1. Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University

2. Objectives:  Overview Nutritional Needs in Children with AKI  Effect of renal support on Nutrition  Diagram of Nutrition Prescription during AKI

3. CATABOLIC, HYPERMETABOLIC STATE Malnutrition Acute Illness: Stress Response  Cytokines, Hormonal changes, Altered Substrate Utilization AKI Acidosis, Uremia, Impaired AA Conversion,  Lipid Oxidation Malnutrition

4. Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus and Jaksic (2002)  Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure  Pediatric patients may not exhibit significant hypermetabolism post-injury?

5.  Substrate Utilization/Nutrient Composition 75%CHO:15% AA: 10% Lipid 15%CHO: 15%AA: 70% Lipid C 13 Glucose, C 13 Acetate Maximum Glu Oxidation 4mg/kg/min Lipogenesis from Excess Glucose Metabolism Gluconeogenesis and Protein Catabolism was not effected [Tappy et al. Crit Care Med 1998;26:860-867]

6. AveEnergy Intake REE Coss-Bu ( Am J Clin Nutr 2001) 0.23 MJ/kg/d >25% Verhoeven (Int Care Med 1998) 0.24 MJ/kg/d >14% Joosten (Nutrition 1999) 0.26 MJ/kg/d >20%

7. Briassoulis et al. (2000)

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

9. Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J Clin Nutr 2001;74:664 Normal Metabolic : Hypermetabolic mREE 0.16 mREE 0.28 Fat Oxidation -22mg/min Fat Oxidation 27mg/min np RQ 1.21 npRQ 0.86 Energy Intake: 0.25MJ/kg/d [55kcal/kg/d] CHO: 10 g/kg/d ; Fat: 1.4g/kg/d; Protein:2.1g/kg/d

10. No Growth occurs during Acute Illness Focus : Prevent Malnutrition Children at Risk: High basal rate of metabolism Limited reserves Baseline poor nutrition + Uremia and acidosis Altered renal Amino Acid metabolism, lipid metabolism, Fluid and Solute Clearance, +  Losses for Renal Replacement Therapy

11. UNA / PCR in Acute Kidney Injury Adult Studies: Protein Catabolic Rate ~ 1.4 - 1.7 g/kg/d [Macias WL, et al. JPEN 1996;20:56-62] [Chima CS, et al. JASN 1993; 3:1516-1521] Pediatric Studies: Urea Nitrogen Appearance UNA ~ 185- 290mg/kg/d ( PCR 1.1- 1.8 g/kg/d) [ Kuttnig M, et al. Child Nephrol Urol 1991;11:74-78] [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]

12. CALORIC SUPPORT:PROTEIN SUPPORT: Adult: npkcal 25kcal/kg/d CHO 5 g/kg/d Fat 0.8-1.2g/kg/d Pediatric: Npkcal 40-65kcal/kg/d Adult: Protein 1.5-2.0 g/kg/d Pediatric: Protein 2.0-3.0 g/kg/d ( Cano N et al Clin Nutr 2006 and 2008)

13. Can Nitrogen Balance be Achieved in AKI patients on CRRT? Conflicting Studies Bellomo et al Ren Fail 1997 Protein Intake : Nitrogen Balance 1.2 g/kg/d AA -5.5 g N /d 2.5 g/kg/d AA -1.9 g N /d

14. 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. 2. Nutrition, 2003 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 hospital stay Protein intake 2.5 g/kg/d: improved survival! Potential for losses during CRRT

16. [Ziegler et al, Ann Intern Med 1992;116:821] 45 BMT patients with Parenteral Glutamine (L-Gln) Supplemention : 0.57g/kg/d Gln &2.07g/kg/d AA Intake Improved Nitrogen Balance: -1.4g/d vs -4.2g/d  Clinical infections: 3/24 vs 9/21  Hospital stay: 29 days vs 36 days [ Schloerb et al; JPEN 1993; 17:407-413]  Hospital stay: 26 days vs 32 days  Total Body Water: -1.2 L vs 2.2 L (Bioimpedance)

17. Lipid Metabolism  Fatty Acid Utilization during acute illness Mitochondrial adaptation to acute stress (Carnitine dependent enzymes) Calvani et al Basic Res Cardiol 2000 Mitochondrial control of FFA oxidation and CHO oxidation AcetylCoA/ CoA ratio on PDH Complex

18. Advantages:  Lower Linoleic concentration  MCT rapidly cleared from plasma  Olive oil less prone to peroxidation  Fish oil beneficial anti-inflammatory Early Studies : Good Safety profile Clin Nutr 2013;32:224 JPEN 2012; 36:81S

19. Water Soluble Vitamins Vit B 1 Def Altered Energy Metabolism,  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

20. Nutritional parameter Nutrition modality Energy Protein Vitamins Trace elements Monitoring Consider - Early enteral feeding, may require parenteral nutrition suppl 35 to 60 kcal/kg/day (0.15-0.27 MJ/kg/day) 20 to 25% as carbohydrates (insulin as needed), 4-5 mg/kg/min Glucose support (Insulin as needed for Hyperglycemia) 2 to 3 g/kg/day with AKI (Increase intake if on High flow CRRT (by 20%) Daily recommended intake (± replacement ) Monitor serum folate, water soluble vitamin levels Daily Recommended Intake MEE, Nitrogen Balance, Electrolytes, Vitamins, Trace elements Glutamine, Carnitine Supplement