Daily Protein Intake and Patient Outcomes in Severe Acute Kidney Injury: Findings of the Randomized Evaluation of Normal versus Augmented Level of Replacement Therapy (RENAL) Trial

Abstract

Background and Aims: We aimed to examine the association between dailyprotein intake (DPI) and outcomes in patients from the Randomized Evaluation of Normal versus Augmented Level (RENAL) trial. Methods: We analyzed the association between DPI and clinical outcomes using multivariable logistic regression, Cox proportional hazards models and time-adjusted analysis. Results: During ICU stay, mean DPI was 37.6 g/day among survivors and 37.7 g/day among nonsurvivors (p = 0.96; DPI of 0.5 g/kg/day). Only 159 (10.9%) of the patients received a mean DPI of >1 g/kg. Patients with a DPI above the median had a 43.1% mortality compared with 46.1% for a DPI below the median (p = 0.25). On multivariate analysis, a lower DPI was not associated with increased odds ratios for 90-day mortality or any secondary outcomes. Cox proportional hazards models and time-adjusted analysis confirmed these findings. Conclusions: In the RENAL study, mean DPI was low. Within the confines of such low DPI, greater amounts of DPI were not independently associated with improved clinical outcomes. Video Journal Club “Cappuccino with Claudio Ronco” at www.karger.com/?doi=363175.

The Impact of Macro-and Micronutrients on Predicting Outcomes of Critically Ill Patients Requiring Continuous Renal Replacement Therapy

“…Inadequate DPI in highly catabolic AKI patients may cause progressive lean body mass loss leading to protein-energy wasting (PEW), cachexia, and poor clinical outcome [ 14 ]. Of note, the mean DPI in our study was 0.6 g/kg/day which was quite similar to a recent post hoc analysis of the RENAL study [ 13 ]. In contrast to our results, such study found that a lower DPI was not associated with increased 90-day mortality or any secondary outcomes (28-day mortality, death in the ICU, in-hospital death, RRT outcome, duration of ICU and hospital stays, duration of mechanical ventilation and RRT, dialysis status at day 90, and any new organ failures).…”

“…Studies in the 1990s and early 2000s had used old-fashioned CRRT technique and did not mention the association between nutritional parameters and clinical outcomes [ 10 – 12 ]. In the post hoc analysis of R andomized E valuation of N ormal versus A ugmented L evel (RENAL) study [ 13 ], low DPI did not show the association of low DPI and the poor clinical outcome. Therefore, there are still conflicting results in clinical studies.…”

Systematic Review With Meta‐Analysis of Patient‐Centered Outcomes, Comparing International Guideline–Recommended Enteral Protein Delivery With Usual Care

“…Recommendations from international critical care guidelines suggest that critically ill patients should receive at least 1.2 g/kg body weight per day of protein via the enteral protein targets, with several studies reporting that during usual critical care management, patients only receive a mean of 0.6-0.8 g/kg per day protein, presumably because of interruptions to feeding, intolerance, and limited availability of higher-protein formulas. [5][6][7][8][9] During critical illness, the frequent occurrence of muscle loss is associated with inferior patient-centered outcomes. 3 Inflammatory mediators, coupled with inactivity, may drive an imbalance between protein breakdown and synthesis, 10,11 with rapid muscle loss of up to 1%-2% of lean body mass per day.…”

Findings from two large randomized controlled trials on renal replacement therapy in acute kidney injury

“…Patients in the RENAL study received a low DPI (0.5 g/kg/day), markedly below current recommendations. However, a low DPI was not independently associated with a decreased risk of death at 90 days or an increase in mechanical ventilation, RRT, ICU, or hospital-free days [36]. Thus, as with DCI, data is not clear on the optimal DPI target in AKI patients.…”