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Raina R, Suchan A, Soundararajan A, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Vitale VS, Crugnale AS, Keller GL, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE, Sethi SK. Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary. Nutrition 2024; 119:112272. [PMID: 38118382 DOI: 10.1016/j.nut.2023.112272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/04/2023] [Accepted: 10/21/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy. METHODS An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy. RESULTS The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy. CONCLUSIONS Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, Ohio, USA; Akron Children's Hospital, Akron, Ohio, USA.
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA; Children's Healthcare of Atlanta, Atlanta, Georgia, USA; ECU Health, Greenville, North Carolina, USA
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Weiwen V Shih
- Children's Hospital Colorado, University of Colorado, Section of Pediatric Nephrology, Aurora, Colorado, USA
| | - Arwa Nada
- Division of Pediatric Nephrology, Department of Pediatrics, Le Bonheur Children's Hospital and St. Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sharon Y Irving
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee, USA; Department of Medicine, University of Tennessee, Knoxville, Tennessee, USA
| | | | - Aylin S Crugnale
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, Ohio, USA
| | | | - Katarina G Berry
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E Bunchman
- Department of Pediatrics, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sidharth K Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta-The Medicity, Gurgaon, India
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Raina R, Suchan A, Sethi SK, Soundararajan A, Vitale VS, Keller GL, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Crugnale AS, Myneni A, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE. Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations. KIDNEY360 2024; 5:285-309. [PMID: 38112754 PMCID: PMC10914214 DOI: 10.34067/kid.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT. METHODS PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023. RESULTS On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points. CONCLUSIONS Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
- Akron Children's Hospital, Akron, Ohio
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, India
| | - Anvitha Soundararajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | | | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
- ECU Health, Greenville, North Carolina
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, United Kingdom
| | - Weiwen V. Shih
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Arwa Nada
- Department of Pediatrics, Division of Pediatric Nephrology, Le Bonheur Children's & St. Jude Children's Research Hospitals, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sharon Y. Irving
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee
- Department of Medicine, University of Tennessee at Knoxville, Knoxville, Tennessee
| | - Aylin S. Crugnale
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Archana Myneni
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Katarina G. Berry
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Jakub Zieg
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E. Bunchman
- Department of Pediatrics, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
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Fell DM, Bitetto EA, Skillman HE. Timing of enteral nutrition and parenteral nutrition in the PICU. Nutr Clin Pract 2023; 38 Suppl 2:S174-S212. [PMID: 37721466 DOI: 10.1002/ncp.11050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.
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Affiliation(s)
- Donna M Fell
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Emily A Bitetto
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
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