The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial.

BACKGROUND: Based on low-quality evidence, current nutrition guidelines recommend the delivery of high-dose protein in critically ill patients. The EFFORT Protein trial showed that higher protein dose is not associated with improved outcomes, whereas the effects in critically ill patients who developed acute kidney injury (AKI) need further evaluation. The overall aim is to evaluate the effects of high-dose protein in critically ill patients who developed different stages of AKI. METHODS: In this post hoc analysis of the EFFORT Protein trial, we investigated the effect of high versus usual protein dose (≥ 2.2 vs. ≤ 1.2 g/kg body weight/day) on time-to-discharge alive from the hospital (TTDA) and 60-day mortality and in different subgroups in critically ill patients with AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria within 7 days of ICU admission. The associations of protein dose with incidence and duration of kidney replacement therapy (KRT) were also investigated. RESULTS: Of the 1329 randomized patients, 312 developed AKI and were included in this analysis (163 in the high and 149 in the usual protein dose group). High protein was associated with a slower time-to-discharge alive from the hospital (TTDA) (hazard ratio 0.5, 95% CI 0.4-0.8) and higher 60-day mortality (relative risk 1.4 (95% CI 1.1-1.8). Effect modification was not statistically significant for any subgroup, and no subgroups suggested a beneficial effect of higher protein, although the harmful effect of higher protein target appeared to disappear in patients who received kidney replacement therapy (KRT). Protein dose was not significantly associated with the incidence of AKI and KRT or duration of KRT. CONCLUSIONS: In critically ill patients with AKI, high protein may be associated with worse outcomes in all AKI stages. Recommendation of higher protein dosing in AKI patients should be carefully re-evaluated to avoid potential harmful effects especially in patients who were not treated with KRT. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov (NCT03160547) on May 17th 2017.

Comparison Between Handgrip Dynamometry and Manual Muscle Testing Performed by Registered Dietitians in Measuring Muscle Strength and Function of Hospitalized Patients.

BACKGROUND: The Academy of Nutrition and Dietetics and American Society the Parenteral and Enteral Nutrition (ASPEN) Consensus Statement recommends a standardized set of diagnostic characteristics to identify adult malnutrition. Due to lack of a consensus definition and challenges with measurements, physical function or performance has traditionally been difficult to assess. The purpose of this study was to determine whether manual muscle testing (MMT) performed by registered dietitians (RDs) can be used as a surrogate measurement of muscle strength and function in hospitalized patients. METHOD: Patients admitted to the heart failure service on the cardiac stepdown units at the Cleveland Clinic Main Campus in Cleveland, Ohio, were eligible for the study, and those who met the inclusion criteria underwent handgrip strength (HGS) testing and evaluation of nutrition status using the Academy/ASPEN Characteristics Recommended for the Identification of Adult Malnutrition. MMT was then performed within 24 hours by a different study investigator blinded to the HGS and malnutrition assessment results. RESULTS: It was found that HGS and MMT overall were in agreement for 84% of patients and that MMT had a high sensitivity (98%) but low specificity (13%). CONCLUSION: This study shows feasibility for RDs to perform MMT on patients to determine muscle strength and functioning. Future practice application may be to incorporate MMT into screening criteria for patients being evaluated for malnutrition and reserve HGS testing only for patients with an abnormal MMT.