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Viner Smith E, Lambell K, Tatucu-Babet OA, Ridley E, Chapple LA. Nutrition considerations for patients with persistent critical illness: A narrative review. JPEN J Parenter Enteral Nutr 2024; 48:658-666. [PMID: 38520657 DOI: 10.1002/jpen.2623] [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: 01/28/2024] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
Critically ill patients experience high rates of malnutrition and significant muscle loss during their intensive care unit (ICU) admission, impacting recovery. Nutrition is likely to play an important role in mitigating the development and progression of malnutrition and muscle loss observed in ICU, yet definitive clinical trials of nutrition interventions in ICU have failed to show benefit. As improvements in the quality of medical care mean that sicker patients are able to survive the initial insult, combined with an aging and increasingly comorbid population, it is anticipated that ICU length of stay will continue to increase. This review aims to discuss nutrition considerations unique to critically ill patients who have persistent critical illness, defined as an ICU stay of >10 days. A discussion of nutrition concepts relevant to patients with persistent critical illness will include energy and protein metabolism, prescription, and delivery; monitoring of nutrition at the bedside; and the role of the healthcare team in optimizing nutrition support.
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Affiliation(s)
- Elizabeth Viner Smith
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kate Lambell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Dietetics and Nutrition, Alfred Health, Melbourne, Australia
| | - Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Emma Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Dietetics and Nutrition, Alfred Health, Melbourne, Australia
| | - Lee-Anne Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
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Araújo F, Posadas-Calleja JG, Raman M, Tosh M, Wischmeyer P, Barreto P, Gillis C. Association between protein intake and functional capacity in critically ill patients: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024. [PMID: 39018085 DOI: 10.1002/jpen.2673] [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: 04/18/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Intensive care unit (ICU) protein benchmarks are based on mortality and morbidity; whether these targets also support functional recovery is unknown. We assessed whether different protein doses influenced patients' functional capacity, measured by the Chelsea Physical Assessment score (CPAx). METHODS Single-center retrospective cohort study on ICU survivors with length of stay ≥7 days admitted between October 2014 and September 2020. Eligible patients were divided according to protein intake (g/kg/day): low (<0.8), medium (0.8-1.19), high (1.2-1.5), and very high (>1.5). Protein dose effect on CPAx was assessed at ICU discharge with analysis of covariance adjusting for age, illness severity, hospital length of stay before ICU admission, time to start nutrition support, and mechanical ventilation duration. We also investigated effect modification by energy intake and nutrition status. RESULTS Enrolled patients (n = 531) were similar for age, nutrition status, and illness severity across groups. CPAxs were nonlinearly associated with protein doses and similar among low, medium, and very high groups. The CPAx for the high group was statistically different (P = 0.014), indicating that the data of three groups could be pooled. Mean CPAx difference remained statistically significant after adjusting for confounding variables (3.9 ± 1.8, P = 0.029 in the four-group model, and 2.7 ± 0.9, P = 0.003 in the pooled two-group model). Energy intake was equivalent between groups and did not modify CPAx. The high group had superior CPAx in both well-nourished and malnourished patients, indicating nutrition status was not an effect modifier. CONCLUSION Protein dose 1.2-1.5 g/kg/day was associated with superior functional capacity at ICU discharge compared with other doses. Neither energy intake nor nutrition status modified functional capacity across groups; therefore, the results appear to be influenced by 1.2-1.5 g/kg/day.
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Affiliation(s)
- Fábio Araújo
- Department of Nutrition Services, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Maitreyi Raman
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maureen Tosh
- Department of Rehabilitation, Alberta Health Services, Calgary, Alberta, Canada
| | - Paul Wischmeyer
- Department of Anesthesiology & Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Priscilla Barreto
- Department of Nutrition Services, Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
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Chen W, Song J, Gong S. Advances in nutritional metabolic therapy to impede the progression of critical illness. Front Nutr 2024; 11:1416910. [PMID: 39036495 PMCID: PMC11259093 DOI: 10.3389/fnut.2024.1416910] [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: 04/13/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024] Open
Abstract
With the advancement of medical care and the continuous improvement of organ support technologies, some critically ill patients survive the acute phase of their illness but still experience persistent organ dysfunction, necessitating long-term reliance on intensive care and organ support, known as chronic critical illness. Chronic critical illness is characterized by prolonged hospital stays, high mortality rates, and significant resource consumption. Patients with chronic critical illness often suffer from malnutrition, compromised immune function, and poor baseline health, which, combined with factors like shock or trauma, can lead to intestinal mucosal damage. Therefore, effective nutritional intervention for patients with chronic critical illness remains a key research focus. Nutritional therapy has emerged as one of the essential components of the overall treatment strategy for chronic critical illness. This paper aims to provide a comprehensive review of the latest research progress in nutritional support therapy for patients with chronic critical illness.
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Affiliation(s)
- Wenwei Chen
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Song
- Zhejiang Hospital, Hangzhou, China
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Wang Y, Ye Y, Xuan L, Xu L, Wang P, Ma J, Wang Y, Chen Y, Miao J, Wang W, Zhou L. Impact of early high protein intake in critically ill patients: a randomized controlled trial. Nutr Metab (Lond) 2024; 21:39. [PMID: 38943189 PMCID: PMC11212281 DOI: 10.1186/s12986-024-00818-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Conflicting findings regarding the impact of High protein intake during the early phase in critically ill patients have been reported. Therefore, we aimed to assess the influence of higher early protein intake on the prognosis of critically ill patients. METHODS This randomized controlled trial involved 173 critically ill patients who stayed in the Intensive Care Unit/Emergency ICU (ICU/EICU) for at least 7 days. The Low group (n = 87) and High group (n = 86) received protein supplementation of 0.8 g/kg.d and 1.5 g/kg.d, respectively, within 1-3 days of enteral nutrition (EN) initiation, with both groups transitioning to 1.5 g/kg.d on the 4th day. The serum prealbumin (PA), blood urea nitrogen/creatinine, and rectus femoris muscle thickness and cross-sectional area of all patients was measured on the 1th, 3rd, 5th, 7th day, and the day of ICU/EICU discharge. RESULTS Patients in both Low and High groups showed no significant differences in age, APACHE II scores, or other demographic and baseline characteristics. There were also no significant differences in the primary outcome (28-day mortality rate) and secondary outcomes (incidence rate of refeeding syndrome and EN tolerance score) between the two groups. However, the Low group exhibited a significantly higher 28-day mortality rate (HR = 2.462, 95% CI: 1.021-5.936, P = 0.045) compared to High group, as determined by Cox proportional hazards models incorporating the time factor. The High group exhibited significantly shorter durations of mechanical ventilation and ICU stay compared to the Low group. Serum PA levels were higher, and rectus femoris muscle atrophy rates were lower in the High group. Furthermore, for septic patients, high protein intake significantly reduced the 28-day mortality rate despite a small sample size (n = 34). CONCLUSIONS Our study indicates that increasing early protein intake to 1.5 g/kg.d may be safe and help improve the nutritional status and prognosis of critically ill patients. TRIAL REGISTRATION This study was registered with the Chinese Clinical Trial Registry (ChiCTR2000039997, https://www.chictr.org.cn/ ).
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Affiliation(s)
- Yifei Wang
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Yanyang Ye
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Lusha Xuan
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Lijie Xu
- Department of science and education, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Pengpeng Wang
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Jun Ma
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Yuyan Wang
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Yanjun Chen
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China
| | - Jinli Miao
- The Yangtze River Delta Biological Medicine Research and Development Center of Zhejiang Province, Yangtze Delta Region Institution of Tsinghua University, Hangzhou, 314006, Zhejiang, China
| | - Wenmin Wang
- The Yangtze River Delta Biological Medicine Research and Development Center of Zhejiang Province, Yangtze Delta Region Institution of Tsinghua University, Hangzhou, 314006, Zhejiang, China
| | - Lingjie Zhou
- Intensive Care Unit, Zhuji Traditional Chinese Medical Hospital, Zhuji, 311800, Zhejiang, China.
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Deana C, Gunst J, De Rosa S, Umbrello M, Danielis M, Biasucci DG, Piani T, Cotoia A, Molfino A, Vetrugno L. Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study. Ann Intensive Care 2024; 14:29. [PMID: 38367198 PMCID: PMC10874356 DOI: 10.1186/s13613-024-01262-w] [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: 11/25/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt. METHODS Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle. RESULTS 72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA. CONCLUSIONS bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.
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Affiliation(s)
- Cristian Deana
- Anesthesia and Intensive Care 1, Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Piazzale S. M. Della Misericordia 15, 33100, Udine, Italy.
| | - Jan Gunst
- Laboratory of Intensive-Care Medicine, Department of Cellular and Molecular Medicine, Louvain, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Louvain, Belgium
| | - Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Michele Umbrello
- Department of Intensive Care and Anaesthesia, ASST Ovest Milanese, Legnano Hospital, Milan, Italy
| | - Matteo Danielis
- Laboratory of Studies and Evidence Based Nursing, Department of Cardiac, Vascular Sciences and Public Health, University of Padua, ThoracicPadua, Italy
| | - Daniele Guerino Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Tommaso Piani
- Health Professions Staff, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Antonella Cotoia
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Unit, Policlinico Riuniti Foggia, University of Foggia, Foggia, Italy
| | - Alessio Molfino
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
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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: 66] [Impact Index Per Article: 66.0] [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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Roy R, MacDonald J, Dark P, Kalra PA, Green D. The estimation of glomerular filtration in acute and critical illness: Challenges and opportunities. Clin Biochem 2023; 118:110608. [PMID: 37479107 DOI: 10.1016/j.clinbiochem.2023.110608] [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: 02/20/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/23/2023]
Abstract
Recent events have made it apparent that the creatinine based estimating equations for glomerular filtration have their flaws. Some flaws have been known for some time; others have prompted radical modification of the equations themselves. These issues persist in part owing to the behaviour of the creatinine molecule itself, particularly in acute and critical illness. There are significant implications for patient treatment decisions, including drug and fluid therapies and choice of imaging modality (contrast vs. non-contrast CT scan for example). An alternative biomarker, Cystatin C, has been used with some success both alone and in combination with creatinine to help improve the accuracy of particular estimating equations. Problems remain in certain circumstances and costs may limit the more widespread use of the alternative assay. This review will explore both the historical and more recent evidence for glomerular filtration estimation, including options to directly measure glomerular filtration (rather than estimate), perhaps the holy grail for both Biochemistry and Nephrology.
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Affiliation(s)
- Reuben Roy
- The University of Manchester, Manchester, Greater Manchester, United Kingdom.
| | - John MacDonald
- Northern Care Alliance NHS Foundation Trust Salford Care Organisation, Salford, Greater Manchester M6 8HD, United Kingdom
| | - Paul Dark
- The University of Manchester, Manchester, Greater Manchester, United Kingdom
| | - Philip A Kalra
- Northern Care Alliance NHS Foundation Trust Salford Care Organisation, Salford, Greater Manchester M6 8HD, United Kingdom
| | - Darren Green
- Northern Care Alliance NHS Foundation Trust Salford Care Organisation, Salford, Greater Manchester M6 8HD, United Kingdom
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Zhao Y, Gong JX, Ji YT, Zhao XY, He L, Cai SZ, Yan XM. Cross-sectional study of characteristics of body composition of 24,845 children and adolescents aged 3-17 years in Suzhou. BMC Pediatr 2023; 23:358. [PMID: 37442965 PMCID: PMC10339479 DOI: 10.1186/s12887-023-04134-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND We aimed to analyze the characteristics of the body composition of children and adolescents aged 3-17 in Suzhou, China. METHODS A cross-sectional study between January 2020 and June 2022 using bioelectrical impedance was conducted to determine the fat mass (FM), fat-free mass (FFM), skeletal muscle mass, and protein and mineral contents of 24,845 children aged 3-17 who attended the Department of Child and Adolescent Healthcare, Children's Hospital of Soochow University, China. Measurement data was presented in tables as mean ± SD, and groups were compared using the independent samples t-test. RESULTS FM and fat-free mass increased with age in both boys and girls. The fat-free mass of girls aged 14-15 decreased after reaching a peak, and that of boys in the same age group was higher than that of the girls (p < 0.05). There were no significant differences in FM between boys and girls younger than 9- and 10-years old. The percentage body fat (PBF) and FM index of girls increased rapidly between 11 and 15 years of age (p < 0.05), and those of boys aged 11-14 were significantly lower (p < 0.05), suggesting that the increase in body mass index (BMI) was mainly contributed by muscle mass (MM) in boys. CONCLUSIONS The body composition of children and adolescents varies according to their age and sex. A misdiagnosis of obesity made on the basis of BMI alone can be avoided if BMI is used in combination with FM index, percentage body fat, and other indexes.
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Affiliation(s)
- Yan Zhao
- Department of Pediatrics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215003, China
| | - Jin-Xin Gong
- Department of Child and Adolescent Healthcare, Children's Hospital of Soochow University, Suzhou, 215025, Jiangsu, China
| | - Yi-Ting Ji
- Department of Child and Adolescent Healthcare, Children's Hospital of Soochow University, Suzhou, 215025, Jiangsu, China
| | - Xiao-Yun Zhao
- Department of Neonatology, Children's Hospital of Soochow University, Suzhou, 215025, Jiangsu, China
| | - Lu He
- Department of Child and Adolescent Healthcare, Children's Hospital of Soochow University, Suzhou, 215025, Jiangsu, China
| | - Shi-Zhong Cai
- Department of Child and Adolescent Healthcare, Children's Hospital of Soochow University, Suzhou, 215025, Jiangsu, China.
| | - Xiang-Ming Yan
- Department of Urology, Children's Hospital of Soochow University, Suzhou, 215025, Jiangsu, China.
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McClelland TJ, Davies T, Puthucheary Z. Novel nutritional strategies to prevent muscle wasting. Curr Opin Crit Care 2023; 29:108-113. [PMID: 36762680 DOI: 10.1097/mcc.0000000000001020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Muscle wasting in critical illness has proven to be refractory to physical rehabilitation, and to conventional nutritional strategies. This presents one of the central challenges to critical care medicine in the 21st century. Novel strategies are needed that facilitate nutritional interventions, identify patients that will benefit and have measurable, relevant benefits. RECENT FINDINGS Drug repurposing was demonstrated to be a powerful technique in the coronavirus disease 2019 pandemic, and may have similar applications to address the metabolic derangements of critical illness. Newer biological signatures may aid the application of these techniques and the association between changes in urea:creatinine ratio and the development of skeletal muscle wasting is increasing. A core outcome set for nutrition interventions in critical illness, supported by multiple international societies, was published earlier this year should be adopted by future nutrition trials aiming to attenuate muscle wasting. SUMMARY The evidence base for the lack of efficacy for conventional nutritional strategies in preventing muscle wasting in critically ill patients continues to grow. Novel strategies such as metabolic modulators, patient level biological signatures of nutritional response and standardized outcome for measurements of efficacy will be central to future research and clinical care of the critically ill patient.
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Affiliation(s)
- Thomas J McClelland
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London
| | - Thomas Davies
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London
- Adult Critical Care Unit, Royal London Hospital, London, UK
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Ridley EJ, Chapple LAS. Nutrition in critical illness-research is worth the EFFORT. Lancet 2023; 401:527-528. [PMID: 36708733 DOI: 10.1016/s0140-6736(23)00091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023]
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC 3004, Australia; Nutrition Department, The Alfred Hospital, Melbourne, VIC, Australia.
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
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Dupuis C, Bret A, Janer A, Guido O, Bouzgarrou R, Dopeux L, Hernandez G, Mascle O, Calvet L, Thouy F, Grapin K, Couhault P, Kinda F, Laurichesse G, Bonnet B, Adda M, Boirie Y, Souweine B. Association of nitrogen balance trajectories with clinical outcomes in critically ill COVID-19 patients: A retrospective cohort study. Clin Nutr 2022; 41:2895-2902. [PMID: 36109282 PMCID: PMC9444301 DOI: 10.1016/j.clnu.2022.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/26/2022] [Accepted: 08/24/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS The intensity and duration of the catabolic phase in COVID-19 patients can differ between survivors and non-survivors. The purpose of the study was to assess the determinants of, and association between, nitrogen balance trajectories and outcome in critically ill COVID-19 patients. METHODS This retrospective monocentric observational study involved patients admitted to the intensive care unit (ICU) of the University Hospital of Clermont Ferrand, France, from January 2020 to May 2021 for COVID-19 pneumonia. Patients were excluded if referred from another ICU, if their ICU length of stay was <72 h, or if they were treated with renal replacement therapy during the first seven days after ICU admission. Data were collected prospectively at admission and during ICU stay. Death was recorded at the end of ICU stay. Comparisons of the time course of nitrogen balance according to outcome were analyzed using two-way ANOVA. At days 3, 5, 7, 10 and 14, uni- and multivariate logistic regression analyses were performed to assess the impact of a non-negative nitrogen-balance on ICU death. To investigate the relationships between nitrogen balance, inflammatory markers and protein intake, linear and non-nonlinear models were run at days 3, 5 and 7, and the amount of protein intake necessary to reach a neutral nitrogen balance was calculated. Subgroup analyses were carried out according to BMI, age, and sex. RESULTS 99 patients were included. At day 3, a similar negative nitrogen balance was observed in survivors and non-survivors: -16.4 g/d [-26.5, -3.3] and -17.3 g/d [-22.2, -3.8] (p = 0.54). The trajectories of nitrogen balance over time thus differed between survivors and non-survivors (p = 0.01). In survivors, nitrogen balance increased over time, but decreased from day 2 to day 6 in non-survivors, and thereafter increased slowly up to day 14. At days 5 and 7, a non-negative nitrogen-balance was protective from death. Administering higher protein amounts was associated with higher nitrogen balance. CONCLUSION We report a prolonged catabolic state in COVID patients that seemed more pronounced in non-survivors than in survivors. Our study underlines the need for monitoring urinary nitrogen excretion to guide the amount of protein intake required by COVID-19 patients.
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Affiliation(s)
- Claire Dupuis
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France,Université Clermont Auvergne, Unité de Nutrition Humaine, INRAe, CRNH Auvergne, F-63000, Clermont-Ferrand, France,Corresponding author.Service de Médecine Intensive et Réanimation, CHU Clermont Ferrand, France
| | - Alexandre Bret
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Alexandra Janer
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Olivia Guido
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Radhia Bouzgarrou
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Loïc Dopeux
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Gilles Hernandez
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Olivier Mascle
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Laure Calvet
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - François Thouy
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Kévin Grapin
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Pierre Couhault
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Francis Kinda
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | | | - Benjamin Bonnet
- CHU Clermont-Ferrand, Service d'Immunologie, Clermont-Ferrand, France,Université Clermont Auvergne, Laboratoire d’Immunologie, ECREIN, UMR1019 UNH, UFR Médecine de Clermont-Ferrand, Clermont-Ferrand, France
| | - Mireille Adda
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
| | - Yves Boirie
- Université Clermont Auvergne, Unité de Nutrition Humaine, INRAe, CRNH Auvergne, F-63000, Clermont-Ferrand, France,CHU Clermont-Ferrand, Service de Nutrition Clinique, Clermont-Ferrand, France
| | - Bertrand Souweine
- CHU Clermont-Ferrand, Service de Réanimation Médicale, Clermont-Ferrand, France
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Chapple LAS, Parry SM, Schaller SJ. Attenuating Muscle Mass Loss in Critical Illness: the Role of Nutrition and Exercise. Curr Osteoporos Rep 2022; 20:290-308. [PMID: 36044178 PMCID: PMC9522765 DOI: 10.1007/s11914-022-00746-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Impaired recovery following an intensive care unit (ICU) admission is thought related to muscle wasting. Nutrition and physical activity are considered potential avenues to attenuate muscle wasting. The aim of this review was to present evidence for these interventions in attenuating muscle loss or improving strength and function. RECENT FINDINGS Randomised controlled trials on the impact of nutrition or physical activity interventions in critically ill adult patients on muscle mass, strength or function are presented. No nutrition intervention has shown an effect on strength or function, and the effect on muscle mass is conflicting. RCTs on the effect of physical activity demonstrate conflicting results; yet, there is a signal for improved strength and function with higher levels of physical activity, particularly when commenced early. Further research is needed to elucidate the impact of nutrition and physical activity on muscle mass, strength and function, particularly in combination.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Selina M Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Stefan J Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
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Puthucheary Z, Rooyackers O. Anabolic Resistance: An Uncomfortable Truth for Clinical Trials in Preventing Intensive Care-acquired Weakness and Physical Functional Impairment. Am J Respir Crit Care Med 2022; 206:660-661. [PMID: 35671483 PMCID: PMC9799124 DOI: 10.1164/rccm.202206-1059ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Zudin Puthucheary
- William Harvey Research InstituteQueen Mary University of LondonLondon, United Kingdom,Adult Critical Care UnitRoyal London HospitalLondon, United Kingdom
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14
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Tjäder I, Klaude M, Hssain AA, Guillet C, Nennesmo I, Wernerman J, Rooyackers O. Variability in Skeletal Muscle Protein Synthesis Rates in Critically Ill Patients. Nutrients 2022; 14:nu14183733. [PMID: 36145109 PMCID: PMC9501828 DOI: 10.3390/nu14183733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Muscle protein synthesis in critically ill patients is, on average, normal despite dramatic muscle loss, but the variation is much larger than in controls. Here, we evaluate if this variation is due to 1) heterogeneity in synthesis rates, 2) morphological variation or infiltrating cells, or 3) heterogeneity in the synthesis of different protein fractions. (2) Methods: Muscle biopsies were taken from both legs of critically ill patients (n = 17). Mixed and mitochondrial protein synthesis rates and morphologies were evaluated in both legs. Synthesis rates of myosin and actin were determined in combined biopsies and compared with controls. (3) Results: Muscle protein synthesis rates had a large variability in the patients (1.4-10.8%/day). No differences in mixed and mitochondrial protein synthesis rates between both legs were observed. A microscopic examination revealed no morphological differences between the two legs or any infiltrating inflammatory cells. The synthesis rates for myosin were lower and for actin they were higher in the muscles of critically ill patients, compared with the controls. (4) Conclusions: The large variation in muscle protein synthesis rates in critically ill patients is not the result of heterogeneity in synthesis rates, nor due to infiltrating cells. There are differences in the synthesis rates of different proteins, but these do not explain the larger variations.
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Affiliation(s)
- Inga Tjäder
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 14186 Huddinge, Sweden
| | - Maria Klaude
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 14186 Huddinge, Sweden
| | - Ali Ait Hssain
- Department of Intensive Care Unit, University Hospital of Clermont-Ferrand, 63100 Clermont-Ferrand, France
| | - Christelle Guillet
- Unité de Nutrition Humaine, Clermont Université, Université d’Auvergne, INRA, 63001 Clermont-Ferrand, France
| | - Inger Nennesmo
- Department of Pathology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Jan Wernerman
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 14186 Huddinge, Sweden
| | - Olav Rooyackers
- Division of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, 14152 Huddinge, Sweden
- Correspondence:
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16
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Voiriot G, Oualha M, Pierre A, Salmon-Gandonnière C, Gaudet A, Jouan Y, Kallel H, Radermacher P, Vodovar D, Sarton B, Stiel L, Bréchot N, Préau S, Joffre J. Chronic critical illness and post-intensive care syndrome: from pathophysiology to clinical challenges. Ann Intensive Care 2022; 12:58. [PMID: 35779142 PMCID: PMC9250584 DOI: 10.1186/s13613-022-01038-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background Post‐intensive care syndrome (PICS) encompasses physical, cognition, and mental impairments persisting after intensive care unit (ICU) discharge. Ultimately it significantly impacts the long‐term prognosis, both in functional outcomes and survival. Thus, survivors often develop permanent disabilities, consume a lot of healthcare resources, and may experience prolonged suffering. This review aims to present the multiple facets of the PICS, decipher its underlying mechanisms, and highlight future research directions. Main text This review abridges the translational data underlying the multiple facets of chronic critical illness (CCI) and PICS. We focus first on ICU-acquired weakness, a syndrome characterized by impaired contractility, muscle wasting, and persisting muscle atrophy during the recovery phase, which involves anabolic resistance, impaired capacity of regeneration, mitochondrial dysfunction, and abnormalities in calcium homeostasis. Second, we discuss the clinical relevance of post-ICU cognitive impairment and neuropsychological disability, its association with delirium during the ICU stay, and the putative role of low-grade long-lasting inflammation. Third, we describe the profound and persistent qualitative and quantitative alteration of the innate and adaptive response. Fourth, we discuss the biological mechanisms of the progression from acute to chronic kidney injury, opening the field for renoprotective strategies. Fifth, we report long-lasting pulmonary consequences of ARDS and prolonged mechanical ventilation. Finally, we discuss several specificities in children, including the influence of the child’s pre-ICU condition, development, and maturation. Conclusions Recent understandings of the biological substratum of the PICS’ distinct features highlight the need to rethink our patient trajectories in the long term. A better knowledge of this syndrome and precipitating factors is necessary to develop protocols and strategies to alleviate the CCI and PICS and ultimately improve patient recovery.
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Affiliation(s)
- Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Necker Hospital, APHP, Centre - Paris University, Paris, France
| | - Alexandre Pierre
- Institut Pasteur de Lille, U1167 - RID-AGE - Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, University Lille, Inserm, CHU Lille, 59000, Lille, France.,Department of Intensive Care Medicine, Critical Care Center, CHU Lille, 59000, Lille, France.,Faculté de Médecine de Tours, Centre d'Etudes des Pathologies Respiratoires, INSERM U1100, University Lille, Tours, France
| | - Charlotte Salmon-Gandonnière
- Service de Médecine Intensive Réanimation, CHRU de Tours, Réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France
| | - Alexandre Gaudet
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, 59000, Lille, France.,Faculté de Médecine de Tours, Centre d'Etudes des Pathologies Respiratoires, INSERM U1100, University Lille, Tours, France.,Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, 59000, Lille, France
| | - Youenn Jouan
- Service de Médecine Intensive Réanimation, CHRU de Tours, Réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France
| | - Hatem Kallel
- Service de Réanimation, Centre Hospitalier de Cayenne, French Guiana, Cayenne, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, 89070, Ulm, Germany
| | - Dominique Vodovar
- Centre AntiPoison de Paris, Hôpital Fernand Widal, APHP, 75010, Paris, France.,Faculté de Pharmacie, UMRS 1144, 75006, Paris, France.,Université de Paris, UFR de Médecine, 75010, Paris, France
| | - Benjamine Sarton
- Critical Care Unit, University Hospital of Purpan, Toulouse, France.,Toulouse NeuroImaging Center, ToNIC, Inserm 1214, Paul Sabatier University, Toulouse, France
| | - Laure Stiel
- Service de Réanimation Médicale, Groupe Hospitalier de la Région Mulhouse Sud Alsace, Mulhouse, France.,INSERM, LNC UMR 1231, FCS Bourgogne Franche Comté LipSTIC LabEx, Dijon, France
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,College de France, Center for Interdisciplinary Research in Biology (CIRB)-UMRS INSERM U1050 - CNRS 7241, Paris, France
| | - Sébastien Préau
- Institut Pasteur de Lille, U1167 - RID-AGE - Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, University Lille, Inserm, CHU Lille, 59000, Lille, France.,Service de Médecine Intensive Réanimation, CHRU de Tours, Réseau CRICS-TRIGGERSEP F-CRIN Research Network, Tours, France
| | - Jérémie Joffre
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, 94143, USA. .,Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France. .,Sorbonne University, Centre de Recherche Saint-Antoine INSERM U938, 75012, Paris, France.
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17
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Chapple LAS, Kouw IWK, Summers MJ, Weinel LM, Gluck S, Raith E, Slobodian P, Soenen S, Deane AM, van Loon LJC, Chapman MJ. Muscle Protein Synthesis Following Protein Administration in Critical Illness. Am J Respir Crit Care Med 2022; 206:740-749. [PMID: 35584344 DOI: 10.1164/rccm.202112-2780oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly understood. Objective To quantify protein digestion and amino acid absorption, and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods Fifteen mechanically ventilated adults (12M; age 50±17y, Body Mass Index (BMI) 27±5kg·m-2) and 10 healthy controls (6M; 54±23y, BMI 27±4kg·m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5h, and a duodenal bolus of intrinsically-labelled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20g protein) over 60min. Arterial blood and muscle samples were taken at baseline (fasting) and for 6h following duodenal protein administration. Data are mean±SD; analysed with 2-way repeated measures ANOVA and independent samples t-test. Measurements and main results Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy controls (0.023±0.013 vs 0.034±0.016%/h; P=0.077). Following protein administration, plasma amino acid availability did not differ between groups (ICU patients 54.2±9.1 vs healthy controls 61.8±13.1%; P=0.12), and myofibrillar protein synthesis rates increased in both groups (0.028±0.010 vs 0.043±0.018 %/h, main time effect P=0.046, P-interaction=0.584) with lower rates in ICU patients compared to healthy controls (main group effect P=0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ~60% lower in ICU patients (0.007±0.007 vs 0.017±0.009 mole % excess (MPE); P=0.007). Conclusion The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.
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Affiliation(s)
- Lee-Anne S Chapple
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia;
| | - Imre W K Kouw
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Maastricht University Medical Centre+, 199236, Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, Limburg, Netherlands
| | - Matthew J Summers
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Luke M Weinel
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Samuel Gluck
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Eamon Raith
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Peter Slobodian
- Central Adelaide Local Health Network, 375072, Pharmacy, Adelaide, South Australia, Australia
| | - Stijn Soenen
- The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Bond University Faculty of Health Sciences and Medicine, 104559, Gold Coast, Queensland, Australia
| | - Adam M Deane
- The University of Melbourne, 2281, Melbourne Medical School, Department of Critical Care, Melbourne, Victoria, Australia
| | - Luc J C van Loon
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Department of Human Biology, Maastricht, Netherlands
| | - Marianne J Chapman
- Royal Adelaide Hospital, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia
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Hildebrandt W, Keck J, Schmich S, Bonaterra GA, Wilhelm B, Schwarzbach H, Eva A, Bertoune M, Slater EP, Fendrich V, Kinscherf R. Inflammation and Wasting of Skeletal Muscles in Kras-p53-Mutant Mice with Intraepithelial Neoplasia and Pancreatic Cancer-When Does Cachexia Start? Cells 2022; 11:1607. [PMID: 35626644 PMCID: PMC9139525 DOI: 10.3390/cells11101607] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023] Open
Abstract
Skeletal muscle wasting critically impairs the survival and quality of life in patients with pancreatic ductal adenocarcinoma (PDAC). To identify the local factors initiating muscle wasting, we studied inflammation, fiber cross-sectional area (CSA), composition, amino acid metabolism and capillarization, as well as the integrity of neuromuscular junctions (NMJ, pre-/postsynaptic co-staining) and mitochondria (electron microscopy) in the hindlimb muscle of LSL-KrasG12D/+; LSL-TrP53R172H/+; Pdx1-Cre mice with intraepithelial-neoplasia (PanIN) 1-3 and PDAC, compared to wild-type mice (WT). Significant decreases in fiber CSA occurred with PDAC but not with PanIN 1-3, compared to WT: These were found in the gastrocnemius (type 2x: −20.0%) and soleus (type 2a: −21.0%, type 1: −14.2%) muscle with accentuation in the male soleus (type 2a: −24.8%, type 1: −17.4%) and female gastrocnemius muscle (−29.6%). Significantly higher densities of endomysial CD68+ and cyclooxygenase-2+ (COX2+) cells were detected in mice with PDAC, compared to WT mice. Surprisingly, CD68+ and COX2+ cell densities were also higher in mice with PanIN 1-3 in both muscles. Significant positive correlations existed between muscular and hepatic CD68+ or COX2+ cell densities. Moreover, in the gastrocnemius muscle, suppressor-of-cytokine-3 (SOCS3) expressions was upregulated >2.7-fold with PanIN 1A-3 and PDAC. The intracellular pools of proteinogenic amino acids and glutathione significantly increased with PanIN 1A-3 compared to WT. Capillarization, NMJ, and mitochondrial ultrastructure remained unchanged with PanIN or PDAC. In conclusion, the onset of fiber atrophy coincides with the manifestation of PDAC and high-grade local (and hepatic) inflammatory infiltration without compromised microcirculation, innervation or mitochondria. Surprisingly, muscular and hepatic inflammation, SOCS3 upregulation and (proteolytic) increases in free amino acids and glutathione were already detectable in mice with precancerous PanINs. Studies of initial local triggers and defense mechanisms regarding cachexia are warranted for targeted anti-inflammatory prevention.
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Affiliation(s)
- Wulf Hildebrandt
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Jan Keck
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
- Department of General, Visceral and Pedriatic Surgery, University Clinics, Georg-August University, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Simon Schmich
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Gabriel A. Bonaterra
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Beate Wilhelm
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Hans Schwarzbach
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Anna Eva
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Mirjam Bertoune
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
| | - Emily P. Slater
- Department of Visceral, Thoracic and Vascular Surgery, University Clinics of Giessen and Marburg, Baldinger Str., 35043 Marburg, Germany; (E.P.S.); (V.F.)
| | - Volker Fendrich
- Department of Visceral, Thoracic and Vascular Surgery, University Clinics of Giessen and Marburg, Baldinger Str., 35043 Marburg, Germany; (E.P.S.); (V.F.)
- Center for Endocrine Surgery, Schön Klinik Hamburg-Eilbek, Dehnhaide 120, 22081 Hamburg, Germany
| | - Ralf Kinscherf
- Institute of Anatomy and Cell Biology, Department of Medical Cell Biology, Philipps-University of Marburg, Robert-Koch-Str. 8, 35032 Marburg, Germany; (J.K.); (S.S.); (G.A.B.); (B.W.); (H.S.); (A.E.); (M.B.); (R.K.)
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Andrade GKPD, Carvalho JB, Nascimento LAD, Rodrigues ALCC, Severine AN. NUTRITIONAL ASSESSMENT TEAM: BODY COMPOSITION ASSESSMENT PROTOCOL IN HOSPITALIZED PATIENTS. CLINICAL NUTRITION OPEN SCIENCE 2022. [DOI: 10.1016/j.nutos.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
OBJECTIVES Ongoing risk of death and poor functional outcomes are important consequences of prolonged critical illness. Characterizing the catabolic phenotype of prolonged critical illness could illuminate biological processes and inform strategies to attenuate catabolism. We aimed to examine if urea-to-creatinine ratio, a catabolic signature of prolonged critical illness, was associated with mortality after the first week of ICU stay. DESIGN Reanalysis of multicenter randomized trial of glutamine supplementation in critical illness (REducing Deaths due to OXidative Stress [REDOXS]). SETTING Multiple adult ICUs. PATIENTS Adult patients admitted to ICU with two or more organ failures related to their acute illness and surviving to day 7. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The association between time-varying urea-to-creatinine ratio and 30-day mortality was tested using Bayesian joint models adjusted for prespecified-covariates (age, kidney replacement therapy, baseline Sequential Organ Failure Assessment, dietary protein [g/kg/d], kidney dysfunction, and glutamine-randomization). From 1,021 patients surviving to day 7, 166 (16.3%) died by day 30. After adjustment in a joint model, a higher time-varying urea-to-creatinine ratio was associated with increased mortality (hazard ratio [HR], 2.15; 95% credible interval, 1.66-2.82, for a two-fold greater urea-to-creatinine ratio). This association persisted throughout the 30-day follow-up. Mediation analysis was performed to explore urea-to-creatinine ratio as a mediator-variable for the increased risk of death reported in REDOXS when randomized to glutamine, an exogenous nitrogen load. Urea-to-creatinine ratio closest to day 7 was estimated to mediate the risk of death associated with randomization to glutamine supplementation (HR, 1.20; 95% CI, 1.04-1.38; p = 0.014), with no evidence of a direct effect of glutamine (HR, 0.90; 95% CI, 0.62-1.30; p = 0.566). CONCLUSIONS The catabolic phenotype measured by increased urea-to-creatinine ratio is associated with increased risk of death during prolonged ICU stay and signals the deleterious effects of glutamine administration in the REDOXS study. Urea-to-creatinine ratio is a promising catabolic signature and potential interventional target.
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Ong C, Lee JH, Leow MKS, Puthucheary ZA. A narrative review of skeletal muscle atrophy in critically ill children: pathogenesis and chronic sequelae. Transl Pediatr 2021; 10:2763-2777. [PMID: 34765499 PMCID: PMC8578782 DOI: 10.21037/tp-20-298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/18/2020] [Indexed: 11/10/2022] Open
Abstract
Muscle wasting is now recognized as a growing, debilitating problem in critically ill adults, resulting in long-term deficits in function and an impaired quality of life. Ultrasonography has demonstrated decreases in skeletal muscle size during pediatric critical illness, although variations exist. However, muscle protein turnover patterns during pediatric critical illness are unclear. Understanding muscle protein turnover during critical illness is important in guiding interventions to reduce muscle wasting. The aim of this review was to explore the possible protein synthesis and breakdown patterns in pediatric critical illness. Muscle protein turnover studies in critically ill children are lacking, with the exception of those with burn injuries. Children with burn injuries demonstrate an elevation in both muscle protein breakdown (MPB) and synthesis during critical illness. Extrapolations from animal models and whole-body protein turnover studies in children suggest that children may be more dependent on anabolic factors (e.g., nutrition and growth factors), and may experience greater muscle degradation in response to insults than adults. Yet, children, particularly the younger ones, are more responsive to anabolic agents, suggesting modifiable muscle wasting during critical illness. There is a lack of evidence for muscle wasting in critically ill children and its correlation with outcomes, possibly due to current available methods to study muscle protein turnover in children-most of which are invasive or tedious. In summary, children may experience muscle wasting during critical illness, which may be more reversible by the appropriate anabolic agents than adults. Age appears an important determinant of skeletal muscle turnover. Less invasive methods to study muscle protein turnover and associations with long-term outcome would strengthen the evidence for muscle wasting in critically ill children.
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Affiliation(s)
- Chengsi Ong
- Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Melvin K S Leow
- Duke-NUS Medical School, Singapore, Singapore.,Clinical Nutrition Research Center, Agency for Science, Technology and Research, Singapore, Singapore.,Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Zudin A Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, Royal London Hospital, London, UK
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Singer P, Bendavid I, BenArie I, Stadlander L, Kagan I. Feasibility of achieving different protein targets using a hypocaloric high-protein enteral formula in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:204. [PMID: 34116714 PMCID: PMC8194118 DOI: 10.1186/s13054-021-03625-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/31/2021] [Indexed: 01/03/2023]
Abstract
Background and aims Combining energy and protein targets during the acute phase of critical illness is challenging. Energy should be provided progressively to reach targets while avoiding overfeeding and ensuring sufficient protein provision. This prospective observational study evaluated the feasibility of achieving protein targets guided by 24-h urinary nitrogen excretion while avoiding overfeeding when administering a high protein-to-energy ratio enteral nutrition (EN) formula. Methods Critically ill adult mechanically ventilated patients with an APACHE II score > 15, SOFA > 4 and without gastrointestinal dysfunction received EN with hypocaloric content for 7 days. Protein need was determined by 24-h urinary nitrogen excretion, up to 1.2 g/kg (Group A, N = 10) or up to 1.5 g/kg (Group B, N = 22). Variables assessed included nitrogen intake, excretion, balance; resting energy expenditure (REE); phase angle (PhA); gastrointestinal tolerance of EN. Results Demographic characteristics of groups were similar. Protein target was achieved using urinary nitrogen excretion measurements. Nitrogen balance worsened in Group A but improved in Group B. Daily protein and calorie intake and balance were significantly increased in Group B compared to Group A. REE was correlated to PhA measurements. Gastric tolerance of EN was good. Conclusions Achieving the protein target using urinary nitrogen loss up to 1.5 g/kg/day was feasible in this hypercatabolic population. Reaching a higher protein and calorie target did not induce higher nitrogen excretion and was associated with improved nitrogen balance and a better energy intake without overfeeding. PhA appears to be related to REE and may reflect metabolism level, suggestive of a new phenotype for nutritional status. Trial registration 0795-18-RMC.
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Affiliation(s)
- Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Jabotinsky Street, 49100, Petah Tikva, Israel.
| | - Itai Bendavid
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Jabotinsky Street, 49100, Petah Tikva, Israel
| | - Ilana BenArie
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Jabotinsky Street, 49100, Petah Tikva, Israel
| | - Liran Stadlander
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Jabotinsky Street, 49100, Petah Tikva, Israel
| | - Ilya Kagan
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Jabotinsky Street, 49100, Petah Tikva, Israel
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23
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Flower L, Page A, Puthucheary Z. Should nutritional therapy be modified to account for mitochondrial dysfunction in critical illness? JPEN J Parenter Enteral Nutr 2021; 45:60-65. [PMID: 34115880 DOI: 10.1002/jpen.2190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/21/2021] [Accepted: 05/10/2021] [Indexed: 11/07/2022]
Abstract
Metabolic dysfunction, and its associated muscle atrophy, remains the most common complication of critical care. At the centre of this is mitochondrial dysfunction, secondary to hypoxia and systemic inflammation. This leads to a bioenergetic crisis, with decreased intramuscular adenosine tri-phosphate content and a reduction in the highly energy dependent process of protein synthesis. Numerous methods have been studied to try and reduce these effects, with only limited success. Trials investigating the use of increased calorie and protein administration have instead found a decrease in relative lean body mass, and a potential increase in morbidity and mortality. Ketone bodies have been proposed as alternative substrates for metabolism in critical illness, with promising results seen in animal models. They are currently being investigated in critical care patients in the Alternative Substrates in the Critically Ill Subjects trial. The evidence to date suggests that individualised feeding regimens may be key in the nutritional approach to critical illness. Consideration of individual patient factors will need to be combined with personalised protein content, total energy load received, and the timings of such feeds. This review covers mitochondrial dysfunction in critical illness, and how it contributes to muscle wasting and the resultant morbidity and mortality and the scientific basis of why current nutritional approaches to date have not been successful in negating this effect. These two factors underpin the need for consideration of alternative nutritional strategies in the critically ill patient. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Luke Flower
- William Harvey Research Institute, Queen Mary University of London, London.,Department of Anaesthesia, University College Hospital, 235 Euston Road, London, UK
| | - Alexandria Page
- William Harvey Research Institute, Queen Mary University of London, London.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, Queen Mary University of London, London.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, UK
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24
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Chapple LAS, Dirks ML, Kouw IW. Stable isotope approaches to study muscle mass outcomes in clinical populations. CLINICAL NUTRITION OPEN SCIENCE 2021. [DOI: 10.1016/j.nutos.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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25
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Comprehensive metabolic amino acid flux analysis in critically ill patients. Clin Nutr 2021; 40:2876-2897. [PMID: 33946038 DOI: 10.1016/j.clnu.2021.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 01/16/2023]
Abstract
Amino acid (AA) metabolism is severely disturbed in critically ill ICU patients. To be able to make a more scientifically based decision on the type of protein or AA nutrition to deliver in ICU patients, comprehensive AA phenotyping with measurements of plasma concentrations and whole body production (WBP) is needed. Therefore, we studied ICU patients and matched control subjects using a novel pulse isotope method to obtain in-depth metabolic analysis. In 51 critically ill ICU patients (SOFA~6.6) and 49 healthy controls, we measured REE and body composition/phase-angle using BIA. In the postabsorptive state, we collected arterial (ized) blood for CRP and AA. Then, we administered an 8 mL solution containing 18 stable AA tracers as a pulse and calculated WBP. Enrichments: LC-MS/MS and statistics: t-test, ANCOVA. Compared to healthy, critically ill ICU patients had lower phase-angle (p < 0.00001), and higher CRP (p < 0.0001). Most AA concentrations were lower in ICU patients (p < 0.0001), except tau-methylhistidine and phenylalanine. WBP of most AA were significantly (p < 0.0001) higher with increases in glutamate (160%), glutamine (46%), and essential AA. Remarkably, net protein breakdown was lower. There were only weak relationships between AA concentrations and WBP. Critically ill ICU patients (SOFA 8-16) had lower values for phase angle (p = 0.0005) and small reductions of most plasma AA concentrations, but higher tau-methylhistidine (p = 0.0223) and hydroxyproline (p = 0.0028). Remarkably, the WBP of glutamate and glutamine were lower (p < 0.05), as was their clearance, but WBP of tau-methylhistidine (p = 0.0215) and hydroxyproline (p = 0.0028) were higher. Our study in critically ill ICU patients shows that comprehensive metabolic phenotyping was able to reveal severe disturbances in specific AA pathways, in a disease severity dependent way. This information may guide improving nutritional compositions to improve the health of the critically ill patient. CLINICAL TRIAL REGISTRY: Data are from the baseline measurements of study NCT02770092 (URL: https://clinicaltrials.gov/ct2/show/NCT02770092) and NCT03628365 (URL: https://clinicaltrials.gov/ct2/show/NCT03628365).
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26
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Abstract
PURPOSE OF REVIEW Timing, dose, and route of protein feeding in critically ill patients treated in an ICU is controversial. This is because of conflicting outcomes observed in randomized controlled trials (RCTs). This inconsistency between RCTs may occur as the physiology of protein metabolism and protein handling in the critically ill is substantially different from the healthy with limited mechanistic data to inform design of RCTs. This review will outline the current knowledge and gaps in the understanding of protein absorption and kinetics during critical illness. RECENT FINDINGS Critically ill patients, both children and adults, lose muscle protein because of substantial increases in protein degradation with initially normal, and over time increasing, protein synthesis rates. Critically ill patients appear to retain the capacity to absorb dietary protein and to use it for building body protein; however, the extent and possible benefit of this needs to be elucidated. More sophisticated methods to study protein absorption and digestion have recently been described but these have yet to be used in the critically ill. SUMMARY Adequate understanding of protein absorption and kinetics during critical illness will help the design of better interventional studies in the future. Because of the complexity of measuring protein absorption and kinetics in the critically ill, very few investigations are executed. Recent data using isotope-labelled amino acids suggests that critically ill patients are able to absorb enteral protein and to synthesize new body protein. However, the magnitude of absorption and anabolism that occurs, and possible benefits for the patients need to be elucidated.
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Affiliation(s)
- Felix Liebau
- Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Division of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Huddinge, Sweden
| | - Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Olav Rooyackers
- Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Division of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Huddinge, Sweden
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27
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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: 5] [Impact Index Per Article: 1.3] [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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28
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Intensive Care Unit-Acquired Weakness: Not just Another Muscle Atrophying Condition. Int J Mol Sci 2020; 21:ijms21217840. [PMID: 33105809 PMCID: PMC7660068 DOI: 10.3390/ijms21217840] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Intensive care unit-acquired weakness (ICUAW) occurs in critically ill patients stemming from the critical illness itself, and results in sustained disability long after the ICU stay. Weakness can be attributed to muscle wasting, impaired contractility, neuropathy, and major pathways associated with muscle protein degradation such as the ubiquitin proteasome system and dysregulated autophagy. Furthermore, it is characterized by the preferential loss of myosin, a distinct feature of the condition. While many risk factors for ICUAW have been identified, effective interventions to offset these changes remain elusive. In addition, our understanding of the mechanisms underlying the long-term, sustained weakness observed in a subset of patients after discharge is minimal. Herein, we discuss the various proposed pathways involved in the pathophysiology of ICUAW, with a focus on the mechanisms underpinning skeletal muscle wasting and impaired contractility, and the animal models used to study them. Furthermore, we will explore the contributions of inflammation, steroid use, and paralysis to the development of ICUAW and how it pertains to those with the corona virus disease of 2019 (COVID-19). We then elaborate on interventions tested as a means to offset these decrements in muscle function that occur as a result of critical illness, and we propose new strategies to explore the molecular mechanisms of ICUAW, including serum-related biomarkers and 3D human skeletal muscle culture models.
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29
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Liu W, Zhao WJ, Wu YH. Study on the differentially expressed genes and signaling pathways in dermatomyositis using integrated bioinformatics method. Medicine (Baltimore) 2020; 99:e21863. [PMID: 32846838 PMCID: PMC7447406 DOI: 10.1097/md.0000000000021863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Dermatomyositis is a common connective tissue disease. The occurrence and development of dermatomyositis is a result of multiple factors, but its exact pathogenesis has not been fully elucidated. Here, we used biological information method to explore and predict the major disease related genes of dermatomyositis and to find the underlying pathogenic molecular mechanism.The gene expression data of GDS1956, GDS2153, GDS2855, and GDS3417 including 94 specimens, 66 cases of dermatomyositis specimens and 28 cases of normal specimens, were obtained from the Gene Expression Omnibus database. The 4 microarray gene data groups were combined to get differentially expressed genes (DEGs). The gene ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichments of DEGs were operated by the database for annotation, visualization and integrated discovery and KEGG orthology based annotation system databases, separately. The protein-protein interaction networks of the DEGs were built from the STRING website. A total of 4097 DEGs were extracted from the 4 Gene Expression Omnibus datasets, of which 2213 genes were upregulated, and 1884 genes were downregulated. Gene ontology analysis indicated that the biological functions of DEGs focused primarily on response to virus, type I interferon signaling pathway and negative regulation of viral genome replication. The main cellular components include extracellular space, cytoplasm, and blood microparticle. The molecular functions include protein binding, double-stranded RNA binding and MHC class I protein binding. KEGG pathway analysis showed that these DEGs were mainly involved in the toll-like receptor signaling pathway, cytosolic DNA-sensing pathway, RIG-I-like receptor signaling pathway, complement and coagulation cascades, arginine and proline metabolism, phagosome signaling pathway. The following 13 closely related genes, XAF1, NT5E, UGCG, GBP2, TLR3, DDX58, STAT1, GBP1, PLSCR1, OAS3, SP100, IGK, and RSAD2, were key nodes from the protein-protein interaction network.This research suggests that exploring for DEGs and pathways in dermatomyositis using integrated bioinformatics methods could help us realize the molecular mechanism underlying the development of dermatomyositis, be of actual implication for the early detection and prophylaxis of dermatomyositis and afford reliable goals for the curing of dermatomyositis.
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Affiliation(s)
- Wei Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine
- Tianjin Key Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, China
| | - Wen-Jia Zhao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine
| | - Yuan-Hao Wu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine
- Tianjin Key Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, China
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30
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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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McKendry J, Thomas ACQ, Phillips SM. Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies. Nutr Clin Pract 2020; 35:607-616. [PMID: 32578900 DOI: 10.1002/ncp.10540] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 05/16/2020] [Indexed: 12/14/2022] Open
Abstract
Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.
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Affiliation(s)
- James McKendry
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Aaron C Q Thomas
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Stuart M Phillips
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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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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33
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Brook MS, Wilkinson DJ, Atherton PJ. An update on nutrient modulation in the management of disease-induced muscle wasting: evidence from human studies. Curr Opin Clin Nutr Metab Care 2020; 23:174-180. [PMID: 32175954 DOI: 10.1097/mco.0000000000000652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Skeletal muscle has many essential roles in maintaining human health, not only being crucial for locomotion, but further as a metabolically important organ. Muscle wasting in disease (cachexia) is highly prevalent, associated with poor clinical outcomes and is not fully reversible with nutritional interventions. Understanding proteostasis in diseased states is of great importance to design novel, effective nutritional/nutraceutical strategies aimed at alleviating muscle wasting. In this review, we will provide an update on muscle kinetics in disease and the effects of nutritional interventions. RECENT FINDINGS Whole body and skeletal muscle kinetics are commonly shown to be imbalanced in disease, promoting overall catabolism that underlies the development of cachexia. However, recent advancements in defining the effectiveness of nutritional interventions on muscle anabolism are clouded by heterogenous patient populations and a lack of direct incorporation stable isotope techniques. Current recommendations are focused on combating malnutrition, with increased protein intake (high in EAA) demonstrating promise. SUMMARY Recent progress in understanding catabolic states in cachexia across disease is minimal. Further, studies investigating muscle-specific protein turnover along with nutritional interventions are scarce. As such, there is a significant requirement for strong RCT's investigating both acute and chronic nutritional interventions and their impact on skeletal muscle in individual disease states.
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Affiliation(s)
- Matthew S Brook
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Clinical, Metabolic and Molecular Physiology, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre, Derby
- Queens Medical Centre, Nottingham, UK
| | - Daniel J Wilkinson
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Clinical, Metabolic and Molecular Physiology, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Philip J Atherton
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Clinical, Metabolic and Molecular Physiology, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Royal Derby Hospital Centre, Derby
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34
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Flower L, Puthucheary Z. Muscle wasting in the critically ill patient: how to minimise subsequent disability. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32339009 DOI: 10.12968/hmed.2020.0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Muscle wasting in critically ill patients is the most common complication associated with critical care. It has significant effects on physical and psychological health, mortality and quality of life. It is most severe in the first few days of illness and in the most critically unwell patients, with muscle loss estimated to occur at 2-3% per day. This muscle loss is likely a result of a reduction in protein synthesis relative to muscle breakdown, resulting in altered protein homeostasis. The associated weakness is associated with in an increase in both short- and long-term mortality and morbidity, with these detrimental effects demonstrated up to 5 years post discharge. This article highlights the significant impact that muscle wasting has on critically ill patients' outcomes, how this can be reduced, and how this might change in the future.
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Affiliation(s)
- Luke Flower
- Department of Anaesthetics, University College Hospital, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, Royal London Hospital, London, UK
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Effect of Intermittent or Continuous Feed on Muscle Wasting in Critical Illness: A Phase 2 Clinical Trial. Chest 2020; 158:183-194. [PMID: 32247714 DOI: 10.1016/j.chest.2020.03.045] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/09/2020] [Accepted: 03/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute skeletal muscle wasting in critical illness is associated with excess morbidity and mortality. Continuous feeding may suppress muscle protein synthesis as a result of the muscle-full effect, unlike intermittent feeding, which may ameliorate it. RESEARCH QUESTION Does intermittent enteral feed decrease muscle wasting compared with continuous feed in critically ill patients? STUDY DESIGN AND METHODS In a phase 2 interventional single-blinded randomized controlled trial, 121 mechanically ventilated adult patients with multiorgan failure were recruited following prospective informed consultee assent. They were randomized to the intervention group (intermittent enteral feeding from six 4-hourly feeds per 24 h, n = 62) or control group (standard continuous enteral feeding, n = 59). The primary outcome was 10-day loss of rectus femoris muscle cross-sectional area determined by ultrasound. Secondary outcomes included nutritional target achievements, plasma amino acid concentrations, glycemic control, and physical function milestones. RESULTS Muscle loss was similar between arms (-1.1% [95% CI, -6.1% to -4.0%]; P = .676). More intermittently fed patients received 80% or more of target protein (OR, 1.52 [1.16-1.99]; P < .001) and energy (OR, 1.59 [1.21-2.08]; P = .001). Plasma branched-chain amino acid concentrations before and after feeds were similar between arms on trial day 1 (71 μM [44-98 μM]; P = .547) and trial day 10 (239 μM [33-444 μM]; P = .178). During the 10-day intervention period the coefficient of variation for glucose concentrations was higher with intermittent feed (17.84 [18.6-20.4]) vs continuous feed (12.98 [14.0-15.7]; P < .001). However, days with reported hypoglycemia and insulin usage were similar in both groups. Safety profiles, gastric intolerance, physical function milestones, and discharge destinations did not differ between groups. INTERPRETATION Intermittent feeding in early critical illness is not shown to preserve muscle mass in this trial despite resulting in a greater achievement of nutritional targets than continuous feeding. However, it is feasible and safe. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02358512; URL: www.clinicaltrials.gov.
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Abstract
PURPOSE OF REVIEW Skeletal muscle wasting during critical illness is the result of disturbed metabolism. No proven effective interventions targeting skeletal muscle mass and function during critical illness currently exist. This review summarizes recent advances regarding the complexity of metabolic factors involved and the challenge of establishing the clinical effects of metabolic interventions targeting the muscle. RECENT FINDINGS Although the catabolic state is limited to the acute phase of critical illness, its subsequent impact on muscle mass and function persists long after ICU discharge. Immobilization, inflammation and disturbed muscle energy and nutrient metabolism are key drivers of muscle protein loss. Current research focuses on the effects of enhanced protein provision, specific substrate delivery and physical exercise. Whilst some interventions have been successful at improving muscle mass, these effects do not always carry over into muscle function or strength. SUMMARY Increased understanding of metabolic derangements during critical illness provides new potential targets for treatment. The potential of dietary protein to attenuate the muscle protein catabolic state has yet to be established in clinical trials. Basic research should focus on ways to further improve the anabolic potential of nutrition by unravelling mechanisms that regulate anabolic and catabolic pathways and energy metabolism.
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Affiliation(s)
- Robert J.J. van Gassel
- Department of Intensive Care Medicine
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, The Netherlands
| | | | - Marcel C.G. van de Poll
- Department of Intensive Care Medicine
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, The Netherlands
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Abstract
PURPOSE OF REVIEW The objective of this review is to describe the impact of protein intake on the outcomes of critically ill patients in the literature published in the preceding 2 years. RECENT FINDINGS Observational studies showed inconsistent results regarding the association of higher protein intake and outcomes of critically ill patients. Randomized controlled trials that directly compared higher versus lower protein intake in ICU patients are scarce, varied considerably in their designs and primary outcomes, and generally had relatively small differences in the amount of delivered protein between the study arms. Systematic reviews of existing studies showed no difference in mortality with higher protein intake. In addition, there is uncertainty regarding high protein provision in the early phase of critical illness. SUMMARY The optimal amount of protein intake in critically ill patients remains largely unclear and is considered a high priority for research. Ongoing clinical trials are likely to provide additional evidence on several important questions including the dose, timing, type of protein and the interaction with caloric intake and exercise.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard - Health Affairs King Abdullah International Medical Research Center College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Wandrag L, Brett SJ, Frost GS, Bountziouka V, Hickson M. Exploration of muscle loss and metabolic state during prolonged critical illness: Implications for intervention? PLoS One 2019; 14:e0224565. [PMID: 31725748 PMCID: PMC6855435 DOI: 10.1371/journal.pone.0224565] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background Muscle wasting in the critically ill is up to 2% per day and delays patient recovery and rehabilitation. It is linked to inflammation, organ failure and severity of illness. The aims of this study were to understand the relationship between muscle depth loss, and nutritional and inflammatory markers during prolonged critical illness. Secondly, to identify when during critical illness catabolism might decrease, such that targeted nutritional strategies may logically be initiated. Methods This study was conducted in adult intensive care units in two large teaching hospitals. Patients anticipated to be ventilated for >48 hours were included. Serum C-reactive protein (mg/L), urinary urea (mmol/24h), 3-methylhistidine (μmol/24h) and nitrogen balance (g/24h) were measured on days 1, 3, 7 and 14 of the study. Muscle depth (cm) on ultrasound were measured on the same days over the bicep (bicep and brachialis muscle), forearm (flexor compartment of muscle) and thigh (rectus femoris and vastus intermedius). Results Seventy-eight critically ill patients were included with mean age of 59 years (SD: 16) and median Intensive care unit (ICU) length of stay of 10 days (IQR: 6–16). Starting muscle depth, 8.5cm (SD: 3.2) to end muscle depth, 6.8cm (SD: 2.2) were on average significantly different over 14 days, with mean difference -1.67cm (95%CI: -2.3 to -1cm), p<0.0001. Protein breakdown and inflammation continued over 14 days of the study. Conclusion Our patients demonstrated a continuous muscle depth loss and negative nitrogen balance over the 14 days of the study. Catabolism remained dominant throughout the study period. No obvious ‘nutritional tipping point” to identify anabolism or recovery could be identified in our cohort. Our ICU patient cohort is one with a moderately prolonged stay. This group showed little consistency in data, reflecting the individuality of both disease and response. The data are consistent with a conclusion that a time based assumption of a tipping point does not exist. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN79066838. Registration 25 July 2012.
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Affiliation(s)
- Liesl Wandrag
- Section for Nutrition Research, Department of Metabolism, Digestion and Reproduction, Imperial College London, England, United Kingdom
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, England, United Kingdom
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, England, United Kingdom
- * E-mail:
| | - Stephen J. Brett
- Centre for Peri-operative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, England, United Kingdom
| | - Gary S. Frost
- Section for Nutrition Research, Department of Metabolism, Digestion and Reproduction, Imperial College London, England, United Kingdom
| | - Vasiliki Bountziouka
- Statistical Support Service, Population, Policy and Practice Programme, Institute of Child Health, University College, London, United Kingdom
| | - Mary Hickson
- Section for Nutrition Research, Department of Metabolism, Digestion and Reproduction, Imperial College London, England, United Kingdom
- Institute of Health and Community, University of Plymouth, Devon, England, United Kingdom
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Haines RW, Zolfaghari P, Wan Y, Pearse RM, Puthucheary Z, Prowle JR. Elevated urea-to-creatinine ratio provides a biochemical signature of muscle catabolism and persistent critical illness after major trauma. Intensive Care Med 2019; 45:1718-1731. [DOI: 10.1007/s00134-019-05760-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/20/2019] [Indexed: 01/04/2023]
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Sundström-Rehal M, Tardif N, Rooyackers O. Can exercise and nutrition stimulate muscle protein gain in the ICU patient? Curr Opin Clin Nutr Metab Care 2019; 22:146-151. [PMID: 30585804 DOI: 10.1097/mco.0000000000000548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The intended purpose of nutritional and exercise interventions during ICU stay is often to limit the muscle loss associated with critical illness. Unfortunately, direct measurements of muscle protein turnover or potential surrogates have often been neglected in clinical trials. RECENT FINDINGS We discuss the potential advantages and drawbacks of common outcome measures for assessing changes in muscle structure and function over time, and how temporal changes in patient physiology require consideration. There is an increasing awareness of emphasizing functional outcomes in recent clinical trials. We here summarize the latest research on therapies attempting to limit muscle loss in ICU patients, with a focus on muscle protein metabolism. No recent or older studies show any effect of nutritional interventions on muscle protein gain, although some smaller studies show a promising positive effect on muscle thickness and function. Some studies show a positive effect of increased physical activity in the ICU on muscle mass and function but heterogeneity of the interventions and outcome measures make any general conclusions impossible. SUMMARY Several knowledge gaps remain regarding the importance of muscle protein regulation as a driver of improved physical function following ICU discharge. In our opinion, physiological investigations are needed to guide the design and interpretation of future clinical trials.
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Affiliation(s)
- Martin Sundström-Rehal
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Nicolas Tardif
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Bear DE, Griffith D, Puthucheary ZA. Emerging outcome measures for nutrition trials in the critically ill. Curr Opin Clin Nutr Metab Care 2018; 21:417-422. [PMID: 30148741 DOI: 10.1097/mco.0000000000000507] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mortality has long been the gold-standard outcome measure for intensive care clinical trials. However, as the critical care community begins to understand and accept that survivorship is associated with functional disability and a health and socioeconomic burden, the clinical and research focus has begun to shift towards long-term physical function RECENT FINDINGS: To use mortality as a primary outcome measure, one would either have to choose an improbable effect (e.g. a difference of 5-10% in mortality as a result of a single intervention) or recruit a larger number of patients, the latter being unfeasible for most critical care trials.Outcome measures will need to match interventions. As an example, amino acids, or intermittent feeding, can stimulate muscle protein synthesis, and so prevention of muscle wasting may seem an appropriate outcome measure when assessing the effectiveness of these interventions. Testing the effectiveness of these interventions requires the development of novel outcome measures that are targeted and acceptable to patients. We describe advancements in dual-energy X-ray absorptiometry scanning, bio-impedence analysis, MRI and muscle ultrasound in this patient group that are beginning to address this development need. SUMMARY New approaches to outcome assessment are beginning to appear in post-ICU research, which promise to improve our understanding of nutrition and exercise interventions on skeletal muscle structure, composition and function, without causing undue suffering to the patient.
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Affiliation(s)
- Danielle E Bear
- Department of Nutrition and Dietetics
- Department of Critical Care
- Lane Fox Clinical Respiratory Research Unit, Guy's and St Thomas' NHS Foundation Trust
- Centre for Human and Applied Physiological Sciences, King's College London
| | - David Griffith
- Anaesthesia, Critical Care and Pain Medicine, The University of Edinburgh, Edinburgh
| | - Zudin A Puthucheary
- Centre for Human and Applied Physiological Sciences, King's College London
- Centre for Human Health and Performance, Department of Medicine, University College London
- Adult Intensive Care Unit, Royal Free Hospital NHS Foundation Trust London, London, UK
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Preiser JC. High protein intake during the early phase of critical illness: yes or no? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:261. [PMID: 30360760 PMCID: PMC6203200 DOI: 10.1186/s13054-018-2196-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/19/2018] [Indexed: 11/10/2022]
Abstract
The rationale for the provision of nitrogen from proteins given via the enteral route or from intravenous amino acids is to boost the synthesis of muscle proteins, and thereby to limit the severity of intensive care unit-acquired weakness by the prevention of muscle loss. However, the optimal timing for supplemental nitrogen provision is a matter of debate and controversy. Indeed, consistent data from retrospective studies support an association between high early protein intakes and better outcomes, while recent post-hoc findings from prospective studies raise safety concerns. This pro–con paper details the arguments of both sides and highlights the need for large-scale prospective studies assessing the safety and efficacy of different levels of protein intake in combination with physical activity and summarizes the currently recruiting clinical trials.
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Affiliation(s)
- Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, B-1070, Brussels, Belgium.
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Parry SM, Chapple LAS, Mourtzakis M. Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review. Nutr Clin Pract 2018; 33:772-789. [PMID: 30358183 DOI: 10.1002/ncp.10213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, South Australia, Australia
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