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Pre-transition nutrition dose and mortality using a CRP-Free operational metabolic transition framework: A MIMIC-IV
Yonatan Gargi1, Neriya Levran2, Dorit Stein3
1Departments of Anesthesiology and Intensive Care, Sheba Medical Center, Ramat Gan, Israel.
Clinical Nutrition ESPEN
|June 25, 2026
Summary
Higher recent nutrition dose before metabolic transition in ICU patients was linked to increased 90-day mortality. This suggests a transition-guided nutrition framework may be beneficial, but further research is needed.
Area of Science:
- Critical Care Medicine
- Metabolic Physiology
- Nutritional Support
Background:
- A physiology-based framework using steroid-corrected insulin-resistance index (IRI) was previously developed to identify the transition from catabolism to recovery.
- An external validation in MIMIC-IV used a C-reactive protein-free rule to identify this transition, aiming to reproduce pre-transition feeding patterns.
Purpose of the Study:
- To externally validate a physiology-based framework for identifying metabolic transition in intensive care unit (ICU) patients.
- To investigate the association between pre-transition nutrition dose and subsequent mortality.
Main Methods:
- Retrospective analysis of 8,732 ICU stays from the MIMIC-IV database.
- Application of a C-reactive protein-free rule (≥40% post-peak IRI decline and ≥3 non-CRP criteria) to identify transition.
- Sequential-landmark models with overlap weighting were used to compare high-dose (≥0.8 kcal/kg/h) versus lower nutrition exposure in the 72 hours preceding transition.
Main Results:
- The C-reactive protein-free rule identified transition in 55.4% of eligible stays.
- Higher recent nutrition dose prior to the model-derived transition time was associated with increased 90-day mortality (OR 1.54, 95% CI 1.08-2.21) after adjustment.
- Patients receiving higher doses had lower APACHE II scores despite similar day-1 SOFA scores.
Conclusions:
- Higher recent nutrition dose before metabolic transition in ICU patients is associated with increased subsequent mortality.
- Findings support a transition-guided nutrition framework but do not establish causality.
- Prospective validation and interventional studies are necessary to inform clinical feeding decisions.
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