Nutrition in CRRT Do the losses exceed the delivery

1
Nutrition in CRRTDo the losses exceed the
delivery?

• Timothy E. Bunchman

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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?

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Protein Amino Acid Metabolism

• Clinically seen as
• Hyper catabolic
• E.g. Rapidly rising BUN
• Over time loss of lean body mass

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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

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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

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Carbohydrate metabolism

• Clinical findings
• hyperglycemia

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Carbohydrate metabolism

• Mechanisms
• Insulin resistance
• Increase in hepatic gluconeogenesis

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Carbohydrate metabolism

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

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Lipid Metabolism

• Clinical findings
• Hypertriglyceridemia

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Lipid Metabolism

• Mechanisms
• Inhibition in lipolysis
• Increase in hepatic triglyceride secretion

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Lipid Metabolism

• Potential causes
• Unknown inhibitor to lipoprotein lipase
• Inflammatory mediators

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Nutrition in PCRRT

• CRRT 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, J Peds

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IgG levels in Infants(Katz et al, J Peds
117258-261, 1990)
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IgG levels in Infants(Katz et al, J Peds
117258-261, 1990)
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Dialysis Losses

• CRRT
• 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 AA/protein losses
• 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 rate _at_ 1 l/hr net u/f/hr 340 mls
• AA losses at 1 liter Dx 9 of total intake
• Dx rate _at_ 2 l/hr net u/f/hr 340 mls
• AA losses at 2 liter Dx12 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
dialysateMaxvold et al, Crit Care Med 2000
Apr28(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

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Nutritional losses Replacement fluid vs
dialysateMaxvold et al, Crit Care Med 2000
Apr28(4)1161-5

• Indirect calorimetry to measure REE
• TPN source of nutrition _at_ 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 2000
Apr28(4)1161-5 )
NS
Amino Acid Losses (g/day/1.73 m2)
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Nutritional losses Replacement fluid vs
dialysateMaxvold et al, Crit Care Med
200028(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

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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)
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? 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?

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? 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

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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)

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Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 2001)
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Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 2001)
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Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 2001)
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Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 2001)
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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

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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

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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)

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So what do we do?

• 2. Keep lipids as part of the formulation but be
  aware that both glucose and lipids effect
  triglycerides

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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 40-60
  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

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Urea Levels HD vs. HFMehta et al, Kid Int,
2001, 601154-1163
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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

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A Study to do

• Serial nitrogen balance, REE, glucose metabolism
  studies throughout the course of the childs
  illness
• Impact upon balance of catabolism to anabolism as
  one increases the protein/AA exposure