Low versus standard calorie and protein feeding and renal dysfunction in ventilated adults with shock: a NUTRIREA-3 post hoc analysis

Intensive Care Medicine: Published: 16 April 2026

Purpose

The optimal intake of artificial nutrition in critically ill patients remains unclear. While calorie and protein intakes affect glomerular function in patients with chronic kidney disease, their relation to renal function at the acute phase of intensive care is insufficiently documented. We aimed to study associations of a low-calorie and low-protein diet with renal outcomes in critically ill patients.

Methods

This post hoc analysis of the NUTRIREA-3 randomized-controlled trial included 3036 mechanically ventilated patients with shock. Calorie and protein intakes during the first 7 days were either low (6 kcal/kg and 0.2–0.4 g protein/kg/d) or standard (25 kcal/kg and 1.0–1.3 g protein/kg/d). The primary outcome was the incidence of acute kidney disease (AKD) during the ICU stay (up to ICU discharge or day 90 after inclusion, whichever occurred first).

Results

AKD during the ICU stay occurred in 669 (44.6%) low-group patients and 691 (46.1%) standard-group patients (hazard ratio, 0.97; 95% CI 0.88–1.07; P = 0.53). The highest urea level and the urea level at ICU discharge were significantly lower in the low group (P = 0.002). No differences were found for renal replacement therapy requirements or other renal outcomes. The results were similar in patients with early kidney dysfunction, severe organ failures, or end-stage chronic kidney disease.

Conclusion

In critically ill patients with shock, early low-calorie and low-protein nutrition for 7 days was not associated with worse renal outcomes or mortality compared to standard feeding, even in patients with preexisting renal dysfunction.

 

The medical management of acute respiratory distress syndrome

Intensive Care Medicine | Published: 22 December 2025

Abstract

Despite advancements in bedside monitoring and paradigm shifts in standard ventilatory practice, mortality from acute respiratory distress syndrome (ARDS) remains high. The recent Global ARDS definition adopts a more pragmatic approach enabling earlier identification across a broader patient spectrum, independent of the interventions being administered. Meanwhile, our understanding of managing this heterogeneous syndrome has shifted towards defining precise subgroups with shared therapeutic targets. Physiological, biological, and radiological phenotypes may modify the response to interventions previously showing indeterminate benefit, making them potentially central to future personalised ARDS management. This narrative review summarises core evidence for the medical and ventilatory management of ARDS, explores emerging concepts, and offers clinicians a framework for current best practice and a roadmap for possible future directions.

 

Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

 by D’Amico, Filippo; Pruna, Alessandro; Putowski, Zbigniew; Dormio, Sara; Ajello, Silvia; Scandroglio, Anna Mara; Lee, Todd C.; Zangrillo, Alberto; Landoni, Giovanni 

 Critical Care Medicine, April 24, 2024.

 Objectives: 

Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality.

Data Sources: 

We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024.

Study Selection: 

Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings.

Data Extraction: 

The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928.

Data Synthesis: 

Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87–0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes.

Conclusions: 

Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.