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Nutrition in CRRT Do the losses exceed the delivery? Timothy E. Bunchman.

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Presentation on theme: "Nutrition in CRRT Do the losses exceed the delivery? Timothy E. Bunchman."— Presentation transcript:

1 Nutrition in CRRT Do the losses exceed the delivery? Timothy E. Bunchman

2 Nutrition in MOSF What are the needs of the patient due to presence of MOSF? Protein Carbohydrate Lipids What are the losses of the patient due to the therapy of CRRT?

3 Protein & Amino Acid Metabolism Clinically seen as Hyper catabolic E.g. Rapidly rising BUN Over time loss of lean body mass

4 Protein & Amino Acid Metabolism Mechanisms Increase in muscle catabolism Decrease in muscle protein synthesis Increase in hepatic gluconeogenesis Ureagenesis Protein synthesis Altered AA transport (cellular) Decrease in renal peptide catabolism

5 Protein & Amino Acid Metabolism Potential causes Insulin resistance Metabolic acidosis Inflammation Catabolic hormones Growth hormone/factor resistance Substrate deficiencies Malnutrition prior to illness Loss on dialysis

6 Carbohydrate metabolism Clinical findings hyperglycemia

7 Carbohydrate metabolism Mechanisms Insulin resistance Increase in hepatic gluconeogenesis

8 Carbohydrate metabolism Potential causes Stress hormones Inflammatory mediators with increase in cytokine (e.g. TNF) expression Metabolic acidosis Pre-existing hyperparathyroidism

9 Lipid Metabolism Clinical findings Hypertriglyceridemia

10 Lipid Metabolism Mechanisms Inhibition in lipolysis Increase in hepatic triglyceride secretion

11 Lipid Metabolism Potential causes Unknown inhibitor to lipoprotein lipase Inflammatory mediators

12 Nutrition in PCRRT CRRT allows solute clearance uremic solutes small molecular sized nutrients (eg oligosaccharides) amino acids and small peptides electrolytes

13 Energy Balance studies Cumulative energy deficits associated with increase mortality Bartlett et al, Surgery % mortality in malnourished 29% mortality in non malnourished Fiaccudori et al, J Am Soc Neph 1996 Is malnutrition an independent predictor of survival in ARF?

14 Nutritional Factors in ARF Increase in protein catabolism underlying and cause of ARF cytokine effects uremia increase in gluconeogenesis and protein degradation hormonal Insulin resistance, diminished protein synthesis metabolic acidosis

15 Nutritional Factors in ARF Dialysis losses protein losses in PD amino acid losses in PCRRT Diminished nutrient utilization Inadequate supplementation failure to measure needs side effects of nutrition supplementation

16 Dialysis Losses Peritoneal Dialysis albumin, protein, immunoglobulin and amino acid losses Katz et al, J Peds

17 IgG levels in Infants (Katz et al, J Peds 117: , 1990) IgGAlbumin Loss (mg/kg) Loss (mg/1.73m2)

18 IgG levels in Infants (Katz et al, J Peds 117: , 1990)

19 Dialysis Losses CRRT small peptide and amino acid Mokrzycki and Kaplan, J Am Soc Neph 1996

20 Protein losses on CRRT Range of amino acid and protein losses 7-50 gms/day Factors effecting AA/protein losses hemofilter size (surface area) and composition nature of solute (molecular size) total ultrafiltration plasma concentration of amino acids/protein

21 CVVH and CVVHDF Polysulfone membranes (Amicon 20 and Fresenius F-80) BFR mls/min Dx FR 1000 mls/hr with net u/f/hr 1600 mls gms/day of protein losses Protein losses on CRRT Mokrzycki and Kaplan, J Am Soc Neph 1996

22 CAVHD AN-69 (0.43 m2; PAN membrane) BFR MAP dependent (80 mls/min) Dx 1 l/hr; net u/f/hr 340 mls AA losses at 1 liter Dx: 9% of total intake Dx 2 l/hr; net u/f/hr 340 mls AA losses at 2 liter Dx:12% of total intake Protein losses on CRRT Davies et al, Crit Care Med, 1991

23 CVVH Polyamide FH 55 (Gambro) BFR 140 mls/min Net u/f/hr 1000 mls Amino Acid losses/day by diagnosis Cardiogenic shock- 7.4 gms Sepsis-3.8 gms Protein losses on CRRT Davenport et al, Crit Care Med 1989

24 Prospective crossover study to evaluate nutritional losses of CVVH vs CVVHD Study design Fixed blood flow rate-4 mls/kg/min HF-400 (0.3 m2 polysulfone) Cross over for 24 hrs each to pre filter replacement or Dx at 2000 mls/hr/1.73 m2 Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5

25 Indirect calorimetry to measure REE TPN source of 120% of REE 70% dextrose 30% lipids Insulin to maintain euglycemia when needed 10% Aminosyn II 1.5 gms/kg/day of protein Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5

26 Comparison of Total Amino Acid losses: CVVH vs CVVHD (Maxvold et al, Crit Care Med 2000 Apr;28(4): ) Amino Acid Losses (g/day/1.73 m2) NS

27 Amino acid and protein losses with this prescription represent between 10-12% of total delivered nutritional proteins Glutamine loss accounted for approximately 20% of total AA loss Some Amino Acid preparations for TPN are deficient in glutamine Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med 2000;28(4):1161-5

28 24 Hr Nitrogen Balance: CVVH vs CVVHD (Maxvold et al, Crit Care Med 2000 ;28(4): ) 24 hr Nitrogen Balance (g/day/1.73 m2) NS

29 ? Glucose loss in the Dialysate 90 kg BMT tx pt with MOSF Begun on CVVD at 2.5 liters of Normocarb Due to acidosis 2 liters of Normocarb added as a prefilter replacement fluid therefore the child is now on CVVHDF Normocarb is glucose free What is the caloric impact of this?

30 ? Calorie deficient due to no glucose in the Dialysate-2 Ultrafiltrate glucose is measured at 109 mg/dl 4.5 liters/hr x 24 hrs = 108 liters uf/day 109 mg/dl = 1090 mg/l = 1.09 gms/l 1.09 gms/l x 108 liters = 117 gms of glucose lost 117 gms x 4 cals/gm = 470 cals lost

31 Is this significant? IVFs are TPN giving 2500 cals/day 5 IVFs for meds, drips, etc all in D5 with a total rate of 200 ccs/hr 200 ccs/hr x 24 hrs = 4800 ccs of D5 D5 has 5 gms/100ccs or 50 gms/ gms x 4.8 liters = 24 gms 24 gms x 4 cal = 96 cals (cals not thought of)

32 Intensive Insulin therapy (Van den Berghe et al NEJM 345: , 2001) Patients Glucose target level mg/dl mg/dl

33 Intensive Insulin therapy (Van den Berghe et al NEJM 345: , 2001)

34

35

36 Trace elements and Vitamins Trace elements are poorly cleared due to protein binding Water soluble vitamins are well cleared and the child is at risk for deficiency

37 Trace elements and Vitamins Vitamin A may be retained and cause toxicity manifested as hypercalemia Vitamin K is not cleared but in patients with MOSF on antibiotics will become deficient and will need supplementation Vitamin D may be depressed if pt had pre existing renal insufficiency Vitamin E levels are depressed in MOSF but are not cleared

38 So what do we do? 1. Keep glucose under control Use insulin freely (yes some of the insulin is cleared ?? How much?) If using ACD-A citrate the D stands for Dextrose (I missed that but I was educated by a NICU nurse)

39 So what do we do? 2. Keep lipids as part of the formulation but be aware that both glucose and lipids effect triglycerides

40 So what do we do? 3. Protein load as an amino acid needs to be targeted Local standard is to target to a BUN of mg/dl Some NICU babies on the current M-60 AN-69 membrane of the PRISMA require 7- 9 gms/kg/day to reach a target of BUN to 30 mg/dl

41 Urea Levels: HD vs. HF Mehta et al, Kid Int, 2001, 60:

42 So what do we do? 4. Use the gut whenever possible Benefit of immune function of enteral formulas Decreases risk of TPN line induced sepsis Bacterial fungal

43 A Study to do Serial nitrogen balance, REE, glucose metabolism studies throughout the course of the childs illness Impact upon balance of catabolism to anabolism as one increases the protein/AA exposure


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