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Teixeira JP, Griffin BR, Pal CA, González-Seguel F, Jenkins N, Jones BM, Yoshida Y, George N, Israel HP, Ghazi L, Neyra JA, Mayer KP. Critical illness myopathy and trajectory of recovery in acute kidney injury requiring continuous renal replacement therapy: a prospective observational trial protocol. BMJ Open 2023; 13:e072448. [PMID: 37217272 PMCID: PMC10230984 DOI: 10.1136/bmjopen-2023-072448] [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: 02/03/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Acute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors. METHODS AND ANALYSIS This protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1-3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling. ETHICS AND DISSEMINATION We anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions. TRIAL REGISTRATION NUMBER NCT05287204.
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Affiliation(s)
- J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Benjamin R Griffin
- Division of Nephrology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Chaitanya Anil Pal
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Felipe González-Seguel
- Servicio Medicina Física y Rehabilitación, Clinica Alemana de Santiago SA, Santiago, Región Metropolitana, Chile
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Región Metropolitana, Chile
| | - Nathanial Jenkins
- Department of Health and Human Physiology, The University of Iowa, Iowa City, Iowa, USA
| | - Beth M Jones
- Department of Orthopedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Yuri Yoshida
- Department of Orthopedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Hayley Puffer Israel
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Lama Ghazi
- Department of Epidemiology, The University of Alabama School of Public Health, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, The University of Alabama Heersink School of Medicine, Birmingham, Alabama, USA
| | - Kirby P Mayer
- Department of Physical Therapy, University of Kentucky College of Health Sciences, Lexington, Kentucky, USA
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Emuron D, Thomas K, Mullane R. The Nutritional Risk Index as a Predictor of 90-Day Dialysis Dependence After Acute Renal Failure: A Pilot Study. J Ren Nutr 2023; 33:29-34. [PMID: 35447334 DOI: 10.1053/j.jrn.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/28/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Return of sufficient renal function to discontinue dialysis following acute renal failure is an important clinical and patient-oriented outcome. Our study sought to develop a model using the Nutritional Risk Index (NRI) to predict 90-day dialysis dependence. METHODS We retrospectively analyzed 77 patients with acute renal failure admitted to a single university medical center's intensive care units between January 2015 and January 2019 with the need for continuous renal replacement therapy. We assessed the predictive ability of the NRI for 90-day dialysis dependence using age, serum total protein, number of vasopressor days, baseline predialysis estimated glomerular filtration rate (eGFR), and Sequential Organ Failure Assessment (SOFA) score as covariates. RESULTS Of the analytic group, 20 (25.9%) had severe nutritional risk, and 16 (20.8%) recovered from acute renal failure at 90 days. The mean age was 57.1 years. The clinical model comprising the NRI, age, serum total protein, number of vasopressor days, SOFA score, and baseline predialysis eGFR had an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.81-0.97), sensitivity 56.3%, and specificity 95%. Exclusion of baseline predialysis eGFR and SOFA score did not significantly decrease model discrimination, AUC 0.87 (95% CI, 0.78-0.97). The AUC was least when serum total protein was dropped from the final model, 0.79 (95% CI, 0.66-0.92). CONCLUSIONS The NRI when used together with other clinical parameters, including serum total protein, may improve the accuracy of predicting renal recovery and independence from dialysis at 90 days.
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Affiliation(s)
- Dennis Emuron
- Fellow, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kaleb Thomas
- Resident, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ryan Mullane
- Assistant Professor, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska.
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Hung KY, Chen ST, Chu YY, Ho G, Liu WL. Nutrition support for acute kidney injury 2020-consensus of the Taiwan AKI task force. J Chin Med Assoc 2022; 85:252-258. [PMID: 34772861 DOI: 10.1097/jcma.0000000000000662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We used evidence-based medicine to suggest guidelines of nutritional support for Taiwanese patients with acute kidney injury (AKI). METHODS Our panel reviewed the medical literature in group meetings to reach a consensus on answering clinical questions related to the effects of the nutritional status, energy/protein intake recommendations, timing of enteral, and parenteral nutrition supplementation. RESULTS Markers of the nutritional status of serum albumin, protein intake, and nitrogen balance had positive relationships with low mortality. A forest plot of the comparison of mortality between a body mass index (BMI) of <18.5 and ≥18.5 kg/m2 was produced using data from seven observational studies which showed that a lower BMI was associated with higher mortality. The energy recommendation of 20-30 kcal/kg body weight (BW)/day was determined to be valid for all stages of AKI. The protein recommendation for noncatabolic AKI patients is 0.8-1.0 g/kg BW/day, and 1.2-2.0 g/kg BW/day is the same as that for the underlying disease that is causing AKI. Protein intake should be at least 1.5 g/kg BW/day and up to 2.5 g/kg BW/day in patients receiving continuous renal replacement therapy. Considering that patients with AKI often have other critical comorbid situations, early enteral nutrition (EN) is suggested, and parenteral nutrition is needed when >60% energy and protein requirements cannot be met via the enteral route in 7-10 days. Low energy intake is suggested in critically ill patients with AKI, which should gradually be increased to meet 80%-100% of the energy target. CONCLUSION By examining evidence-based research, we provide practicable nutritional guidelines for AKI patients.
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Affiliation(s)
- Kai-Yin Hung
- Department of Nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Shu-Tzu Chen
- Department of Nutrition and Health Sciences, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yu-Ying Chu
- Department of Nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Guanjin Ho
- Critical Care Surgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan, ROC
| | - Wei-Lun Liu
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
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Chen L, Wu X, Qin H, Zhu H. The PCT to Albumin Ratio Predicts Mortality in Patients With Acute Kidney Injury Caused by Abdominal Infection-Evoked Sepsis. Front Nutr 2021; 8:584461. [PMID: 34141715 PMCID: PMC8203818 DOI: 10.3389/fnut.2021.584461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 03/29/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose: Considerable evidence suggests that inflammation and malnutrition are common in patients with acute kidney injury (AKI) and correlated with mortality of various diseases. Despite this, few studies have reported the underlying predictive effects of inflammatory and nutritional markers in combination on the mortality of AKI patients. Herein, we aimed to explore the values of PCT and CRP as well as the ratios of PCT/Alb and CRP/Alb in the poor prognosis of patients with sepsis-induced AKI. Patients and Methods: A total of 171 patients with AKI, caused by abdominal infection-evoked sepsis, were retrospectively studied and divided into a survival group (107 cases) and a non-survival group (64 cases). Univariate analysis was used to compare the clinical data of the two groups. Multivariate logistic regression analysis was used to analyze the independent risk factors of poor prognosis in patients with sepsis-induced AKI. The ROC curve was used to evaluate the diagnostic value of PCT, CRP, PCT/Alb, and CRP/Alb in the poor prognosis of patients with sepsis-induced AKI. Results: Univariate analysis revealed that the values of PCT, CRP, CRP/Alb, and PCT/Alb were significantly different between AKI survival and non-survival groups, and further analysis found that PCT and PCT/Alb were independent risk factors for poor prognosis in patients with sepsis-induced AKI after adjusting with age and gender. Of note, the predictive accuracy (0.864 vs. 0.807), specificity (83.2 vs. 69.2), and sensitivity (79.7 vs. 76.6) of PCT/Alb were all higher than that of the simple PCT. Conclusions: The ratio of PCT to Alb is an independent risk factor possessing a robust and accurate risk assessment for the poor prognosis of patients with sepsis-induced AKI, and it offers the potential to improve the management of this type of disease and a lower resultant mortality.
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Affiliation(s)
- Lijuan Chen
- Department of Pharmacy, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Xiaoli Wu
- Department of Pharmacy, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Haiyan Qin
- Department of Pharmacy, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Hongchao Zhu
- Department of Nuclear Medicine, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
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Li L, Dai L, Wang X, Wang Y, Zhou L, Chen M, Wang H. Predictive value of the C-reactive protein-to-prealbumin ratio in medical ICU patients. Biomark Med 2017; 11:329-337. [PMID: 28326826 DOI: 10.2217/bmm-2016-0266] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
AIM This prospective study aimed to evaluate the relationship between the ratio of C-reactive protein-to-prealbumin (CRP/PAB) and clinical outcomes in medical intensive care unit patients. MATERIALS & METHODS All 240 consecutive adult patients were enrolled in this study with demographic and clinical features collected. RESULTS Compared with patients belonging to the CRP/PAB ≤0.24 group, hospital mortality and the total length of stay in hospital (TLSH) were significantly increased in patients in the CRP/PAB >0.24 group. CRP/PAB and Acute Physiology and Chronic Health Evaluation II score score were independently correlated with hospital mortality while CRP/PAB and age were independently associated with TLSH. CONCLUSION CRP/PAB were independently correlated with hospital mortality and TLSH in medical intensive care unit.
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Affiliation(s)
- Li Li
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Lihua Dai
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Xiao Wang
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Yao Wang
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Luocheng Zhou
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Miao Chen
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Hairong Wang
- Department of Emergency, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
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Wooley JA, Btaiche IF, Good KL. Metabolic and Nutritional Aspects of Acute Renal Failure in Critically Ill Patients Requiring Continuous Renal Replacement Therapy. Nutr Clin Pract 2017; 20:176-91. [PMID: 16207655 DOI: 10.1177/0115426505020002176] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid-base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.
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Affiliation(s)
- Jennifer A Wooley
- St Joseph Mercy Hospital, Clinical Nutrition/Pharmacy, 5301 East Huron River Dr, PO Box 995, Ann Arbor, MI 48106, USA.
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DCoH: A novel biomarker for diagnosing acute kidney injury. Med Hypotheses 2016; 95:27-30. [PMID: 27692160 DOI: 10.1016/j.mehy.2016.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 08/14/2016] [Indexed: 11/21/2022]
Abstract
Initial diagnosis of acute kidney injury (AKI) is usually based on measuring serum-creatinine and blood urea nitrogen levels; however such measurements are still poor in identifying renal injuries at initial stages. These standard matrices are not enough to monitor the outcome and progression of AKI. The prognosis prevents proper treatment and timely delay in providing putative therapeutic agents. The cost effective therapies to get delayed, patient health gets compromised and ultimately requires renal transplant due to end-stage renal disease, which is another major problematic factor due to shortage kidney donors. To establish effective therapies for AKI the need will be facilitated by developing and identifying reliable, sensitive biomarkers which can be detected early during all stages of AKI, even during preclinical and clinical studies. Although reaching to human clinical trials takes years of thorough evaluations, preliminary studies should be carried out effectively by: (a) Employing cell culture analysis, (b) use of AKI animal models, studying various gene regulated networks, and biomarkers, and (c) patient serum sampling and testing. As elevated phenylalanine are indicative of AKI onset within 4h, its levels is controlled, 4a-Hydroxy-tetrahydrobiopterin dehydratase/dimerization cofactor of HNF-1 (DCoH). There is a possibility of targeting DCoH to the current bedside list of biomarkers involved in AKI onset.
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Abstract
BACKGROUND Treatment for acute kidney Injury (AKI) primarily relies on treating the underlying cause and maintaining the patient until kidney function has recovered. Enteral and parenteral nutrition are commonly used to treat nutritional disorders in AKI patients, however their efficacy in treating AKI are still debated. This review was first published in 2010. OBJECTIVES To evaluate the effectiveness and safety of nutritional support for patients with AKI. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Chinese Biomedical Disc, VIP and China National Knowledge Infrastructure (CNKI).Date of last search: 4 July 2012 SELECTION CRITERIA All randomised controlled trials (RCTs) reported for AKI and nutrition were included. DATA COLLECTION AND ANALYSIS Authors independently assessed study quality and extracted data. Results were expressed as risk ratio (RR) with 95% confidence intervals (CI) or mean difference (MD). MAIN RESULTS Eight studies (257 participants) were included. An overall pooled analysis was not performed due to the different interventions used and different outcomes measured. Selection bias was not reported (unclear) in six studies and was adequately reported (low) for random sequence generation in two studies. Participant/personnel blinding was adequately reported in one study and unclear in seven. Incomplete outcome reporting bias was low in six studies and high in two. Selective reporting was low in six studies, unclear in one study, and high in one study. No other biases were detected. There was a significant increase in recovery rate for AKI (RR 1.70, 95% CI 1.70 to 2.79) and survival in dialysed patients (RR 3.56, 95% CI 0.97 to 13.08) for intravenous essential L-amino acids (EAA) compared to hypertonic glucose alone. Compared to lower calorie-total parenteral nutrition (TPN), higher calorie-TPN did not improve estimated nitrogen balance, protein catabolic rate, or urea generation rate; but increased serum triglycerides, glucose, insulin need and nutritional fluid administration. There was no difference between groups in estimated nitrogen balance, but there were differences between urea nitrogen appearance (MD 0.98, 95% CI 0.25 to 1.71) and net protein utilisation (MD 21.50%, 95% CI 0.39 to 42.61). Urea nitrogen appearance was lower in the low nitrogen intake group than in the high nitrogen intake group. There was no significant difference in death between EAA and general amino acids (GAA) (RR 1.52, 95% CI 0.63 to 3.68). High dose amino acids did not improve cumulative water excretion, furosemide requirement, nitrogen balance or death compared to normal dose amino acids. Glucose+EAA+histidin had better nitrogen balance than glucose+GAA; glucose+nitrogen+fat significantly increased serum creatinine compared with glucose+GAA; glucose+EAA+histidin significantly improved nitrogen balance, U/P urea and serum creatinine, but increased plasma urea compared to glucose+nitrogen+fat. AUTHORS' CONCLUSIONS There was insufficient evidence found to support the effectiveness of nutritional support for AKI. Further high quality studies are required to provide reliable evidence of the effect and safety of nutritional support.
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Affiliation(s)
- Yi Li
- Department of Intensive Care Unit, Sichuan Cancer Hospital, Chengdu, China
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Pouresmaeil R, Razeghi E, Ahmadi F. Correlation of serum lead levels with inflammation, nutritional status, and clinical complications in hemodialysis patients. Ren Fail 2012; 34:1114-7. [PMID: 22889119 DOI: 10.3109/0886022x.2012.713281] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The aim of this study was to determine blood lead level (BLL) in hemodialysis (HD) patients and their relation with high-sensitivity C-reactive protein (hsCRP) and albumin which are inflammatory and nutritional biomarkers, respectively, and clinical complications. A total of 93 patients, who were dialyzed at least for 3 months, were included in the study. Blood samples were collected before HD and BLL was measured and categorized as three equal groups: low normal (BLL < 8 μg/dL), middle normal (BLL = 8-10.6 μg/dL), and high normal (BLL > 10.6 μg/dL). All patients had normal BLL, 9.7 ± 3.4 g/dL. Patients with abnormal hsCRP level (>3 mg/L) had higher BLL than other patients (16.4 ± 0.8 vs. 11.5 ± 2.7 mg/L, p = 0.003). Patients with BLL > 10.6 μg/dL had significantly lower hemoglobin, ferritin, iron, and albumin levels and higher hsCRP and intact parathyroid hormone (iPTH) levels than the patients with BLL < 8 μg/dL. In addition, BLL revealed a significant positive correlation with duration of dialysis. We concluded that BLL associated to inflammation, malnutritional status, iron-deficiency condition, and high iPTH level in HD patients.
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Affiliation(s)
- Rahmat Pouresmaeil
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran
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López Martínez J, Sánchez-Izquierdo Riera JA, Jiménez Jiménez FJ. [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): acute renal failure]. Med Intensiva 2012; 35 Suppl 1:22-7. [PMID: 22309748 DOI: 10.1016/s0210-5691(11)70005-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Nutritional support in acute renal failure must take into account the patient's catabolism and the treatment of the renal failure. Hypermetabolic failure is common in these patients, requiring continuous renal replacement therapy or daily hemodialysis. In patients with normal catabolism (urea nitrogen below 10 g/day) and preserved diuresis, conservative treatment can be attempted. In these patients, relatively hypoproteic nutritional support is essential, using proteins with high biological value and limiting fluid and electrolyte intake according to the patient's individual requirements. Micronutrient intake should be adjusted, the only buffering agent used being bicarbonate. Limitations on fluid, electrolyte and nitrogen intake no longer apply when extrarenal clearance techniques are used but intake of these substances should be modified according to the type of clearance. Depending on their hemofiltration flow, continuous renal replacement systems require high daily nitrogen intake, which can sometimes reach 2.5 g protein/kg. The amount of volume replacement can induce energy overload and therefore the use of glucose-free replacement fluids and glucose-free dialysis or a glucose concentration of 1 g/L, with bicarbonate as a buffer, is recommended. Monitoring of electrolyte levels (especially those of phosphorus, potassium and magnesium) and of micronutrients is essential and administration of these substances should be individually-tailored.
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Gervasio JM, Garmon WP, Holowatyj M. Nutrition Support in Acute Kidney Injury. Nutr Clin Pract 2011; 26:374-81. [DOI: 10.1177/0884533611414029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Jane M. Gervasio
- Butler University, College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Wesley P. Garmon
- Butler University, College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Michael Holowatyj
- Butler University, College of Pharmacy and Health Science, Indianapolis, Indiana
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The ratio of CRP to prealbumin levels predict mortality in patients with hospital-acquired acute kidney injury. BMC Nephrol 2011; 12:30. [PMID: 21714897 PMCID: PMC3142490 DOI: 10.1186/1471-2369-12-30] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 06/29/2011] [Indexed: 12/19/2022] Open
Abstract
Background Animal and human studies suggest that inflammation and malnutrition are common in acute kidney injury (AKI) patients. However, only a few studies reported CRP, a marker of inflammation, albumin, prealbumin and cholesterol, markers of nutritional status were associated with the prognosis of AKI patients. No study examined whether the combination of inflammatory and nutritional markers could predict the mortality of AKI patients. Methods 155 patients with hospital-acquired AKI were recruited to this prospective cohort study according to RIFLE (Risk, Injury, Failure, Lost or End Stage Kidney) criteria. C-reactive protein (CRP), and the nutritional markers (albumin, prealbumin and cholesterol) measured at nephrology consultation were analyzed in relation to all cause mortality of these patients. In addition, CRP and prealbumin were also measured in healthy controls (n = 45), maintenance hemodialysis (n = 70) and peritoneal dialysis patients (n = 50) and then compared with AKI patients. Results Compared with healthy controls and end-stage renal disease patients on maintenance hemodialysis or peritoneal dialysis, patients with AKI had significantly higher levels of CRP/prealbumin (p < 0.001). Higher level of serum CRP and lower levels of albumin, prealbumin and cholesterol were found to be significant in the patients with AKI who died within 28 days than those who survived >28 days. Similarly, the combined factors including the ratio of CRP to albumin (CRP/albumin), CRP/prealbumin and CRP/cholesterol were also significantly higher in the former group (p < 0.001 for all). Multivariate analysis (Cox regression) revealed that CRP/prealbumin was independently associated with mortality after adjustment for age, gender, sepsis and sequential organ failure assessment (SOFA, p = 0.027) while the others (CRP, albumin, prealbumin, cholesterol, CRP/albumin and CRP/cholesterol) became non-significantly associated. The hazard ratio was 1.00 (reference), 1.85, 2.25 and 3.89 for CRP/prealbumin increasing according to quartiles (p = 0.01 for the trend). Conclusions Inflammation and malnutrition were common in patients with AKI. Higher level of the ratio of CRP to prealbumin was associated with mortality of AKI patients independent of the severity of illness and it may be a valuable addition to SOFA score to independent of the severity of illness and it may be a valuable addition to SOFA score to predict the prognosis of AKI patients.
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Fiaccadori E, Cremaschi E, Regolisti G. Nutritional Assessment and Delivery in Renal Replacement Therapy Patients. Semin Dial 2011; 24:169-75. [DOI: 10.1111/j.1525-139x.2011.00831.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Soporte nutricional en la insuficiencia renal aguda. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70571-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Fiaccadori E, Regolisti G, Cabassi A. Specific nutritional problems in acute kidney injury, treated with non-dialysis and dialytic modalities. NDT Plus 2010; 3:1-7. [PMID: 25949400 PMCID: PMC4421537 DOI: 10.1093/ndtplus/sfp017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Accepted: 01/21/2009] [Indexed: 01/04/2023] Open
Abstract
Patients who develop AKI, especially in the intensive care unit (ICU), are at risk of protein-energy malnutrition, which is a major negative prognostic factor in this clinical condition. Despite the lack of evidence from controlled trials of its effect on outcome, nutritional support by the enteral (preferentially) and/or parenteral route appears clinically indicated in most cases of ICU-acquired AKI, independently of the actual nutritional status of the patient, in order to prevent deterioration in the nutritional state with all its known complications. Extrapolating from data in other conditions, it seems intrinsically unlikely that starvation of a catabolic patient is more beneficial than appropriate nutritional support by an expert team with the skills to avoid the potential complications of the enteral and parenteral nutrition methodologies. By the same token, it is ethically impossible to conduct a trial in which the control group undergoes prolonged starvation. The primary goals of nutritional support in AKI, which represents a well-known inflammatory and pro-oxidative condition, are the same as those for other critically ill patients with normal renal function, i.e. to ensure the delivery of adequate nutrition, to prevent protein-energy wasting with its attendant metabolic complications, to promote wound healing and tissue repair, to support immune system function, to accelerate recovery and to reduce mortality. Patients with AKI on RRT should receive a basic intake of at least 1.5 g/kg/day of protein with an additional 0.2 g/kg/day to compensate for amino acid/protein loss during RRT, especially when daily treatments and/or high efficiecy modalities are used. Energy intake should consist of no more than 30 kcal non-protein calories or 1.3 × BEE (Basal Energy Expenditure) calculated by the Harris-Benedict equation, with ∼30-35% from lipid, as lipid emulsions. For nutritional support, the enteral route is preferred, although it often needs to be supplemented through the parenteral route in order to meet nutritional requirements.
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Affiliation(s)
- Enrico Fiaccadori
- Internal Medicine and Nephrology Department , Parma University Medical School , Parma , Italy
| | - Giuseppe Regolisti
- Internal Medicine and Nephrology Department , Parma University Medical School , Parma , Italy
| | - Aderville Cabassi
- Internal Medicine and Nephrology Department , Parma University Medical School , Parma , Italy
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Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) in the ICU is associated with an increased risk of protein-energy wasting (PEW), a major negative prognostic factor. This review illustrates recently published data and guidelines concerning nutritional problems in AKI, pointing out complexities and peculiarities of the syndrome. RECENT FINDINGS The main goals of nutritional support in AKI on renal replacement therapy (RRT) are to ensure the provision of adequate amounts of nutrients, to prevent PEW, to promote tissue reparation, to support the immune system, and possibly to reduce mortality. The enteral route should be preferred, even though parenteral nutrition is often required to target nutritional needs. Special attention should be paid both to the impact of RRT on macronutrient and micronutrient losses, and to the risk of complications. In fact, due to both the acute loss of the kidneys' homeostatic function, and the frequent need of RRT, patients with AKI are especially prone to hypoglycemia and hyperglycemia, hypertriglyceridemia, fluid balance alterations, electrolyte and acid-base derangements. SUMMARY This review highlights the most recent concepts and recommendations for nutritional support in AKI, stressing the need for a close integration between adequate nutrition and RRT in this clinical condition, with the aim of carefully tailoring both therapies on patients' changing needs. Recent findings about the renoprotective role of some nutrients (glutamine, omega-3 fatty acids) are also discussed.
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Abstract
BACKGROUND Treatment for acute kidney Injury (AKI) primarily relies on treating the underlying cause and maintaining the patient until kidney function has recovered. Enteral and parenteral nutrition are commonly used to treat nutritional disorders in AKI patients, however their efficacy in treating AKI are still debated. OBJECTIVES To evaluate the effectiveness and safety of nutritional support for patients with AKI. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Chinese Biomedical Disc, VIP and China National Knowledge Infrastructure (CNKI). SELECTION CRITERIA All randomised controlled trials (RCTs) reported for AKI and nutrition were included. DATA COLLECTION AND ANALYSIS Review authors independently assessed study quality and extracted data. Results were expressed as risk ratio (RR) with 95% confidence intervals (CI) or mean difference (MD). MAIN RESULTS Eight studies (257 participants) were included. An overall pooled analysis was not performed due to the different interventions used and different outcomes measured. There was a significant increase in recovery rate for AKI (RR 1.70, 95% CI 1.70 to 2.79) and survival in dialysed patients (RR 3.56, 95% CI 0.97 to 13.08) for intravenous essential L-amino acids (EAA) compared to hypertonic glucose alone. Compared to lower calorie-total parenteral nutrition (TPN), higher calorie-TPN did not improve estimated nitrogen balance, protein catabolic rate, or urea generation rate, but increased serum triglycerides, glucose, insulin need and nutritional fluid administration. There was no difference between groups in estimated nitrogen balance, but there were differences between urea nitrogen appearance (MD 0.98, 95% CI 0.25 to 1.71) and net protein utilisation (MD 21.50%, 95% CI 0.39 to 42.61). Urea nitrogen appearance was lower in the low nitrogen intake group than in the high nitrogen intake group. There was no significant difference in death between EAA and general amino acids (GAA) (RR 1.52, 95% CI 0.63 to 3.68). High dose amino acids did not improve cumulative water excretion, furosemide requirement, nitrogen balance or death compared to normal dose amino acids. Glucose+EAA+histidin had better nitrogen balance than glucose+GAA; glucose+nitrogen+fat significantly increased serum creatinine compared with glucose+GAA; glucose+EAA+histidin significantly improved nitrogen balance, U/P urea and serum creatinine, but increased plasma urea compared to glucose+nitrogen+fat. AUTHORS' CONCLUSIONS There is not enough evidence to support the effectiveness of nutritional support for AKI. Further high quality studies are required to provide reliable evidence of the effect and safety of nutritional support.
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Affiliation(s)
- Yi Li
- Department of Nephrology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan, China, 610041
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Stein J, Boehles HJ, Blumenstein I, Goeters C, Schulz R. Amino acids - Guidelines on Parenteral Nutrition, Chapter 4. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2009; 7:Doc24. [PMID: 20049071 PMCID: PMC2795371 DOI: 10.3205/000083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 12/16/2022]
Abstract
Protein catabolism should be reduced and protein synthesis promoted with parenteral nutrion (PN). Amino acid (AA) solutions should always be infused with PN. Standard AA solutions are generally used, whereas specially adapted AA solutions may be required in certain conditions such as severe disorders of AA utilisation or in inborn errors of AA metabolism. An AA intake of 0.8 g/kg/day is generally recommended for adult patients with a normal metabolism, which may be increased to 1.2-1.5 g/kg/day, or to 2.0 or 2.5 g/kg/day in exceptional cases. Sufficient non-nitrogen energy sources should be added in order to assure adequate utilisation of AA. A nitrogen calorie ratio of 1:130 to 1:170 (g N/kcal) or 1:21 to 1:27 (g AA/kcal) is recommended under normal metabolic conditions. In critically ill patients glutamine should be administered parenterally if indicated in the form of peptides, for example 0.3-0.4 g glutamine dipeptide/kg body weight/day (=0.2-0.26 g glutamine/kg body weight/day). No recommendation can be made for glutamine supplementation in PN for patients with acute pancreatitis or after bone marrow transplantation (BMT), and in newborns. The application of arginine is currently not warranted as a supplement in PN in adults. N-acetyl AA are only of limited use as alternative AA sources. There is currently no indication for use of AA solutions with an increased content of glycine, branched-chain AAs (BCAA) and ornithine-alpha-ketoglutarate (OKG) in all patients receiving PN. AA solutions with an increased proportion of BCAA are recommended in the treatment of hepatic encephalopathy (III-IV).
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Affiliation(s)
- J Stein
- Dept. Internal Medicine, University of Frankfurt, Germany
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20
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Nutrition support therapy in acute kidney injury: distinguishing dogma from good practice. Curr Gastroenterol Rep 2009; 11:325-31. [PMID: 19615309 DOI: 10.1007/s11894-009-0047-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute kidney injury (AKI) is a frequently observed complication in critically ill patients. Its presentation may range from the early risk of renal dysfunction to complete renal failure. Morbidity and mortality in the AKI patient increase with the decline of renal function. Appropriate nutrition therapy is essential in the medical management of the AKI patient. Assessment of nutritional requirements should take into account the patient's underlying complication, comorbid medical conditions, and severity of the renal dysfunction. Various stages of AKI determine the direction of nutrition therapy. Additionally, understanding the macro- and micronutrient modifications and electrolyte and vitamin alterations that should be implemented are vital for better patient outcomes.
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Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr 2009; 28:378-86. [PMID: 19464088 DOI: 10.1016/j.clnu.2009.04.002] [Citation(s) in RCA: 384] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/15/2022]
Abstract
In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.
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Affiliation(s)
- M Braga
- Department of Surgery, San Raffaele University, Milan, Italy
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Scurlock C, Raikhelkar J, Mechanick JI. Impact of new technologies on metabolic care in the intensive care unit. Curr Opin Clin Nutr Metab Care 2009; 12:196-200. [PMID: 19202391 DOI: 10.1097/mco.0b013e328321cd8f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Technological innovations in the ICU have lead to extraordinary advances in modern critical care. Renal replacement therapy (RRT) innovations and ventricular assist devices (VAD) are now becoming common interventions in the ICU environment. The purpose of this article is to describe the impact of RRT and VAD on critical care medicine with particular reference to metabolic care. RECENT FINDINGS Continuous venovenous hemofiltration and slow low efficient daily dialysis are effective modalities of RRT in hemodynamically unstable patients. These continuous forms of RRT can result in accentuated protein and nutrient losses but also provide an opportunity for intradialytic parenteral nutrition support. VAD patients typically have cardiac cachexia and develop chronic critical illness syndrome. Intensive metabolic support, incorporating trophic, concentrated, semielemental enteral nutrition, supplemental parenteral nutrition, and intensive insulin therapy is a rational strategy to implement in VAD patients. Unfortunately, there is insufficient evidence at this time to support the routine use of these nutritional interventions with RRT and VAD. SUMMARY Patients requiring RRT or VAD are at high nutritional risk, which negatively affects ICU outcome. Prompt nutritional risk assessment and early optimization of metabolic care is crucial in this patient population.
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Affiliation(s)
- Corey Scurlock
- Cardiothoracic Surgical Intensive Care Unit, Department of Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
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23
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Abstract
During the past half decade there has been a paradigm shift in the view of acute kidney disease that has resulted in a change in nomenclature from the older term, "acute renal failure," to "acute kidney injury" (AKI). This article reviews the new criteria for diagnosis and staging of AKI and summarizes the current understanding of the many causes of AKI and the approach to diagnosis and management.
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Affiliation(s)
- Patricia Khalil
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, A-919 Sciafe Hall, 3550 Terrace Street, Pittsburgh, PA 15213, USA
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24
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Btaiche IF, Mohammad RA, Alaniz C, Mueller BA. Amino Acid Requirements in Critically Ill Patients with Acute Kidney Injury Treated with Continuous Renal Replacement Therapy. Pharmacotherapy 2008; 28:600-13. [DOI: 10.1592/phco.28.5.600] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Latif MMAE, . EMD, . LMAEL, . NAEL. Urinary Epidermal Growth Factor Excretion: A Useful Prognostic Marker for Progression of Renal Damage in Children. JOURNAL OF MEDICAL SCIENCES 2007. [DOI: 10.3923/jms.2007.1171.1176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Affiliation(s)
- Abiodun A Omoloja
- Nephrology Department, The Children's Medical Center, Dayton, Ohio, USA
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López-Herce J, Sánchez C, Carrillo A, Mencía S, Santiago MJ, Bustinza A, Vigil D. Transpyloric enteral nutrition in the critically ill child with renal failure. Intensive Care Med 2006; 32:1599-605. [PMID: 16826386 DOI: 10.1007/s00134-006-0271-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 06/08/2006] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To study the efficacy and tolerance of transpyloric enteral nutrition (TEN) in the critically ill child with acute renal failure (ARF). DESIGN Prospective observational study. SETTING Paediatric intensive care unit. PATIENTS Critically ill children with ARF who received TEN were included in the study. They were compared with the remaining 473 critically ill children receiving TEN in this period. Tolerance of nutrition and gastrointestinal complications were assessed. INTERVENTION Transpyloric enteral nutrition. MEASUREMENTS AND RESULTS Fifty-three critically ill children with ARF aged between 3 days and 17 years received TEN. Children with ARF more frequently received parenteral nutrition before TEN (56.6%) than the other patients (17.5%). The incidence of shock, hepatic alterations and mortality was significantly higher in patients with ARF than in the remaining children. In children with ARF the mean duration of the TEN was 16.5-27.3 days and the maximum caloric intake was 77-26.7 kcal/kg/day. Thirteen patients (24.5%) presented gastrointestinal complications, 9 (17%) abdominal distension and/or excessive gastric residue, 5 (9.4%) diarrhoea, 1 necrotising enterocolitis and 1 duodenal perforation. The frequency of gastrointestinal complications was significantly higher in children with ARF. TEN was definitive suspended in five patients due to gastrointestinal complications. Four of these patients were treated with continuous renal replacement therapy. Thirty percent of patients died during TEN. In only one patient was the death related to complications of the nutrition. CONCLUSIONS Critically ill children with ARF tolerate TEN, although the incidence of gastrointestinal complications is higher than in other critically ill children.
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Affiliation(s)
- Jesús López-Herce
- Gregorio Marañón General University Hospital, Paediatric Intensive Care Unit, Dr Castelo 47, 28009 Madrid, Spain.
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28
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Gill N, Nally JV, Fatica RA. Renal failure secondary to acute tubular necrosis: epidemiology, diagnosis, and management. Chest 2005; 128:2847-63. [PMID: 16236963 DOI: 10.1378/chest.128.4.2847] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute tubular necrosis (ATN) is a form of acute renal failure (ARF) that is common in hospitalized patients. In critical care units, it accounts for about 76% of cases of ARF. Despite the introduction of hemodialysis > 30 years ago, the mortality rates from ATN in hospitalized and ICU patients are about 37.1% and 78.6%, respectively. The purpose of this review is to discuss briefly the cause, diagnosis, and epidemiology of ARF, and to review in depth the clinical trials performed to date that have examined the influence of growth factors, hormones, antioxidants, diuretics, and dialysis. In particular, the role of the dialysis modality, dialyzer characteristics, and dosing strategies are discussed.
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Affiliation(s)
- Namita Gill
- Department of General Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA.
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29
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Fiaccadori E, Maggiore U, Rotelli C, Giacosa R, Picetti E, Parenti E, Meschi T, Borghi L, Tagliavini D, Cabassi A. Effects of different energy intakes on nitrogen balance in patients with acute renal failure: a pilot study. Nephrol Dial Transplant 2005; 20:1976-80. [PMID: 15998652 DOI: 10.1093/ndt/gfh956] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Thus far, there have been no controlled studies to examine optimal levels of energy provision in critically ill patients with acute renal failure (ARF) receiving artificial nutrition. METHODS After a 24 h nitrogen-free regimen (20% dextrose), we assigned during an open-label, AB/BA-crossover-trial, 10 ARF patients receiving both total parenteral nutrition (TPN) and renal replacement therapy (seven males; mean age 72 years, range 60-83; mean APACHE II score 27.1, range 23-34, mechanical ventilation 8/10) to a lower calorie-TPN regimen (30 kcal/kg/day) and to a higher calorie-TPN regimen (40 kcal/kg/day), each for 3 days. Nitrogen intake was 0.25 g/kg/day for both regimens. We estimated nitrogen balance, protein catabolic rate and urea generation rate by urea kinetic methods based on both timed blood samples of serum urea and direct urea quantification from dialysis fluid. RESULTS Two patients were excluded from the analysis (due to death and serum triglycerides above 5.1 mmol/l, respectively). Compared with the lower calorie-TPN, the higher calorie-TPN regimen did not improve estimated nitrogen balance [+1.55 g/day (95% confidence interval: -0.95 to +4.05, P = 0.18)], protein catabolic rate [-0.10 g/kg/day (-0.33 to +0.14, P = 0.35)], or urea generation rate [-1.3 mg/min (-5.2 to +2.7, P = 0.46)], whereas it increased serum triglycerides [+1.36 mmol/l (+0.53 to +2.19, P = 0.007)], glucose [+1.15 mmol/l (+0.07 to +2.24, P = 0.041)], insulin need [+20.4 U/day (+8.3 to +32.6, P = 0.006)] and nutritional fluid administration [+468 ml/day (+370 to +566, P<0.001)]. CONCLUSIONS The present study, conducted in a small group of subjects, shows that in critically ill patients with ARF on a nitrogen intake of 0.25 g/kg/day, an energy provision of 40 kcal/kg/day does not improve nitrogen balance estimates compared with a 30 kcal/kg/day intake; instead, it may increase the risk of artificial nutrition-related side-effects.
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Affiliation(s)
- Enrico Fiaccadori
- Dipartimento di Clinica Medica, Nefrologia and Scienze della Prevenzione, Università degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy.
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30
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Abstract
Despite improvements in medical and dialytic therapies, mortality rates for patients with complicated acute renal failure (ARF) remains tragically high-above 50%. Mortality rates also remain persistently high in patients with ARF and preexisting or hospital-acquired malnutrition. ARF causes significant changes in substrate utilization largely because of the metabolic consequences of acute uremia compounded by underlying stress from acute illness. Alterations in protein or amino acid, carbohydrate, and lipid metabolism as well as fluid, electrolyte, and acid-base balance need to be considered when providing nutritional therapy in patients with ARF. Also, the degree of renal impairment, which influences the need for renal replacement therapy (RRT), impacts nutritional requirements. As medical management is becoming highly aggressive in treating ARF with RRT, the ability to provide adequate nutrition is enhanced; however, no consensus on optimal caloric and macro-/micronutrient requirements is available. More current research is required to clarify nutritional needs of this patient population. Nevertheless, individualizing nutrition care and integrating nutritional therapies within a team setting is essential in providing optimal patient care in the presence of ARF.
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Affiliation(s)
- Jill M Strejc
- Department of Nutrition, UCLA Medical Center, Los Angeles, CA 90095-1661, USA.
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31
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Berger MM, Shenkin A, Revelly JP, Roberts E, Cayeux MC, Baines M, Chioléro RL. Copper, selenium, zinc, and thiamine balances during continuous venovenous hemodiafiltration in critically ill patients. Am J Clin Nutr 2004; 80:410-6. [PMID: 15277163 DOI: 10.1093/ajcn/80.2.410] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Acute renal failure is a serious complication in critically ill patients and frequently requires renal replacement therapy, which alters trace element and vitamin metabolism. OBJECTIVE The objective was to study trace element balances during continuous renal replacement therapy (CRRT) in intensive care patients. DESIGN In a prospective randomized crossover trial, patients with acute renal failure received CRRT with either sodium bicarbonate (Bic) or sodium lactate (Lac) as a buffering agent over 2 consecutive 24-h periods. Copper, selenium, zinc, and thiamine were measured with highly sensitive analytic methods in plasma, replacement solutions, and effluent during 8-h periods. Balances were calculated as the difference between fluids administered and effluent losses and were compared with the recommended intakes (RI) from parenteral nutrition. RESULTS Nineteen sessions were conducted in 11 patients aged 65 +/- 10 y. Baseline plasma concentrations of copper were normal, whereas those of selenium and zinc were below reference ranges; glutathione peroxidase was in the lower range of normal. The replacement solutions contained no detectable copper, 0.01 micromol Se/L (Bic and Lac), and 1.42 (Bic) and 0.85 (Lac) micromol Zn/L. Micronutrients were detectable in all effluents, and losses were stable in each patient; no significant differences were found between the Bic and Lac groups. The 24-h balances were negative for selenium (-0.97 micromol, or 2 times the daily RI), copper (-6.54 micromol, or 0.3 times the daily RI), and thiamine (-4.12 mg, or 1.5 times the RI) and modestly positive for zinc (20.7 micromol, or 0.2 times the RI). CONCLUSIONS CRRT results in significant losses and negative balances of selenium, copper, and thiamine, which contribute to low plasma concentrations. Prolonged CRRT is likely to result in selenium and thiamine depletion despite supplementation at recommended amounts.
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Affiliation(s)
- Mette M Berger
- Surgical Intensive Care Unit and Burns Centre, University Hospital, BH 08.660, CH 1011 Lausanne, Switzerland.
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32
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Fischer JR, Pantaleo V, Francey T, Cowgill LD. Veterinary hemodialysis: advances in management and technology. Vet Clin North Am Small Anim Pract 2004; 34:935-67, vi-vii. [PMID: 15223210 DOI: 10.1016/j.cvsm.2004.03.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemodialysis (HD) is a renal replacement therapy that can enable recovery of patients in acute kidney failure and prolong survival for patients with end-stage kidney failure. HD is also uniquely suited for management of refractory volume overload and removal of certain toxins from the bloodstream. Over the last decade, veterinary experience with HD has deepened and refined and its geographic availability has increased. As awareness of the usefulness and availability of dialytic therapy increases among veterinarians and pet owners and the number of veterinary dialysis facilities increases, dialytic management will become the standard of advanced care for animals with severe intractable uremia.
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Affiliation(s)
- Julie R Fischer
- University of California Veterinary Medical Center at San Diego, PO Box 9415, 6525 Calle del Nido, Rancho Santa Fe, CA, USA.
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33
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Druml W. Acute renal failure is not a ?cute? renal failure! Intensive Care Med 2004; 30:1886-90. [PMID: 15480546 DOI: 10.1007/s00134-004-2344-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2004] [Accepted: 05/14/2004] [Indexed: 10/26/2022]
Affiliation(s)
- Wilfred Druml
- Department of Medicine III, Division of Nephrology, Vienna General Hospital, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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Schmidt A, Fabrizii V, Maier C, Riedl M, Schmidt A, Kotzmann H, Geyer G, Luger A. Normal regulation of elevated plasma ghrelin concentrations in dialysis patients. Wien Klin Wochenschr 2004; 116:235-9. [PMID: 15143862 DOI: 10.1007/bf03041053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic renal failure is often associated with malnutrition, and malnourished patients are subject to increased morbidity and mortality. Therefore plasma concentrations of the stomach-derived peptide hormone ghrelin, which has been shown to exert potent GH-releasing and appetite-stimulating effects, were determined and correlated with nutritional parameters. METHODS Twenty-four patients (15 male, 9 female) undergoing hemodialysis (HD) were studied. In addition, six patients were studied before and one hour after ingestion of a meal and five were studied immediately before and at the end of the dialysis session. RESULTS Chronic renal insufficiency was associated with significantly elevated ghrelin levels (320.1 +/- 57 fmol/mL vs. 75.6 +/- 12.4 fmol/mL in controls; p < 0.007). Plasma ghrelin concentrations were also significantly higher in the 16 normal-weight patients than in the eight overweight or obese patients (399.6 +/- 76.3 fmol/mL vs. 161.1 +/- 41.3 fmol/mL; p < 0.03). Ingestion of food induced a decrease in five out of six patients tested (mean 242.3 +/- 66.5 fmol/mL vs. 186 +/- 30.7 fmol/mL; n.s.). HD also resulted in a significant decrease of elevated ghrelin concentrations: ghrelin was in the normal range at the end of HD in four of the five patients tested. Plasma ghrelin concentrations did not correlate with nutritional parameters except for cholinesterase which was negatively correlated to ghrelin. CONCLUSION Plasma ghrelin concentrations are elevated in HD. The fact that ghrelin concentrations are higher in normal-weight than in overweight or obese HD patients and suppressed after ingestion of a meal suggests that the regulation of ghrelin release is retained in HD patients, albeit shifted to a higher level.
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Affiliation(s)
- Adele Schmidt
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, University of Vienna, General Hospital of Vienna, Vienna, Austria
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35
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Fiaccadori E, Maggiore U, Giacosa R, Rotelli C, Picetti E, Sagripanti S, Melfa L, Meschi T, Borghi L, Cabassi A. Enteral nutrition in patients with acute renal failure. Kidney Int 2004; 65:999-1008. [PMID: 14871420 DOI: 10.1111/j.1523-1755.2004.00459.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Systematic studies on safety and efficacy of enteral nutrition in patients with acute renal failure (ARF) are lacking. METHODS We studied enteral nutrition-related complications and adequacy of nutrient administration during 2525 days of artificial nutrition in 247 consecutive patients fed exclusively by the enteral route: 65 had normal renal function, 68 had ARF not requiring renal replacement therapy, and 114 required renal replacement therapy. RESULTS No difference was found in gastrointestinal or mechanical complications between ARF patients and patients with normal renal function, except for high gastric residual volumes, which occurred in 3.1% of patients with normal renal function, 7.3% of patients with ARF not requiring renal replacement therapy, 13.2% of patients with ARF on renal replacement therapy (P= 0.02 for trend), and for nasogastric tube obstruction: 0.0%, 5.9%, 14%, respectively (P < 0.001). Gastrointestinal complications were the most frequent cause of suboptimal delivery; the ratio of administered to prescribed daily volume was well above 90% in all the three groups. Definitive withdrawal of enteral nutrition due to complications was documented in 6.1%, 13.2%. and 14.9% of patients, respectively (P= 0.09 for trend). At regimen, mean delivered nonprotein calories were 19.8 kcal/kg (SD 4.6), 22.6 kcal/kg (8.4), 23.4 kcal/kg (6.5); protein intake was 0.92 g/kg (0.21), 0.87 g/kg (0.25), and 0.92 g/kg (0.21), the latter value being below that currently recommended for ARF patients on renal replacement therapy. Median fluid intake with enteral nutrition was 1440 mL (range 720 to 1960), 1200 (720 to 2400), and 960 (360 to 1920). CONCLUSION Enteral nutrition is a safe and effective nutritional technique to deliver artificial nutrition in ARF patients. Parenteral amino acid supplementation may be required, especially in patients with ARF needing renal replacement therapy.
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Affiliation(s)
- Enrico Fiaccadori
- Dipartimento di Clinica Medica, Nefrologia & Scienze della Prevenzione, Università degli Studi di Parma, Italy.
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Scheinkestel CD, Kar L, Marshall K, Bailey M, Davies A, Nyulasi I, Tuxen DV. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003; 19:909-16. [PMID: 14624937 DOI: 10.1016/s0899-9007(03)00175-8] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We measured the energy and protein needs in 50 sequential, critically ill, ventilated patients requiring continuous renal replacement therapy (CRRT) for renal failure by using indirect calorimetry and three sequential isocaloric protein-feeding regimes of 1.5, 2.0, and 2.5 g. kg(-1). d(-1). We also assessed the compliance of actual feeding with target feeding and correlated the predictive energy requirements of the formulae with the actual energy expenditure (EE) measured by indirect calorimetry. We also determined whether these feeding regimes affected patient outcome. METHODS The energy and protein needs of 50 consecutive, critically ill patients (31 male; age 53.3 +/- 17.4 y; Acute Physiology and Chronic Health Evaluation (APACHE II) score: 26.0 +/- 8.0; Acute Physiology and Chronic Health Evaluation score predicted risk of death: 50.0 +/- 25.0%) were assessed by using indirect calorimetry and ultrafiltrate nitrogen loss. Entry into this study was on commencement of CRRT. To eliminate any beneficial effect from the passage of time on nitrogen balance, 10 of the 50 patients were randomized to receive 2.0 g. kg(-1). d(-1) throughout the study, and the others received an escalating isocaloric feeding regime (1.5, 2.0, and 2.5 g. kg(-1). d(-1)) at 48-h intervals. Enteral feeding was preferred, but if this was not tolerated or unable to meet target, it was supplemented or replaced by a continuous infusion of total parenteral nutrition. Energy was given to meet caloric requirements as predicted by the Schofield equation corrected by stress factors or based on the metabolic cart readings of EE and was kept constant for all patients throughout the trial. Patients were stabilized on each feeding regime for at least 24 h before samples of dialysate were taken for nitrogen analysis at 8-h intervals on the second day. CRRT was performed by using a blood pump with a blood flow of 100 to 175 mL/min. Dialysate was pumped in and out counter-currently to the blood flow at 2 L/h. A biocompatible polyacrylonitrile hemofilter was used in all cases. RESULTS EE was 2153 +/- 380 cal/d and increased by 56 +/- 24 cal/d (P < 0.0001) throughout the 6-d study period to 2431 +/- 498 cal/d. At study entry, the mean predicted (Schofield) caloric requirement was 2101 +/- 410. Patients received 99% of the predicted energy requirements. However, the mean EE was 11% higher at 2336 +/- 482 calories. This difference was not uniform. If the predicted caloric requirement was less than 2500, the EE exceeded the predicted by an average of 19%. If the predicted caloric requirement was greater than 2500, the EE on average was 6% less than predicted. This relation was significant (P = 0.025) and has not been described previously. Nitrogen balance was inversely related to EE (P = 0.05), positively related to protein intake (P = 0.0075), and more likely to be attained with protein intakes larger than 2 g. kg(-1). d(-1) (P = 0.0001). Nitrogen balance became positive in trial patients over time but were negative in control patients over time (P = 0.0001). Nitrogen balance was directly associated with hospital outcome (P = 0.03) and intensive care unit outcome (P = 0.02). For every 1-g/d increase in nitrogen balance, the probability of survival increased by 21% (P = 0.03; odds ratio, 1.211; 95% confidence limits, 1.017,1.443). Further, although enterally and parenterally fed patients had lower mortalities than predicted, the presence of enteral feeding, even after adjusting for predicted risk of death, had a statistically significant benefit to patient outcome (P = 0.04). CONCLUSIONS This study found that a metabolic cart can improve the accuracy of energy provision and that a protein intake of 2.5 g. kg(-1). d(-1) in these patients increases the likelihood of achieving a positive nitrogen balance and improving survival. Enteral feeding is preferable, but if this is not possible or does not achieve the target, then it should be supplemented by parenteral feeding.
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Affiliation(s)
- C D Scheinkestel
- Department of Intensive Care, Alfred Hospital, Melbourne, Australia, Australia.
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Abstract
Acute renal failure (ARF) is associated with morbidity and mortality in excess of 50% in the intensive care unit (ICU) setting. A variety of outcome measures have been described in published reports of ARF, however, the studies often do not distinguish between clinical outcomes and surrogate endpoints. Multiple factors can influence these outcomes, including variations in practice. It is important to be aware of the potential effects of these factors when clinical trials are planned and executed for ARF patients. For any intervention trial, knowledge of the natural history of the disease and process of care informs the design and conduct of the trial. Standardization of a definition for ARF and of the criteria for initiation, frequency, duration, and withdrawal of dialysis support would be of great benefit. This article provides a critical appraisal of outcomes research in ARF and describes an approach for selecting appropriate endpoints for future clinical research in ARF.
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Affiliation(s)
- Ravindra L Mehta
- Department of Medicine, University of California, San Diego, CA, USA.
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Émulsions lipidiques et durée d'efficacité des hémofiltres dans l'hémodiafiltration continue. NUTR CLIN METAB 2002. [DOI: 10.1016/s0985-0562(02)00115-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Despite the increasing obesity of the American population, many chronically ill patients are malnourished. When this malnutrition is combined with the hypermetabolic response and protein catabolism of an acute event, such as an operation, nutritional support becomes an important facet for optimal critical care. This chapter reviews the basic tenants of nutritional support with special emphasis on patients with pulmonary compromise. Important aspects of caloric and protein support are discussed and enteral nutrition is emphasized because of its numerous advantages and documented improvement in outcome.
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Affiliation(s)
- Katherine Trahan
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1173, USA.
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