Individualization of nutritional treatment through use of biomarkers in polymorbid medical inpatients

Abstract

Background: Disease-related malnutrition in medical inpatients is highly prevalent and associated with significantly increased morbidity, disability, short- and long-term mortality, impaired recovery from illness, and cost of care. Nutritional support has been shown to be an effective treatment to reduce these risks. Yet, there is growing evidence suggesting that not all patients respond equally to nourishment and individualization to the patient's specific situation is needed. Addressing the heterogeneity in treatment responses and translating the findings into clinical practice through evidence-based recommendations are thus two major challenges for improving nutritional care in the future. Methods: This work combines two different methodological approaches, including (a) updating the treatment guideline for nutritional support of polymorbid patients in collaboration with the European Society of Clinical Nutrition and Metabolism (ESPEN) based on a systematic review and meta-analysis process with development of recommendations regarding individualization of treatment, and (b) using clinical data from the randomized controlled Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) to investigate the use of specific biomarkers and amino acids (i.e., arginine, glutamine and tryptophan) as well other parameters to improve the prediction of treatment response. Results: In 2023, we updated the ESPEN guideline based on new evidence. It now comprises 32 instead of 22 recommendations covering several aspects of nutritional support including indication, route of feeding, energy and protein targets, micronutrient requirements, monitoring, and intervention procedures, as well as three new recommendations on individualization of nutritional therapy. In several analyses using the EFFORT trial data, we found that the metabolism of the amino acids arginine, glutamine and tryptophan provided prognostic information on the occurrence of adverse clinical outcomes but did not help to predict response to nutritional treatment. In an additional analysis, we found that adapting nutritional risk scores, by removing parameters reflecting disease severity, improved their predictive value for treatment response. Patients having high adapted scores showed a significant survival benefit from nutritional support, whereas this was not observed for patients having low adapted scores. Conclusion: This work focuses on the individualization of nutritional care for medical inpatients through the elaboration of clinical guidelines and specific analysis of new parameters in a large treatment trial. This is an important step in translating new research findings on malnutrition phenotyping, underlying pathophysiology and treatment response into clinical practice and may help to improve treatment of patients in the near future.