Nutrition in Pediatric Critical Care: Protein Losses in CRRT

1. Nutrition in PCRRT Norma J Maxvold Pediatric Critical Care maxvold

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) maxvold

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

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 maxvold

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 maxvold

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 maxvold

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 maxvold

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 maxvold

9. Protein losses on CRRTMokrzycki 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 maxvold

10. Protein losses on CRRTDavies 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 Dx:12% of total intake maxvold

11. Protein losses on CRRTDavenport 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 maxvold

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 maxvold

13. Nutritional losses Replacement fluid vs dialysateMaxvold et al, Crit Care Med April 2000 • Indirect calorimetry to measure REE • TPN source of nutrition @ 120% of REE • 70% dextrose • 30% lipids • Insulin to maintain euglycemia when needed • 10% Aminosyn II • 1.5 gms/kg/day of protein maxvold

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 maxvold

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 maxvold

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) maxvold

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 maxvold