NUTRITION IN AKI Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University
Feb 25, 2016
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 REECoss-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 AKIEnergy 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 metabolismLimited reserves
Baseline poor nutrition+
Uremia and acidosisAltered 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 AKICALORIC 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/di 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 VitaminsVit B1 Def Altered Energy Metabolism,
h Lactic Acid, Tubular damageVit 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