Urine Titin N-Fragment as a Biomarker of Muscle Injury for Critical Illness Myopathy

The Japanese Critical Care Nutrition Guideline 2024

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

Early urea-to-creatinine ratio to predict rapid muscle loss in critically ill patients with sepsis: a single-center retrospective observational study

BACKGROUND

Patients with sepsis in the intensive care unit (ICU) often experience rapid muscle loss. The urea-to-creatinine ratio (UCR) is thought to reflect muscle breakdown (creatinine) and catabolism (urea) and is commonly used to assess nutritional and metabolic status. This study aimed to investigate whether changes in UCR (ΔUCR) can predict the development of rapid muscle loss in patients with sepsis.

METHODS

This retrospective observational study was conducted in a university ICU between 2014 and 2021, involving adult patients (≥ 18 years) diagnosed with sepsis. The primary outcome was the incidence of rapid muscle loss during ICU hospitalization. Changes in the cross-sectional muscle area at the third lumbar vertebra (L3SMA) were measured using CT images to evaluate muscle loss. Rapid muscle loss was defined as a change in ΔL3SMA greater than 2% per day. Multivariable logistic regression was used to examine the association between UCR or ΔUCR and rapid muscle loss. The area under the receiver operating characteristic curve (AUC) was calculated to assess the predictive performance of UCR or ΔUCR for rapid muscle loss.

RESULTS

Of the 482 patients, 141 (29.2%) experienced rapid muscle loss during their ICU stay. Multivariable logistic regression analysis revealed that ΔUCR was significantly associated with an increased risk of rapid muscle loss, with an odds ratio (OR) of 1.02 [95% CI: 1.01, 1.02]. The AUC for ΔUCR in predicting rapid muscle loss was 0.76 [95% CI: 0.68-0.83], with a threshold value of 19.4 µmol urea/µmol creatinine for ΔUCR.

CONCLUSION

The results demonstrate that ΔUCR is independently associated with rapid muscle loss in patients with sepsis and the AUC of the ROC curve for the ability of ΔUCR to predict rapid muscle loss was 0.76. Though additional prospective data are needed, our results suggest that ΔUCR may be useful in the early identification of critically ill patients with sepsis at risk of rapid muscle loss.

Early Mobilization Using a Mobile Patient Lift in the ICU: A Randomized Controlled Trial

OBJECTIVES

To ascertain whether a mobile patient lift facilitates early mobilization in ventilated ICU patients.

DESIGN

A single-center, open-label, randomized controlled trial.

SETTING

An academic ICU in Tokyo.

PATIENTS

Eighty patients were admitted to ICU and expected ventilation for at least 48 hours.

INTERVENTIONS

In the intervention group, in addition to the rehabilitation protocol received by the control group, patients were assisted in sitting, standing, transfers, and walking using the mobile patient lift.

MEASUREMENTS AND MAIN RESULTS

The intervention group predominantly stood faster than the control group (1.0 vs. 3.0 d, p < 0.01). The Intervention group also had significantly higher Functional Status Score-ICU scores at ICU discharge. However, the Medical Research Council score and Barthel index at discharge, length of ICU stay, and number of ventilator-free days did not differ between the two groups.

CONCLUSIONS

The use of mobile patient lifts facilitates the earlier standing of patients on ventilators. This may contribute to patients improved physical function in the ICU.

TRIAL REGISTRATION

The study protocol was registered with the University Hospital Medical Information Network (UMIN) under the registration number UMIN000044965. Registered July 30, 2021.

Acute muscle loss assessed using panoramic ultrasound in critically ill adults: a prospective observational study

PURPOSE

Panoramic ultrasound is one of the recently introduced ultrasound evaluation techniques. We herein examined the relationship between the cross-sectional area of the rectus femoris muscle on panoramic ultrasound and its volume based on the gold standard computed tomography (CT) evaluation.

METHODS

This was a single-center prospective observational study. A panoramic ultrasound assessment of the cross-sectional area of the rectus femoris muscle and a simple CT evaluation of its volume were performed on days 1 and 7 of hospitalization. Physical functions were assessed at discharge.

RESULTS

Twenty patients were examined. The rate of change in the cross-sectional area of the rectus femoris muscle on panoramic ultrasound correlated with that in its volume on CT (correlation coefficient 0.59, p = 0.0061). In addition, a correlation was observed between the absolute value for the rectus femoris muscle cross-sectional area on panoramic ultrasound and physical functions at discharge. Rectus femoris muscle distances did not correlate with either.

CONCLUSION

In the acute phase of critical illness, the cross-sectional area of the rectus femoris muscle on panoramic images correlated with its volume on CT and, thus, it is a valid method for assessing muscle mass.

Urinary titin N-fragment as a predictor of decreased skeletal muscle mass in patients with interstitial lung diseases

This study aimed to examine the validity of urinary N-terminal titin fragment/creatinine (urinary N-titin/Cr) reflecting muscle damage biomarker in patients with interstitial lung disease. This retrospective study enrolled patients with interstitial lung disease. We measured urinary N-titin/Cr. Furthermore, we measured the cross-sectional areas of the pectoralis muscles above the aortic arch (PMCSA) and erector spinae muscles of the 12th thoracic vertebra muscles (ESMCSA) to assess muscle mass until 1 year. We examined the correlation between urinary N-titin/Cr and the change in muscle mass. We plotted receiver operating characteristic curves to estimate the cut-off points for urinary N-titin/Cr for distinguishing the greater-than-median and smaller-than-median reduction of muscle mass after 1 year. We enrolled 68 patients with interstitial lung disease. The median urinary N-titin/Cr value was 7.0 pmol/mg/dL. We observed significant negative correlations between urinary N-titin/Cr and changes in the PMCSA after 1 year (p < 0.001) and changes in the ESMCSA after 6 months (p < 0.001) and 1 year (p < 0.001). The cut-off points for urinary N-titin/Cr were 5.2 pmol/mg/dL and 10.4 pmol/mg/dL in the PMCSA and ESMCSA, respectively. In summary, urinary N-titin/Cr may predict muscle loss in the long-term and act as a clinically useful biomarker reflecting muscle damage.

Coagulopathy correlates with muscle titin injury in critically ill patients

PURPOSE

We hypothesized that coagulopathy independently contributes to muscle injury focusing to titin fragmentation, and investigated their correlations.

MATERIAL AND METHODS

We conducted a post-hoc analysis of an observational study, in which we evaluated muscle injury with the biomarker titin. Coagulopathy was assessed on the first day using the Japanese diagnostic criteria of acute-phase disseminated intravascular coagulopathy (JAAM-DIC). Mean N-titin/Cre measured on days 1, 3, 5, and 7 was assigned as the primary outcome.

RESULTS

Overall, 111 eligible patients were included. Mean N-titin/Cre were significantly higher in the JAAM-DIC group. A multivariable analysis identified JAAM-DIC as independent risk factors for mean N-titin/Cre while other severity scores were not.

CONCLUSIONS

Coagulopathy correlated with muscle titin fragmentation, as an independent risk factor.

TRIAL REGISTRATION NUMBER

The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

Assessment of catabolic state in infants with the use of urinary titin N-fragment

BACKGROUND

Urinary titin N-fragment levels have been used to assess the catabolic state, and we used this biomarker to evaluate the catabolic state of infants.

METHODS

We retrospectively measured urinary titin N-fragment levels of urinary samples. The primary outcome was its changes according to postmenstrual age. The secondary outcomes included differences between gestational age, longitudinal change after birth, influence on growth, and relationship with blood tests.

RESULTS

This study included 219 patients with 414 measurements. Urinary titin N-fragment exponentially declined with postmenstrual age. These values were 12.5 (7.1-19.6), 8.1 (5.1-13.0), 12.8 (6.0-21.3), 26.4 (16.4-52.0), and 81.9 (63.3-106.4) pmol/mg creatinine in full, late, moderate, very, and extremely preterm infants, respectively (p < 0.01). After birth, urinary levels of titin N-fragment exponentially declined, and the maximum level within a week was associated with the time to return to birth weight in preterm infants (ρ = 0.39, p < 0.01). This was correlated with creatine kinase in full-term infants (ρ = 0.58, p < 0.01) and with blood urea nitrogen in preterm infants (ρ = 0.50, p < 0.01).

CONCLUSIONS

The catabolic state was increased during the early course of the postmenstrual age and early preterm infants.

IMPACT

Catabolic state in infants, especially in preterm infants, was expected to be increased, but no study has clearly verified this. In this retrospective study of 219 patients with 414 urinary titin measurements, the catabolic state was exponentially elevated during the early postmenstrual age. The use of the urinary titin N-fragment clarified catabolic state was prominently increased in very and extremely preterm infants.

Novel protocol combining physical and nutrition therapies, Intensive Goal-directed REhabilitation with Electrical muscle stimulation and Nutrition (IGREEN) care bundle

Background

Although the combination of rehabilitation and nutrition may be important for the prevention of intensive care unit (ICU)-acquired weakness, a protocolized intervention of this combination has not yet been reported. We herein developed an original combined protocol and evaluated its efficacy.

Methods

In this single-center historical control study, we enrolled adult patients admitted to the ICU. Patients in the control group received standard care, while those in the intervention group received the protocol-based intervention. The ICU mobility scale was used to set goals for early mobilization and a neuromuscular electrical stimulation was employed when patients were unable to stand. The nutritional status was assessed for nutritional therapy, and target calorie delivery was set at 20 or 30 kcal/kg/day and target protein delivery at 1.8 g/kg/day in the intervention group. The primary endpoint was a decrease in femoral muscle volume in 10 days assessed by computed tomography.

Results

Forty-five patients in the control group and 56 in the intervention group were included in the analysis. Femoral muscle volume loss was significantly lower in the intervention group (11.6 vs 14.5%, p = 0.03). The absolute risk difference was 2.9% (95% CI 0.1–5.6%). Early mobilization to a sitting position by day 10 was achieved earlier (p = 0.03), and mean calorie delivery (20.1 vs. 16.8 kcal/kg/day, p = 0.01) and mean protein delivery (1.4 vs. 0.8 g/kg/day, p < 0.01) were higher in the intervention group.

Conclusion

The protocolized intervention, combining early mobilization and high-protein nutrition, contributed to the achievement of treatment goals and prevention of femoral muscle volume loss.

Trial registration number

The present study is registered at the University Hospital Medical Information Network-clinical trials registry (UMIN000040290, Registration date: May 7, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03827-8.

Urinary Titin N-Fragment Evaluation in a Randomized Controlled Trial of Beta-Hydroxy-Beta-Methylbutyrate for Acute Mild Trauma in Older Adults

The effects of beta-hydroxy-beta-methylbutyrate (HMB) complex administration and the significance of titin, a biomarker of muscle injury, in elderly minor trauma patients in acute phase has not been established. In this single-center, randomized controlled study, trauma patients aged ≥ 70 years with an injury severity score < 16 were included. Titin values on days 1 and 3 were measured and the intervention group received HMB complex (2.4 g of HMB + 14 g of glutamine + 14 g of arginine) and the control group received glutamine complex (7.2 g of protein including 6 g of glutamine). The cross-sectional area of the rectus femoris (RFCSA) on ultrasound, grip strength, and the Barthel Index were assessed on the first day of rehabilitation and after 2 weeks. We analyzed 24 HMB and 25 control participants. Titin values on day 3 correlated with grip strength (r = -0.34, p = 0.03) and the Barthel Index (r = -0.39, p = 0.01) at follow-up. HMB complex supplementation had no effect on the RFCSA (2.41 vs. 2.45 cm², p = 0.887), grip strength (13.3 vs. 13.1 kg, p = 0.946), or the Barthel Index (20.0 vs. 50.0, p = 0.404) at follow-up. Titin values might associate with subsequent physical function. Short-term HMB complex supplementation from acute phase did not ameliorate muscle injury.

Urinary Titin N-Fragment as a Biomarker of Muscle Atrophy, Intensive Care Unit-Acquired Weakness, and Possible Application for Post-Intensive Care Syndrome

Titin is a giant protein that functions as a molecular spring in sarcomeres. Titin interconnects the contraction of actin-containing thin filaments and myosin-containing thick filaments. Titin breaks down to form urinary titin N-fragments, which are measurable in urine. Urinary titin N-fragment was originally reported to be a useful biomarker in the diagnosis of muscle dystrophy. Recently, the urinary titin N-fragment has been increasingly gaining attention as a novel biomarker of muscle atrophy and intensive care unit-acquired weakness in critically ill patients, in whom titin loss is a possible pathophysiology. Furthermore, several studies have reported that the urinary titin N-fragment also reflected muscle atrophy and weakness in patients with chronic illnesses. It may be used to predict the risk of post-intensive care syndrome or to monitor patients' condition after hospital discharge for better nutritional and rehabilitation management. We provide several tips on the use of this promising biomarker in post-intensive care syndrome.