1. Nutrition and Disease & Injury States
Barbara Magnuson, PharmD BCNSP
Nutrition Support Service

2. Disease Specific Enteral Products
Patient Specific products/modifications
Renal disease
Liver disease
Malabsorption
Surgery, Trauma, Burns
Respiratory
Diabetes

3. Acute vs. Chronic Acute Kidney Injury (AKI) Chronic Kidney Disease
Decrease GFR over days – weeks
Quick accumulation of creatinine, nitrogen waste (BUN), fluid volume, and electrolytes * * *
Etiology – drugs, shock, volume
Usually reversible
Chronic Kidney Disease
Structural or functional changes over > 3 months
Usually does not improve

4. AKI Not hypermetabolic by itself
Calories: Assess patient by their primary injury or current nutritional status and 20-30kcal/kg
CHO:
Often hyperglycemic with insulin resistance
Fats:
Often elevated triglycerides (TGLY), monitor levels if receiving IV lipid emulsions

5. AKI
Protein:
Hypercatabolism – usually b/c of concomitant issues
Dose - specific for injury or type of dialysis used
BOTH Essential and Non-essential amino acids
Fluids:
May need concentrated nutrition/fluids if low urine output and no other losses (GI)
May require high volume replacement if high output, dilute urine

6. AKI – Electrolytes, TE, MVI
Sodium: Often impaired Na elimination
Potassium, Magnesium, & Phosphorus:
Accumulates until dialysis
Usually restricted or eliminated in TF or TPN until dialysis initiated
Trace elements: No adjustments until dialysis
Vitamins: No adjustments until dialysis

7. 1980’s Historical Perspective
HD patients had EXTREME protein restrictions to postpone HD or minimize uremia
TPN and EN provided only essential AA
Lacks arginine (only conditionally essential)
Thought was: the body can synthesize all the remaining non-essential amino acids
Ammonia elevated & Urea still increased
Resulted in protein malnutrition
Poor wound healing of diabetic wounds

8. Nutrition with HemoDialysis (HD)
Hemodialysis: 2-4 hours, 2-4 times weekly
Calories:
HD itself may slightly increase metabolism
20-30kcal/kg, lower end for obesity and higher end if underweight. May need up to 35kcal/kg if severly malnourished
Glucose calories absorbed from dialysate ( kcal)

9. Nutrition with HemoDialysis (HD)
Protein:
Do NOT restrict protein in AKI to reduce urea accumulation to avoid dialysis (unless temporary)
Nitrogen is lost during HD
Increase protein: 1-1.5g/kg/d
Electrolytes:
K & Mg: can be liberalized once dialysis initiated
Phosphorus: accumulates - restrictions needed & drug binders
Trace elements/Vitamins:
Replace water soluble (B’s and C) due to loss in dialysis.
Do not replace fat soluble Vitamin A & D
Supplement Vitamin D only if deficient

10. Nutrition with Chronic Renal Replacement Therapy (CRRT)
Continuous Dialysis over 24 hours
Calories:
Depends on injuries, disease states, or nutritional status
Often hypermetabolic unless chemically paralyzed or sedated (propofol)
Protein:
Aggressively removes nitrogen
Replace protein with g/kg/day to maintain positive nitrogen for protein synthesis

11. Nutrition with Chronic Renal Replacement Therapy (CRRT)
Continuous Dialysis over 24 hours
Electrolytes:
Often requires K, Mg, and Phos replacements
Vitamins/Trace elements
Selenium supplements
copper and zinc removed by dialysis but not always supplemented.
Do not restrict

12. Chronic Kidney Disease
Pre-dialysis: commondly elevated BUN and Cr
Calories:
Depends on GFR and nutritional status
Hyperglycemia often present
Protein:
Option: Reduction to 0.6g/kg/day
If malnourished or wounds present – increase to 1-1.2g/kg until wound healing begins
Peritoneal dialysis 1.3 g/kg/d
Fat:
Often elevated triglycerides
Carnitine: amino acid needed to transport fatty acids across mitochondria – removed by dialysis
No current guidelines for carnitine supplement

13. Chronic Kidney Disease
Sodium: 1 to 4 g/day – depends on comorbidity
Potassium: restriction is based on serum values
Phosphorus: restricted
stages 1 and 2: (if > 4.6) 8-12 mg/g protein
stages 3-5: 800-1,000 mg/d
Foods with Phos: dark colas, beer, dairy, fish, and beans
Calcium:
stages 1-3: g/d

14. Phosphorus Binders
Avoid these medications 3hr after or 1hr before binding agents
Calcium Carbonate (Tums®) OTC
500mg TID with meals (200mg elemental Ca)
1gram Calcium carbonate binds to 39mg phos
Calcium acetate (PhosLo®) Rx capsule with powder
667mg TID with meals (168mg elemental Ca)
1gram Calcium acetate binds to 45mg phos
Sevelamer Carbonate (Renvela®) Rx VERY Expensive
800mg TID with meals
Lowers LDL cholesterol also
Lanthum Carbonate (FosRenol®) Rx
mg TID with meals, VERY expensive for 90)
Aluminum hydroxide – NOT first line therapy

15. Enteral Products – Renal Failure
Volume concentrated
Electrolytes:
Low in sodium
Potassium varies
RenalCalR - very calorically concentrated, NO electrolytes, very low protein (used as a pre dialysis formula when electrolytes are elevated)
NeproR - low electrolytes, volume concentrated, high protein formula

16. Renalcal® High caloric density (2.0 kcal/ml) Low protein
34.4g/L (7% kcal from protein)
High CHO load (58%)
Contains no Na, K, Ca, Phos, Mg, or Vit K
Indications:
Patients with Acute renal failure requiring a protein restriction (pre-dialysis)
Appropriate for patients with hyperkalemia
Not appropriate for patients receiving dialysis
Does NOT meet 100% of RDIs

17. Dialysis products Novasource ® RENAL Nepro® Low K, Mg, and Phos
Calories: 2.0 kcal/mL (calorie dense)
Protein: 90.7g/L (18% Calories)
Nepro®
Calories:1.8 kcal/mL (calorie dense)
Protein: 84g/L (18% Calories)
Low K, Mg, and Phos
Indications:
Acute and chronic renal failure
Dialysis (IHD)

18. Nutrition in Liver Disease/Cirrhosis
End Stage Liver Disease:
Impaired detoxification of metabolites
Often malnourished pt. – especially protein and vitamins
Typically poor dietary protein intake
Serum Albumin usually low
poor protein intake
poor synthesis

19. Nutrition in Liver Disease/Cirrhosis
High aldosterone & ADH levels
Sodium and Water retained
Potassium wasted
Edema present
low albumin
alkolosis
Weight – varies from underweight malnourished, obese, or edematous weight – be cautious
Serum ammonia can be elevated
Nitrogen from protein
Nitrogen from endogenous amino acid breakdown

20. Hepatic Encephalopathy (HE)- Etiology
Hepatic encephalopathy is a worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood.
Symptoms: Confusion, Altered level of consciousness  coma
Causes: Infections, Sepsis, Spontaneous bacterial peritonitis
Ammonia accumulation  blood brain barrier
Ammonia  glutamine  astrocyte swelling  HE

21. Hepatic Encephalopathy (HE)- Etiology
Aromatic amino acids (AAA)  false neurotransmitters
Branch Chain amino acids - depleted
Increase benzodiazepine receptor expression (GABA)
Exogenous factors – narcotics & sedatives
Zinc deficiency
Constipation
Variceal & GI bleed
Azotemia
Alkolosis

22. Nutrition in Liver Diseases:
Calories:
Hyper-metabolism with acute hepatitis
30-40kcal /kg or HBE x 1.2 if underweight
20-25kcal /IBW kg if obese
Use Ideal body weight if ascites present
50-60% calories from CHO
10-20% calories as fat
CHO:
Poor glycogen reserves and utilization
Often hyperglycemic due to insulin resistance
4-6small meals/day with CHO rich late evening snack

23. Nutrition in Liver Diseases:
Fat:
Elevated triglycerides because of increased lipolysis for primary fuel (75% fuel instead of 35% for healthy liver)
Fat malabsorption – inadequate bile delivery to the duodenum and pancreatic lipase deficiency often accompanies cirrhosis
Essential fatty acid deficiency due to fat malabsorption
Fluids/Electrolytes:
Restricting sodium in diet is critical
Fluid restriction if edema is present
Potassium supplements (caution for spironolactone therapy)
Magnesium supplements (worsen diarrhea)

24. Nutrition in Liver Diseases:
Protein:
g/kg/day (ESPN guidelines)
Protein Calories provide 20-30% total
If Encephalopathic and protein intolerant:
Increase vegetable and diary protein
Low levels of AAA, methionine, ammoniagenic AA
Reduce protein to g/kg until HE resolves
Add branch chain amino acids
***Severe chronic protein restriction in liver disease will result in Protein Calorie Malnutrition ***

25. Liver Disease & Micronutrients
At risk for folate and magnesium deficiency
Thiamine deficiency  Wernicke’s encephalopathy
Vitamin A, D, & E deficiency: Fat malabsorption – due to pancreatic exocrine insufficiency & cholestasis
Zinc deficiency: diuretics, protein restrictions, diarrhea
Zn and Mg deficiency  distorted taste sensation (dysgeusia)
Zinc – supplement 600mg/day – may improve amino acid metabolism and HE grade
Selenium - Supplement 40mcg/day
Manganese & Copper
Elimination via the bile
If cholestasis present - reduce or eliminate from TPN

26. Branch Chain Amino Acids
Essential AA are depleted
Normalization promotes protein synthesis and reduces ammonia concentrations
Aromatic Amino Acids – elevated
BCAA – possibly compete with AAA to cross the BBB
Leucine potent stimulator of HGF (Human Growth Factor) production & hepatic regeneration
Possibly improves protein catabolism in cirrhosis
ESPEN – recommends BCAA for decompensated liver cirrhosis
Unpalatable & Costly
Fail to consistently improve HE

27. Enteral Nutrition Liver Disease
??? efficacy
Low Sodium formulas
Low protein (11% of calories)
Added Branch Chain amino acids
Low aromatic amino acids
Low fat
Medium Chain Triglycerides
Ex. HepaticAid IIR, NutraHepR

28. TPN: Liver Disease HepatAmine 8%
Mixture of essential and nonessential amino acids
High concentrations of the BCAA
Low concentrations of methionine and AAA
The rationale for HepatAmine is based on observations of plasma amino acid imbalances and on theories which postulate that these abnormal patterns are causally related to the development of hepatic encephalopathy.

29. Special Disease States
Chronic Malabsorption
Short bowel syndrome
Radiation enteritis
Enteric fistulas
Inflammatory Bowel Disease

30. Short Bowel Syndrome Short bowel syndrome
Must have 100cm of small bowel
Must have 60cm of small bowel & colon
TPN may need to be used for weeks to months following resection of ischemic or diseased bowel
Enteral nutrition should be initiated as soon as the bowel is healthy enough to feed

31. Short Bowel Syndrome Calories: CHO: 25-30kcal/kg (less if obese)
If the bowel is diseased, it may take 50kcal/kg ingested to absorb 50%
CHO:
AVOID Simple sugars  create a high osmotic load  diarrhea
Fiber  short chain fatty acids in the colon for energy  flatulence

32. Short Bowel Syndrome Fat: Protein
Malabsorption due to low pancreatic enzymes and bile salt malabsorption in the ileum
No dietary fat restrictions if lacking a colon and more ileum (absorption site)
Fat restriction and supplemental complex CHO if colon is present
Supplement Medium Chain Triglycerides
Protein
Single amino acids – saturate absorption
Peptides and Standard Protein - optimal

33. Short Bowel Syndrome Fluids & Electrolytes: Vitamins & Trace elements:
High losses of most all electrolytes, and water (2-4L/day diarrhea)
Supplement Na, K, & Mg (caution: supplements may exacerbate diarrhea)
Unabsorbed fatty acids bind calcium in the GI  Elevated oxylates absorption (because GI calcium unavialable to bind) 
may increase renal oxylate stones
Vitamin D deficiency exacerbates calcium deficiency
Vitamins & Trace elements:
Supplement trace elements in TPN & may need extra zinc
Vitamin B12 injections may be necessary montly
Oral multivitamin with minerals is critical

34. Semi-elemental Formulas
Simple and small carbohydrates
Low residue – no fiber (some EN has fiber)
Small di and tri-peptides (best absorbed)
Low total fat (long chain fatty acids)
Supplemented with medium chain fatty acids
Preferred products for malabsorption or short bowel syndrome, radiation enteritis, or chronic diarrhea
Example: Peptamen® Vital HN ®

35. Peptamen 1.5 1.5 kcal/ml 67.6g/L protein (18% kcal from protein)
1500kcal meets 100% of RDIs
77 % Free Water
Contains no fiber
Semi-Elemental formula – uses:
GI impaired patients with malabsorption
Chylothorax or chylo-acsitis
Transitioning patients from TPN to enteral nutrition
Peptide-based formula with whey protein
MCT oil for easy absorption.
May be consumed orally with flavor packets

36. Short Bowel Syndrome Transitioning from TPN or EN
Small volumes every 2-3 hr with oral rehydration solutions
No sugar sodas
Sodium and potassium often necessary to add to sports drinks
Medications – NO SORBITOL!
Loperamide and lomotil may be life-time requirements
PPI or H2 RA – reduces gastric acid hypersecretion
rhGH and glutamine – enhance bowel adaptation

37. Surgery, Trauma, Burns Hypermetabolic – high calories (25-35kcal/kg)
Hypercatabolic & wound healing: very high protein ( g/kg)
High potassium & phosphorus needs for burns
Supplemented: vitamin C, glutamine, arginine, selenium, branch chain amino acids
Increased zinc for wound healing

38. Immunonutrition/Pharmaconutrition
Supplemented arginine:
Restores T-cell function
Pathway to nitric oxide
Supplemented glutamine:
Enterocytes utilize for fuel
Enhances cellular immune
Supplemented Omega 3 fatty acids
low inflammatory component
Improves postooerative outcomes in GI surgery
Imapact AR® - given TID preop x 5days

39. Immunonutrition/Pharmaconutrition
Impact ® Peptide 1.5
Calories: 1.5 kcal/mL
Protein: 94g/L (25% Calories)
L-arginine    18.7 g/L
L-glutamine   8.1 g/L
Nucleotides  1.8 g/L
Fats: MCT:LCT Ratio: 50:50  (n6:n3 Ratio:  1.4:1) EPA + DHA 4.9 g/L
Pivot 1.5®
Calories: 1.5 kcal/ml
Protein: 94g/L protein (25% calories)
Arginine (13 gm/L)
Glutamine (6.5 gm/L)
Omega-3 fatty acids

40. Juven® Supplements enteral feeds or PO diet
Arginine (7gm) and Glutamine (7gm)
Orange and Fruit juice flavors
Not a complete protein supplement
To drink or administer via FT
Used to promote wound healing.
Appropriate for trauma, burns, and skin breakdown
Helps build and maintain lean body mass

41. Chronic Obstructive Pulmonary Disease (COPD)
Emphysema/COPD - the walls between the air sacs are damaged and destroyed leading to fewer and larger air sacs instead of many tiny ones
Reduced gas exchange & Accumulation of CO2
CHO – metabolized primarily to CO2
Low CHO diet– to decrease CO2 accumulation
Calories – HBE x 1.3 or 25kcal/kg unless obese
Challenge to increase calories without excessive CHO
Overfeeding  increased CHO  CO2

42. Chronic Obstructive Pulmonary Disease (COPD)
Fat  least amount of CO2
Enteral products with Low CHO
Remaining calories - high fat
Example: Pulmocare® % fat
???? Efficacy, Massive diarrhea
Protein – dosed for nutritional status
Ventilator Dependant Bedridden
Decrease calories but maintain high protein diet

43. Acute Respiratory Distress Syndrome
ARDS:
Poor oxygenation
Life threatening
Severe inflammatory process
Calories & Protein
Likely extremely hypermetabolic & hypercatabolic unless pharmacologic paralysis or sedation
25-30kcal/kg
1.5g/kg/day protein

44. Acute Respiratory Distress Syndrome
Theory:
Decrease or eliminate pro-inflammatory precursors: ie. Omega 6 Fatty acids
Supplement Omega 3 fatty acids
Recent Study showed increase mortality with Oxepa compared to TwoCal HN, ?? Study design and propofol used for sedation
Example: Oxepa®

45. Oxepa® Moderate kcal (1.5 kcal/ml) Moderate protein
62.7g/L (16.7% kcal from protein)
Contains a unique fat blend of high Omega-3 fatty acids to modulate the inflammatory response. Low Omega-6 fatty acids
ONLY Indication:
ventilated patients with ARDS (possibly SIRS and Sepsis)
1420kcal meets 100% of RDIs
Contains no fiber
79% Free Water

46. Diabetes Carbohydrate Consistent diets
Less total CHO and simple sugars
More complex carbohydrates & fiber
Supplement or Substitute meal???
Avoid excess calories and excess total carbohydrates for overweight patients!
Ex. Glucerna® – 22% protein (high), 45% fat, complex CHO

47. Glucerna 1.5 ® Calorically dense (1.5 Cal/mL)
High protein 82.5g/L protein (22% of calories)
Prebiotics - scFOS® (2.4 g/8 fl oz)
omega-3 fatty acids from canola oil (3 g of ALA per 1500 Cal), AHA recommendations
Beneficial for diabetics or hyperglycemia in ICU patients requiring high protein doses

48. TPN Case  TF
CD is a 35yo male, 5'10", 80kg admitted to UKMC for severe dehydration.
CD has excessive drainage from a duodenal fistula resultant from a gun shot wound to the abdomen he received 3 months ago.
Transitioning from TPN to Enteral Nutrition
Which formula type is optimal?
What rate will meet his needs?
Needs: Kcal/day, 112g/d - 128g/d

49. TPN Case  TF Transitioning from TPN to Enteral Nutrition
Which formula type is optimal?
A semi-elemental product is likely to be best tolerated after 3 months of bowel rest
Ex. Peptamen 1.5
60ml/hr provides 2160kcal & 97g/day protein
Add 2 beneprotein daily (12g/day & 50kcal)
Or 2 Juven daily (28g or glutamine & Arginine)

50. Case #2
AJ is a 20yo, 86kg, 75” multi-fracture trauma patient in the ICU and requires:
kcal/d
g/d of protein
Which of the given example enteral products and rate will best meet his needs?

51. Enteral Products Product Kcal/ml Prot (g)/L Fibersource HN® 1.2 54
Peptamen 1.5 ®
Glucerna 1.5®
Pivot ®
Nutren 2.0®

52. Case #2 Protein: 120-150g/d Calories: 2150-2550 kcal/d
Rate Total Protein
Product (ml/hr) (Kcal/d) (Gm/d)
Fibersource HN ®
Glucerna 1.5®
PivotR
Nutren 2.0®

53. Case
What if AJ, a 20yo, 86kg, 75” has 25% full-thickness burns in addition to his trauma injuries?
Increase calories to (30-35kcal/kg) kcal
Increase Protein to 2-2.5g/kg ( g)
Increase Pivot to 80ml/hr
2880kcal & 180g/day protein
Add 2 Juven packets daily (14g glutamine & 14g arginine) for additional wound healing