Nutrition during pediatric CRRT

1. Nutrition during pediatric CRRT Matthew L. Paden, MD Associate Professor of Pediatric Critical Care Director, Pediatric ECMO

2. Disclosures • I’m a pediatric intensivist, talking about renal disease and nutrition….

3. What do we know about it?

4. What do we know about it?

8. Disclosures • I’m a pediatric intensivist, talking about renal disease and nutrition…. • I don’t know how to optimally feed a critically ill child, whether on CRRT or not. • Neither does anyone else.

9. Recent review of the topic

10. What do we know? • Critical illness and AKI alter normal metabolic pathways • Increased gluconeogenesis • Decreased glycolysis • Increased amino acid oxidation • Increased protein breakdown • Decreased protein synthesis • Impaired lipolysis

11. Acute and Chronic malnutrition are common • Pre-existing malnutrition is under-recognized • Castillo et al (doi:10.1186/1471-2369-13-125) • 174 pediatric CRRT patients • 35% were less than the 3rd percentile for weight • 51% mortality vs. 33% mortality if >3rd percentile • High risk of protein debt in the first 5 days in the PICU

12. Total energy needs • For critically ill children with AKI • “20-30% above basal needs” • “35-65 kcal/kg/day” • REE via metabolic cart or equations • Equations can both under and over estimate REE • Kyle, et al. – only getting ~2/3 of daily calories • Zappitelli, et al – REE of ~150% was common • Daily weights • Ben-Hamouda et al – “The patient’s initial weight was 74 kg, and despite feeding to targets validated by repeated indirect calorimetry, the patient lost 18 kg by day 60.”

13. Carbohydrates – How to measure/monitor it? • Glucose monitoring • Unclear how often, role of insulin, degree of glucose control

14. Carbohydrates – How much to prescribe? • 20-25% of total energy needs • Maximum glucose oxidation rate is ~5 mg/kg/min (Tappy et al, Crit Care Med 1998) • Remember to account for replacement fluid and ACD as potential sources of carbohydrate • New, et al (doi:10.3945/ajcn.116.139014) – measured in adults this was responsible for ~512 kcal/day • No clear recommendations about amount of glucose in replacement or dialysate fluids

15. Carbohydrates – Outcomes? • Risk vs. benefit • Further adult studies showed no benefit of strict glycemic control in a medical ICU • Higher hypoglycemia rate in children with strict control • Effects of additional CO2 generation on mechanical ventilation

16. Protein – How to measure/monitor it? • Total urinary nitrogen • Measurement is laborious • Urinary urea nitrogen (UUN) • 80-90% total nitrogen in non-stressed patients • Not valid for AKI, sepsis, liver failure • Urea nitrogen appearance (UNA) • Normalized protein catabolism rate (nPCR) • Fluctuation with metabolically unstable patients • Some pediatric data estimating 1-2 g/kg/day • Nitrogen balance

17. Amino Acid in AKI on CRRT Review

18. Protein - How much to prescribe? • Protein turnover is highest in youngest infants • Net nitrogen balance is commonly negative in critical illness and AKI • ASPEN Recommendations

19. Protein - How much to prescribe? • Not validated for AKI or CRRT • Total protein to make up 40-50% of energy provided • Additional ~10-20% increase in amino acids due to CRRT losses (Maxvold et al 2000 and Zappitelli et al 2009) • ? Role for additional glutamine is unclear • Usually this ends up being 2-3 g/kg/day

20. Protein – Outcomes? • RENAL study – (Adults) • Dietary protein intake is not associated with mortality • Kritmetapak et al – (Adults) • Dietary protein intake and albumin associated with mortality (AUC 0.78, OR 4.62) • Scheinkestel, et al – (Adults) • Positive nitrogen balance, but not protein intake, is associated with mortality • Castillo et al – (Kids) • Protein energy wasting malnutrition associated with mortality (OR 2.11, CI 1.067-4.173) • Often protein is restricted – PPCRRT data • Prior to CRRT - ~1 gram/kg/day • CRRT – increased to 1.3-2 grams/kg/day

21. Trace Elements – How to measure/monitor it? • Serial monitoring of levels is important • Cost?

22. Trace Elements - How much to prescribe? • Little published data in adults

23. Trace Elements - How much to prescribe? • Little published data for kids • Pasko, et al – 5 kids on CRRT – “The daily supplemented trace elements that were removed by CVVHDF never exceeded 20%, and, in most cases, they were less than 5% of the corresponding parenteral trace element supplementation.” • Zappitelli, et al – 15 kids on CVVHD – • Seleniumand folate decreased • Copper, chromium, zinc, manganese increased or unchanged

24. Trace Elements - How much to prescribe? • Little published data for kids • Pasko, et al – 5 kids on CRRT – “The daily supplemented trace elements that were removed by CVVHDF never exceeded 20%, and, in most cases, they were less than 5% of the corresponding parenteral trace element supplementation.” • Start with standard trace element preparation • Extra ~100 mcg/day of selenium (adult data) • Guided by levels for individual patients • Consider additional folate for “long term” CRRT

25. Vitamin C

26. Vitamin C

27. Trace Elements – Outcomes? • Success treating known deficiencies that are symptomatic. • The outcome of monitoring and treatment of trace elements remains unknown at this point.

28. Other…. • Fat • 30-40% of energy needs • Risk of essential fatty acid deficiency • Omega-3, fish oil, etc. – unclear role currently • Carnitine • Sgambat, et al (doi:10.1111/hdi.12341) – (42 CRRT Kids) • Baseline ~1/3rd are carnitine deficient • 1 week of CRRT - ~2/3rds are deficient • 2 weeks of CRRT - ~90% deficient • OR of ~5 for mortality if deficient • Ben-Hamouda, et al (doi:10.1016/j.nut.2016.09.012) • Cardiomyopathy and skeletal breakdown from severe deficiency

29. Summary