High protein diets are associated with increased bacterial translocation in septic guinea pigs

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

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03870-5.

Beneficial effect of amino acid supplementation, especially cysteine, on body nitrogen economy in septic rats

BACKGROUND AND AIMS

Muscle wasting and increased synthesis of proteins and compounds involved in host defense characterize severe injury. The aims of the studies reported were to determine which amino acids exhibited an increased tissue content linked to anabolic processes in infected rats by comparison with healthy pair-fed controls, and to explore whether diets supplemented with these amino acids attenuate the catabolic response to infection.

METHODS

Total amino acid content of the liver and the rest of the body were measured in control well-fed rats, in infected rats and their pair-fed controls 2 days after infection. In the nutritional protocols, infected rats were fed with a diet supplemented with alanine (basal diet), or threonine, serine, aspartate, asparagine and arginine (AA) or AA+cysteine (complete diet).

RESULTS

Infection significantly increased liver total amino acid content by 38% for most amino acids. In contrast, the percentage increase was cysteine 79.3, threonine 45.3, aspartate-asparagine 46.3 and serine 46.5. Whole body without liver content of most amino acids decreased after infection due to the catabolic response, while the content of cysteine increased by 6% (P<0.05) and those of threonine and arginine did not decrease. After infection, animals fed the complete diet lost less weight than animals fed the basal diet (P<0.05). Furthermore, AA plus cysteine supplementation reduced significantly urinary nitrogen excretion and muscle wasting.

CONCLUSIONS

The results provide evidence that diet supplementation with cysteine, threonine, serine, aspartate-asparagine and arginine supports the synthesis of vital proteins to spare body protein catabolism during infection.

Contribution of microbial amino acids to amino acid homeostasis of the host

Among the reasons suggested for the discrepancy between N balance and tracer-derived indispensable amino acid (IAA) requirement estimates is the possibility that the metabolic requirement is met not only by the diet but also by IAA synthesized de novo by the gastrointestinal microflora, which are then absorbed. It is therefore crucial to better understand and quantify the microbial biosynthesis of amino acids in the human gastrointestinal tract and its potential role in providing IAA to meet human amino acid requirement. Here, the available evidence on the contribution of microbial amino acids to the host's amino acid homeostasis, applying the (15)N labeling paradigm, is summarized. Between 1 and 20% of circulating plasma lysine, urinary lysine and body protein lysine of the host, respectively, is derived from intestinal microbial sources and corresponds to a gross microbial lysine contribution of 11-68 mg. kg(-1). d(-1) in adult humans with an adequate protein intake when fecal or ileal microbial lysine enrichment is used as precursor. Factors affecting estimates of net microbial IAA contribution are discussed. It appears that the small intestine is responsible for a large part of microbial lysine uptake, although some absorption from the large intestine cannot be excluded. Nonoxidative lysine losses from the human gastrointestinal tract, which were found to be between 3.9 to 8.5 mg. kg(-1). d(-1), are necessary to estimate the net contribution of microbial IAA. It is reasonable to assume that microbial amino acid synthesis in the human gastrointestinal tract utilizes a mixture of various nitrogen sources, i.e., endogenous amino acids, urea and ammonia. Microbes in the small intestine may rely more on endogenous amino acids. Deprivation of nutrients, the intake of certain dietary nonstarch oligosaccharides, lipids, as well as protein intake level and source and level of consumption of certain amino acids can affect the composition and metabolic activity of the intestinal microflora and thus its fermentation products potentially available to the host. In conclusion, with the use of the (15)N labeling paradigm, a significant contribution of microbial lysine to the host lysine homeostasis is found. However, to assess the net contribution of microbial IAA and its importance in defining the adult IAA requirement, this is not the ultimately successful experimental strategy because the interpretation of results is complicated by the nitrogen recycling in the gut, the uncertainty of the precursor pool of absorption and the limited data on nonoxidative IAA losses from the human gastrointestinal tract.

Effect of pentoxifylline on survival and intestinal cytokine messenger RNA transcription in a rat model of ongoing peritoneal sepsis

OBJECTIVE

Septic animals receiving high-protein liquid diets have increased mortality and increased production of cytokines by the gut compared with animals receiving low-protein diets. The purpose of this study was to evaluate the ability of pentoxifylline to alter gut cytokine production in a rat model of prolonged acute peritonitis, to determine its effect on survival in such animals, and to determine whether alteration of gut cytokine production was associated with survival.

DESIGN

Prospective, randomized animal study.

SETTING

Research laboratory.

SUBJECTS

Male Lewis rats weighing between 250 and 300 g.

INTERVENTIONS

Anesthetized rats had placement of a gastrostomy, followed 1 wk later by implantation of a bacteria-filled osmotic minipump into the peritoneal cavity. Rats were fed a high-protein (20% total energy) enteral diet. Saline or pentoxifylline (5 or 20 mg/kg im) was administered daily beginning at the time of pump implantation.

MEASUREMENTS AND MAIN RESULTS

Septic rats fed the high-protein liquid diet and given pentoxifylline in a dose of 5 mg/kg/day demonstrated improved survival compared with saline-treated animals or animals given the high dose (20 mg/kg/day) of pentoxifylline (p< .05). Administration of pentoxifylline at 5 mg/kg/day also down regulated the production of IL-6 messenger RNA (mRNA) in liver and lipopolysaccharide binding protein mRNA in the liver and intestine of septic animals given the high-protein liquid diet.

CONCLUSION

Low-dose (but not high-dose) pentoxifylline administration reduced production of some, but not all, cytokines studied in the gut and liver in a rat model of acute peritonitis and this reduced production was associated with an improved survival in such animals.

[Protein and energy needs of the infant with severe malnutrition. Application in a hospital environment for the treatment of malnutrition caused by deficient intake]

Severe malnutrition is defined by a weight for height below 70% of international standards or by presence of oedema in a clinically undernourished child. Severe malnutrition associated with oedema is called kwashiorkor. The origin of oedemas of kwashiorkor is still debated, but its relation with protein deficiency is strongly questioned. The same dietary management is now recommended for malnutrition with or without oedema. Present recommendations are based, as for well nourished children, on the separate estimation of nutritional requirements for maintenance and growth. Total requirements vary between 0.7 g/kg/day in the first few days of treatment to 5 g/kg/day or more when weight gain is maximum. As a result of high energy requirement during catch-up growth, protein requirements never exceed 10 to 12% of total energy needs.