Early high protein intake and mortality in critically ill ICU patients with low skeletal muscle area and -density

Abstract

Background & aims: Optimal nutritional support during the acute phase of critical illness remains controversial. We hypothesized that patients with low skeletal muscle area and -density may specifically benefit from early high protein intake. Aim of the present study was to determine the association between early protein intake (day 2e4) and mortality in critically ill intensive care unit (ICU) patients with normal skeletal muscle area, low skeletal muscle area, or combined low skeletal muscle area and -density. Methods: Retrospective database study in mechanically ventilated, adult critically ill patients with an abdominal CT-scan suitable for skeletal muscle assessment around ICU admission, admitted from January 2004 to January 2016 (n ¼ 739). Patients received protocolized nutrition with protein target 1.2e1.5 g/kg/ day. Skeletal muscle area and -density were assessed on abdominal CT-scans at the 3rd lumbar vertebra level using previously defined cut-offs. Results: Of 739 included patients (mean age 58 years, 483 male (65%), APACHE II score 23), 294 (40%) were admitted with normal skeletal muscle area and 445 (60%) with low skeletal muscle area. Two hundred (45% of the low skeletal muscle area group) had combined low skeletal muscle area and -density. In the normal skeletal muscle area group, no significant associations were found. In the low skeletal muscle area group, higher early protein intake was associated with lower 60-day mortality (adjusted hazard ratio (HR) per 0.1 g/kg/day 0.82, 95%CI 0.73e0.94) and lower 6-month mortality (HR 0.88, 95%CI 0.79e0.98). Similar associations were found in the combined low skeletal muscle area and -density subgroup (HR 0.76, 95%CI 0.64e0.90 for 60-day mortality and HR 0.80, 95%CI 0.68e0.93 for 6month mortality). Conclusions: Early high protein intake is associated with lower mortality in critically ill patients with low skeletal muscle area and -density, but not in patients with normal skeletal muscle area on admission. These findings may be a further step to personalized nutrition, although randomized studies are needed to assess causality.

The Role of Dysbiosis in Critically Ill Patients With COVID-19 and Acute Respiratory Distress Syndrome

“…The VHPF facilitated feeding without increasing energy intake, which is consistent with previous ESPEN guidelines (176). However, early high protein intake is associated with a lower mortality rate only in patients with a low skeletal muscle area at hospital admission, not in those with a normal skeletal muscle area (177). Another study found that improvement in daily protein intake could reduce 3-month mortality after hospital discharge (178).…”

Review of evolution and current status of protein requirements and provision in acute illness and critical care

“…Mortality was significantly higher in the patients with low skeletal muscle mass. Early high-protein intake was associated with lower 60-day (HR: 0.16, 95% CI: 0.05e0.55) and 6-month (HR: 0.32; 95% CI: 0.14e0.74) mortality in patients with low skeletal muscle area and density, but not in patients with normal skeletal muscle area when adjusted for confounders [94]. More research on the relationship between protein delivery/dose and muscle mass is needed.…”

“…Most studies have focussed on endpoints such as mortality and length of stay which are likely affected by multiple factors [97]. Nevertheless, early high-protein intake has been associated with reduced mortality in patients with low skeletal muscle area and density in a recent retrospective analysis (NCT02817646; N ¼ 739) in mechanically ventilated ICU patients with normal or low skeletal muscle mass (based on CT scan) [94]. Mortality was significantly higher in the patients with low skeletal muscle mass.…”

Nutrition evaluation and management of critically ill patients with COVID‐19 during post–intensive care rehabilitation

“…Specifically in patients with SARS-CoV-2 infection, comorbidities such as diabetes, arterial hypertension and cardiovascular disease can co-exist and further aggravate nutritional status 1,5 . Malnutrition is responsible for high morbidity at discharge from the ICU 6 and, conversely, optimal nutritional status has been shown to be associated with fewer complications, shorter stays in the ICU, and lower mortality in two recent large retrospective studies including ICU patients 7,8 . Moreover, according to a recent Italian cohort of 268 patients, it has been shown that all patients with COVID-19 are at nutritional risk, and 1/3 of them are malnourished 9 American Society for Parenteral and Enteral Nutrition (ASPEN), but specific cohort studies in this population are lacking 10,11 .…”