Nutrition in PCRRT

1
Nutrition in PCRRT

• Norma J Maxvold
• Pediatric Critical Care

2
Nutrition in Acute Renal Failure

• ARF altered metabolic state
• Increase catabolic state
• Altered amino acid metabolism
• Altered protein metabolism
• High urea nitrogen appearance (production and
  elimination)

3
Nutrition in PCRRT

• PCRRT allows solute clearance
• uremic solutes
• small molecular sized nutrients (eg
  oligosaccharides)
• amino acids and small peptides
• electrolytes

4
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

5
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

6
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

7
Dialysis Losses

• Peritoneal Dialysis
• albumin, protein, immunoglobulin and amino acid
  losses
• Katz et al,
• PCRRT
• small peptide and amino acid
• Mokrzycki and Kaplan, J Am Soc Neph 1996

8
Protein losses on CRRT

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

9
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

10
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 FR 1 and 2 liter/hr net u/f/hr 340 mls
• AA losses at 1 liter Dx 9 of total intake
• AA losses at 2 liter Dx12 of total intake

11
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

12
Nutritional losses Replacement fluid vs
dialysateMaxvold et al, Crit Care Med April 2000

• 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
  FRF or Dx flow at 2000
  mls/hr/1.73 m2

13
Nutritional losses Replacement fluid vs
dialysateMaxvold et al, Crit Care Med April 2000

• 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

14
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
Nutritional losses Replacement fluid vs
dialysateMaxvold et al, Crit Care Med April 2000

• 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

16
24 Hr Nitrogen Balance CVVH vs CVVHD(Maxvold
et al, Crit Care Med April 2000)
NS
24 hr Nitrogen Balance (g/day/1.73 m2)
17
Conclusion

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