Transcript Nutrition in Dialysis - Pediatric Continuous Renal Replacement

Nutrition in PCRRT
Norma J Maxvold
Pediatric Critical Care
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Nutrition in Acute Renal Failure
 ARF = altered metabolic state
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Increase catabolic state
Altered amino acid metabolism
Altered protein metabolism
High urea nitrogen appearance (production
and elimination)
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Nutrition in PCRRT
 PCRRT allows solute clearance
• uremic solutes
• small molecular sized nutrients (eg
oligosaccharides)
• amino acids and small peptides
• electrolytes
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Is malnutrition an independent
predictor of survival in ARF?
 Energy Balance studies
• Cumulative energy deficits associated with
increase mortality
– Bartlett et al, Surgery 1986
• 48% mortality in malnourished
• 29% mortality in non malnourished
– Fiaccudori et al, J Am Soc Neph 1996
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Nutritional Factors in ARF
 Increase in protein catabolism
• underlying and cause of ARF
– cytokine effects
• uremia
– increase in gluconeogenesis and protein
degradation
• hormonal
– Insulin resistance, diminished protein synthesis
• metabolic acidosis
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Nutritional Factors in ARF
 Dialysis losses
• protein losses in PD
• amino acid losses in PCRRT
 Diminished nutrient utilization
 Inadequate supplementation
• failure to measure needs
• side effects of nutrition supplementation
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Dialysis Losses
 Peritoneal Dialysis
• albumin, protein, immunoglobulin and amino
acid losses
– Katz et al,
 PCRRT
• small peptide and amino acid
– Mokrzycki and Kaplan, J Am Soc Neph 1996
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Protein losses on CRRT
 Range of amino acid and protein losses
• 7-50 gms/day
 Factors effecting amino acid/protein
losses
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hemofilter size (surface area) and composition
nature of solute (molecular size)
total ultrafiltration
plasma concentration of amino acids/protein
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Protein losses on CRRT
Mokrzycki and Kaplan, J Am Soc Neph 1996
 CVVH and CVVHDF
 Polysulfone membranes
• (Amicon 20 and Fresenius F-80)
 BFR 100-300 mls/min
 Dx FR 1000 mls/hr with net u/f/hr 1600 mls
 1.2 - 7.5 gms/day of protein losses
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Protein losses on CRRT
Davies et al, Crit Care Med, 1991
 CAVHD
 AN-69 (0.43 m2; PAN membrane)
 BFR MAP dependent (80 mls/min)
 Dx FR 1 and 2 liter/hr; net u/f/hr 340 mls
 AA losses at 1 liter Dx:
9% of total intake
 AA losses at 2 liter Dx:12% of total intake
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Protein losses on CRRT
Davenport et al, Crit Care Med 1989
 CVVH
 Polyamide FH 55 (Gambro)
 BFR
140 mls/min
 Net u/f/hr 1000 mls
 Amino Acid losses/day by diagnosis
• Cardiogenic shock- 7.4 gms
• Sepsis-3.8 gms
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Nutritional losses
Replacement fluid vs dialysate
Maxvold et al, Crit Care Med April 2000
 Prospective crossover study to evaluate
nutritional losses of CVVH vs CVVHD
 Study design
• Fixed blood flow rate-4 mls/kg/min
• HF-400 (0.3 m2 polysulfone)
• Cross over for 24 hrs each to
FRF or Dx flow at 2000 mls/hr/1.73 m2
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Nutritional losses
Replacement fluid vs dialysate
Maxvold et al, Crit Care Med April 2000
 Indirect calorimetry to measure REE
 TPN source of nutrition @ 120% of REE
• 70% dextrose
• 30% lipids
• Insulin to maintain euglycemia when needed
 10% Aminosyn II
• 1.5 gms/kg/day of protein
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Comparison of Total Amino Acid
losses: CVVH vs CVVHD
(Maxvold et al, Crit Care Med April 2000)
Amino Acid Losses
(g/day/1.73 m2)
16
12.4
11.6
14
12
10
NS
8
6
4
2
0
CVVH
CVVHD
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Nutritional losses
Replacement fluid vs dialysate
Maxvold et al, Crit Care Med April 2000
 Amino acid and protein losses with this
prescription represent between 10-12% of
total delivered nutritional proteins
 Glutamine loss accounted for
approximately 20% of total AA loss
 Some Amino Acid preparations for TPN are
deficient in glutamine
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24 Hr Nitrogen Balance:
CVVH vs CVVHD
(Maxvold et al, Crit Care Med April 2000)
24 hr Nitrogen Balance
(g/day/1.73 m2)
4
-0.44
-3.68
2
0
NS
-2
-4
-6
-8
-10
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Conclusion
 Amino Acid and total protein losses in
PCRRT may represent 10-12% of intake
 At 1.5 gms/kg/day nitrogen balance was
not reached
 Glutamine losses may potentiate nitrogen
imbalance
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