Augmented Renal Clearance Following Traumatic Injury in Critically Ill Patients Requiring Nutrition Therapy

Abstract

The intent of this study was to ascertain the prevalence of augmented renal clearance (ARC) in patients with traumatic injuries who require nutrition therapy and identify factors associated with ARC. Adult patients admitted to the trauma intensive care unit from January 2015 to September 2016 who received enteral or parenteral nutrition therapy and had a 24 h urine collection within 4 to 14 days after injury were retrospectively evaluated. Patients with a serum creatinine concentration > 1.5 mg/dL, required dialysis, or had an incomplete urine collection were excluded. ARC was defined as a measured creatinine clearance > 149 mL/min/1.73 m2. Two hundred and three patients were evaluated. One hundred and two (50%) exhibited ARC. A greater proportion of patients with ARC were male (86% vs. 67%; p = 0.004), had traumatic brain injury (33% vs. 9%; p = 0.001), a higher injury severity score (30 ± 11 vs. 26 ± 12; p = 0.015), were younger (36 ± 15 vs. 54 ± 17 years; p = 0.001), had a lower serum creatinine concentration (0.7 ± 2 vs. 0.9 ± 0.2 mg/dL; p = 0.001) and were more catabolic (nitrogen balance of −10.8 ± 13.0 vs. −6.2 ± 9.2 g/d; p = 0.004). The multivariate analysis revealed African American race and protein intake were also associated with ARC. Half of critically ill patients with traumatic injuries experience ARC. Patients with multiple risk factors for ARC should be closely evaluated for dosing of renally-eliminated electrolytes, nutrients, and medications.

Augmented Renal Clearance, Muscle Catabolism and Urinary Nitrogen Loss: Implications for Nutritional Support in Critically Ill Trauma Patients

“…Patients with higher protein intakes were characterized by higher levels of CRCL, without statistical difference regarding ∆CSA and %∆CSA compared to patients who received low protein intakes. These results are in accordance with a recent study suggesting a worsened nitrogen balance (−10.8 ± 13.0 vs. −6.2 ± 9.2 g/day, p = 0.004) in critically ill patients with ARC, although this study was impaired by the lack of muscle mass measurements and longitudinal data (only the first measurement being used for analysis) [5]. Of note, the authors also found a significant association between ARC and increased protein intake (adjusted OR: 2.06 [1.09, 3.91]).…”

“…Early targeted protein intake is thought to improve short-term outcome, reduce muscle wasting and hospital mortality [2,3]. Despite several limitations, determination of nitrogen balance is one of the most common methods to assess muscle catabolism and determine the targeted protein requirement [4,5].…”

External Validation of the Augmented Renal Clearance Predictor in Critically Ill COVID-19 Patients

“…We found that ARC occurred relatively early after ICU admission, which is opposed to the findings of Beunders et al, who found that ARC occurred late on median (IQR) day 28 (21–42) following ICU admission during COVID-19 infections [ 17 ], but is in line with the findings of previous studies in general ICU patients (the highest ARC prevalence was observed on day 5) and critically ill COVID-19 patients (the median (IQR) first day of ARC was day 2 (3–5) of ICU stay) [ 1 , 19 ]. Next, age was ranked as the third most important feature, which was expected since age has consistently shown a significant inverse association with ARC in many studies [ 7 , 9 , 10 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. Age might be more relevant in this patient population since it has been noticed that some COVID-19 variants are more prevalent in young patients [ 34 , 35 ].…”

Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system for augmented renal clearance prediction in a trauma subgroup of a mixed ICU population

“…In critically ill patients, prevalence of ARC usually ranges from 20% to 65% 1,3–5,7,9,11–14,20,22–27 . Higher prevalence has been reported in specific groups of patients such as traumatic brain injury (TBI) (85%) 28 and subarachnoid haemorrhage (100%) 29 .…”

“…4,7,12,22 In critically ill patients, prevalence of ARC usually ranges from 20% to 65%. 1,[3][4][5]7,9,[11][12][13][14]20,[22][23][24][25][26][27] Higher prevalence has been reported in specific groups of patients such as traumatic brain injury (TBI) (85%) 28 and subarachnoid haemorrhage (100%). 29 Several risk factors of ARC have been identified such as younger age, male sex, trauma and lower severity of illness expressed by the Sequential Organ Failure Assessment (SOFA) score or the Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score.…”