1. Nutrition in CRRT Do the losses exceed the delivery?
Timothy E. Bunchman

2. Nutrition in MOSF
What are the needs of the patient due to presence of MOSF?
Protein
Carbohydrate
Lipids
What are the losses of the patient due to the therapy of CRRT?

3. Protein & Amino Acid Metabolism
Clinically seen as
Hyper catabolic
E.g. Rapidly rising BUN
Over time loss of lean body mass

4. Protein & Amino Acid Metabolism
Mechanisms
Increase in muscle catabolism
Decrease in muscle protein synthesis
Increase in hepatic
gluconeogenesis
Ureagenesis
Protein synthesis
Altered AA transport (cellular)
Decrease in renal peptide catabolism

5. Protein & Amino Acid Metabolism
Potential causes
Insulin resistance
Metabolic acidosis
Inflammation
Catabolic hormones
Growth hormone/factor resistance
Substrate deficiencies
Malnutrition prior to illness
Loss on dialysis

6. Carbohydrate metabolism
Clinical findings
hyperglycemia

7. Carbohydrate metabolism
Mechanisms
Insulin resistance
Increase in hepatic gluconeogenesis

8. Carbohydrate metabolism
Potential causes
Stress hormones
Inflammatory mediators with increase in cytokine (e.g. TNF) expression
Metabolic acidosis
Pre-existing hyperparathyroidism

9. Lipid Metabolism
Clinical findings
Hypertriglyceridemia

10. Lipid Metabolism Mechanisms Inhibition in lipolysis
Increase in hepatic triglyceride secretion

11. Lipid Metabolism Potential causes
Unknown inhibitor to lipoprotein lipase
Inflammatory mediators

12. Nutrition in PCRRT CRRT allows solute clearance uremic solutes
small molecular sized nutrients (eg oligosaccharides)
amino acids and small peptides
electrolytes

13. 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

14. 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

15. 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

16. Dialysis Losses Peritoneal Dialysis
albumin, protein, immunoglobulin and amino acid losses
Katz et al, J Peds

17. IgG levels in Infants (Katz et al, J Peds 117:258-261, 1990)
Albumin
Loss
(mg/kg)
(mg/1.73m2)

18. IgG levels in Infants (Katz et al, J Peds 117:258-261, 1990)

19. Dialysis Losses CRRT small peptide and amino acid
Mokrzycki and Kaplan, J Am Soc Neph 1996

20. Protein losses on CRRT Range of amino acid and protein losses
7-50 gms/day
Factors effecting AA/protein losses
hemofilter size (surface area) and composition
nature of solute (molecular size)
total ultrafiltration
plasma concentration of amino acids/protein

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

22. 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 1 l/hr; net u/f/hr 340 mls
AA losses at 1 liter Dx: 9% of total intake
Dx 2 l/hr; net u/f/hr 340 mls
AA losses at 2 liter Dx:12% of total intake

23. 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

24. Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5
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 pre filter replacement or Dx at 2000 mls/hr/1.73 m2

25. Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5
Indirect calorimetry to measure REE
TPN source of 120% of REE
70% dextrose
30% lipids
Insulin to maintain euglycemia when needed
10% Aminosyn II
1.5 gms/kg/day of protein

26. Comparison of Total Amino Acid losses: CVVH vs CVVHD (Maxvold et al, Crit Care Med 2000 Apr;28(4): ) NS
Amino Acid Losses
(g/day/1.73 m2)

27. Nutritional losses Replacement fluid vs dialysate Maxvold et al, Crit Care Med 2000;28(4):1161-5
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

28. 24 Hr Nitrogen Balance: CVVH vs CVVHD (Maxvold et al, Crit Care Med 2000 ;28(4):1161-5 )NS
24 hr Nitrogen Balance
(g/day/1.73 m2)

29. ? Glucose loss in the Dialysate
90 kg BMT tx pt with MOSF
Begun on CVVD at 2.5 liters of Normocarb
Due to acidosis 2 liters of Normocarb added as a prefilter replacement fluid therefore the child is now on CVVHDF
Normocarb is glucose free
What is the caloric impact of this?

30. ? Calorie deficient due to no glucose in the Dialysate-2
Ultrafiltrate glucose is measured at 109 mg/dl
4.5 liters/hr x 24 hrs = 108 liters uf/day
109 mg/dl = 1090 mg/l = 1.09 gms/l
1.09 gms/l x 108 liters = 117 gms of glucose lost
117 gms x 4 cals/gm = 470 cals lost

31. Is this significant? IVFs are TPN giving 2500 cals/day
5 IVFs for meds, drips, etc all in D5 with a total rate of 200 ccs/hr
200 ccs/hr x 24 hrs = 4800 ccs of D5
D5 has 5 gms/100ccs or 50 gms/1000
50 gms x 4.8 liters = 24 gms
24 gms x 4 cal = 96 cals (cals not thought of)

32. Intensive Insulin therapy (Van den Berghe et al NEJM 345:1359-67, 2001)
Patients
557
544
Glucose target level
mg/dl
mg/dl

33. Intensive Insulin therapy (Van den Berghe et al NEJM 345:1359-67, 2001)

34. Intensive Insulin therapy (Van den Berghe et al NEJM 345:1359-67, 2001)

35. Intensive Insulin therapy (Van den Berghe et al NEJM 345:1359-67, 2001)

36. Trace elements and Vitamins
Trace elements are poorly cleared due to protein binding
Water soluble vitamins are well cleared and the child is at risk for deficiency

37. Trace elements and Vitamins
Vitamin A may be retained and cause toxicity manifested as hypercalemia
Vitamin K is not cleared but in patients with MOSF on antibiotics will become deficient and will need supplementation
Vitamin D may be depressed if pt had pre existing renal insufficiency
Vitamin E levels are depressed in MOSF but are not cleared

38. So what do we do? 1. Keep glucose under control
Use insulin freely (yes some of the insulin is cleared ?? How much?)
If using ACD-A citrate the D stands for Dextrose
(I missed that but I was educated by a NICU nurse)

39. So what do we do?
2. Keep lipids as part of the formulation but be aware that both glucose and lipids effect triglycerides

40. So what do we do?
3. Protein load as an amino acid needs to be targeted
Local standard is to target to a BUN of mg/dl
Some NICU babies on the current M-60 AN-69 membrane of the PRISMA require 7-9 gms/kg/day to reach a target of BUN to 30 mg/dl

41. Urea Levels: HD vs. HF Mehta et al, Kid Int, 2001, 60:1154-1163

42. So what do we do? 4. Use the gut whenever possible
Benefit of immune function of enteral formulas
Decreases risk of TPN line induced sepsis
Bacterial
fungal

43. A Study to do
Serial nitrogen balance, REE, glucose metabolism studies throughout the course of the child’s illness
Impact upon balance of catabolism to anabolism as one increases the protein/AA exposure