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Nutrition in AKI

Nutrition in AKI. Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University. Nutrition In AKI. Objectives: Overview Nutritional Needs in Children with AKI

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Nutrition in AKI

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

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

  3. Nutrition in AKI CATABOLIC, HYPERMETABOLIC STATE Malnutrition AKI Acidosis, Uremia, Impaired AA Conversion, iLipid Oxidation Acute Illness: Stress Response hCytokines, Hormonal changes, Altered Substrate Utilization Malnutrition

  4. Energy Expenditure • 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? 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)

  5. Substrate Utilization/Nutrient Composition 75%CHO:15% AA: 10% Lipid 15%CHO: 15%AA: 70% Lipid C13 Glucose, C13 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. Hypermetabolism in Children with Critical Illness 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. Comparison of MEE vs. cREE Briassoulis et al. (2000)

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

  9. Nutrition in AKI Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J ClinNutr2001;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. Nutrition in AKI 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, + hLosses for Renal Replacement Therapy

  11. Protein Turnover in Renal Disease 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 NephrolUrol 1991;11:74-78] [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]

  12. Nutrition in AKI 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 ClinNutr 2006 and 2008)

  13. Nutrition and PCRRT 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. Does increasing protein intake help? • 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

  15. Glutamine Supplementation [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 i 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)

  16. Nutrition and PCRRT 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

  17. SMOFlipid IV Emulsion 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 ClinNutr 2013;32:224 JPEN 2012; 36:81S

  18. Potential for losses during CRRT Water Soluble Vitamins • Vit B1 Def Altered Energy Metabolism, h Lactic Acid, Tubular damage • Vit B6Def Altered Amino acid and lipid metabolism • FolateDef Anemia • Vit C Def Limit 200 mg/d as precursor to Oxalic acid

  19. Nutrition in Children with AKI

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