The Balance trial: Individualized precision nutrition therapy in critical ill patients treated with continuous venovenous hemofiltration: The impact of indirect calorimetry and bioenergetic balance on energetic need

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BACKGROUND AND AIMS: Personalized precision nutrition therapy is associated with better outcomes but is challenging to achieve. One of the reasons is that indirect calorimetry (IC), the gold standard for measuring the resting energy expenditure (REE), is not yet common practice. Predictive equations are used but have found to be inaccurate. The ICU environment also introduces several sources of non-nutritional energy (NNE) which have to be accounted for in order to avoid overfeeding. Patients undergoing continuous venovenous hemofiltration (CVVH) are especially impacted by this NNE as often citrate is added and the filter acts as a siphon of energy due to the loss of lactate and glucose in the effluent. This complex interaction, of which the net effect is called the bioenergetic balance (BEB), can lead to both a net positive gain or net negative loss of energy. We aimed to validate the correlation between energetic need, measured REE with IC, and predicted REE in our CVVH population. Additionally, this study aimed to evaluate the extent to which the BEB influenced the energetic need of patients undergoing CVVH. Finally, a new predictive model using anthropometric and biochemical data was built and evaluated. PATIENTS AND METHODS: We analyzed adult ICU patients who underwent CVVH, with at least one IC and BEB measurement between 01/01/2021 and 31/12/2022. Demographics, treatment modalities, blood analysis and data from measured REE, predicted REE and BEB were collected. Statistical analyses were performed using SPSS version 28, including descriptive statistics linear regression, intraclass correlation coefficients (ICC), and Bland-Altman plots. RESULTS: Measured REE correlated moderately with both predictive equations (ESPEN 2019's equation: ICC 0.524; Harris-Benedict: ICC 0.486). However, energetic need correlated weakly with both equations (ESPEN 2019 equation: ICC 0.263; Harris-Benedict: ICC 0.374). The energetic need showed an acceptable ICC (0.661), but clinically poor correlation with measured REE. The average measured REE was 1820 kcal, with variable BEBs ranging from -467 to +609 kcal. In patients treated with citrate, BEB averages were +439 (±124) kcal and when treated without citrate they were -327 (±82) kcal. A new multivariate linear regression model based on the variables proposed by Ponce et al. performed better than standard equations but still exhibited subpar correlation. CONCLUSION: In critically ill patients treated with CVVH, existing equations do not accurately predict REE. The BEB has a clinically relevant influence on the energetic needs of patients, and not accounting for it could therefore lead to both under- and overfeeding, potentially leading to adverse outcomes. A novel equation had the strongest correlation with measured REE, at the cost of requiring significantly more data input.

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