Calorie intake and patient outcomes in severe acute kidney injury: findings from The Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study trial

Rinaldo Bellomo, Alan Cass, Louise Cole, Simon Finfer, Martin Gallagher, Joanne Lee, Serigne Lo, Colin McArthur, Shay McGuinness, John Myburgh, Robyn Norton, Carlos Scheinkestel, RENAL Study Investigators, Steve Su, Imogen Mitchell, Rebecca Ashley, Jelena Gissane, Katya Malchukova, Jamie Ranse, Asif Raza, Kiran Nand, Treena Sara, David Millis, Jeff Tan, Helen Wong, Peter Harrigan, Elise Crowfoot, Miranda Hardie, Deepak Bhonagiri, Sharon Micallef, Jorge Brieva, Melissa Lintott, Louise Cole, Rebecca Gresham, Maria Nikas, Leonie Weisbrodt, Yahya Shehabi, Frances Bass, Michelle Campbell, Victoria Stockdale, Simon Finfer, Susan Ankers, Julie Potter, Richard Totaro, Dorrilyn Rajbhandari, John Myburgh, Vanessa Dhiacou, Alina Jovanovska, Francesca Munster, Priya Nair, Jeff Breeding, Claire Burns, Ashoke Banerjee, Maridy Morrison, Caroline Pfeffercorn, Anne Ritchie, Shay McGuinness, Heidi Buhr, Rachael Parke, Colin McArthur, Jeanette Bell, Lynette Newby, Seton Henderson, Michael Kalkoff, Cathy West, John Morgan, Lorraine Rudder, Joanne Sutton, Peter Garrett, Nicole Groves, Shona McDonald, Jennifer Palmer, Chris Joyce, Meg Harwood, Jean Helyar, Benjamin Mackie, Jeff Lipman, Robert Boots, Claire Bertenshaw, Melissa Lassig-Smith, Arthas Flabouris, Jason Edwards, Justine Rivett, Andrew Turner, Tanya Field, Kathryn Marsden, Rinaldo Bellomo, Claire Mathlin, Donna Goldsmith, John Edington, Catherine Boschert, Julie Smith, Benno Ihle, Michael Graan, Samuel Ho, John Botha, Nina Fowler, Jodi McInness, Naomi Pratt, Neil Orford, Tania Elderkin, Melissa Fraser, Christopher Wright, Sue Burton, Carly Culhane, Pauline Galt, Rebecca Rutzou, Megan Roberston, Deborah Barge, Tania Caf, Belinda Howe, Antony Tobin, Nicole Groves, Roger Smith, Carlos Scheinkestel, Andrew Davies, Lynne Murray, Rachael Nevill, Shirley Vallance, Sue Varley, Vickie White, Craig French, Lorraine Little, Heike Raunow, David Blythe, Anna Palermo, Geoff Dobb, Melanie Boardman, Jenny Chamberlain, Andree Gould, Geraldine McEntaggart, Samantha Perryman, Linda Thomas, Rinaldo Bellomo, Alan Cass, Louise Cole, Simon Finfer, Martin Gallagher, Joanne Lee, Serigne Lo, Colin McArthur, Shay McGuinness, John Myburgh, Robyn Norton, Carlos Scheinkestel, RENAL Study Investigators, Steve Su, Imogen Mitchell, Rebecca Ashley, Jelena Gissane, Katya Malchukova, Jamie Ranse, Asif Raza, Kiran Nand, Treena Sara, David Millis, Jeff Tan, Helen Wong, Peter Harrigan, Elise Crowfoot, Miranda Hardie, Deepak Bhonagiri, Sharon Micallef, Jorge Brieva, Melissa Lintott, Louise Cole, Rebecca Gresham, Maria Nikas, Leonie Weisbrodt, Yahya Shehabi, Frances Bass, Michelle Campbell, Victoria Stockdale, Simon Finfer, Susan Ankers, Julie Potter, Richard Totaro, Dorrilyn Rajbhandari, John Myburgh, Vanessa Dhiacou, Alina Jovanovska, Francesca Munster, Priya Nair, Jeff Breeding, Claire Burns, Ashoke Banerjee, Maridy Morrison, Caroline Pfeffercorn, Anne Ritchie, Shay McGuinness, Heidi Buhr, Rachael Parke, Colin McArthur, Jeanette Bell, Lynette Newby, Seton Henderson, Michael Kalkoff, Cathy West, John Morgan, Lorraine Rudder, Joanne Sutton, Peter Garrett, Nicole Groves, Shona McDonald, Jennifer Palmer, Chris Joyce, Meg Harwood, Jean Helyar, Benjamin Mackie, Jeff Lipman, Robert Boots, Claire Bertenshaw, Melissa Lassig-Smith, Arthas Flabouris, Jason Edwards, Justine Rivett, Andrew Turner, Tanya Field, Kathryn Marsden, Rinaldo Bellomo, Claire Mathlin, Donna Goldsmith, John Edington, Catherine Boschert, Julie Smith, Benno Ihle, Michael Graan, Samuel Ho, John Botha, Nina Fowler, Jodi McInness, Naomi Pratt, Neil Orford, Tania Elderkin, Melissa Fraser, Christopher Wright, Sue Burton, Carly Culhane, Pauline Galt, Rebecca Rutzou, Megan Roberston, Deborah Barge, Tania Caf, Belinda Howe, Antony Tobin, Nicole Groves, Roger Smith, Carlos Scheinkestel, Andrew Davies, Lynne Murray, Rachael Nevill, Shirley Vallance, Sue Varley, Vickie White, Craig French, Lorraine Little, Heike Raunow, David Blythe, Anna Palermo, Geoff Dobb, Melanie Boardman, Jenny Chamberlain, Andree Gould, Geraldine McEntaggart, Samantha Perryman, Linda Thomas

Abstract

Introduction: Current practice in the delivery of caloric intake (DCI) in patients with severe acute kidney injury (AKI) receiving renal replacement therapy (RRT) is unknown. We aimed to describe calorie administration in patients enrolled in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study and to assess the association between DCI and clinical outcomes.

Methods: We performed a secondary analysis in 1456 patients from the RENAL trial. We measured the dose and evolution of DCI during treatment and analyzed its association with major clinical outcomes using multivariable logistic regression, Cox proportional hazards models, and time adjusted models.

Results: Overall, mean DCI during treatment in ICU was low at only 10.9 ± 9 Kcal/kg/day for non-survivors and 11 ± 9 Kcal/kg/day for survivors. Among patients with a lower DCI (below the median) 334 of 729 (45.8%) had died at 90-days after randomization compared with 316 of 727 (43.3%) patients with a higher DCI (above the median) (P = 0.34). On multivariable logistic regression analysis, mean DCI carried an odds ratio of 0.95 (95% confidence interval (CI): 0.91-1.00; P = 0.06) per 100 Kcal increase for 90-day mortality. DCI was not associated with significant differences in renal replacement (RRT) free days, mechanical ventilation free days, ICU free days and hospital free days. These findings remained essentially unaltered after time adjusted analysis and Cox proportional hazards modeling.

Conclusions: In the RENAL study, mean DCI was low. Within the limits of such low caloric intake, greater DCI was not associated with improved clinical outcomes.

Trial registration: ClinicalTrials.gov number, NCT00221013.

Figures

Figure 1
Figure 1
Graphic representation of mean daily caloric intake (DCI) over the first 2 weeks of observation after randomization according to survival status at 90 days.
Figure 2
Figure 2
Kaplan-Meier plots before and after excluding early deaths. (a) Kaplan-Meier graph of survival plots from randomization to day 90 stratified by the delivery of lower (below median) or higher (above median) daily calorie intake (DCI) during the index ICU admission. No P-values are provided as the plot is not adjusted for confounders and is shown to emphasize the reversal of the curve (see Figure 2b) once early deaths are excluded. (b) Kaplan-Meier graph of survival plots from randomization to day 90 stratified by the delivery of lower (below median) or higher (above median) DCI during the index ICU admission, after exclusion of patients who died in the first 96 hrs. No P-values are provided as the plot is not adjusted for confounders and is shown to emphasize the reversal of the curves (see Figure 2a) once early deaths are excluded.

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