImageJ. JPEN J Parenter Enteral Nutr 2015; 40:308-18. [PMID: 26392166 DOI: 10.1177/0148607115604149] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/28/2015] [Indexed: 12/24/2022]
Abstract
Diagnostic computed tomography (CT) scans provide numerous opportunities for body composition analysis, including quantification of abdominal circumference, abdominal adipose tissues (subcutaneous, visceral, and intermuscular), and skeletal muscle (SM). CT scans are commonly performed for diagnostic purposes in clinical settings, and methods for estimating abdominal circumference and whole-body SM mass from them have been reported. A supine abdominal circumference is a valid measure of waist circumference (WC). The valid correlation between a single cross-sectional CT image (slice) at third lumbar (L3) for abdominal SM and whole-body SM is also well established. Sarcopenia refers to the age-associated decreased in muscle mass and function. A single dimensional definition of sarcopenia using CT images that includes only assessment of low whole-body SM has been validated in clinical populations and significantly associated with negative outcomes. However, despite the availability and precision of SM data from CT scans and the relationship between these measurements and clinical outcomes, they have not become a routine component of clinical nutrition assessment. Lack of time, training, and expense are potential barriers that prevent clinicians from fully embracing this technique. This tutorial presents a systematic, step-by-step guide to quickly quantify abdominal circumference as a proxy for WC and SM using a cross-sectional CT image from a regional diagnostic CT scan for clinical identification of sarcopenia. Multiple software options are available, but this tutorial uses ImageJ, a free public-domain software developed by the National Institutes of Health.
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Affiliation(s)
| | - Jacob M Haus
- University of Illinois at Chicago, Chicago, Illinois
| | | | | | - Winnie Mar
- University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | | | - Liam McKeever
- University of Illinois at Chicago, Chicago, Illinois
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Fischer M, JeVenn A, Hipskind P. Evaluation of Muscle and Fat Loss as Diagnostic Criteria for Malnutrition. Nutr Clin Pract 2015; 30:239-48. [DOI: 10.1177/0884533615573053] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
| | - Andrea JeVenn
- Nutrition Support Team, Cleveland Clinic, Cleveland, Ohio
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Liebau F, Wernerman J, van Loon LJC, Rooyackers O. Effect of initiating enteral protein feeding on whole-body protein turnover in critically ill patients. Am J Clin Nutr 2015; 101:549-57. [PMID: 25733640 DOI: 10.3945/ajcn.114.091934] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Critically ill patients are susceptible to protein catabolism. Enteral feeding may ameliorate protein loss, but its effect is not well characterized in terms of protein kinetics. OBJECTIVE We established a method of quantifying the effect of enteral protein feeding on whole-body protein turnover and studied critically ill patients receiving early enteral nutrition. DESIGN In a proof-of-concept study, we established, in healthy subjects (n = 6), a method of measuring the effect of continuous enteral protein feeding on whole-body protein turnover by using ¹³C-phenylalanine (¹³C-Phe) intrinsically labeled casein by a nasogastric feeding tube and an intravenous ²H₅-Phe tracer. The protocol was applied to study critically ill patients (n = 10) during the initial hypocaloric-hyponitrogenous dose of enteral nutrition. RESULTS Patients were catabolic with a negative protein balance. The median splanchnic extraction fraction of hourly dietary Phe intake was 92% (range: 86-99%); that is, the availability of dietary Phe in arterial plasma was low. In patients with a stable parenteral amino acid supply (n = 7), the median net protein balance improved during enteral feeding from -8.6 to -5.8 μmol · kg body weight⁻¹ · h⁻¹ (P = 0.018). CONCLUSIONS Whole-body protein turnover and the contribution of dietary protein can be quantified in critically ill patients by using intravenous and enteral stable-isotope Phe tracers. The whole-body protein balance improved during early hypocaloric-hyponitrogenous enteral protein feeding in these patients.
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Affiliation(s)
- Felix Liebau
- From the Department of Anesthesiology and Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden (FL, JW, and OR), and NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands (LJCvL)
| | - Jan Wernerman
- From the Department of Anesthesiology and Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden (FL, JW, and OR), and NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands (LJCvL)
| | - Luc J C van Loon
- From the Department of Anesthesiology and Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden (FL, JW, and OR), and NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands (LJCvL)
| | - Olav Rooyackers
- From the Department of Anesthesiology and Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden (FL, JW, and OR), and NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands (LJCvL)
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Weijs PJM, Cynober L, DeLegge M, Kreymann G, Wernerman J, Wolfe RR. Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:591. [PMID: 25565377 PMCID: PMC4520087 DOI: 10.1186/s13054-014-0591-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Proteins and amino acids are widely considered to be subcomponents in nutritional support. However, proteins and amino acids are fundamental to recovery and survival, not only for their ability to preserve active tissue (protein) mass but also for a variety of other functions. Understanding the optimal amount of protein intake during nutritional support is therefore fundamental to appropriate clinical care. Although the body adapts in some ways to starvation, metabolic stress in patients causes increased protein turnover and loss of lean body mass. In this review, we present the growing scientific evidence showing the importance of protein and amino acid provision in nutritional support and their impact on preservation of muscle mass and patient outcomes. Studies identifying optimal dosing for proteins and amino acids are not currently available. We discuss the challenges physicians face in administering the optimal amount of protein and amino acids. We present protein-related nutrition concepts, including adaptation to starvation and stress, anabolic resistance, and potential adverse effects of amino acid provision. We describe the methods for assessment of protein status, and outcomes related to protein nutritional support for critically ill patients. The identification of a protein target for individual critically ill patients is crucial for outcomes, particularly for specific subpopulations, such as obese and older patients. Additional research is urgently needed to address these issues.
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Affiliation(s)
- Peter J M Weijs
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Intensive Care Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Nutrition and Dietetics, Amsterdam University of Applied Sciences, Wibautstraat 2-4 1091 GM, Amsterdam, the Netherlands. .,EMGO+ Institute of Health and Care Research, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Luc Cynober
- Clinical Chemistry Department, Cochin and Hôtel-Dieu Hospitals, APHP, 1 place du Parvis Notre-Dame 75004, Paris, France. .,Nutrition Lab, EA 4466, Department of Experimental, Metabolic and Clinical Biology, Faculty of Pharmacy, Paris Descartes University, 12 rue de l'Ecole de Médicine 75270, Paris, France.
| | - Mark DeLegge
- Baxter Healthcare, Deerfield, IL, 60015-4625, USA.
| | - Georg Kreymann
- Baxter Healthcare SA Europe, CH-8010, Zürich, Switzerland.
| | - Jan Wernerman
- Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 86, Stockholm, Sweden.
| | - Robert R Wolfe
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, 4243 Ireland St #336, College Station, TX, 77843, USA.
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Prado CMM, Heymsfield SB. Lean tissue imaging: a new era for nutritional assessment and intervention. JPEN J Parenter Enteral Nutr 2014; 38:940-53. [PMID: 25239112 PMCID: PMC4361695 DOI: 10.1177/0148607114550189] [Citation(s) in RCA: 369] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Body composition refers to the amount of fat and lean tissues in our body; it is a science that looks beyond a unit of body weight, accounting for the proportion of different tissues and its relationship to health. Although body weight and body mass index are well-known indexes of health status, most researchers agree that they are rather inaccurate measures, especially for elderly individuals and those patients with specific clinical conditions. The emerging use of imaging techniques such as dual energy x-ray absorptiometry, computerized tomography, magnetic resonance imaging, and ultrasound imaging in the clinical setting have highlighted the importance of lean soft tissue (LST) as an independent predictor of morbidity and mortality. It is clear from emerging studies that body composition health will be vital in treatment decisions, prognostic outcomes, and quality of life in several nonclinical and clinical states. This review explores the methodologies and the emerging value of imaging techniques in the assessment of body composition, focusing on the value of LST to predict nutrition status.
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Affiliation(s)
- Carla M M Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB, Canada
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Rooyackers O, Wernerman J. Imaging opens possibilities both to target and to evaluate nutrition in critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:144. [PMID: 25032892 PMCID: PMC4057292 DOI: 10.1186/cc13882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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