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Nutrition in CRRT Do the losses exceed the delivery?

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Nutrition in CRRT Do the losses exceed the delivery? Timothy E. Bunchman Nutrition in MOSF What are the needs of the patient due to presence of MOSF? – PowerPoint PPT presentation

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Title: Nutrition in CRRT Do the losses exceed the delivery?


1
Nutrition in CRRTDo 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
117258-261, 1990)
18
IgG levels in Infants(Katz et al, J Peds
117258-261, 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 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

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 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

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
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

25
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

26
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)
27
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

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 3451359-67, 2001)
33
Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 2001)
34
Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 2001)
35
Intensive Insulin therapy(Van den Berghe et al
NEJM 3451359-67, 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 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

41
Urea Levels HD vs. HFMehta et al, Kid Int,
2001, 601154-1163
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 childs
    illness
  • Impact upon balance of catabolism to anabolism as
    one increases the protein/AA exposure
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