1. maxvold Nutrition in PCRRT Norma J Maxvold Pediatric Critical Care

2. maxvold Nutrition in Acute Renal Failure b ARF = altered metabolic state Increase catabolic stateIncrease catabolic state Altered amino acid metabolismAltered amino acid metabolism Altered protein metabolismAltered protein metabolism High urea nitrogen appearance (production and elimination)High urea nitrogen appearance (production and elimination)

3. maxvold Nutrition in PCRRT b PCRRT allows solute clearance uremic solutesuremic solutes small molecular sized nutrients (eg oligosaccharides)small molecular sized nutrients (eg oligosaccharides) amino acids and small peptidesamino acids and small peptides electrolyteselectrolytes

4. maxvold b Energy Balance studies Cumulative energy deficits associated with increase mortalityCumulative energy deficits associated with increase mortality –Bartlett et al, Surgery 1986 48% mortality in malnourished48% mortality in malnourished 29% mortality in non malnourished29% mortality in non malnourished –Fiaccudori et al, J Am Soc Neph 1996 Is malnutrition an independent predictor of survival in ARF?

5. maxvold Nutritional Factors in ARF b Increase in protein catabolism underlying and cause of ARFunderlying and cause of ARF –cytokine effects uremiauremia –increase in gluconeogenesis and protein degradation hormonalhormonal –Insulin resistance, diminished protein synthesis metabolic acidosismetabolic acidosis

6. maxvold Nutritional Factors in ARF b Dialysis losses protein losses in PDprotein losses in PD amino acid losses in PCRRTamino acid losses in PCRRT b Diminished nutrient utilization b Inadequate supplementation failure to measure needsfailure to measure needs side effects of nutrition supplementationside effects of nutrition supplementation

7. maxvold Dialysis Losses b Peritoneal Dialysis albumin, protein, immunoglobulin and amino acid lossesalbumin, protein, immunoglobulin and amino acid losses –Katz et al, b PCRRT small peptide and amino acidsmall peptide and amino acid –Mokrzycki and Kaplan, J Am Soc Neph 1996

8. maxvold Protein losses on CRRT b Range of amino acid and protein losses 7-50 gms/day7-50 gms/day b Factors effecting amino acid/protein losses hemofilter size (surface area) and compositionhemofilter size (surface area) and composition nature of solute (molecular size)nature of solute (molecular size) total ultrafiltrationtotal ultrafiltration plasma concentration of amino acids/proteinplasma concentration of amino acids/protein

9. maxvold b CVVH and CVVHDF b Polysulfone membranes (Amicon 20 and Fresenius F-80)(Amicon 20 and Fresenius F-80) b BFR 100-300 mls/min b Dx FR 1000 mls/hr with net u/f/hr 1600 mls b 1.2 - 7.5 gms/day of protein losses Protein losses on CRRT Mokrzycki and Kaplan, J Am Soc Neph 1996

10. maxvold b CAVHD b AN-69 (0.43 m2; PAN membrane) b BFR MAP dependent (80 mls/min) b Dx FR 1 and 2 liter/hr; net u/f/hr 340 mls b AA losses at 1 liter Dx: 9% of total intake b AA losses at 2 liter Dx:12% of total intake Protein losses on CRRT Davies et al, Crit Care Med, 1991

11. maxvold b CVVH b Polyamide FH 55 (Gambro) b BFR 140 mls/min b Net u/f/hr 1000 mls b Amino Acid losses/day by diagnosis Cardiogenic shock- 7.4 gmsCardiogenic shock- 7.4 gms Sepsis-3.8 gmsSepsis-3.8 gms Protein losses on CRRT Davenport et al, Crit Care Med 1989

12. maxvold b Prospective crossover study to evaluate nutritional losses of CVVH vs CVVHD b Study design Fixed blood flow rate-4 mls/kg/minFixed blood flow rate-4 mls/kg/min HF-400 (0.3 m2 polysulfone)HF-400 (0.3 m2 polysulfone) Cross over for 24 hrs each to FRF or Dx flow at 2000 mls/hr/1.73 m2Cross over for 24 hrs each to FRF or Dx flow at 2000 mls/hr/1.73 m2 Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med April 2000

13. maxvold b Indirect calorimetry to measure REE b TPN source of nutrition @ 120% of REE 70% dextrose70% dextrose 30% lipids30% lipids Insulin to maintain euglycemia when neededInsulin to maintain euglycemia when needed b 10% Aminosyn II 1.5 gms/kg/day of protein1.5 gms/kg/day of protein Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med April 2000

14. maxvold 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) NS

15. maxvold b Amino acid and protein losses with this prescription represent between 10-12% of total delivered nutritional proteins b Glutamine loss accounted for approximately 20% of total AA loss b Some Amino Acid preparations for TPN are deficient in glutamine Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med April 2000

16. maxvold 24 Hr Nitrogen Balance: CVVH vs CVVHD (Maxvold et al, Crit Care Med April 2000) 24 hr Nitrogen Balance (g/day/1.73 m2) NS

17. maxvold Conclusion b Amino Acid and total protein losses in PCRRT may represent 10-12% of intake b At 1.5 gms/kg/day nitrogen balance was not reached b Glutamine losses may potentiate nitrogen imbalance