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: / )
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: /ajcn ) – 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
Age (years)
Protein (g/kg/day)
0-2
2-3
2-13
1.5-2
13-18
1.5

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 )
Often protein is restricted – PPCRRT data
Prior to CRRT - ~1 gram/kg/day
CRRT – increased to grams/kg/day

21. Trace Elements – How to measure/monitor it?
Serial monitoring of levels is important
Cost?
Test
2016 CHOA Charge
Copper
$45.33
Folate
$39.54
Selenium
$5.09
Zinc
$7.79
Manganese
$5.79
Chromium
$7.27
Vitamin C
$10.98
CRRT/day
~$950

22. Trace Elements - How much to prescribe?
Little published data in adults
Citation
Increased
No Change
Decreased
Berger et al (PMID )
Zinc
Selenium / Copper
Thiamine
Fernman-Ekholm (doi: /
Vitamin B12
Folate
Klein, et al (JPEN 26:77-93)
Kritmetapak, et al (doi: /journal.pone )
Zinc / Copper
Selenium
Kamel, et al (doi: / )
Thiamine / Pyridoxine
Vitamin C / Folate
Ben-Hamouda, et al (doi: /j.nut )
Copper / Selenium

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 –
Selenium and 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 Carnitine 30-40% of energy needs
Risk of essential fatty acid deficiency
Omega-3, fish oil, etc. – unclear role currently
Carnitine
Sgambat, et al (doi: /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: /j.nut )
Cardiomyopathy and skeletal breakdown from severe deficiency

29. Summary