Presentation is loading. Please wait.

Presentation is loading. Please wait.

Nutrition In Pediatric CRRT Michael Zappitelli, MD, MSc Nutrition in AKI AND CRRT McGill University Health Center Montreal, Quebec, Canada.

Similar presentations


Presentation on theme: "Nutrition In Pediatric CRRT Michael Zappitelli, MD, MSc Nutrition in AKI AND CRRT McGill University Health Center Montreal, Quebec, Canada."— Presentation transcript:

1 Nutrition In Pediatric CRRT Michael Zappitelli, MD, MSc Nutrition in AKI AND CRRT McGill University Health Center Montreal, Quebec, Canada

2 Objectives Discuss the impact of nutrition in acute kidney injury... and vice versa Discuss clearance of nutrition and nutrition adjustment in pediatric CRRT.

3 Critical Illness Acute Kidney Injury Poorer outcome, increased mortality No real prevention/treatment Left with : 1) Modifying the negative effects of AKI 2) Providing adequate nutrition ??? Modify outcome??? X X

4 Critical Illness hormone changes -Acute: increase -Later: decrease cytokines Altered substrate utilization CH2O: hepatic gluconeogenesis (shift away from glycolysis) lipogenesis - Inefficient glucose oxidation - Insulin resistance - Shift in use of amino acids: gluconeogenesis + APRs MALNUTRITION Acute Kidney Injury Uremia Acidosis Altered Glucose metab. Cytokines Impaired nutrient transport Inefficient/inadequate supply Impaired A.a. conversion lipid oxidation

5 Critical Illness and Nutrition Adequate nutrition needed for recovery + normal functioning of growing child. 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.

6 Critical Illness and Nutrition Children: high risk of malnutrition. Children: high risk of malnutrition. High basal metabolic rates. High basal metabolic rates. Limited energy reserves. Limited energy reserves. High (15-30%) baseline poor nutrition. High (15-30%) baseline poor nutrition.

7 Malnutrition AND AKI Same difficulties/pathophysiology + Same difficulties/pathophysiology + Increased difficulty in nutrition provision. Increased difficulty in nutrition provision. Higher rate of baseline malnutrition/ comorbidities Metabolic changes of AKI. Metabolic changes of AKI. Children with AKI – increased risk of malnutrition at PICU discharge. Children with AKI – increased risk of malnutrition at PICU discharge. RRT – increases nutritional losses.

8 Nutrition and AKI Problem: No evidence-based guidelines. Difficulty to show effect on hard outcomes. Recommendations based on 1)Adult studies 2)Known metabolic alterations with AKI 3)Nutrition in critically ill children 4)Measuring nutritional losses by RRT.

9 Critical Illness – Energy needs Metabolic needs vary according to the injury. 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.

10 AKI and energy needs Controversial – AKI per se may not affect energy expenditure. Controversial – AKI per se may not affect energy expenditure. Affected more by coexisting conditions. Affected more by coexisting conditions. Almost no data on pediatric AKI and energy needs. Almost no data on pediatric AKI and energy needs.

11 Indirect calorimetry AND CRRT IC: measure resting energy expenditure. IC: measure resting energy expenditure. Based on: Expired CO2 and O2 (O2 consumption + CO2 production). Based on: Expired CO2 and O2 (O2 consumption + CO2 production). Potential problem with CRRT Potential problem with CRRT Hemofilter Dialysis fluid Effluent HCO3/CO2 fluxes May affect IC measurements. IC may not be reliable?

12 Critical Illness – Energy needs Controversy: ? RDA ? 25-30% above REE. 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.

13 Carbohydrates Patients become hyperglycemic. Insulin resistance, hepatic gluconeogenesis. Stress hormones Stress hormones Inflammatory mediators and cytokines Inflammatory mediators and cytokines Metabolic acidosis Metabolic acidosis Pre-existing hyperparathyroidism Pre-existing hyperparathyroidism

14 Critical Illness - protein Protein synthesis AND breakdown are increased: breakdown more increased. Protein synthesis AND breakdown are increased: breakdown more increased. Manifestation: net negative nitrogen balance, skeletal muscle wasting. Nitrogen balance = Nin – Nout. Nitrogen balance = Nin – Nout.

15 Critical Illness & AKI - protein Protein metabolism abnormal: Protein metabolism abnormal: -Reduced renal synthesis of amino acids -Altered amino acid uptake -Factors related to critical illness (elevated stress hormones, increased hepatic gluconeogenesis, relative insulin resistance).

16 AKI and protein Protein synthesis CAN be increased by providing more amino acids. Protein synthesis CAN be increased by providing more amino acids. Bellomo et al, Int J of Artif Organs, 2002 Scheinkestel et al, Nutrition, 2003 Still very difficult to achieve positive N balance. Still very difficult to achieve positive N balance.

17 Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted Amino Acid Day 2 (n=15) Day 5 (n=9) K 1 CVVHD CVVHD Losses K Renal (n=2) K CVVHD CVVHD Losses K Renal (n=3) (ml/min/1.73m 2 ) (mcg/kg/d) (ml/min/1.73m 2 ) Mean±SD, Median Mean±SD, Median Mean Tau Asp Thr Ser Asn Glu Gln Pro Gly Ala Cit Val Cys Met Ile Leu Tyr Phe Orn Lys His Arg 104.5±179.0, ±11.1, ±111.2, ±5.4, ±483.7, ±4.1, ±349.8, ±4.4, ±25.0, ±18.5, ±25.1, ±5.9, ±25.6, ±8.6, ±27.7, ±3.3, ±32.1, ±8.1, ±19.8, ±3.4, ±10.6, ±4.0, ±5.0, ±0.7, ±20.1, ±63.7, ±152.9, ±30.7, ±32.7, ±22.2, ±21.9, ±11.2, ±25.7, ±16.1, ±30.2, ±7.1, ±24.6, ±21.2, ±38.8, ±11.5, ±24.3, ±4.5, ±50.4, ±1.1, ±22.0, ±13.4, ±37.3, ±6.9, ±54.5, ±1.2, ±29.9, ±1.1, ±19.9, ±13.5, ±31.1, ±1.8, ±29.8, ±5.7, ±34.7, ±2.7, ±20.9, ±9.2, ±28.8, ±5.2, ±23.3, ±13.5, ±41.3, ±2.7, ±20.8, ±23.1, ±29.7, ±6.2, ±8.7, ±5.0, ±249.7, ±3.4, ±9.0, ±11.1, ±299.5, ±8.9, ±15.8, ±15.9, ±66.3, ±3.8, ±17.1, ±23.4, ±68.6, ±4.8, CVVHD clearance of amino acids measured on Day 2 and Day 5 N=15

18 Combined results of clearance of essential amino acids by CRRT. Zappitelli et al (submitted) and Maxvold et al, Critical Care, 2000 (n=6). Several studies, adult and child: ~ 10-20% intake lost through hemofilter. Both studies: Highest losses with Glutamine/Glutamic acid

19 Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted Amino Acid 2 CVVHD initiation % low/normal/high 3 Day 2 % low/high/normal Day 5 % low/normal/high Tau Asp Thr Ser Asn Glu Gln Pro Gly Ala Cit Val Cys Met Ile Leu Tyr Phe Orn Lys His Arg 43±96, 16 0/ 93.3/6.7 40±102, / 86.7/ ±14, / 88.9/ 0 4±3, 3 0/ 100.0/ 0 5±5, 3 6.7/ 93.3/ 0 13±16, / 66.7/ ±81, /60.0/ ±54, / 80.0/ ±67, 95 0/ 88.9/ ±26, / 40.0/ 0 65±30, / 46.7/ 0 66±34, / 55.6/ 0 37±21, 30 0/ 100.0/ 0 42±23, 43 0/ 93.3/ ±27, / 77.8/ ±89, 23 0/ 86.7/ ±55, 37 0/ 80.0/ ±146, / 44.4/ ±146, / 53.3/ 0 372±167, 364 0/ 33.3/ ±261, / 55.6/ ±66, / 93.3/ 0 142±69, 127 0/ 100.0/ 0 182±113, 132 0/ 88.9/ ±135, / 66.7/ ±89, / 66.7/ ±100, / 77.8/ ±133, / 80.0/ ±149, / 80.0/ ±192, / 77.8/ ±7, / 86.7/ 0 12±8, / 80.0/ 0 12±7, / 77.8/ 0 148±58, / 80.0/ 0 144±43, / 93.3/ 0 140±57, / 88.9/ 0 27±25, / 60.0/ ±24, / 60.0/ ±35, / 55.6/ ±52, / 80.0/ ±39, / 53.3/ ±16, 26 0/ 88.9/ ±19, / 86.7/ 0 43±22, / 93.3/ 0 45±23, 41 0/ 88.9/ ±34, 70 0/ 93.3/ ±28, 95 0/ 100.0/ 0 101±41, / 77.8/ ±38, / 73.3/ ±27, / 86.7/ ±27, / 77.8/ 0 92±59, 71 0/ 73.3/ ±63, 79 0/ 46.7/ ±45, 87 0/ 44.4/ ±37, 38 0/ 86.7/ ±41, 51 0/ 86.7/ ±84, / 77.8/ ±65, 136 0/ 86.7/ ±84, 153 0/ 66.7/ ±90, / 66.7/ ±32, / 80.0/ ±38, / 80.0/ ±36, / 77.8/ ±26, / 80.0/ 0 74±56, 55 0/ 93.3/ ±31, / 88.9/ 0 Amino Acid serum levels measured on Days 1, 2 and 5

20 Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted CVVHD initiation (N=15) Day 2 (N=15) Day 5 (N=9) Mean±SD, Median Mean±SD, Median Mean±SD, Median Protein 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, 2.08 NA -0.88±1.60, ±0.19, ±27.6, ±22.3, ±18.4, ±25.4, ±21.7, ±17.7, Protein and energy intake and output at CVVHD1 initiation, Day 2 and Day 5. Maxvold et al, Crit Care Med, 2000 Protein intake was 1.5 g/kg/day – Negative nitrogen balance Its not easy to achieve a positive nitrogen balance. Logic: bigger filter, higher Qd or Quf = increased clearance

21 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. 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, critically ill adults on CRRT: 1.5 vs 2.0 vs 2.5 g/kg/day. 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 protein intake. NB related to hospital stay NB related to hospital stay Protein intake 2.5 g/kg/d: improved survival! Protein intake 2.5 g/kg/d: improved survival!

22 What are we doing? Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. Age (years) CRRT duration (days) Diagnostic category Sepsis/Infection Renal Respiratory Cardiac Hematology Oncology Gastrointestinal/Hepatic Other CRRT indication Electrolyte imbalance Fluid overload only Fluid overload and electrolytes CRRT modality CVVHD CVVH CVVHDF 8.8 ± 6.8 (8.1, 12.8) 10.2±10.7 (7.0, 11.0) days N (%) 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)

23 Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. Protein intake (g/kg/day) Day of CRRT Daily change in protein prescription during treatment with CRRT.

24 Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. Caloric Intake (kcal/kg/day) Day of CRRT Daily change in caloric prescription during treatment with CRRT.

25 Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. Characteristics (N) Protein intake (g/kg/day) Initial Maximal Gender Males (111) Females (84) p-value 1 Age Group 1 year (35) 1 to 13 years (95) >13 years (65) p-value MODS (155) No MODS (40) p-value Survival Survivors (117) Non-survivors (78) p-value CRRT indication Electrolytes (31) Fluid overload (66) Electrolytes and f luid overload (98) p-value 1.4, 1.0[1.4] 2.0, 1.6[1.6] 1.3, 1.0[1.2] 1.9, 1.8[1.5] , 1.8[1.5] 2.5, 2.4[2.3] 1.3, 1.0[1.2] 2.0, 1.9[1.5] 1.4, 1.0[1.0] 1.6, 1.3[1.1] * 1.3, 1.0[1.2] 1.9, 1.8[1.5] 1.5, 1.0[0.8] 2.0, 1.3[1.7] , 1.0[1.2] 2.0, 1.6[1.5] 1.3, 1.0[1.3] 1.8, 1.8[1.7] , 1.0[0.9] 1.6, 1.4[1.1] 1.6, 1.2[1.2] 2.1, 1.8[1.8] 1.2, 1.0[1.3] 2.0, 1.8[1.6] All groups: -Maximal protein>initial Multivariate predictors of maximal protein intake - Younger age - Higher initial protein Rx - #CRRT days Protein Rx >2g/kg/day in 40%

26 Critical Illness & AKI - Lipids LDL and VLDL LDL and VLDL Cholesterol and HDL-Cholesterol Cholesterol and HDL-Cholesterol Impaired Lipolysis Impaired Lipolysis Lipase Activity ~50% Lipase Activity ~50% Lipoprotein Lipase Lipoprotein Lipase Hepatic Triglyceride Lipase Hepatic Triglyceride Lipase

27 Critical Illness - Vitamins Water Soluble Vit B 1 Def Altered Energy Metabolism, Lactic Acid, Tubular damage Lactic Acid, Tubular damage Vit B 6 Def Altered Amino acid and lipid metabolism metabolism Folate Def Anemia Folate Def Anemia Vit C Def Limit 200 mg/d as precursor to Oxalic acid Oxalic acid Potential for losses during CRRT.

28 Critical Illness - Vitamins Fat Soluble Vit D Def Hypocalcemia Vit A Excess renal catabolism of retinol binding protein retinol binding protein Vit E Def >50% plasma and RBC

29 CRRT-Vitamins Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted * *

30 Critical Illness – trace metals Deficiencies linked to: Deficiencies linked to: -Lymphocyte dysfunction -Cardiovascular dysfunction -Platelet activity -Antioxidant function -Wound healing

31 Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted K 1 Day 2 K Day 5 Serum concentrations­­­­­­­­­­­­­­­­­­_____________________ (ml/min/1.73m 2 ) (ml/min/1.73m 2 ) Initiation Day 2 Day 5 Reference range 2 Selenium Copper Chromium Zinc Manganese Folate 10.1±7.2, ±3.9, ±19, 49 61±24, 59 64±23, to 190 (µg/l) 0.4±0.3, ±0.46, ±21, 87 L 3 110±27, ±27, to 190 (µg/dl) 24.0±10.6, ±7.1, ±1, 2 2±1, 2 2±0.4, 2 0 to 2.1 (µg/l) 4.2±4.1, ±2.4, ±44, 53 L 68±28, 61 76±38, to 120 (µg/dl) 9.0±12.9, ±121.4, 5.1 9±16, 4 H 3 8±15, 3 H 8±15, 3 H 0 to 2 (µg/l) 29.4±54.9, ±3.2, ±12, 12 10±4, 9 8±2, to 40 (ng/l) Churchwell et al, NDT, 2007 Critically ill adults receiving CVVHD and CVVHDF Transmembrane clearances Much lower clearance of selenium and chromium Overall, trace metal clearance negligible.

32 Synthesis Nutritional parameter Nutrition modality Energy Protein Vitamins Trace elements Monitoring Consider - 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 intake - Monitor serum folate, water soluble vitamin levels ± replacement - Daily recommended intake -Resting energy expenditure, nitrogen balance, electrolytes, vitamins, trace elements - Glutamine

33 Acknolwedgements Timothy E. Bunchman Norma J. Maxvold Stuart L. Goldstein


Download ppt "Nutrition In Pediatric CRRT Michael Zappitelli, MD, MSc Nutrition in AKI AND CRRT McGill University Health Center Montreal, Quebec, Canada."

Similar presentations


Ads by Google