Norma J Maxvold MD
Associate Professor of Pediatrics
Pediatric Critical Care Medicine
Children’s Hospital of Richmond
Virginia Commonwealth University
Objectives:
 Overview Nutritional Needs in Children with AKI

Effect of renal support on Nutrition

Diagram of Nutrition Prescription during AKI
Acute Illness: Stress Response
hCytokines, Hormonal changes,
Altered Substrate Utilization
AKI
Acidosis,
Uremia,
Impaired AA
Conversion,
iLipid Oxidation
CATABOLIC, HYPERMETABOLIC
STATE
Malnutrition
Malnutrition


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?
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)

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]
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)
>20%
0.26 MJ/kg/d
Briassoulis et al. (2000)


IC: measure resting energy expenditure.
Based on: Expired CO2 and O2 (O2
consumption + CO2 production).
Potential problem with CRRT
HCO3/CO2 fluxes
May affect IC
measurements.
IC may not be
reliable?
Hemofilter
Effluent
Dialysis fluid
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 0.28
Fat 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
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
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]
CALORIC SUPPORT:
Adult:
npkcal 25kcal/kg/d
CHO
Fat
PROTEIN SUPPORT:
Adult:
Protein 1.5-2.0 g/kg/d
5 g/kg/d
0.8-1.2g/kg/d
Pediatric:
Pediatric:
Npkcal 40-65kcal/kg/d Protein 2.0-3.0 g/kg/d
( Cano N et al Clin Nutr 2006 and
2008)
Can Nitrogen Balance be Achieved
in AKI patients on CRRT?
Conflicting Studies
Bellomo et al
Protein Intake
1.2 g/kg/d AA
2.5 g/kg/d AA
Ren Fail 1997
:
Nitrogen Balance
-5.5 g N /d
-1.9 g N /d
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
for losses nitrogen
during CRRT balance.
levels andPotential
b) positive
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!
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
[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
i Hospital stay: 29 days vs 36 days
[ Schloerb et al; JPEN 1993; 17:407-413]
i Hospital stay: 26 days vs 32 days
i Total Body Water: -1.2 L vs 2.2 L (Bioimpedance)
Lipid Metabolism
h Fatty Acid Utilization during acute illness
Mitochondrial adaptation to acute stress
(Carnitine dependent enzymes)
Calvani et al
Basic Res Cardiol 2000
Mitochondrial control of FFA oxidation and CHO oxidation
AcetylCoA/ CoA ratio on PDH Complex
Advantages:
 Lower Linoleic concentration
 MCT rapidly cleared from plasma
 Olive oil less prone to peroxidation
 Fish oil beneficial anti-inflammatory
Early Studies : Good Safety profile
Clin Nutr 2013;32:224
JPEN 2012; 36:81S
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
Nutritional parameter
Nutrition modality
- Early enteral feeding, may require parenteral nutrition suppl
Energy
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)
Protein
2 to 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, Vitamins, Trace elements
Consider
Glutamine, Carnitine Supplement