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Zhao X, Li J, Liu H, Shi K, He Q, Sun L, Xue J, Jiang H, Wei L. Association of Geriatric Nutritional Risk Index with short-term mortality in patients with severe acute kidney injury: a retrospective cohort study. Ren Fail 2024; 46:2374449. [PMID: 38973429 PMCID: PMC11232638 DOI: 10.1080/0886022x.2024.2374449] [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: 01/19/2024] [Accepted: 06/25/2024] [Indexed: 07/09/2024] Open
Abstract
OBJECTIVES Geriatric Nutritional Risk Index (GNRI) is a new and simple index recently introduced to assess nutritional status, and its predictive value for clinical outcomes has been demonstrated in patients with chronic kidney disease. However, the association between the GNRI and prognosis has not been evaluated so far in patients with acute kidney injury (AKI), especially in those receiving continuous renal replacement therapy (CRRT). METHODS A total of 1096 patients with severe AKI initiating CRRT were identified for inclusion in this retrospective observational study. Patients were divided into three groups according to GNRI tertiles, with tertile 1 as the reference. The outcomes of interest were the 28- and 90-days of all-cause mortality. The associations between GNRI and clinical outcomes were estimated using multivariate Cox proportional hazards model analysis. RESULTS The overall mortality rates at 28- and 90-days were 61.6% (675/1096) and 71.5% (784/1096), respectively. After adjusting for multiple confounding factors, GNRI was identified as an independent prognostic factor for 28-days all-cause mortality (HR, 0.582; 95% CI, 0.467-0.727; p < .001 for tertile 3 vs. tertile 1) as well as 90-days all-cause mortality (HR, 0.540; 95% CI, 0.440-0.661; p < .001 for tertile 3 vs. tertile 1). The observed inverse associations were robust across subgroup analysis, and were more pronounced in elderly patients over 65 years of age. Finally, incorporating GNRI in a model with established risk factors might significantly improve its predictive power for the short-term death. CONCLUSIONS GNRI is considered to be a useful prognostic factor in patients with severe AKI initiating CRRT, especially in elderly patients.
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Affiliation(s)
- Xue Zhao
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jie Li
- Department of Nephrology, He'nan Provincial People's Hospital, Zhengzhou, China
| | - Hua Liu
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Kehui Shi
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Quan He
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Lingshuang Sun
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jinhong Xue
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Hongli Jiang
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Limin Wei
- Department of Critical Care Nephrology and Blood Purification, The First Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
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Vuong KT, Vega MR, Casey L, Swartz SJ, Srivaths P, Osborne SW, Rhee CJ, Arikan AA, Joseph C. Clearance and nutrition in neonatal continuous kidney replacement therapy using the Carpediem™ system. Pediatr Nephrol 2024; 39:1937-1950. [PMID: 38231233 DOI: 10.1007/s00467-023-06237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Infants with kidney failure (KF) demonstrate poor growth partly due to obligate fluid and protein restrictions. Delivery of liberalized nutrition on continuous kidney replacement therapy (CKRT) is impacted by clinical instability, technical dialysis challenges, solute clearance, and nitrogen balance. We analyzed delivered nutrition and growth in infants receiving CKRT with the Cardio-Renal, Pediatric Dialysis Emergency Machine (Carpediem™). METHODS Single-center observational study of infants receiving CKRT with the Carpediem™ between June 1 and December 31, 2021. We collected prospective circuit characteristics, delivered nutrition, anthropometric measurements, and illness severity Score for Neonatal Acute Physiology-II. As a surrogate to normalized protein catabolic rate in maintenance hemodialysis, we calculated normalized protein nitrogen appearance (nPNA) using the Randerson II continuous dialysis model. Descriptive statistics, Spearman correlation coefficient, Mann Whitney, Wilcoxon signed rank, receiver operating characteristic curves, and Kruskal-Wallis analysis were performed using SAS version 9.4. RESULTS Eight infants received 31.9 (22.0, 49.7) days of CKRT using mostly (90%) regional citrate anticoagulation. Delivered nutritional volume, protein, total calories, enteral calories, nPNA, and nitrogen balance increased on CKRT. Using parenteral nutrition, 90 ml/kg/day should meet caloric and protein needs. Following initial weight loss of likely fluid overload, exploratory sensitivity analysis suggests weight gain occurred after 14 days of CKRT. Despite adequate nutritional delivery, goal weight (z-score = 0) and growth velocity were not achieved until 6 months after CKRT start. Most (5 infants, 62.5%) survived and transitioned to peritoneal dialysis (PD). CONCLUSIONS Carpediem™ is a safe and efficacious bridge to PD in neonatal KF. Growth velocity of infants on CKRT appears delayed despite delivery of adequate calories and protein.
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Affiliation(s)
- Kim T Vuong
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Molly R Vega
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Lauren Casey
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Sarah J Swartz
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Poyyapakkam Srivaths
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Scott W Osborne
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Christopher J Rhee
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Ayse Akcan Arikan
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Catherine Joseph
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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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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4
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Wong Vega M, Starr MC, Brophy PD, Devarajan P, Soranno DE, Akcan-Arikan A, Basu R, Goldstein SL, Charlton JR, Barreto E. Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:981-992. [PMID: 37878137 PMCID: PMC10817838 DOI: 10.1007/s00467-023-06178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND In the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI. METHODS During the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized. RESULTS Two consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-"omics" in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments. CONCLUSIONS Neonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.
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Affiliation(s)
- Molly Wong Vega
- Renal and Apheresis Services, Texas Children's Hospital, Houston, TX, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Bioengineering, Purdue University, West Lafayette, IN, USA
| | - Ayse Akcan-Arikan
- Divisions of Critical Care and Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rajit Basu
- Division of Critical Care, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22901, USA.
| | - Erin Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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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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Nesargi S, Steflik H, Kamath N, Selewski D, Gist KM, Menon S. Optimizing Nutrition in Neonates with Kidney Dysfunction. Neoreviews 2024; 25:e25-e35. [PMID: 38161179 DOI: 10.1542/neo.25-1-e25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
The nutritional management of neonates with kidney disease is complex. There may be significant differences in nutritional needs based on the duration and cause of kidney dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD). Furthermore, the treatment modality, including acute (continuous renal replacement therapy and peritoneal dialysis [PD]) and chronic (intermittent hemodialysis and PD) approaches may differentially affect nutritional losses and dietary needs. In this review, we discuss the pathophysiology of compromised nutrition in neonates with AKI and CKD. We also summarize the existing data and consensus recommendations on the provision of nutrition to neonates with AKI and CKD. We highlight the paucity of data on micronutrient losses and the need for future prospective studies to enhance nutritional supplementation to hopefully improve outcomes in these patients.
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Affiliation(s)
- Saudamini Nesargi
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, India
| | - Heidi Steflik
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Nivedita Kamath
- Department of Pediatric Nephrology, St. Johns Medical College Hospital, Bangalore, India
| | - David Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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Vega MRW, Cerminara D, Desloovere A, Paglialonga F, Renken-Terhaerdt J, Walle JV, Shaw V, Stabouli S, Anderson CE, Haffner D, Nelms CL, Polderman N, Qizalbash L, Tuokkola J, Warady BA, Shroff R, Greenbaum LA. Nutritional management of children with acute kidney injury-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2023; 38:3559-3580. [PMID: 36939914 PMCID: PMC10514117 DOI: 10.1007/s00467-023-05884-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/21/2023]
Abstract
The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
| | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - José Renken-Terhaerdt
- Wilhemina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Vanessa Shaw
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University, Hippokratio Hospital, Thessaloniki, Greece
| | | | - Dieter Haffner
- Hannover Medical School, Children's Hospital, Hannover, Germany
| | | | | | | | - Jetta Tuokkola
- New Children's Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Larry A Greenbaum
- Emory University, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
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8
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Wong Vega M, Vuong KT, Chmielewski J, Gollins L, Slagle C, Srivaths PR, Akcan Arikan A. Nutrition for critically ill children and neonates requiring dialysis: Application of clinical practice recommendations. Nutr Clin Pract 2023; 38 Suppl 2:S139-S157. [PMID: 37721460 DOI: 10.1002/ncp.11048] [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: 04/03/2023] [Revised: 07/02/2023] [Accepted: 07/08/2023] [Indexed: 09/19/2023] Open
Abstract
Approximately 30% of all children and neonates admitted to the intensive care unit (ICU) experience acute kidney injury (AKI). Children with AKI are largely poorly fed and experience high rates of malnutrition. Nutrition prescription and provision are exceptionally challenging for critically ill neonates, infants, and children with AKI given the dynamic nature of AKI and its respective treatment modalities. Managing the nutrition prescription of critically ill neonates, infants, and children with AKI requires nutrition support clinicians to have a high-level understanding of the various treatment modalities for AKI, which can affect the patient's protein, fluid, electrolyte, and mineral needs. Accurate and timely nutrition assessment in critically ill neonates and children with AKI can be flawed owing to difficulty obtaining accurate anthropometric parameters. Recently, the Pediatric Renal Nutrition Taskforce introduced clinical practice recommendations for the nutrition management of children with AKI. In this review, we will discuss the practical implications of these recent guidelines and work to bridge the knowledge and practice gaps for pediatric and neonatal nutrition support clinicians providing nutrition therapy for patients with AKI in the ICU. We also appraise special nutrition-related considerations for neonates with AKI given newer available renal replacement treatment modalities.
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Affiliation(s)
- Molly Wong Vega
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Kim T Vuong
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Chmielewski
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura Gollins
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Poyyapakkam R Srivaths
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ayse Akcan Arikan
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Criticial Care Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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9
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Lion RP, Vega MR, Smith EO, Devaraj S, Braun MC, Bryan NS, Desai MS, Coss-Bu JA, Ikizler TA, Akcan Arikan A. The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children. Pediatr Nephrol 2022; 37:433-441. [PMID: 34386851 DOI: 10.1007/s00467-021-05162-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In critically ill children with acute kidney injury (AKI), continuous kidney replacement therapy (CKRT) enables nutrition provision. The magnitude of amino acid loss during continuous venovenous hemodiafiltration (CVVHDF) is unknown and needs accurate quantification. We investigated the mass removal and clearance of amino acids in pediatric CVVHDF. METHODS This is a prospective observational cohort study of patients receiving CVVHDF from August 2014 to January 2016 in the pediatric intensive care unit (PICU) of a tertiary children's hospital. RESULTS Fifteen patients (40% male, median age 2.0 (IQR 0.7, 8.0) years) were enrolled. Median PICU and hospital lengths of stay were 20 (9, 59) and 36 (22, 132) days, respectively. Overall survival to discharge was 66.7%. Median daily protein prescription was 2.00 (1.25, 2.80) g/kg/day. Median daily amino acid mass removal was 299.0 (174.9, 452.0) mg/kg body weight, and median daily amino acid mass clearance was 18.2 (13.5, 27.9) ml/min/m2, resulting in a median 14.6 (8.3, 26.7) % protein loss. The rate of amino acid loss increased with increasing dialysis dose and blood flow rate. CONCLUSION CVVHDF prescription and related amino acid loss impact nutrition provision, with 14.6% of the prescribed protein removed. Current recommendations for protein provision for children requiring CVVHDF should be adjusted to compensate for circuit-related loss. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Richard P Lion
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Molly R Vega
- Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - E O'Brien Smith
- Department of Pediatrics and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Sridevi Devaraj
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Michael C Braun
- Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Nathan S Bryan
- Department of Pediatrics and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jorge A Coss-Bu
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Talat Alp Ikizler
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ayse Akcan Arikan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA. .,Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA. .,Texas Children's Hospital, 6651 Main Street, Houston, TX, 77030, USA.
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Nutrition in children with continuous renal replacement therapy. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Santiago Lozano MJ, Alonso Álvarez C, Álvarez Heidbüchel C, Fernández Lafever S, Solana García MJ, López-Herce Cid J. [Nutrition in children with continuous renal replacement therapy]. An Pediatr (Barc) 2019; 92:208-214. [PMID: 31734157 DOI: 10.1016/j.anpedi.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/18/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION The aim of this study was to analyse the nutritional state, diet and gastrointestinal complications of children that require continuous renal replacement therapy (CRRT). MATERIAL AND METHODS A retrospective analysis of a database, which included the information about patients who required CRRT between the years 2013 and 2017. Data were collected on the replacement technique, type of nutrition, calorie and protein intake, gastrointestinal complications, and clinical course. RESULTS A total of 65 children (61.5% male) were treated with CRRT, and 24 patients (37%) also needed ECMO support. Just over one-quarter (27.7%) of patients had a weight less than P3, and 48.4% of them a height less than P3. At the beginning of the technique, 31 children (47.7%) received enteral nutrition, at the end, there were 52 patients receiving enteral nutrition (80%). The transpyloric tube was used to provide nutrition in 76% of the cases. The median caloric intake was 63kcal/kg/day, and the protein intake was 1.6g/kg/day. There were gastrointestinal difficulties during the process in 48 patients (73.8%), with 29 (44.6%) patients being diagnosed with gastric distension or excessive gastric remains, 22 (33.8%) with constipation, 8 (12.3%) with vomiting, and 4 (6.1%) diarrhoea. One patient treated with ECMO presented with intestinal ischaemia. Enteral nutrition was cancelled in 3 patients (4.6%) due to the complications. There was no relationship between complications and type of diet or ECMO assistance. CONCLUSIONS A high percentage of children treated with CRRT showed undernutrition but they had adequate tolerance to the enteral nutrition. Although the gastrointestinal complications percentage was high in few subjects, these complications are the reason why enteral nutrition was stopped.
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Affiliation(s)
- Maria José Santiago Lozano
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España.
| | - Cristina Alonso Álvarez
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Caterina Álvarez Heidbüchel
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Sarah Fernández Lafever
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Maria José Solana García
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
| | - Jesús López-Herce Cid
- Servicio de Cuidados Intensivos Pediátricos, Departamento de Salud Pública y Maternoinfantil, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Red de Salud Maternoinfantil y del Desarrollo, Madrid, España
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