Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University.

NUTRITION IN AKI

Norma J Maxvold MDAssociate Professor of PediatricsPediatric Critical Care MedicineChildren’s Hospital of Richmond

Virginia Commonwealth University

NUTRITION IN AKI

Objectives: Overview Nutritional Needs in Children

with AKI

Effect of renal support on Nutrition

Diagram of Nutrition Prescription during AKI

NUTRITION IN AKI

CATABOLIC, HYPERMETABOLIC STATE Malnutrition

Acute Illness: Stress Response

hCytokines, Hormonal changes,Altered Substrate Utilization

AKIAcidosis,Uremia,

Impaired AA Conversion,

iLipid Oxidation

Malnutrition

Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson

et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus

and Jaksic (2002)

Energy Expenditure

Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure

Pediatric patients may not exhibit significant hypermetabolism post-injury?

Substrate Utilization/Nutrient Composition 75%CHO:15% AA: 10% Lipid 15%CHO: 15%AA: 70% Lipid C13 Glucose, C13 Acetate Maximum Glu Oxidation 4mg/kg/min Lipogenesis from Excess Glucose Metabolism Gluconeogenesis and Protein Catabolism was not

effected [Tappy et al. Crit Care Med 1998;26:860-867]

Hypermetabolism in Children with Critical Illness

AveEnergy Intake REE

Coss-Bu( Am J Clin Nutr 2001) 0.23 MJ/kg/d >25%

Verhoeven(Int Care Med 1998) 0.24 MJ/kg/d >14%

Joosten (Nutrition 1999) 0.26 MJ/kg/d >20%

Briassoulis et al. (2000)

Comparison of MEE vs. cREE

Indirect calorimetry AND CRRT

IC: measure resting energy expenditure. Based on: Expired CO2 and O2 (O2

consumption + CO2 production). Potential problem with CRRT

Hemofilter

Dialysis fluidEffluent

HCO3/CO2 fluxes May affect ICmeasurements.

IC may not be reliable?

NUTRITION IN AKI

Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J Clin Nutr 2001;74:664

Normal Metabolic : Hypermetabolic mREE 0.16 mREE 0.28Fat Oxidation -22mg/min Fat Oxidation 27mg/min np RQ 1.21 npRQ 0.86

Energy Intake: 0.25MJ/kg/d [55kcal/kg/d]

CHO: 10 g/kg/d ; Fat: 1.4g/kg/d; Protein:2.1g/kg/d

NUTRITION IN AKI No Growth occurs during Acute Illness

Focus : Prevent Malnutrition

Children at Risk:High basal rate of metabolism

Limited reservesBaseline poor nutrition

+Uremia and acidosis

Altered renal Amino Acid metabolism, lipid metabolism,Fluid and Solute Clearance,

+hLosses for Renal Replacement Therapy

Protein Turnover in Renal Disease

UNA / PCR in Acute Kidney Injury• Adult Studies:• Protein Catabolic Rate ~ 1.4 - 1.7 g/kg/d [Macias WL, et al. JPEN 1996;20:56-62] [Chima CS, et al. JASN 1993; 3:1516-1521]

Pediatric Studies: Urea Nitrogen Appearance UNA ~ 185- 290mg/kg/d (PCR 1.1- 1.8 g/kg/d) [ Kuttnig M, et al. Child Nephrol Urol 1991;11:74-78] [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]

NUTRITION IN AKI

CALORIC SUPPORT: PROTEIN SUPPORT:

Adult:npkcal 25kcal/kg/dCHO 5 g/kg/dFat 0.8-1.2g/kg/d

Pediatric:Npkcal 40-65kcal/kg/d

Adult:Protein 1.5-2.0 g/kg/d

Pediatric:Protein 2.0-3.0 g/kg/d

( Cano N et al Clin Nutr 2006 and 2008)

Nutrition and PCRRT

Can Nitrogen Balance be Achieved in AKI patients on CRRT? Conflicting Studies Bellomo et al Ren Fail 1997

Protein Intake : Nitrogen Balance 1.2 g/kg/d AA -5.5 g N /d 2.5 g/kg/d AA -1.9 g N /d

Does increasing protein intake help?

Scheinkestel et al.1. Nutrition, 2003 In 11 critically ill adults on CRRT, protein intake

2.5 g/kg/day led to a) normal amino acid levels and b) positive nitrogen balance.

2. Nutrition, 2003 50 critically ill adults on CRRT: 1.5 vs 2.0 vs 2.5

g/kg/day. NB related to protein intake. NB related to hospital stay Protein intake 2.5 g/kg/d: improved survival!

Potential for losses during CRRT

0

10

20

30

40

50

60

K

ml/min/1.73m2

Thr Glu Gln Pro Gly Ala Val Met Phe Lys His Arg

Amino Acids

Glutamine Supplementation

[Ziegler et al, Ann Intern Med 1992;116:821] 45 BMT patients with Parenteral Glutamine (L-Gln)

Supplemention : 0.57g/kg/d Gln &2.07g/kg/d AA Intake

Improved Nitrogen Balance: -1.4g/d vs -4.2g/d

i Clinical infections: 3/24 vs 9/21 Hospital stay: 29 days vs 36 days

[ Schloerb et al; JPEN 1993; 17:407-413] Hospital stay: 26 days vs 32 days Total Body Water: -1.2 L vs 2.2 L (Bioimpedance)

Nutrition and PCRRT

Lipid Metabolism Fatty Acid Utilization during acute illness Mitochondrial adaptation to acute stress (Carnitine dependent enzymes) Calvani et al Basic Res Cardiol 2000Mitochondrial control of FFA oxidation and CHO oxidation AcetylCoA/ CoA ratio on PDH Complex

SMOFlipid IV Emulsion

Advantages: Lower Linoleic concentration MCT rapidly cleared from plasma Olive oil less prone to peroxidation Fish oil beneficial anti-inflammatoryEarly Studies : Good Safety profileClin Nutr 2013;32:224JPEN 2012; 36:81S

Potential for losses during CRRT

Water Soluble Vitamins

Vit B1 Def Altered Energy Metabolism, h Lactic Acid, Tubular damage

Vit B6 Def Altered Amino acid and lipid metabolism

Folate Def Anemia Vit C Def Limit 200 mg/d as precursor to

Oxalic acid

Nutrition in Children with AKINutritional parameter

Nutrition modality

Energy

Protein

Vitamins

Trace elements

Monitoring

Consider

- Early enteral feeding, may require parenteral nutrition suppl

35 to 60 kcal/kg/day (0.15-0.27 MJ/kg/day)20 to 25% as carbohydrates (insulin as needed), 4-5 mg/kg/min Glucose support (Insulin as needed for Hyperglycemia)

2 to 3 g/kg/day with AKI (Increase intake if on High flow CRRT (by 20%)

Daily recommended intake (± replacement ) Monitor serum folate, water soluble vitamin levels

Daily Recommended Intake

MEE, Nitrogen Balance, Electrolytes, Vitamins, Trace elements

Glutamine, Carnitine Supplement