Protein intake and outcome of critically ill patients: analysis of a large international database using piece-wise exponential additive mixed models

Background Proteins are an essential part of medical nutrition therapy in critically ill patients. Guidelines almost universally recommend a high protein intake without robust evidence supporting its use. Methods Using a large international database, we modelled associations between the hazard rate of in-hospital death and live hospital discharge (competing risks) and three categories of protein intake (low: < 0.8 g/kg per day, standard: 0.8–1.2 g/kg per day, high: > 1.2 g/kg per day) during the first 11 days after ICU admission (acute phase). Time-varying cause-specific hazard ratios (HR) were calculated from piece-wise exponential additive mixed models. We used the estimated model to compare five different hypothetical protein diets (an exclusively low protein diet, a standard protein diet administered early (day 1 to 4) or late (day 5 to 11) after ICU admission, and an early or late high protein diet). Results Of 21,100 critically ill patients in the database, 16,489 fulfilled inclusion criteria for the analysis. By day 60, 11,360 (68.9%) patients had been discharged from hospital, 4,192 patients (25.4%) had died in hospital, and 937 patients (5.7%) were still hospitalized. Median daily low protein intake was 0.49 g/kg [IQR 0.27–0.66], standard intake 0.99 g/kg [IQR 0.89– 1.09], and high intake 1.41 g/kg [IQR 1.29–1.60]. In comparison with an exclusively low protein diet, a late standard protein diet was associated with a lower hazard of in-hospital death: minimum 0.75 (95% CI 0.64, 0.87), and a higher hazard of live hospital discharge: maximum HR 1.98 (95% CI 1.72, 2.28). Results on hospital discharge, however, were qualitatively changed by a sensitivity analysis. There was no evidence that an early standard or a high protein intake during the acute phase was associated with a further improvement of outcome. Conclusions Provision of a standard protein intake during the late acute phase may improve outcome compared to an exclusively low protein diet. In unselected critically ill patients, clinical outcome may not be improved by a high protein intake during the acute phase. Study registration ID number ISRCTN17829198

High-protein intake and early exercise in adult intensive care patients: a prospective, randomized controlled trial to evaluate the impact on functional outcomes

Background We evaluated the efficacy of high protein intake and early exercise versus standard nutrition care and routine physiotherapy on the outcome of critically ill patients. Methods We randomized mechanically ventilated patients expected to stay in the intensive care unit (ICU) for 4 days. We used indirect calorimetry to determine energy expenditure and guide caloric provision to the patients randomized to the high protein and early exercise (HPE) group and the control group. Protein intakes were 1.48 g/kg/day and 1.19 g/kg/day medians respectively; while the former was submitted to two daily sessions of cycle ergometry exercise, the latter received routine physiotherapy. We evaluated the primary outcome physical component summary (PCS) score at 3 and 6 months) and the secondary outcomes (handgrip strength at ICU discharge and ICU and hospital mortality). Results We analyzed 181 patients in the HPE (87) and control (94) group. There was no significant difference between groups in relation to calories received. However, the amount of protein received by the HPE group was significantly higher than that received by the control group (p < 0.0001). The PCS score was significantly higher in the HPE group at 3 months (p = 0.01) and 6 months (p = 0.01). The mortality was expressively higher in the control group. We found an independent association between age and 3-month PCS and that between age and group and 6-month PCS. Conclusion This study showed that a high-protein intake and resistance exercise improved the physical quality of life and survival of critically ill patients. Trial registration Research Ethics Committee of Hospital São Domingos: Approval number 1.487.683, April 09, 2018. The study protocol was registered in ClinicalTrials.gov (NCT03469882, March 19,2018).

Does high protein intake cause tubular injury in very preterm neonates?

Background: Very preterm birth rate was 10.8% of all preterm in Asia. Early aggressive nutritional strategies in very preterm neonates is important for catching up growth; however, preterm kidneys have fewer, immature functional nephrons. Studies have showed that high protein intake induces nephron hypertrophy, proteinuria, and glomerular sclerosis through single nephron glomerular hyperfiltration (SNGHF), which leads to glomerulotubular injury. Aim: to analyse the correlation between protein intake and glomerulotubular injury in very preterm neonates. Method: A prospective cohort study was conducted in neonatal units of two hospitals in Jakarta. Urine samples were taken three times at post-natal ages 0-48 hours (T1), 72 hours (T2), and 21 days (T3) for determining the urinary neutrophil gelatinase-associated lipocalin to creatinine (uNGAL/Cr) ratio. Protein intake were given in accordance with local guideline while considering the clinical condition of participants. Protein levels from formula milk were recorded daily from 14-21 days of age, while breastmilk protein was measured twice by using a human milk analyser. Urinary NGAL (uNGAL) was tested with an ELISA. Glomerulotubular injury was defined as a uNGAL/Cr ratio ≥1 SD (22.74 ng/mg) at post-natal age 21 days. High protein intake was defined as average protein intake ≥ 3 g/kg/day. Results: Fifty-nine very preterm neonates were recruited, of which 39 completed the study. Glomerulotubular injury was found in 9 of 39 participants (23%). The proportion of glomerulotubular injury in very preterm neonates who had received high protein intake vs low protein intake was 5 of 29 vs 4 of 10 participants, respectively. The median of uNGAL/Cr ratio was not significantly different in the high vs low protein intake group (3.54 (range: 0.69-89.16) ng/mg vs (6.88 (range: 0.32-66.64)) ng/mg, respectively. The uNGAL/C ratio was not correlated with protein intake. However, it was inversely correlated with gestational age and birth weight. Conclusions: The proportion of glomerulotubular injury in very preterm neonates given high protein diet was 5 of 29. The uNGAL/Cr ratio was increased at the post-natal age of 72 hours and decreased in 21 days in both high and low protein intake groups. High protein intake was not correlated with glomerulotubular injury.

High-Protein Energy-Restriction: Effects on Body Composition, Contractile Properties, Mood, and Sleep in Active Young College Students

Background: It is often advised to ensure a high-protein intake during energy-restricted diets. However, it is unclear whether a high-protein intake is able to maintain muscle mass and contractility in the absence of resistance training.Materials and Methods: After 1 week of body mass maintenance (45 kcal/kg), 28 male college students not performing resistance training were randomized to either the energy-restricted (ER, 30 kcal/kg, n = 14) or the eucaloric control group (CG, 45 kcal/kg, n = 14) for 6 weeks. Both groups had their protein intake matched at 2.8 g/kg fat-free-mass and continued their habitual training throughout the study. Body composition was assessed weekly using multifrequency bioelectrical impedance analysis. Contractile properties of the m. rectus femoris were examined with Tensiomyography and MyotonPRO at weeks 1, 3, and 5 along with sleep (PSQI) and mood (POMS).Results: The ER group revealed greater reductions in body mass (Δ −3.22 kg vs. Δ 1.90 kg, p &lt; 0.001, partial η2 = 0.360), lean body mass (Δ −1.49 kg vs. Δ 0.68 kg, p &lt; 0.001, partial η2 = 0.152), body cell mass (Δ −0.85 kg vs. Δ 0.59 kg, p &lt; 0.001, partial η2 = 0.181), intracellular water (Δ −0.58 l vs. Δ 0.55 l, p &lt; 0.001, partial η2 = 0.445) and body fat percentage (Δ −1.74% vs. Δ 1.22%, p &lt; 0.001, partial η2 = 433) compared to the CG. Contractile properties, sleep onset, sleep duration as well as depression, fatigue and hostility did not change (p &gt; 0.05). The PSQI score (Δ −1.43 vs. Δ −0.64, p = 0.006, partial η2 = 0.176) and vigor (Δ −2.79 vs. Δ −4.71, p = 0.040, partial η2 = 0.116) decreased significantly in the ER group and the CG, respectively.Discussion: The present data show that a high-protein intake alone was not able to prevent lean mass loss associated with a 6-week moderate energy restriction in college students. Notably, it is unknown whether protein intake at 2.8 g/kg fat-free-mass prevented larger decreases in lean body mass. Muscle contractility was not negatively altered by this form of energy restriction. Sleep quality improved in both groups. Whether these advantages are due to the high-protein intake cannot be clarified and warrants further study. Although vigor was negatively affected in both groups, other mood parameters did not change.

Comparison of Different Nutritional and Lifestyle Factors between Glaucoma Patients and an Age-Matched Normal Population

Purpose To compare nutritional and lifestyle factors between glaucoma patients and an age-matched control group. Methods One hundred and ninety (190) glaucoma patients were enrolled in this study. The control group comprised 97 age-matched participants. Data on physical activity, nicotine smoking, and several nutritional habits like coffee and alcohol consumption as well as high-salt and high-protein intake were collected using a standardised questionnaire. Results Age and gender were not statistically significantly different between the groups. There was a tendency for higher physical activity in the glaucoma group in comparison to the control group (47.3 vs. 35.4%; p = 0.056). Statistically significantly more glaucoma patients were nonsmokers (n = 169; 89.4%) compared to the control group (n = 64; 66.7%; p = 0.001). Glaucoma patients were also more often teetotal compared to the control group (21.6% compared to 14.4%; p < 0.001). Similarly, more glaucoma patients drank larger amounts of coffee in comparison to the control group (p = 0.001). One hundred and seventy-six (96.7%) glaucoma patients and 88 (90.7%) control subjects had high-protein intake (p = 0.035). High-salt intake was significantly lower in the glaucoma group (69.3 vs. 73.2%; p = 0.018). Of the 190 glaucoma patients, 81 had early visual field impairments (MD > − 6 dB) and 109 patients had moderate (MD between − 6 dB and − 12 dB) to severe (MD < − 12 dB) visual field defects. The severity of visual field defects, whether early, moderate, or severe, had no statistically significant impact on lifestyle parameters. Conclusion Contrary to our original hypothesis that glaucoma patients would tend to follow an unhealthier lifestyle than the control group, the opposite was seen. Presumably, the cause of this healthier lifestyle is the desire to contribute positively through the course of the disease.