Presentation on theme: "Review of Nutritional Requirements"— Presentation transcript:
0Nutrition in Acute Kidney Injury Antonio R. Paraiso, MD, FPCP, FPSNMedical Specialist IV, NKTIAsst. Professor, College of Medicine, UERMMMCI
1Review of Nutritional Requirements FOSSILFUELSORGANICFUELSMECHANICAL ENGINEMETABOLIC ENGINEO2COMBUSTIONHEATKCalWASTE
2OXIDATIVE METABOLISM OF ORGANIC FUELS ENERGY YIELDLIPID9.1 kcal/gPROTEIN4.0 kcal/gGLUCOSE3.75 kcal/g
3DAILY ENERGY EXPENDITURE Predictive equationsBEE (Basal Energy Expenditure) kcal/24 hrMen = 66 + (13.7 x wt) + (5.0 x ht) – (6.7 x Age)Women = (9.6 x wt) + (1.8 x ht) – (4.7 x age)REE (Resting Energy Expenditure)REE = 1.2 x BEESimplified computations: kcal/kg ideal body wt depending on activityCaloric requirements: 70% from carbohydrates & 30% from fatsProtein requirements: 0.8 to 1.2 in normal metabolism, 1.2 to 1.8 in hypercatabolism
4ENDOGENOUS FUEL STORES FUEL STORES IN HEALTHY ADULTSFUEL SOURCEAMOUNT (KG)ENERGY YIELD (KCAL)ADIPOSE TISSUE15.0141,000MUSCLE PROTEIN6.024,000TOTAL GLYCOGEN0.09900TOTAL KCAL165,900Energy stores can last up to 10 days depending of the rate of catabolism.Carbohydrate stores are limited and daily intake is needed for CNS functions which rely heavily on carbohydratesIn periods of starvation fat and protein (from breakdown of adipose tissue and muscle) become the main sources of calories
5METABOLIC ALTERATIONS IN AKI HYPERMETABOLIC STATEEnergy expenditure (EE) being proportional to the amount of stressAlthough active solute transport in a functioning kidney is an energy-consuming process, the presence of AKI by itself (in the absence of critical illness) does not seem to affect resting EE (REE)EE in AKI patients is therefore determined mainly by the underlying condition. Studies in chronic kidney disease yield conflicting results varying between increased, normal, or even decreased REE.
6METABOLIC ALTERATIONS IN AKI ‘DIABETES OF STRESS'hyperglycemia and insulin resistanceHepatic gluconeogenesis (from amino acids and lactate) increases mainly due to the action of catabolic hormones such as glucagon, epinephrine, and cortisolThe normal suppressive action of exogenous glucose and insulin on hepatic gluconeogenesis is decreasedPeripheral glucose utilization in insulin-dependent tissues (muscle and fat) is also decreased
7METABOLIC ALTERATIONS IN AKI UNDERLYING CRITICAL ILLNESSIn normal conditions, the kidney plays an important role in glucose homeostasisThe loss of kidney function by itself may contribute to the altered carbohydrate metabolism in AKI
8METABOLIC ALTERATIONS IN AKI PROTEIN CATABOLISM AND NET NEGATIVE NITROGEN BALANCEThe increased protein synthesis is unable to compensate for the higher proteolysisIn the acute phase, this catabolic response may be beneficial, providing amino acids for hepatic gluconeogenesis (supplying substrate for vital tissues such as the brain and immune cells) and for synthesis of proteins involved in immune function and in the acute-phase response.
9METABOLIC ALTERATIONS IN AKI PROTEIN CATABOLISM AND NET NEGATIVE NITROGEN BALANCEHowever, the sustained hypercatabolism in the chronic phase of critical illness results in a substantial loss of lean body mass and in muscle weakness and decreased immune functionProtein catabolic rates may go up to 1.3 and 1.8 g/kg per dayProtein catabolism also accelerates the increases of serum potassium and phosphorus
10METABOLIC ALTERATIONS IN AKI ABNORMAL NUTRIENT PROCESSINGThe malnutrition of starvation is due deficits in essential nutrients and nutrient intake will correct the malnutritionThe malnutrition in AKI and other critical illnesses is due to a disease-induced abnormal nutrient processing. Nutrient intake alone may not correct the malnutrition. The underlying disease must be addressed
11METABOLIC ALTERATIONS IN AKI NUTRIENT TOXICITYIn healthy subjects ,5% of glucose is metabolized to lactate. In critically ill patients, this may rise up to 85%
12Who Should Get Nutritional Support? Patients who:Cannot meet nutrient requirementsHave documented inadequate oral intakeHave unpredictable return of GI functionNeed a prolonged period of NPO/bowel rest
13IF THE GUT IS AVAILABLE, USE IT!!! NUTRITIONAL SUPPORTENTERAL NUTRITION (EN) IS ALWAYS BETTER THAN PARENTERAL NUTRITION (PN)Meta-analyses comparing EN with PN - no difference in mortalityLower incidence of infectious complications with ENmay be explained by the higher incidence of hyperglycemia in patients receiving PNIF THE GUT IS AVAILABLE, USE IT!!!
14EN –vs- PN OUTCOMES IN CRITICALLY ILL ADULT PATIENTS Infectious complicationsFavors ENFavors PNA systematic review of the literatureGramlich, K et al, Nutrition 2004
15EN -vs- PN Mortality Gramlich, K et al, Nutrition 2004 Favors EN Favors PNGramlich, K et al, Nutrition 2004
16NUTRITIONAL SUPPORT IN AKI EARLY VERSUS LATE ENMeta-analysis showed reduced infectious complications and length of hospital stay with early EN, but no effect on noninfectious complications or mortalityHowever, enterally fed critically ill patients often do not meet their nutritional targets, especially in the first days of ICU stayAdequate early nutrition is easier with the parenteral routeMost of the mortality benefits of PN suggests that PN should be given when EN cannot be initiated within 24 hours of ICU admission
17The rationale for early EN Use of the gut stimulates GALT & MALT ➡ resulting in enhanced immune responseEarly feeding can trigger gut immunity and thereby improve outcomesDelay or failure may promote a pro-inflammatory state with ⇧ disease severity & morbidityMcClave, J Clin Gastro, Sept 2002
18The rationale for early EN Absence of gut stimulation is associated with gut atrophyChanges in gut integrity begin w/in 6 hrsHigher incidence of infection/ sepsis“Window of opportunity” = 24 – 48 hrsZaloga GP. Crit Care Med 1999;27:259McClave, J Clin Gastro, Sept 2002
19NUTRITIONAL SUPPORT IN AKI OPTIMAL AMOUNT OF CALORIESOverfeeding should be avoidedHyperglycemiaexcess lipid depositionAzotemiaexcess carbon dioxide (CO2) production with difficult weaning from the respiratorinfectious complications
20NUTRITIONAL SUPPORT IN AKI OPTIMAL AMOUNT OF CALORIESAlthough not based on solid evidence, recent recommendations suggest a nonprotein energy supply25 to 30 kcal/kg per day in men and 20 to 25 kcal/kg per day in womenThe proposed proportions of nonprotein energy supply are 60% to 70% of carbohydrate and 30% to 40% of fat
21NUTRITIONAL SUPPORT IN AKI OPTIMAL AMOUNT OF CALORIESResults from two recent trials renewed interest in hypocaloric feeding, combining normal protein with reduced caloric supplyfewer infectious complications and reduced ICUcaloric intake of between 33% and 66% of the target was associated with better survival
22NUTRITIONAL SUPPORT IN AKI PROTEIN INTAKEGoal is to improve protein synthesis and nitrogen balanceAlthough negative nitrogen balances are associated with the worst outcomes, there are no randomized studies comparing different protein or nitrogen intakes with regard to clinical outcomes in ICU patientsAlthough the ideal amount is still debated, a protein intake of between 1.2 and 1.6 g/kg per day (0.16 to 0.24 g nitrogen/kg per day) is usually recommendedBecause many nonessential amino acids are not readily synthesized or increasingly used in critically ill patients, the combination of essential and nonessential amino acids is supposed to be superior
23ROLE OF SPECIFIC COMPONENTS GlutamineMost abundant amino acid in the bodyImportant fuel for cells of the immune systemIn stress situations, concentrations decrease and it becomes a 'conditionally' essential amino acidAvailable guidelines recommend enteral and parenteral supplementationAntioxidant micronutrientsMicronutrients (vitamins and trace elements) play a key role in metabolism, immune function, and antioxidant processes, AKI patients have increased oxidative stressThey are deficient in critically ill patients and should be supplementedSelenium, zinc, vitamin E, and vitamin C show promising effects on infectious complications and/or mortality in ICU patientsRecommended vitamin C in AKI varies between 30 to 100 mg
24ROLE OF SPECIFIC COMPONENTS ImmunonutrientsNutrients with an immune-modulating effect include: glutamine, arginine, nucleotides, and omega-3 fatty acidsArginine is a precursor of nitric oxide synthesis and may be detrimental in critically ill patients with an ongoing inflammatory responseMeta-analysis aggregating the results of three RCTs of enteral supplementation of omega-3 fatty acids (fish oil) in patients with acute respiratory distress syndrome demonstrated that enteral formula enriched with fish oils significantly reduces mortality and ventilator days and tended to reduce ICU length of stay. A role for exogenous omega-3 fatty acids in human renal protection is, at this moment, purely speculative.Cocktails of several immunonutients (containing glutamine, arginine, nucleotides, and omega-3 fatty acids) in critically ill patients showed no difference in clinical outcome with standard EN
25AKIEtiology and severity of AKI is diverse Recommendations for nutritional support can at best be described as debatable
26CATEGORIES OF AKI PRE-RENAL INTRA-RENAL POST-RENAL Decreased renal perfusion of whatever cause with preserved integrity of the renal parechymaINTRA-RENALRenal parenchymal disease usually post-ischemic or nephrotoxic and is classicall associated with atnPOST-RENALAcute obstruction of the urinary tract
27SEVERITY OF AKI RIFLE CRITERIA (As recommended by the ADQI) RISK of renal dysfunctionINJURY to the kidneyFAILURE of kidney functionLOSS of functionEND stage kidney diseaseSEVERITYOUTCOME
28RECOMMENDATIONS FOR NUTRITION IN ACUTE KIDNEY INJURY CONSERVATIVE(NON-DIALYZED)DIALYZEDCASESUSUALLYMILDERCASESMORESEVERE?EN or PNThere are no largerandomized controlled trials (RCTs)investigating the effect ofnutritional supportversus starvation in AKI
29RECOMMENDATIONS IN CRRT The effect of CRRT on EE and protein catabolic rate is probably small and not clinically relevant.Blood-membrane contact during RRT may induce a protein catabolic effect – debatable nutritional significanceProtein intake: we do not know the metabolic fate of the administered amino acidsmay be used for synthesis of 'beneficial' proteinsmay be burnt for energyMay join the inflammatory mediator poolDaily amino acid losses may reach between 10 and 15 gExtracorporeal losses of lipoproteins are not to be expectedThe optimal nutritional support strategy for patients with AKI requiring CRRT remains a matter of controversy.
30Traditional administration of PN Infusion from single bottles via Y-connection early in the history of parenteral nutrition
31KABIVEN: 3 CHAMBER BAGALL IN ONE means that all nutrients in a dose needed for 1 day, such as theamino acid solution, the glucose solution(s) and the lipid emulsion as well asadditions such as electrolytes, trace elements and vitamins are mixed in onesingle container. This admixture is administered over 24 hours via one singleconnection at a constant rate to the patient.
32KABIVEN: Advantages of the All in One system Improved safetySaving hospital time and moneyImproved vein tolerance due to the lipids containedOptimal peripheral parenteral nutritionMetabolic advantagesSafe, efficient and well-toleratedIncreased patient convenience and satisfactionFacilitating home PN (HPN)
33Kabiven® Characteristics The Kabiven range: Kabiven (central) 1900 kcal to meet total requirementsKabiven Peripheral1000 kcal as a supplement1400 kcal as a supplement or for TPN
35Nutritional support for acute kidney injury Li Y, Tang X, Zhang J, Wu T Main resultsCompared to lower calorie-total parenteral nutrition (TPN), higher calorie-TPN did not improve estimated nitrogen balance, protein catabolic rate, or urea generation rate, but increased serum triglycerides, glucose, insulin need and nutritional fluid administration.Urea nitrogen appearance was lower in the low nitrogen intake group than in the high nitrogen intake group.There was no significant difference in death between EAA and general amino acids (GAA) (RR 1.52, 95% CI 0.63 to 3.68). High dose amino acids did not improve cumulative water excretion, furosemide requirement, nitrogen balance or death compared to normal dose amino acids.Authors' conclusionsThere is not enough evidence to support the effectiveness of nutritional support for AKI. Further high quality studies are required to provide reliable evidence of the effect and safety of nutritional support
36OUR CONCLUSIONS Use the GUT if available!!! Non-dialyzed AKI: low protein, adequate carbohydratesDialyzed AKI: although no strong evidence is available, physiologic arguments favor nutritional supportIf PN is to be used, KABIVEN’s all-in-one 3 chamber bag is convenient either for central or peripheral vein administration