Presentation on theme: "Nutrition In Pediatric CRRT"— Presentation transcript:
1Nutrition In Pediatric CRRT Michael Zappitelli, MD, MScNutrition in AKI AND CRRTMcGill University Health CenterMontreal, Quebec, Canada
2ObjectivesDiscuss the impact of nutrition in acute kidney injury... and vice versaDiscuss clearance of nutrition and nutrition adjustment in pediatric CRRT.
3No real prevention/treatment Poorer outcome, increased mortality Critical IllnessXNo real prevention/treatmentAcute Kidney InjuryXLeft with:1) Modifying the negative effects of AKI2) Providing adequate nutrition??? Modify outcome???Poorer outcome, increased mortality
4Critical Illness Acute Kidney Injury hormone changesAcute: increaseLater: decrease↑ cytokinesAltered substrate utilizationCH2O: ↑hepatic gluconeogenesis(shift away from glycolysis)↑lipogenesis- Inefficient glucose oxidation- Insulin resistance- Shift in use of amino acids:gluconeogenesis + APR’sMALNUTRITIONImpaired nutrient transportInefficient/inadequate supplyImpaired A.a. conversion↓lipid oxidationUremiaAcidosisAltered Glucosemetab.CytokinesAcute Kidney Injury
5Critical Illness and Nutrition Adequate nutrition needed for recovery + normal functioning of growing child.Tissue synthesis and immune function.Desire to avoid over- and under-feeding.Underfeeding: increase morbidity, mortality, infection, wound healing, length of ventilation.
6Critical Illness and Nutrition Children: high risk of malnutrition.High basal metabolic rates.Limited energy reserves.High (15-30%) baseline poor nutrition.
7Malnutrition AND AKI Same difficulties/pathophysiology + Increased difficulty in nutrition provision.Higher rate of baseline malnutrition/ comorbiditiesMetabolic changes of AKI.Children with AKI – increased risk of malnutrition at PICU discharge.RRT – increases nutritional losses.
8Nutrition and AKI Problem: No evidence-based guidelines. Difficulty to show effect on hard outcomes.Recommendations based onAdult studiesKnown metabolic alterations with AKINutrition in critically ill childrenMeasuring nutritional losses by RRT.
9Critical Illness – Energy needs Metabolic needs vary according to the injury.RDA versus predictive equations vs direct measurement (indirect calorimetry).No single predictive equation shown to accurately estimate REE.Limitations to indirect calorimetry in critically ill patients.
10AKI and energy needsControversial – AKI per se may not affect energy expenditure.Affected more by coexisting conditions.Almost no data on pediatric AKI and energy needs.
11Indirect calorimetry AND CRRT IC: measure resting energy expenditure.Based on: Expired CO2 and O2 (O2 consumption + CO2 production).Potential problem with CRRTMay affect ICmeasurements.IC may not bereliable?HCO3/CO2 fluxesHemofilterEffluentDialysis fluid
12Critical Illness – Energy needs Controversy: ? RDA ? 25-30% above REE.Mean REE in literature: 35 to 60 kcal/kg/day ( MJ/kg/day)Adults: kcal/kg/day – probably need more in children.Almost no studies in AKI.
13Carbohydrates Patients become hyperglycemic. Insulin resistance, ↑hepatic gluconeogenesis.Stress hormonesInflammatory mediators and cytokinesMetabolic acidosisPre-existing hyperparathyroidism
14Critical Illness - protein Protein synthesis AND breakdown are increased: breakdown more increased.Manifestation: net negative nitrogen balance, skeletal muscle wasting.Nitrogen balance = Nin – Nout.
15Critical Illness & AKI - protein Protein metabolism abnormal:Reduced renal synthesis of amino acidsAltered amino acid uptakeFactors related to critical illness (elevated stress hormones, increased hepatic gluconeogenesis, relative insulin resistance).
16AKI and proteinProtein synthesis CAN be increased by providing more amino acids.Bellomo et al, Int J of Artif Organs, 2002Scheinkestel et al, Nutrition, 2003Still very difficult to achieve positive N balance.
17therapy in critically ill children. Zappitelli et al, submitted Amino acid, trace metal and folate clearance by continuous renal replacementtherapy in critically ill children. Zappitelli et al, submittedCVVHD clearance of amino acids measured on Day 2 and Day 5 N=15AminoAcidDay 2 (n=15) Day 5 (n=9)K1 CVVHD CVVHD Losses K Renal (n=2) K CVVHD CVVHD Losses K Renal (n=3)(ml/min/1.73m2) (mcg/kg/d) (ml/min/1.73m2) (ml/min/1.73m2) (mcg/kg/d) (ml/min/1.73m2)Mean±SD, Median Mean±SD, Median Mean Mean±SD, Median Mean±SD, Median MeanTauAspThrSerAsnGluGlnProGlyAlaCitValCysMetIleLeuTyrPheOrnLysHisArg104.5±179.0, ±11.1, ±111.2, ±5.4,335.8±483.7, ±4.1, ±349.8, ±4.4,31.9±25.0, ±18.5, ±25.1, ±5.9,29.1±25.6, ±8.6, ±27.7, ±3.3,37.2±32.1, ±8.1, ±19.8, ±3.4,9.4±10.6, ±4.0, ±5.0, ±0.7,19.4±20.1, ±63.7, ±152.9, ±30.7,38.3±32.7, ±22.2, ±21.9, ±11.2,28.1±25.7, ±16.1, ±30.2, ±7.1,26.1±24.6, ±21.2, ±38.8, ±11.5,25.6±24.3, ±4.5, ±50.4, ±1.1,24.8±22.0, ±13.4, ±37.3, ±6.9,27.4±54.5, ±1.2, ±29.9, ±1.1,18.0±19.9, ±13.5, ±31.1, ±1.8,29.9±29.8, ±5.7, ±34.7, ±2.7,22.9±20.9, ±9.2, ±28.8, ±5.2,22.2±23.3, ±13.5, ±41.3, ±2.7,23.9±20.8, ±23.1, ±29.7, ±6.2,8.4±8.7, ±5.0, ±249.7, ±3.4,7.7±9.0, ±11.1, ±299.5, ±8.9,13.2±15.8, ±15.9, ±66.3, ±3.8,15.8±17.1, ±23.4, ±68.6, ±4.8,
18Combined results of clearance of essential amino acids by CRRT. Zappitelli et al (submitted) and Maxvold et al, Critical Care, 2000 (n=6).Grey bars represent amino acid clearance achieved by continuous veno-venous hemofiltration  and black bars from continuous veno-venous hemodialysis .K, clearance; Thr, threonine; Glu, glutamic acid; Gln, glutamine; Pro, Proline; Gly, Glycine; Ala, Alanine; Val, Valine; Met, Methionine; Phe, Phenylalanine; Lys, Lysine; His, Histidine; Arg, Arginine. This graph was derived using data from: Crit Care Med : and J Am Soc Nephrol :767A.Several studies, adult and child: ~ 10-20% intake “lost” through hemofilter.Both studies: Highest losses with Glutamine/Glutamic acid
20therapy in critically ill children. Zappitelli et al, submitted Amino acid, trace metal and folate clearance by continuous renal replacementtherapy in critically ill children. Zappitelli et al, submittedProtein and energy intake and output at CVVHD1 initiation, Day 2 and Day 5.CVVHD initiation (N=15) Day 2 (N=15) Day 5 (N=9)Mean±SD, Median Mean±SD, Median Mean±SD, MedianProtein intake (g/kg/d)N balance (g/kg/d)Caloric intake (kcal/kg/d)Caloric balance (kcal/kg/day)1.98±1.24, ±1.02, ±0.60, 2.08NA ±1.60, ±0.19, -0.2432.6±27.6, ±22.3, ±18.4, 42.7-0.4±25.4, ±21.7, ±17.7, +10.8Maxvold et al, Crit Care Med, 2000Protein intake was 1.5 g/kg/day – Negative nitrogen balanceIt’s not easy to achieve a positive nitrogen balance.Logic: bigger filter, higher Qd or Quf = increased clearance
21Does increasing protein intake help? Scheinkestel et al.1. Nutrition, 2003In 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, 200350 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 stayProtein intake 2.5 g/kg/d: improved survival!
22What are we doing?Protein and calorie prescription for children and young adults receiving CRRT:a report from the Prospective Pediatric Continuous Renal Replacement TherapyRegistry group. Zappitelli et al, submitted.Age (years)CRRT duration (days)Diagnostic category Sepsis/InfectionRenalRespiratoryCardiacHematology Oncology Gastrointestinal/HepaticOtherCRRT indicationElectrolyte imbalanceFluid overload onlyFluid overload and electrolytesCRRT modalityCVVHDCVVHCVVHDF8.8 ± 6.8 (8.1, 12.8)10.2±10.7 (7.0, 11.0) daysN (%)74 (38.1)29 (15.0)12 (6.2)21 (10.8)35 (18.0)15 (7.7)9 (4.6)31 (15.9)66 (33.9)98 (50.3)94 (48.2)52 (26.7)49 (25.1)
23Daily change in protein prescription during treatment with CRRT. Protein and calorie prescription for children and young adults receiving CRRT:a report from the Prospective Pediatric Continuous Renal Replacement TherapyRegistry group. Zappitelli et al, submitted.Daily change in protein prescription during treatment with CRRT.Protein intake(g/kg/day)Day of CRRT
24Daily change in caloric prescription during treatment with CRRT. Protein and calorie prescription for children and young adults receiving CRRT:a report from the Prospective Pediatric Continuous Renal Replacement TherapyRegistry group. Zappitelli et al, submitted.Daily change in caloric prescription during treatment with CRRT.Caloric Intake(kcal/kg/day)Day of CRRT
25Registry group. Zappitelli et al, submitted. Protein and calorie prescription for children and young adults receiving CRRT:a report from the Prospective Pediatric Continuous Renal Replacement TherapyRegistry group. Zappitelli et al, submitted.Characteristics (N)Protein intake (g/kg/day)Initial MaximalGenderMales (111)Females (84)p-value1Age Group≤ 1 year (35)1 to ≤13 years (95)>13 years (65)p-valueMODS (155)No MODS (40)SurvivalSurvivors (117)Non-survivors (78)CRRT indicationElectrolytes (31)Fluid overload (66)Electrolytes andfluid overload (98)1.4, 1.0[1.4] , 1.6[1.6]1.3, 1.0[1.2] , 1.8[1.5]1.5, 1.8[1.5] , 2.4[2.3]1.3, 1.0[1.2] , 1.9[1.5]1.4, 1.0[1.0] , 1.3[1.1]*1.3, 1.0[1.2] , 1.8[1.5]1.5, 1.0[0.8] , 1.3[1.7]1.4, 1.0[1.2] , 1.6[1.5]1.3, 1.0[1.3] , 1.8[1.7]1.2, 1.0[0.9] , 1.4[1.1]1.6, 1.2[1.2] , 1.8[1.8]1.2, 1.0[1.3] , 1.8[1.6]All groups:Maximal protein>initialMultivariate predictors ofmaximal protein intakeYounger ageHigher initial protein Rx#CRRT daysProtein Rx >2g/kg/day in 40%
26Critical Illness & AKI - Lipids h LDL and VLDLiCholesterol and HDL-CholesterolImpaired LipolysisLipase Activity ~50%i Lipoprotein Lipasei Hepatic Triglyceride Lipase
27Critical Illness - Vitamins Water SolubleVit B1 Def Altered Energy Metabolism,h Lactic Acid, Tubular damageVit B6 Def Altered Amino acid and lipidmetabolismFolate Def AnemiaVit C Def Limit 200 mg/d as precursor toOxalic acidPotential for losses during CRRT.
28Critical Illness - Vitamins Fat SolubleVit D Def HypocalcemiaVit A Excess i renal catabolism ofretinol binding proteinVit E Def i >50% plasma and RBC
29CRRT-VitaminsAmino acid, trace metal and folate clearance by continuous renal replacementtherapy in critically ill children. Zappitelli et al, submitted**
31therapy in critically ill children. Zappitelli et al, submitted Amino acid, trace metal and folate clearance by continuous renal replacementtherapy in critically ill children. Zappitelli et al, submittedK1 Day K Day Serum concentrations_____________________(ml/min/1.73m2) (ml/min/1.73m2) Initiation Day Day Reference range2SeleniumCopperChromiumZincManganeseFolate10.1±7.2, ±3.9, ±19, ±24, ±23, to 190 (µg/l)0.4±0.3, ±0.46, ±21, 87 L ±27, ±27, to 190 (µg/dl)24.0±10.6, ±7.1, ±1, ±1, ±0.4, to (µg/l)4.2±4.1, ±2.4, ±44, 53 L ±28, ±38, to 120 (µg/dl)9.0±12.9, ±121.4, ±16, 4 H ±15, 3 H ±15, 3 H to (µg/l)29.4±54.9, ±3.2, ±12, ±4, ±2, to 40 (ng/l)Churchwell et al, NDT, 2007Critically ill adults receiving CVVHD and CVVHDFTransmembrane clearancesMuch lower clearance of selenium and chromiumOverall, trace metal clearance negligible.
32Synthesis Nutritional parameter Nutrition modality Energy Protein VitaminsTrace elementsMonitoringConsider- Early enteral feeding, will often require parenteral nutrition- Approximately 25% above basal metabolic needs as measured by metabolic cart or estimated with equations.20 to 25% as carbohydrates (insulin as needed)30 to 40% lipid formulations (20% lipid emulsions)40 to 50% protein- 2 to 3 g/kg/day with AKI- Increase intake if on CRRT (by 20%)- Daily recommended intakeMonitor serum folate, water soluble vitamin levels ± replacementResting energy expenditure, nitrogen balance, electrolytes, vitamins, trace elementsGlutamine
33Acknolwedgements Timothy E. Bunchman Norma J. Maxvold Stuart L. Goldstein