NUTRITIONAL CONCERNS
FOR CHILDREN ON RRT
NJ Maxvold MD
Associate Professor Pediatrics
Children’s Hospital of Richmond-Virginia Commonwealth University
No Growth occurs during
Acute Illness
Focus : Prevent Malnutrition
Children at Risk:
High basal rate of metabolism
Limited reserves
Baseline poor nutrition
+
Uremia and acidosis
Altered renal Amino Acid metabolism, lipid metabolism,
Fluid and Solute Clearance,
+
hLosses for Renal Replacement Therapy
REVIEW OF ENERGY NEEDS AND UTILIZATION OF
FUEL
• Hulst J et al.Clin Nutr 2004;23:223-32 & 1381-9
•
a) intakes of calories and protein recorded. Balance calculated by subtracting actual
intake from RDA, over a max of 14 days.
• b) Patients were also followed up to 6 months for anthropometric parameters
anthropometric parameters : Wt, Ht, OHC, MUAC,CC, BSF,TSF
24 % Undernourished on Admission
Mean Energy deficits
27 kcal/kg – Preterm neonates
20 kcal/kg – Term neonates
12 kcal/kg – Older children
Mean Protein deficits;
0.6 g/kg/day – Preterm
0.3 g/kg/day – Term Newborns
0.2 g/kg/day – Children
6 months follow up, almost all children had recovered their
nutrition status.
MALNUTRITION IN PICU POPULATION
WITH AKI
Retrosp Review : Nutrition support in first 5 days
Incidence of Malnutrition was 20% in PICU population
 Incidence of Malnutrition was 33% in PICU Patients with
Injury or Failure ( pRIFLE Definition)
Kyle UG et al Clin J Am Soc Nephrol, 2013; 8: 568–574
Critical Illness
hormone changes
-Acute: increase
-Later: decrease
↑ cytokines
MALNUTRITION
Uremia
Acidosis
Altered Glucose
metab.
Cytokines
Altered substrate utilization
CHO: ↑hepatic gluconeogenesis
(shift away from glycolysis)
↑lipogenesis
- Inefficient glucose oxidation
- Insulin resistance
- Shift in use of amino acids:
gluconeogenesis + APR’s
Impaired nutrient transport
Inefficient/inadequate supply
Impaired A.a. conversion
↓lipid oxidation
Acute Kidney Injury
COMPARISON OF MEE VS. CREE
Briassoulis et al. (2000)
Energy and Substrate Use in Acute Illness in Children:
Coss-Bu et al Am J Clin Nutr 2001;74:664
Normal Metabolic
mREE
0.16
Fat Oxidation -22mg/min
np RQ
1.21
:
Hypermetabolic
mREE 0.28
Fat Oxidation 27mg/min
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
INSULIN RESISTANCE IN AKI AND ACUTE
CRITICAL ILLNESS
Fuel Substrate Changes in Acute Illness:
1. ↓ Carbohydrate Utilization : ~ 5 mg/kg/min of Glucose
2. ↑ FFA Utilization
3. Protein Catabolism to supply Gluconeogenesis and Hepatic Acute
Phase Proteins
TAPPY ET AL. CRIT CARE MED 1998;26:860-867
• 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]
• ↑ FFA Utilization Occurs :Early phase of Critical Illness
Yet in Acute Kidney Failure
•
Impaired Lipolysis: Lipase Activity ~50%
i Lipoprotein Lipase
i Hepatic Triglyceride Lipase
LIPID METABOLISM IN ARF
Impaired Lipolysis
Lipase Activity ~50%
Altered Lipid Profile :
↑ LDL and VLDL
•
↓ Cholesterol and HDL-Cholesterol
CHOLESTEROL: CONDITIONAL ESSENTIAL
NUTRIENT IN ARF?
• Supply of free Cholesterol [4 g/l] added to 20% Lipid emulsions
Results:
Reduced Plasma Triglycerides with reduced plasma ½ life and h total
body clearance
Fraction of Lipid Oxidation Improved
Druml et al, Wien Klin Worchenschr 2003;115/21-22:767-774
AKI CATABOLIC STRESS
• Insulin Resistance
• Hepatic Gluconeogenesis
• Uremic Toxin Metabolic Impairment
• Acidosis
• Catabolic Factors: Stress Hormones, Hyperparathyroidism
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]
PROTEIN INTAKE AND ICU OUTCOMES
• Prospective Cohort Danish Study:
Allingstrup MJ et al. Clin Nutr 2012;31:462-468
• N=113 Adult Intubated severe sepsis or >15% Burn: Energy and Protein Intake,
Nitrogen and Energy Balance was monitored
Low Protein/AA
Intake
(53.8 g/d)
K-M Survival
Probability on Day 10
49%
Medium Protein/AA
Intake
(84.3 g/d)
High Protein/AA
Intake
(114.9 g/d)
79%
88%
• Only ↑ Protein Provision was Associated with ↓ Mortality:
HR (Risk of Death vs time) ↓ 2% for every additional gram of protein provided.
• No Associated found Between Hazard of Mortality and Energy or Nitrogen
Balance
SCHEINKESTEL CD ET AL. NUTRITION 2003;19:909-16
Protein Intake and Outcomes in ICU Patients on RRT:
N=50 Mechanically Ventilated, CRRT Patients with APACHE 26 ± 8 (ROD50±25%)
Protein Diet
Nitrogen Balance
Control: N=10
Intervention: N=40
2g/kg/d x 6 days
1.5 - 2.0 - 2.5 g/kg/d
Escalation at 48˚ Intervals
Negative Over Time
Positive over time in
Response to ↑ Protein
Support
Energy Expenditure (IC): Increased by 56±24 cal/day over the study period
Daily Energy (kcal) kept constant and Determined by IC when available or Schofield Equation.
Nitrogen balance determined on the second day of the prescription.
CRRT : Q Bld=100-170mL/min, CVVD at 2L/hr, AN-69 (0.6m2)
NUTRITION AND PCRRT
Can Nitrogen Balance be Achieved in AKI patients on
CRRT?
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
Bellomo et al Renal Failure 1997
Protein and calorie prescription for children and young adults receiving CRRT:
a report from the Prospective Pediatric Continuous Renal Replacement Therapy
Registry group.
Zappitelli M et al, Crit Care Med 2008;36:3239-3245
2
1
0
Protein intake
(g/kg/day)
3
4
5
Daily change in protein prescription during treatment with CRRT.
1
2
3
4
5
6
excludes outside values
Day of CRRT
7
8
9
10
PROTEIN LOSSES ON RRT: SLOW IHD, PD,
CVVHD
IHD
PD:IPD for 10hr/day:
(Qbld=80ml/min, Acute PD for 36hrs :
D=1.8L/hr x 12 hr, CAPD for 24hr/day
SA=0.7m2
AA/Protein loss
(grams)
6g/day
% AA intake lost via
RRT
16%
Diet prescription
AA/Protein
NP kcal [CHO: Lipid]
40 g/day
2000-2400 kcal/d
IPD=12.9 g/d
Acute PD=23.3 g (15.5g/d)
CAPD= 8.8 g/d
CVVHD(Qbld=150mL
/min,
D= 1-2L/hr,UF=
0.67L/hr, SA=0.5m2
12g/day
NA
5-12%
NA
2.5g/kg/day
35kcal/kg/day [60:40]
Kihara M et al. Intensive Care Med 1997;23:110-3
Blumenkrantz MJ et al. Kidney Int 1981;19:593-602
Bellomo r et al, Int J Artif Organs 200225:261-8
Davenport
(1989)
Davies
(1991)
Bellomo
(2002)
Calorie Intake
NPkcal (CHO:Fat)
1450 kcal
( ~70:30)
2000-2400 kcal
AA Intake g/day
60 g AA
(1L Vamin9)
60:84:112 AA
1L of
Vamin9:14:18
AA Loss/day
2.4g/d : 7.9g/d
NA
2100 kcal
(60:40)
2.5g/kg/day
(1 L Synthamin
17)
Maxvold
(2000)
1.25 x mEE
(70 : 30)
1.5g/kg/day
Aminosyn II
~ 12g/day
CVVH:12.5g/d/1.73
m2
CVVHD:11.6g/d/1.73
m2
% Dietary AA Loss
4% : 13%
N2 Balance: g/day
NA
RRT Prescript:
UF rate: L/hr
HF SA = m2
0.5L/hr : 1L/hr
0.6 m2
4%:9%:12%
~ 12%
NA
-1.8g/d
UF:0.5L/hr:
D:1L/hr : D2L/hr
0.43m2
UF:0.67L/hr
D :1-2L/hr
0.5 m2
Davenport A et al, Blood Purif 1989;7:192-6
Bellomo R et al, Int J Art Organs 2002;25:261-8
~11.5%
CVVH: -3.68 g/d
CVVHD: -0.44 g/d
UF : 2L/hr
D : 2L/hr
0.3 m2
Davies SP et al, Crit Care Med 1991;19:1510-5
Maxvold N et al Crit Care Med 2000;28:1161-5
Combined results of clearance of essential amino acids by CRRT.
Zappitelli et al Intensive Care Med 2009 (n=15)
and Maxvold et al, Crit Care Med 2000 (n=6)
60
50
40
K
ml/min/1.73m2
30
20
10
0
Thr Glu Gln Pro Gly Ala Val Met Phe Lys His Arg
Amino Acids
Several studies, adult and child: ~ 10-20% intake “lost” through hemofilter.
Both studies: Highest losses with Glutamine/Glutamic acid
Trace metal and folate CVVHD clearance
in Children
K Day 2
K Day 5
_
Serum Concentrations______________________
(ml/min/1.73m2) (ml/min/1.73m2)
Initiation
Selenium
10.1±7.2, 9.5
8.6±3.9, 7.2
55±19, 49
Copper
0.4±0.3, 0.3
0.54±0.46, 0.44
Chromium
Day 2
61±24, 59
Day 5
Reference range2
64±23, 63
23 to 190 (µg/l)
88±21, 87 L3 110±27, 106
104±27, 103
90 to 190 (µg/dl)
24.0±10.6, 25.4 24.7±7.1, 26.0
2±1, 2
2±1, 2
2±0.4, 2
0 to 2.1 (µg/l)
Zinc
4.2±4.1, 3.2
4.0±2.4, 2.9
66±44, 53 L
68±28, 61
76±38, 68
60 to 120 (µg/dl)
Manganese
9.0±12.9, 4.6
38.2±121.4, 5.1
9±16, 4 H3
8±15, 3 H
8±15, 3 H
0 to 2
Folate
29.4±54.9, 16.2 15.6±3.2, 16.3
16±12, 12
10±4, 9
8±2, 7
5.4 to 40 (ng/l)
Zappitelli M, et al, Intensive Care Med 2009;35:698-706
(µg/l)
[VAN DEN BERGHE G, ET AL. CRIT CARE MED
2003; 31:359-366]
Normoglycemic Control [80-110
mg/dl]
Crit Illness
i Polyneuropathy
i Bacteremia
i Inflammation
i Anemia
Reduction of Mortality
Insulin Dose was the Independent
Determinant:
• ARF
INSULIN AND MUSCLE PROTEIN BALANCE
Insulin- Anabolic hormone for Muscle Metabolism:
Catabolic State:
Insulin effect on MPS (AA Uptake)
MPS
MPB
• Insulin effect on MPB (Ubiqutin-Proteasome)
•
•
Ikizler,TA. J Renal Nutr 2007;17:13-16
Insulin
Resistance
Imbalance of MPB with MPS result in PEW
Reid M, Li YP. Resp Res 2001;2:269-272
NUTRITION IN CHILDREN WITH AKI
Nutritional parameter
Nutrition modality
- Early enteral feeding, may require parenteral nutrition supplement
Energy
35 to 60 kcal/kg/day (0.15-0.27 MJ/kg/day)
25-35%Carbohydrate: 35-45% Lipid (Insulin as needed for Hyperglycemia)
25-40% Protein
>2
Protein
- 3 g/kg/day with AKI
(Increase intake if on High flow CRRT (by 20%)
Vitamins
Daily recommended intake (± replacement )
Monitor serum folate, water soluble vitamin levels
Trace elements
Daily Recommended Intake
Monitoring
MEE, Nitrogen Balance, Electrolytes, Triglycerides,Vitamins, Trace elements
Conditional Nutrients??
Glutamine, Carnitine , Biotin, free Cholesterol