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Lee YF, Lin PR, Wu SH, Hsu HH, Yang SY, Kor CT. Impact of the prognostic nutritional index on renal replacement therapy-free survival and mortality in patients on continuous renal replacement therapy. Ren Fail 2024; 46:2365394. [PMID: 38874108 PMCID: PMC11232640 DOI: 10.1080/0886022x.2024.2365394] [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: 01/25/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND The survival of critically ill patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT) is highly dependent on their nutritional status. OBJECTIVES The prognostic nutritional index (PNI) is an indicator used to assess nutritional status and is calculated as: PNI = (serum albumin in g/dL) × 10 + (total lymphocyte count in/mm3) × 0.005. In this retrospective study, we investigated the correlation between this index and clinical outcomes in critically ill patients with AKI receiving CRRT. METHODS We analyzed data from 2076 critically ill patients admitted to the intensive care unit at Changhua Christian Hospital, a tertiary hospital in central Taiwan, between January 1, 2010, and April 30, 2021. All these patients met the inclusion criteria of the study. The relationship between PNI and renal replacement therapy-free survival (RRTFS) and mortality was examined using logistic regression models, Cox proportional hazard models, and propensity score matching. High utilization rate of parenteral nutrition (PN) was observed in our study. Subgroup analysis was performed to explore the interaction effect between PNI and PN on mortality. RESULTS Patients with higher PNI levels exhibited a greater likelihood of achieving RRTFS, with an adjusted odds ratio of 2.43 (95% confidence interval [CI]: 1.98-2.97, p-value < 0.001). Additionally, these patients demonstrated higher survival rates, with an adjusted hazard ratio of 0.84 (95% CI: 0.72-0.98) for 28-day mortality and 0.80 (95% CI: 0.69-0.92) for 90-day mortality (all p-values < 0.05), compared to those in the low PNI group. While a high utilization rate of parenteral nutrition (PN) was observed, with 78.86% of CRRT patients receiving PN, subgroup analysis showed that high PNI had an independent protective effect on mortality outcomes in AKI patients receiving CRRT, regardless of their PN status. CONCLUSIONS PNI can serve as an easy, simple, and efficient measure of lymphocytes and albumin levels to predict RRTFS and mortality in AKI patients with require CRRT.
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Affiliation(s)
- Yu-Fu Lee
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Pei-Ru Lin
- Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
| | - Shin-Hwar Wu
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsin-Hui Hsu
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Shu-Yun Yang
- Division of Critical Care Internal Medicine, Department of Emergency Medicine and Critical Care, Changhua Christian Hospital, Changhua, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua, Taiwan
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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2
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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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3
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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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4
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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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5
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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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6
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Lumlertgul N, Cameron LK, Bear DE, Ostermann M. Micronutrient Losses during Continuous Renal Replacement Therapy. Nephron Clin Pract 2023; 147:759-765. [PMID: 37611551 DOI: 10.1159/000531947] [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: 05/16/2023] [Accepted: 07/09/2023] [Indexed: 08/25/2023] Open
Abstract
Acute kidney injury impacts the micronutrient status by various mechanisms including decreased enteral absorption, changes in redistribution, altered metabolism, and increased consumption. When renal replacement therapy (RRT) is applied, there are additional losses of vitamins, trace elements, and amino acids, and their derivatives due to diffusion or adhesion. Varied data exist regarding the degree of micronutrient losses and plasma concentrations in patients who receive RRT, and these differ by RRT modality, dose, duration, and type of micronutrient. Water-soluble vitamins, selenium, copper, and carnitine are among the most frequently reported depleted nutrients. The role of micronutrient supplementation in critically ill patients undergoing RRT and the optimal dose and mode of administration are yet to be determined.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand,
- Faculty of Medicine, Centre of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand,
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK,
| | - Lynda K Cameron
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College London, London, UK
| | - Danielle E Bear
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, Guy's and St Thomas' NHS Foundation Trust, Department of Critical Care, London, UK
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7
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Carnitine Deficiency after Long-Term Continuous Renal Replacement Therapy. Case Rep Crit Care 2022; 2022:4142539. [PMID: 36035086 PMCID: PMC9402317 DOI: 10.1155/2022/4142539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
A 60-year-old man was admitted in the intensive care unit (ICU) for a rapidly progressive respiratory failure due to SARS-CoV-2 infection. He developed numerous complications including acute kidney injury (AKI) requiring prolonged continuous renal replacement therapy (CRRT). Enteral feeding was initiated on day 8. Despite nutritional management, there was a remarkable amyotrophy and weight loss. On day 85 in the ICU, the patient became progressively unresponsive. An extensive metabolic workup was performed, and blood results showed hyperammoniemia and hypertriglyceridemia. Plasma free carnitine level was low, as was also copper. After carnitine supplementation, the neurological condition rapidly improved, and metabolic perturbations regressed. Prolonged CRRT may be complicated by clinically significant deficiency in micronutrients and trace elements.
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Kelley J, Sullivan E, Norris M, Sullivan S, Parietti J, Kellogg K, Scott AI. Carnitine deficiency among hospitalized pediatric patients: A retrospective study of critically ill patients receiving extracorporeal membrane oxygenation therapy. JPEN J Parenter Enteral Nutr 2021; 45:1663-1672. [PMID: 34415080 PMCID: PMC9293107 DOI: 10.1002/jpen.2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background The metabolic demands associated with critical illness place patients at risk for nutrition deficits. Carnitine is a small molecule essential for fatty acid oxidation and gluconeogenesis. Secondary carnitine deficiency can have clinically significant complications and has been observed anecdotally in patients receiving extracorporeal membrane oxygenation (ECMO) therapy at our institution. Guidelines for monitoring and supplementing carnitine are lacking. This retrospective study determined whether critically ill pediatric patients receiving ECMO have an increased risk of carnitine deficiency. Methods Acylcarnitine analysis was performed on residual specimens from patients who received ECMO therapy. The control data were a convenience sample gathered by chart review of patients who had been tested for carnitine during a hospitalization. Results Acylcarnitines were measured in 217 non‐ECMO patients and 81 ECMO patients. Carnitine deficiency, based on age‐specific reference ranges, was observed in 41% of ECMO cases compared with 21% of non‐ECMO cases. Multivariable analysis of age‐matched patients identified that the odds of carnitine deficiency were significantly lower among patients on the floor compared with ECMO patients (odds ratio, 0.21; 95% CI, 0.10–0.44). Age‐specific frequency of qualitative carnitine deficiency ranged from 15% (patients >5 years old) to 56% (patients 1 week to 1 month old) in ECMO patients and 15% (patients >5 years old) to 34% (patients 1–5 years old) in non‐ECMO patients. Conclusion In this study, ECMO patients were carnitine deficient more frequently compared with other inpatients, with the highest rates of deficiency among ECMO patients between 1 week and 1 month old.
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Affiliation(s)
- Jenna Kelley
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin Sullivan
- Biostatistics, Epidemiology, and Analytics for Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Marie Norris
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, USA
| | - Sarah Sullivan
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jennifer Parietti
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly Kellogg
- Department of Nutrition Services, Seattle Children's Hospital, Seattle, Washington, USA
| | - Anna I Scott
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Berger MM, Broman M, Forni L, Ostermann M, De Waele E, Wischmeyer PE. Nutrients and micronutrients at risk during renal replacement therapy: a scoping review. Curr Opin Crit Care 2021; 27:367-377. [PMID: 34039873 PMCID: PMC8270509 DOI: 10.1097/mcc.0000000000000851] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Malnutrition is frequent in patients with acute kidney injury. Nutrient clearance during renal replacement therapy (RRT) potentially contributes to this complication. Although losses of amino acid, trace elements and vitamins have been described, there is no clear guidance regarding the role of micronutrient supplementation. RECENT FINDINGS A scoping review was conducted with the aim to review the existing literature on micronutrients status during RRT: 35 publications including data on effluent losses and blood concentrations were considered relevant and analysed. For completeness, we also included data on amino acids. Among trace elements, negative balances have been shown for copper and selenium: low blood levels seem to indicate potential deficiency. Smaller size water soluble vitamins were found in the effluent, but not larger size liposoluble vitamins. Low blood values were frequently reported for thiamine, folate and vitamin C, as well as for carnitine. All amino acids were detectable in effluent fluid. Duration of RRT was associated with decreasing blood values. SUMMARY Losses of several micronutrients and amino acids associated with low blood levels represent a real risk of deficiency for vitamins B1 and C, copper and selenium: they should be monitored in prolonged RRT. Further Research is urgently required as the data are insufficient to generate strong conclusions and prescription recommendations for clinical practice.
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Affiliation(s)
- Mette M. Berger
- Lausanne University Hospital (CHUV) & University of Lausanne, Lausanne, Switzerland
| | - Marcus Broman
- Perioperative and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Lui Forni
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Department of Clinical & Experimental Medicine, School of Biosciences & Medicine, University of Surrey, Surrey
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas’ Foundation Hospital, Department of Critical Care, London, UK
| | | | - Paul E. Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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10
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Sgambat K, Clauss S, Moudgil A. Effect of levocarnitine supplementation on myocardial strain in children with acute kidney injury receiving continuous kidney replacement therapy: a pilot study. Pediatr Nephrol 2021; 36:1607-1616. [PMID: 33389092 DOI: 10.1007/s00467-020-04862-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/13/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Carnitine plays a key role in energy production in the myocardium and is efficiently removed by continuous kidney replacement therapy (CKRT). Effects of levocarnitine supplementation on myocardial function in children receiving CKRT have not been investigated. METHODS This controlled pilot cohort study of 48 children investigated effects of levocarnitine supplementation on myocardial strain in children receiving CKRT for acute kidney injury (AKI). Children (n = 9) with AKI had total (TC) and free plasma carnitine (FC) measurements and echocardiogram for longitudinal and circumferential strain at baseline (prior to CKRT) and follow-up (on CKRT for > 1 week with intravenous levocarnitine supplementation, 20 mg/kg/day). Intervention group was compared with three controls: (1) CKRT controls (n = 10) received CKRT > 1 week (+AKI, no levocarnitine), (2) ICU controls (n = 9) were parenteral nutrition-dependent for > 1 week (no AKI, no levocarnitine), and (3) healthy controls (n = 20). RESULTS In the Intervention group, TC and FC increased from 36.0 and 18 μmol/L to 93.5 and 74.5 μmol/L after supplementation. TC and FC of unsupplemented CKRT controls declined from 27.2 and 18.6 μmol/L to 12.4 and 6.6 μmol/L, which was lower vs. ICU controls (TC 32.0, FC 26.0 μmol/L), p < 0.05. Longitudinal and circumferential strain of the Intervention group improved from - 18.5% and - 18.3% to - 21.1% and - 27.6% after levocarnitine supplementation; strain of CKRT controls (-14.4%, -20%) remained impaired and was lower vs. Intervention and Healthy Control groups at follow-up, p < 0.05. CONCLUSIONS Levocarnitine supplementation is associated with repletion of plasma carnitine and improvement in myocardial strain and may benefit pediatric patients undergoing prolonged CKRT.
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Affiliation(s)
- Kristen Sgambat
- Department of Nephrology, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC, 20010, USA.
| | - Sarah Clauss
- Department of Cardiology, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Asha Moudgil
- Department of Nephrology, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC, 20010, USA
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Ostermann M, Lumlertgul N, Mehta R. Nutritional assessment and support during continuous renal replacement therapy. Semin Dial 2021; 34:449-456. [PMID: 33909935 DOI: 10.1111/sdi.12973] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/24/2021] [Accepted: 03/19/2021] [Indexed: 01/03/2023]
Abstract
Malnutrition is highly prevalent in patients with acute kidney injury, especially in those receiving renal replacement therapy (RRT). For the assessment of nutritional status, a combination of screening tools, anthropometry, and laboratory parameters is recommended rather than a single test. To avoid underfeeding and overfeeding during RRT, energy expenditure should be measured by indirect calorimetry or calculated using predictive equations. Nitrogen balance should be periodically measured to assess the degree of catabolism and to evaluate protein intake. However, there is limited data for nutritional targets specifically for patients on RRT, such as protein intake. The composition of commercial solutions for continuous renal replacement therapy (CRRT) varies. CRRT itself can be associated with both, nutrient losses into the effluent fluid and caloric gain from dextrose, lactate, and citrate. The role of micronutrient supplementation, and potential use of micronutrient enriched CRRT solutions in this setting is unknown, too. This review provides an overview of existing knowledge and uncertainties related to nutritional aspects in patients on CRRT and emphasizes the need for more research in this area.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' Hospital, London, UK
| | - Nuttha Lumlertgul
- Department of Critical Care, Guy's & St Thomas' Hospital, London, UK.,Division of Nephrology, Department of Internal Medicine and Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Ravindra Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA, USA
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Honore PM, Barreto Gutierrez L, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Liver injury without liver failure in COVID-19 patients: how to explain, in some cases, elevated ammonia without hepatic decompensation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:352. [PMID: 32546201 PMCID: PMC7296517 DOI: 10.1186/s13054-020-03088-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Leonel Barreto Gutierrez
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Luc Kugener
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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13
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Ostermann M, Summers J, Lei K, Card D, Harrington DJ, Sherwood R, Turner C, Dalton N, Peacock J, Bear DE. Micronutrients in critically ill patients with severe acute kidney injury - a prospective study. Sci Rep 2020; 10:1505. [PMID: 32001725 PMCID: PMC6992767 DOI: 10.1038/s41598-020-58115-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/09/2019] [Indexed: 11/24/2022] Open
Abstract
Malnutrition is common in patients with acute kidney injury (AKI) and the risk of mortality is high, especially if renal replacement therapy is needed. Between April 2013 through April 2014, we recruited critically ill adult patients (≥18 years) with severe AKI in two University hospitals in London, UK, and measured serial plasma concentrations of vitamin B1, B6, B12, C and D, folate, selenium, zinc, copper, iron, carnitine and 22 amino acids for six consecutive days. In patients receiving continuous renal replacement therapy (CRRT), the concentrations of the same nutrients in the effluent were also determined. CRRT patients (n = 31) had lower plasma concentrations of citrulline, glutamic acid and carnitine at 24 hrs after enrolment and significantly lower plasma glutamic acid concentrations (74.4 versus 98.2 μmol/L) at day 6 compared to non-CRRT patients (n = 24). All amino acids, trace elements, vitamin C and folate were detectable in effluent fluid. In >30% of CRRT and non-CRRT patients, the plasma nutrient concentrations of zinc, iron, selenium, vitamin D3, vitamin C, trytophan, taurine, histidine and hydroxyproline were below the reference range throughout the 6-day period. In conclusion, altered micronutrient status is common in patients with severe AKI regardless of treatment with CRRT.
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Affiliation(s)
- Marlies Ostermann
- King's College London, Guy's & St Thomas' Foundation Hospital, Department of Critical Care, London, UK.
| | - Jennifer Summers
- NIHR Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, School of Population Health and Environmental Sciences, London, UK
| | - Katie Lei
- Guy's & St Thomas' Foundation Hospital, Department of Critical Care, London, UK
| | - David Card
- Nutristasis Unit, Viapath, St Thomas' Hospital, London, UK
| | | | - Roy Sherwood
- King's College Hospital NHS Foundation Trust, Department of Clinical Biochemistry, London, UK
| | | | - Neil Dalton
- King's College London, WellChild Laboratory, London, UK
| | - Janet Peacock
- NIHR Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, School of Population Health and Environmental Sciences, London, UK
| | - Danielle E Bear
- King's College London, Guy's & St Thomas' Foundation Hospital, Department of Critical Care, London, UK
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Connor MJ, Karakala N. Continuous Renal Replacement Therapy: Reviewing Current Best Practice to Provide High-Quality Extracorporeal Therapy to Critically Ill Patients. Adv Chronic Kidney Dis 2017; 24:213-218. [PMID: 28778360 DOI: 10.1053/j.ackd.2017.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Continuous renal replacement therapy (CRRT) use continues to expand globally. Despite improving technology, CRRT remains a complex intervention. Delivery of high-quality CRRT requires close collaboration of a multidisciplinary team including members of the critical care medicine, nephrology, nursing, pharmacy, and nutrition support teams. While significant gaps in medical evidence regarding CRRT persist, the growing evidence base supports evolving best practice and consensus to define high-quality CRRT. Unfortunately, there is wide variability in CRRT operating characteristics and limited uptake of these best practices. This article will briefly review the current best practice on important aspects of CRRT delivery including CRRT dose, anticoagulation, dialysis vascular access, fluid management, and drug dosing in CRRT.
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Semba RD, Trehan I, Li X, Moaddel R, Ordiz MI, Maleta KM, Kraemer K, Shardell M, Ferrucci L, Manary M. Environmental Enteric Dysfunction is Associated with Carnitine Deficiency and Altered Fatty Acid Oxidation. EBioMedicine 2017; 17:57-66. [PMID: 28122695 PMCID: PMC5360565 DOI: 10.1016/j.ebiom.2017.01.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/03/2017] [Accepted: 01/17/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Environmental enteric dysfunction (EED), a condition characterized by small intestine inflammation and abnormal gut permeability, is widespread in children in developing countries and a major cause of growth failure. The pathophysiology of EED remains poorly understood. METHODS We measured serum metabolites using liquid chromatography-tandem mass spectrometry in 400 children, aged 12-59months, from rural Malawi. Gut permeability was assessed by the dual-sugar absorption test. FINDINGS 80.7% of children had EED. Of 677 serum metabolites measured, 21 were negatively associated and 56 were positively associated with gut permeability, using a false discovery rate approach (q<0.05, p<0.0095). Increased gut permeability was associated with elevated acylcarnitines, deoxycarnitine, fatty acid β-oxidation intermediates, fatty acid ω-oxidation products, odd-chain fatty acids, trimethylamine-N-oxide, cystathionine, and homocitrulline, and with lower citrulline, ornithine, polyphenol metabolites, hippurate, tryptophan, and indolelactate. INTERPRETATION EED is a syndrome characterized by secondary carnitine deficiency, abnormal fatty acid oxidation, alterations in polyphenol and amino acid metabolites, and metabolic dysregulation of sulfur amino acids, tryptophan, and the urea cycle. Future studies are needed to corroborate the presence of secondary carnitine deficiency among children with EED and to understand how these metabolic derangements may negatively affect the growth and development of young children.
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Affiliation(s)
- Richard D Semba
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Indi Trehan
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, USA
| | - Ximin Li
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ruin Moaddel
- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - M Isabel Ordiz
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, USA
| | | | - Klaus Kraemer
- Sight and Life, Basel, Switzerland; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michelle Shardell
- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Luigi Ferrucci
- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Mark Manary
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO, USA
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