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Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University
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Objectives: Overview Nutritional Needs in Children with AKI Effect of renal support on Nutrition Diagram of Nutrition Prescription during AKI
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CATABOLIC, HYPERMETABOLIC STATE Malnutrition Acute Illness: Stress Response Cytokines, Hormonal changes, Altered Substrate Utilization AKI Acidosis, Uremia, Impaired AA Conversion, Lipid Oxidation Malnutrition
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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) 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?
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Substrate Utilization/Nutrient Composition 75%CHO:15% AA: 10% Lipid 15%CHO: 15%AA: 70% Lipid C 13 Glucose, C 13 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]
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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%
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Briassoulis et al. (2000)
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IC: measure resting energy expenditure. Based on: Expired CO2 and O2 (O2 consumption + CO2 production). Potential problem with CRRT Hemofilter Dialysis fluid Effluent HCO3/CO2 fluxes May affect IC measurements. IC may not be reliable?
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Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J Clin Nutr 2001;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
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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, + Losses for Renal Replacement Therapy
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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 Nephrol Urol 1991;11:74-78] [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]
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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 Clin Nutr 2006 and 2008)
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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
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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
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[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 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)
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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
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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 Clin Nutr 2013;32:224 JPEN 2012; 36:81S
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Water Soluble Vitamins Vit B 1 Def Altered Energy Metabolism, Lactic Acid, Tubular damage Vit B 6 Def Altered Amino acid and lipid metabolism metabolism Folate Def Anemia Folate Def Anemia Vit C Def Limit 200 mg/d as precursor to Oxalic acid Oxalic acid
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Nutritional parameter Nutrition modality Energy Protein Vitamins Trace elements Monitoring Consider - Early enteral feeding, may require parenteral nutrition suppl 35 to 60 kcal/kg/day (0.15-0.27 MJ/kg/day) 20 to 25% as carbohydrates (insulin as needed), 4-5 mg/kg/min Glucose support (Insulin as needed for Hyperglycemia) 2 to 3 g/kg/day with AKI (Increase intake if on High flow CRRT (by 20%) Daily recommended intake (± replacement ) Monitor serum folate, water soluble vitamin levels Daily Recommended Intake MEE, Nitrogen Balance, Electrolytes, Vitamins, Trace elements Glutamine, Carnitine Supplement
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