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Sabatino A, Fiaccadori E, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Cuerda C, Bischoff SC. ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2024; 43:2238-2254. [PMID: 39178492 DOI: 10.1016/j.clnu.2024.08.002] [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: 07/15/2024] [Accepted: 08/02/2024] [Indexed: 08/25/2024]
Abstract
BACKGROUND AND AIMS Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD. METHODS The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process. RESULTS The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements. CONCLUSION The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.
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Affiliation(s)
- Alice Sabatino
- Division of Renal Medicine, Baxter Novum. Department of Clinical Science, Intervention and Technology. Karolinska Institute, Stockholm, Sweden.
| | - Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Department of Intensive Care Medicine, Universitair Ziekenhuis Brussel, Department of Clinical Nutrition, Vitality Research Group, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Brussels, Belgium
| | - Joop Jonckheer
- Department of intensive Care Medicine, University Hospital Brussel (UZB), Brussels, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussel, Belgium
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine. Universidad Complutense. Madrid, Spain
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Fukuda Y, Ushigome E, Yamazaki M, Fukui M. Postoperative Insulin Dose for Cardiac Artery Bypass Graft and Other Cardiac Surgeries in Patients with Type 2 Diabetes: A Retrospective Study. Vasc Health Risk Manag 2024; 20:59-68. [PMID: 38414907 PMCID: PMC10898479 DOI: 10.2147/vhrm.s447077] [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: 10/28/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024] Open
Abstract
Purpose Recommendations on perioperative glycemic control in cardiac surgery are based on coronary artery bypass graft surgery (CABG), though coronary artery disease and valvular disease are pathologically distinct. We aimed to compare the postoperative insulin requirement between CABG and other cardiac surgeries in type 2 diabetic patients and identify predictive factors for the maximum postoperative insulin dose. Patients and Methods We retrospectively included 60 Japanese patients with diabetes/glucose intolerance (HbA1c > 37 mmol/mol [5.6%]) who were hospitalized for cardiovascular surgery between April 2017 and March 2019. We categorized the subjects into the CABG and non-CABG groups, and performed subgroup analysis on patients who received postoperative insulin therapy. Results The CABG group required a significantly higher insulin dose on postoperative days 2, 5, 6, and 7, and a significantly higher maximum postoperative insulin dose (24.6 U vs 9.7 U, P < 0.001) than the non-CABG group. Multivariate linear regression analyses showed that the independent determinants of the maximum postoperative insulin dose were HbA1c and duration of diabetes in the non-CABG group, and HbA1c in the CABG group. Conclusion CABG had a higher postoperative insulin requirement than other cardiovascular surgeries; early aggressive insulin therapy is indicated, especially for patients with higher HbA1c levels/longer duration of diabetes.
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Affiliation(s)
- Yukiko Fukuda
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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3
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Fiaccadori E, Sabatino A, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Singer P, Cuerda C. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2021; 40:1644-1668. [PMID: 33640205 DOI: 10.1016/j.clnu.2021.01.028] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.
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Affiliation(s)
- Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alice Sabatino
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Adamasco Cupisti
- Nephrology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Intensive Care, University Hospital Brussels (UZB), Department of Nutrition, UZ Brussel, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Bruxelles, Belgium
| | | | - Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Uranga A, Quintana JM, Aguirre U, Artaraz A, Diez R, Pascual S, Ballaz A, España PP. Predicting 1-year mortality after hospitalization for community-acquired pneumonia. PLoS One 2018; 13:e0192750. [PMID: 29444151 PMCID: PMC5812619 DOI: 10.1371/journal.pone.0192750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/30/2018] [Indexed: 12/27/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a major public health problem with high short- and long-term mortality. The main aim of this study was to develop and validate a specific prognostic index for one-year mortality in patients admitted for CAP. Methods This was an observational, prospective study of adults aged ≥18 years admitted to Galdakao-Usansolo Hospital (Bizkaia, Spain) from January 2001 to July 2009 with a diagnosis of CAP surviving the first 15 days. The entire cohort was divided into two parts, in order to develop a one-year mortality predictive model in the derivation cohort, before validation using the second cohort. Results A total of 2351 patients were included and divided into a derivation and a validation cohort. After deaths within 15 days were excluded, one-year mortality was 10.63%. A predictive model was created in order to predict one-year mortality, with a weighted score that included: aged over 80 years (4 points), congestive heart failure (2 points), dementia (6 points), respiratory rate ≥30 breaths per minute (2 points) and blood urea nitrogen >30 mg/dL (3 points) as predictors of higher risk with C-index of 0.76. This new model showed better predictive ability than current risk scores, PSI, CURB65 and SCAP with C-index of 0.73, 0.69 and 0.70, respectively. Conclusions An easy-to-use score, called the one-year CAPSI, may be useful for identifying patients with a high probability of dying after an episode of CAP.
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Affiliation(s)
- Ane Uranga
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
- * E-mail:
| | - Jose M. Quintana
- Research Unit, Galdakao-Usansolo Hospital - Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain
| | - Urko Aguirre
- Research Unit, Galdakao-Usansolo Hospital - Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain
| | - Amaia Artaraz
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Rosa Diez
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Silvia Pascual
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Aitor Ballaz
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Pedro P. España
- Department of Respiratory Medicine, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
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Kamel AY, Dave NJ, Zhao VM, Griffith DP, Connor MJ, Ziegler TR. Micronutrient Alterations During Continuous Renal Replacement Therapy in Critically Ill Adults: A Retrospective Study. Nutr Clin Pract 2017; 33:439-446. [PMID: 28727945 DOI: 10.1177/0884533617716618] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is commonly used to provide renal replacement therapy in the intensive care unit. Limited published data suggest that CRRT may lead to depletion of water-soluble vitamins and trace elements. The goal of this study was to identify the incidence of trace element and vitamin deficiencies in critically ill patients during CRRT. MATERIALS AND METHODS This study is based on a retrospective chart review of patients who were referred to Emory University Hospital's nutrition support services and had at least 1 serum micronutrient level measured during CRRT (thiamin, pyridoxine, ascorbic acid, folate, zinc, and copper) between April 1, 2009, and June 1, 2012. RESULTS Seventy-five patients were included in the study. Nine of 56 patients (16%) had below-normal whole blood thiamin concentrations, and 38 of 57 patients (67%) had below-normal serum pyridoxine levels. Serum ascorbic acid and folate deficiencies were identified among 87% (13 of 15) and 33% (3 of 9) of the study patients, respectively. Nine of 24 patients had zinc deficiency (38%), and 41 of 68 patients had copper deficiency (60%). Of the 75 total subjects, 60 patients (80%) had below-normal levels of at least 1 of the micronutrients measured. CONCLUSIONS The incidence of various micronutrient deficiencies in critically ill patients who required CRRT was higher than previously reported. Prospective studies are needed to determine the impact of CRRT on micronutrient status and the potential clinical and metabolic efficacy of supplementation in the intensive care unit setting.
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Affiliation(s)
- Amir Y Kamel
- Department of Pharmacy, UF Health and University of Florida, Gainesville, Florida, USA
| | - Nisha J Dave
- Department of Pharmaceutical Services, Emory University Hospital, Atlanta, Georgia, USA
| | - Vivian M Zhao
- Department of Pharmaceutical Services, Emory University Hospital, Atlanta, Georgia, USA
| | - Daniel P Griffith
- Department of Pharmaceutical Services, Emory University Hospital, Atlanta, Georgia, USA
| | - Michael J Connor
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine and Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Center for Clinical and Molecular Nutrition, Emory University, Atlanta, Georgia, USA
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6
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Patkova A, Joskova V, Havel E, Kovarik M, Kucharova M, Zadak Z, Hronek M. Energy, Protein, Carbohydrate, and Lipid Intakes and Their Effects on Morbidity and Mortality in Critically Ill Adult Patients: A Systematic Review. Adv Nutr 2017; 8:624-634. [PMID: 28710148 PMCID: PMC5502871 DOI: 10.3945/an.117.015172] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The guidelines for nutritional support in critically ill adult patients differ in various aspects. The optimal amount of energy and nutritional substrates supplied is important for reducing morbidity and mortality, but unfortunately this is not well known, because the topic is complex and every patient is individual. The aim of this review was to gather recent pertinent information concerning the nutritional support of critically ill patients in the intensive care unit (ICU) with respect to the energy, protein, carbohydrate, and lipid intakes and the effect of their specific utilization on morbidity and mortality. Enteral nutrition (EN) is generally recommended over parenteral nutrition (PN) and is beneficial when administered within 24-48 h after ICU admission. In contrast, early PN does not provide substantial advantages in terms of morbidity and mortality, and the time when it is safe and beneficial remains unclear. The most advantageous recommendation seems to be administration of a hypocaloric (<20 kcal · kg-1 · d-1), high-protein diet (amino acids at doses of ≥2 g · kg-1 · d-1), at least during the first week of critical illness. Another important factor for reducing morbidity is the maintenance of blood glucose concentrations at 120-150 mg/dL, which is accomplished with the use of insulin and lower doses of glucose of 1-2 g · kg-1 · d-1, because this prevents the risk of hypoglycemia and is associated with a better prognosis according to recent studies. A fat emulsion is used as a source of required calories because of insulin resistance in the majority of patients. In addition, lipid oxidation in these patients is ∼25% higher than in healthy subjects.
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Affiliation(s)
- Anna Patkova
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Vera Joskova
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Eduard Havel
- Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Kovarik
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Monika Kucharova
- Biophysics and Physical Chemistry, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic; and,Departments of Research and Development and
| | | | - Miloslav Hronek
- Departments of Biological and Medical Sciences and .,Departments of Research and Development and
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Nusshag C, Weigand MA, Zeier M, Morath C, Brenner T. Issues of Acute Kidney Injury Staging and Management in Sepsis and Critical Illness: A Narrative Review. Int J Mol Sci 2017; 18:E1387. [PMID: 28657585 PMCID: PMC5535880 DOI: 10.3390/ijms18071387] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/24/2017] [Accepted: 06/24/2017] [Indexed: 12/19/2022] Open
Abstract
Acute kidney injury (AKI) has a high incidence on intensive care units around the world and is a major complication in critically ill patients suffering from sepsis or septic shock. The short- and long-term complications are thereby devastating and impair the quality of life. Especially in terms of AKI staging, the determination of kidney function and the timing of dialytic AKI management outside of life-threatening indications are ongoing matters of debate. Despite several studies, a major problem remains in distinguishing between beneficial and unnecessary "early" or even harmful renal replacement therapy (RRT). The latter might prolong disease course and renal recovery. AKI scores, however, provide an insufficient outcome-predicting ability and the related estimation of kidney function via serum creatinine or blood urea nitrogen (BUN)/urea is not reliable in AKI and critical illness. Kidney independent alterations of creatinine- and BUN/urea-levels further complicate the situation. This review critically assesses the current AKI staging, issues and pitfalls of the determination of kidney function and RRT timing, as well as the potential harm reflected by unnecessary RRT. A better understanding is mandatory to improve future study designs and avoid unnecessary RRT for higher patient safety and lower health care costs.
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Affiliation(s)
- Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, 162, Im Neuenheimer Feld, D-69120 Heidelberg, Germany.
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 110, Im Neuenheimer Feld, D-69120 Heidelberg, Germany.
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, 162, Im Neuenheimer Feld, D-69120 Heidelberg, Germany.
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, 162, Im Neuenheimer Feld, D-69120 Heidelberg, Germany.
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, 110, Im Neuenheimer Feld, D-69120 Heidelberg, Germany.
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8
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New AM, Nystrom EM, Frazee E, Dillon JJ, Kashani KB, Miles JM. Continuous renal replacement therapy: a potential source of calories in the critically ill. Am J Clin Nutr 2017; 105:1559-1563. [PMID: 28468893 PMCID: PMC6546225 DOI: 10.3945/ajcn.116.139014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 03/29/2017] [Indexed: 01/04/2023] Open
Abstract
Background: Overfeeding can lead to multiple metabolic and clinical complications and has been associated with increased mortality in the critically ill. Continuous venovenous hemofiltration (CVVH) represents a potential source of calories that is poorly recognized and may contribute to overfeeding complications.Objective: We aimed to quantify the systemic caloric contribution of acid-citrate-dextrose regional anticoagulation and dextrose-containing replacement fluids in the CVVH circuit.Design: This was a prospective study in 10 critically ill adult patients who received CVVH from April 2014 to June 2014. Serial pre- and postfilter blood samples (n = 4 each) were drawn and analyzed for glucose and citrate concentrations on each of 2 consecutive days.Results: Participants included 5 men and 5 women with a mean ± SEM age of 61 ± 4 y (range: 42-84 y) and body mass index (in kg/m2) of 28 ± 2 (range: 18.3-36.2). There was generally good agreement between data on the 2 study days (CV: 7-11%). Mean ± SEM pre- and postfilter venous plasma glucose concentrations in the aggregate group were 152 ± 10 and 178 ± 9 mg/dL, respectively. Net glucose uptake from the CVVH circuit was 54 ± 5 mg/min and provided 295 ± 28 kcal/d. Prefilter plasma glucose concentrations were higher in patients with diabetes (n = 5) than in those without diabetes (168 ± 12 compared with 140 ± 14 mg/dL; P < 0.05); however, net glucose uptake was similar (46 ± 8 compared with 61 ± 6 mg/min; P = 0.15). Mean ± SEM pre- and postfilter venous plasma citrate concentrations were 1 ± 0.1 and 3.1 ± 0.2 mmol/L, respectively. Net citrate uptake from the CVVH circuit was 60 ± 2 mg/min and provided 218 ± 8 kcal/d.Conclusions: During CVVH there was a substantial net uptake of both glucose and citrate that delivered exogenous energy and provided ∼512 kcal/d. Failure to account for this source of calories in critically ill patients receiving nutrition on CVVH may result in overfeeding.
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Affiliation(s)
| | | | | | | | | | - John M Miles
- Endocrine Research Unit, Mayo Clinic, Rochester, MN
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Sanches ACS, Góes CRD, Bufarah MNB, Balbi AL, Ponce D. Resting energy expenditure in critically ill patients: Evaluation methods and clinical applications. Rev Assoc Med Bras (1992) 2017; 62:672-679. [PMID: 27925048 DOI: 10.1590/1806-9282.62.07.672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/28/2016] [Indexed: 01/15/2023] Open
Abstract
Patients on intensive care present systemic, metabolic, and hormonal alterations that may adversely affect their nutritional condition and lead to fast and important depletion of lean mass and malnutrition. Several factors and medical conditions can influence the energy expenditure (EE) of critically ill patients, such as age, gender, surgery, serious infections, medications, ventilation modality, and organ dysfunction. Clinical conditions that can present with EE change include acute kidney injury, a complex disorder commonly seen in critically ill patients with manifestations that can range from minimum elevations in serum creatinine to renal failure requiring dialysis. The nutritional needs of this population are therefore complex, and determining the resting energy expenditure is essential to adjust the nutritional supply and to plan a proper diet, ensuring that energy requirements are met and avoiding complications associated with overfeeding and underfeeding. Several evaluation methods of EE in this population have been described, but all of them have limitations. Such methods include direct calorimetry, doubly labeled water, indirect calorimetry (IC), various predictive equations, and, more recently, the rule of thumb (kcal/kg of body weight). Currently, IC is considered the gold standard.
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Affiliation(s)
- Ana Cláudia Soncini Sanches
- MSc in Pathophysiology in Internal Medicine from Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Júlio de Mesquita Filho (FMB-Unesp), Botucatu, SP, Brazil
| | | | | | - André Luiz Balbi
- Adjunct Professor of Nephrology, Department of Internal Medicine, FMB-Unesp, Botucatu, SP, Brazil
| | - Daniela Ponce
- Habilitation (BR: Livre-docência) in Nephrology, Department of Internal Medicine, FMB-Unesp, Botucatu, SP, Brazi
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10
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Tang Q, Li Z, Huang D, Wang C, Jiang X, Cheng C, Chen Y. Continuous renal replacement therapy-the new treatment of seriously hyperglycemia. Am J Emerg Med 2016; 34:2469.e3-2469.e4. [PMID: 27390090 DOI: 10.1016/j.ajem.2016.06.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 06/13/2016] [Indexed: 01/26/2023] Open
Affiliation(s)
- Qian Tang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.
| | - Zhiyong Li
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Huang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Chengpan Wang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xianshu Jiang
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Changqin Cheng
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yanmei Chen
- Department of Endocrinology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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11
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Shiao CC, Wu PC, Huang TM, Lai TS, Yang WS, Wu CH, Lai CF, Wu VC, Chu TS, Wu KD. Long-term remote organ consequences following acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:438. [PMID: 26707802 PMCID: PMC4699348 DOI: 10.1186/s13054-015-1149-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) has been a global health epidemic problem with soaring incidence, increased long-term risks for multiple comorbidities and mortality, as well as elevated medical costs. Despite the improvement of patient outcomes following the advancements in preventive and therapeutic strategies, the mortality rates among critically ill patients with AKI remain as high as 40–60 %. The distant organ injury, a direct consequence of deleterious systemic effects, following AKI is an important explanation for this phenomenon. To date, most evidence of remote organ injury in AKI is obtained from animal models. Whereas the observations in humans are from a limited number of participants in a relatively short follow-up period, or just focusing on the cytokine levels rather than clinical solid outcomes. The remote organ injury is caused with four underlying mechanisms: (1) “classical” pattern of acute uremic state; (2) inflammatory nature of the injured kidneys; (3) modulating effect of AKI of the underlying disease process; and (4) healthcare dilemma. While cytokines/chemokines, leukocyte extravasation, oxidative stress, and certain channel dysregulation are the pathways involving in the remote organ damage. In the current review, we summarized the data from experimental studies to clinical outcome studies in the field of organ crosstalk following AKI. Further, the long-term consequences of distant organ-system, including liver, heart, brain, lung, gut, bone, immune system, and malignancy following AKI with temporary dialysis were reviewed and discussed.
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Affiliation(s)
- Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Saint Mary's Hospital Luodong, 160 Chong-Cheng South Road, Luodong, Yilan, 265, Taiwan.,Saint Mary's Medicine, Nursing and Management College, 160 Chong-Cheng South Road, Luodong, Yilan, 265, Taiwan
| | - Pei-Chen Wu
- Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, 92, Sec. 2, Zhongshan N. Road, Taipei, 10449, Taiwan
| | - Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, 579, Sec. 2, Yunlin Road, Douliu City, Yunlin County, 640, Taiwan
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital, Bei-Hu Branch, 87 Neijiang Street, Taipei, 108, Taiwan
| | - Wei-Shun Yang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Hisn-Chu Branch, No.25, Lane 442, Sec. 1, Jingguo Road, Hsin-Chu City, 300, Taiwan
| | - Che-Hsiung Wu
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chun-Fu Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan.
| | - Tzong-Shinn Chu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
| | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Zhong-Zheng District, Taipei, 100, Taiwan
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Relation between elevated blood urea nitrogen, clinical features or comorbidities, and clinical outcome in patients hospitalized for acute heart failure syndromes. Int J Cardiol 2015; 201:311-4. [PMID: 26301667 DOI: 10.1016/j.ijcard.2015.08.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/04/2015] [Indexed: 11/24/2022]
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Shindo Y, Ito R, Kobayashi D, Ando M, Ichikawa M, Goto Y, Fukui Y, Iwaki M, Okumura J, Yamaguchi I, Yagi T, Tanikawa Y, Sugino Y, Shindoh J, Ogasawara T, Nomura F, Saka H, Yamamoto M, Taniguchi H, Suzuki R, Saito H, Kawamura T, Hasegawa Y. Risk factors for 30-day mortality in patients with pneumonia who receive appropriate initial antibiotics: an observational cohort study. THE LANCET. INFECTIOUS DISEASES 2015; 15:1055-1065. [PMID: 26145194 DOI: 10.1016/s1473-3099(15)00151-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 03/04/2015] [Accepted: 03/25/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Appropriate initial antibiotics are essential for the treatment of infectious diseases. However, some patients with pneumonia might develop adverse outcomes, despite receiving appropriate initial antibiotics. We aimed to clarify the risk factors for 30-day mortality in patients who received appropriate initial antibiotics and to identify potential candidates who would benefit from adjunctive therapy. METHODS From March 15, to Dec 22, 2010, we did a prospective, observational study at ten medical institutions in hospitalised patients (aged ≥20 years) with pneumonia. We did a multivariable logistic regression analysis to calculate odds ratios (ORs) and 95% CI to assess the risk factors for 30-day mortality. This study was registered with the University Medical Information Network in Japan, number UMIN000003306. FINDINGS The 30-day mortality was 11% (61 of 579 patients) in the appropriate initial antibiotic treatment group and 17% (29 of 168) in the inappropriate initial antibiotic treatment group. Albumin concentration of less than 30 mg/L (adjusted OR 3·39, 95% CI 1·83-6·28), non-ambulatory status (3·34, 1·84-6·05), pH of less than 7·35 (3·13, 1·52-6·42), respiration rate of at least 30 breaths per min (2·33, 1·28-4·24), and blood urea nitrogen of at least 7·14 mmol/L (2·20, 1·13-4·30) were independent risk factors in patients given appropriate initial antibiotic treatment. The 30-day mortality was 1% (one of 126 patients), 1% (two of 168), 17% (23 of 137), 22% (20 of 89), and 44% (14 of 32) for patients with no, one, two, three, and four or five risk factors, respectively. INTERPRETATION Patients with two or more risk factors were at a higher risk of death during the 30 days assessed than were individuals with no or one risk factor, despite appropriate initial antibiotic treatment. Therefore, adjunctive therapy might be important for improving outcomes in patients with two or more risk factors. FUNDING Central Japan Lung Study Group.
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Affiliation(s)
- Yuichiro Shindo
- Institute for Advanced Research, Nagoya University, Nagoya, Japan; Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Ryota Ito
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Respiratory Medicine, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Daisuke Kobayashi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Motoshi Ichikawa
- Department of Respiratory Medicine and Allergy, Toyota Kosei Hospital, Toyota, Japan; Department of Respiratory Medicine, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Yasuhiro Goto
- Department of Respiratory Medicine, Nagoya Ekisaikai Hospital, Nagoya, Japan; Division of Respiratory Medicine and Clinical Allergy, Department of Internal Medicine, Fujita Health University, Toyoake, Japan
| | - Yasutaka Fukui
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Mai Iwaki
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Junya Okumura
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Ikuo Yamaguchi
- Department of Central Laboratory, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan
| | - Yoshimasa Tanikawa
- Department of Respiratory Medicine and Allergy, Toyota Kosei Hospital, Toyota, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Joe Shindoh
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Tomohiko Ogasawara
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Fumio Nomura
- Department of Respiratory Medicine, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hideo Saka
- Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan
| | - Masashi Yamamoto
- Department of Respiratory Medicine, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Hiroyuki Taniguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Ryujiro Suzuki
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Hiroshi Saito
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | | | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Epidemiologic Behavior and Estimation of an Optimal Cut-Off Point for Homeostasis Model Assessment-2 Insulin Resistance: A Report from a Venezuelan Population. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:616271. [PMID: 27379332 PMCID: PMC4897148 DOI: 10.1155/2014/616271] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/24/2014] [Accepted: 08/25/2014] [Indexed: 12/17/2022]
Abstract
Background. Mathematical models such as Homeostasis Model Assessment have gained popularity in the evaluation of insulin resistance (IR). The purpose of this study was to estimate the optimal cut-off point for Homeostasis Model Assessment-2 Insulin Resistance (HOMA2-IR) in an adult population of Maracaibo, Venezuela. Methods. Descriptive, cross-sectional study with randomized, multistaged sampling included 2,026 adult individuals. IR was evaluated through HOMA2-IR calculation in 602 metabolically healthy individuals. For cut-off point estimation, two approaches were applied: HOMA2-IR percentile distribution and construction of ROC curves using sensitivity and specificity for selection. Results. HOMA2-IR arithmetic mean for the general population was 2.21 ± 1.42, with 2.18 ± 1.37 for women and 2.23 ± 1.47 for men (P = 0.466). When calculating HOMA2-IR for the healthy reference population, the resulting p75 was 2.00. Using ROC curves, the selected cut-off point was 1.95, with an area under the curve of 0.801, sensibility of 75.3%, and specificity of 72.8%. Conclusions. We propose an optimal cut-off point of 2.00 for HOMA2-IR, offering high sensitivity and specificity, sufficient for proper assessment of IR in the adult population of our city, Maracaibo. The determination of population-specific cut-off points is needed to evaluate risk for public health problems, such as obesity and metabolic syndrome.
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Sood S, Chen Y, McIntire K, Rabkin R. Acute acidosis attenuates leucine stimulated signal transduction and protein synthesis in rat skeletal muscle. Am J Nephrol 2014; 40:362-70. [PMID: 25358492 DOI: 10.1159/000366524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 08/05/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND Critical illnesses are often complicated by acute metabolic acidosis, which if persistent, adversely affects outcome. Among the harmful effects that it might cause are impaired utilization of nutrients, increased proteolysis and depressed protein synthesis, leading to muscle wasting. As the amino acid leucine stimulates protein synthesis by activating mTOR signaling, we explored whether in acidosis, impaired leucine-stimulated signaling might be a contributor to the depressed protein synthesis. METHODS Male pair-fed rats were gavaged with NH4Cl (acidosis) or NaCl (control) for 2 days and then gavaged once with leucine and sacrificed 45 min later. Extensor digitorum longus muscles were isolated, incubated with or without leucine and protein synthesis measured. The anterior tibial muscle signaling was analysed by Western immunobloting. RESULTS Despite pair-feeding, acidotic rats lost body and muscle weight vs. controls. Moreover, leucine-induced protein synthesis in isolated muscle from acidotic rats was impaired. In-vivo, 45 min after an oral leucine load, anterior tibial muscle mTOR and 4E-BP1 phosphorylation increased significantly and comparably in control and acidotic rats. In contrast, leucine-stimulated phosphorylation of S6K1, a regulator of translation initiation and protein synthesis, was attenuated to approximately 56% of the control value (p < 0.05). CONCLUSION This study reveals that an acute metabolic acidosis impairs leucine-stimulated protein synthesis and activation of signaling downstream of mTOR at the level of S6K1. We propose that this S6K1 abnormality may account in part, for the resistance to leucine-stimulated muscle protein synthesis, and may thereby contribute to the impaired nutrient utilization and ultimately the muscle wasting that develops in acidosis.
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Affiliation(s)
- Sumita Sood
- Research Service, Veterans Affairs Health Care Palo Alto, Palo Alto, Calif., USA
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Prognostic factors of Pneumocystis jirovecii pneumonia in patients without HIV infection. J Infect 2014; 69:88-95. [DOI: 10.1016/j.jinf.2014.02.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 02/14/2014] [Accepted: 02/23/2014] [Indexed: 11/18/2022]
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Downs J. Nutritional management of acute kidney injury in the critically ill: a focus on enteral feeding. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2014. [DOI: 10.1080/16070658.2014.11734508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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McCarthy MS, Phipps SC. Special nutrition challenges: current approach to acute kidney injury. Nutr Clin Pract 2013; 29:56-62. [PMID: 24344254 DOI: 10.1177/0884533613515726] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Acute kidney injury (AKI), previously known as acute renal failure, is defined as a sudden decline in glomerular filtration rate with accumulation of metabolic waste products, toxins, and drugs, as well as alteration in the intrinsic functions of the kidney. Reports of mortality are as high as 80%, with numerous contributing causes including infection, cardiorespiratory complications, and cardiovascular disease. Concurrent with the high prevalence of critical illness in this population is the protein energy wasting (PEW), seen in up to 42% of patients upon intensive care unit admission. The pathophysiologic derangements of critical illness, the low energy and protein stores, and uremic complications require early nutrition intervention to attenuate the inflammatory response and oxidative stress, improve endothelial function, stabilize blood sugar, and preserve lean body mass. This article addresses the unique challenges of nutrition support for the patient with AKI in the setting of critical illness and renal replacement therapy. Evidence-based recommendations are provided to meet the macronutrient and micronutrient requirements of this heterogeneous and complex patient population.
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Affiliation(s)
- Mary S McCarthy
- Mary S. McCarthy, RN, Center for Nursing Science & Clinical Inquiry, Madigan Army Medical Center, MCHJ-CNI 1-57-7, 9040A Jackson Ave, Tacoma, WA 98431, USA.
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Autologous transplantation of endothelial progenitor cells to prevent multiple organ dysfunction syndromes in pig. J Trauma Acute Care Surg 2013; 74:508-15. [PMID: 23147181 DOI: 10.1097/ta.0b013e3182703420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It was observed that the number and function of endothelial progenitor cells (EPCs) decreased sharply in the progression of multiple organ dysfunction syndrome (MODS), and it may be the main pathogenesis for MODS. We aim to perform autologous transplantation of EPCs on animal models of MODS to investigate whether EPCs might be used to prevent MODS caused by severe sepsis. METHODS A total of 60 pigs were randomly divided into three groups: subjected to hemorrhagic shock + resuscitation + endotoxemia only (MODS group); performed autologous transplantation of EPCs after hemorrhagic shock + resuscitation + endotoxemia (transplantation group); and control group. Mononuclear cells of animals of the transplantation group were isolated by density-gradient centrifugation for ex vivo expansion, and the six-passage EPCs labeled with 5-carboxyfluorescein diacetate succinimidyl ester were autologously transplanted at a density of 1 × 10(7) cells/kg body weight at the 24th hour after endotoxemia. The function of important organs was monitored continuously to assess the effects of autologous transplantation of EPCs on MODS. RESULTS All animals of the MODS group developed MODS (100%), and 17 (85%) of 20 animals died because of MODS; the incidence of MODS and mortality rate in the transplantation group were 45% (9 of 20 pigs; p < 0.01) and 35% (7 of 20 pigs; p < 0.01). In transplantation group, the incidence of pulmonary dysfunction, cardiac dysfunction, hepatosis, and renal dysfunction were 40%, 10%, 5%, and 15%, respectively. The capillary densities of important organs, including the heart, liver, kidney, intestine, and lung, after autologous transplantation of EPCs were significantly higher than those in the MODS group (p < 0.01). CONCLUSION Autologous transplantation of EPCs could migrate to injured organs and induce angiogenesis to restore blood flow that could improve the function of important organs. It could prevent the incidence of MODS and reduce mortality rate caused by trauma and severe sepsis. Autologous transplantation of EPCs would be a novel, cell-based, vascular endothelium-targeted therapeutic strategy for MODS.
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Fiaccadori E, Regolisti G, Maggiore U. Specialized nutritional support interventions in critically ill patients on renal replacement therapy. Curr Opin Clin Nutr Metab Care 2013; 16:217-24. [PMID: 23242314 DOI: 10.1097/mco.0b013e32835c20b0] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Optimal nutritional requirements and nutrient intake composition for patients with acute kidney injury remain a partially unresolved issue. Targeting nutritional support to the actual protein and energy needs improves the clinical outcome of critically ill patients, yet very few data are currently available on this topic in acute kidney injury. In this specific clinical condition the risk for underfeeding and overfeeding may be increased by factors interfering on nutrient need estimation, such as rapidly changing body weight due to fluid balance variations, nutrient losses and hidden calorie sources from renal replacement therapy. Moreover, as acute kidney injury is now considered a kidney-centered inflammatory syndrome, the renoprotective role of specific pharmaconutrients with anti-inflammatory properties remains to be fully defined. This review is aimed at discussing recently published results concerning quantitative and qualitative aspects of the nutritional approach to acute kidney injury in critically ill patients. RECENT FINDINGS Nutrient needs in patients with acute kidney injury can be difficult to estimate, and should be directly measured, especially in the ICU setting. In fact, recent findings suggest that hidden calorie sources not routinely taken into account - for example, calories from anticoagulants and replacement solutions for renal replacement therapy - could be quantitatively relevant in these patients. Moreover, recent experimental data indicate a possible role for some pharmaconutrients with anti-inflammatory effects (glutamine, and omega-3 fatty acids), in both the prevention of renal function worsening, and in the fostering of renal function recovery after an episode of acute kidney injury. SUMMARY Acute kidney injury includes a highly heterogeneous group of patients with widely varying nutrient needs and intakes. Nutritional requirements, in their quantitative and qualitative aspects, should be frequently assessed, individualized, and carefully integrated with renal replacement therapy, in order to avoid both underfeeding and overfeeding, as well as to exploit possible positive pharmacologic effects of specific nutrients.
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Affiliation(s)
- Enrico Fiaccadori
- Renal Failure Unit, Clinical and Experimental Medicine Department, Parma University, Parma, Italy.
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Manu P, Asif M, Khan S, Ashraf H, Mani A, Guvenek-Cokol P, Lee H, Kane JM, Correll CU. Risk factors for medical deterioration of psychiatric inpatients: opportunities for early recognition and prevention. Compr Psychiatry 2012; 53:968-74. [PMID: 22520089 DOI: 10.1016/j.comppsych.2012.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 02/29/2012] [Accepted: 03/12/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Medical deterioration during admission to free-standing psychiatric hospitals is distressing for patients, interrupts bio-behavioral interventions, and places a substantial burden on health care resources. Emergency transfers to a general hospital are a reasonable marker of significant medical deterioration, but have not been assessed systematically. OBJECTIVE To use clinical data available at the time of psychiatric admission to identify risk factors for transfers to a general hospital. METHOD Retrospective review of the hospital course of 1000 adults consecutively admitted for an average of 19.1 ± 21.3 days to a single free-standing psychiatric hospital in 2010. RESULTS One hundred forty-four patients (14.4%) were transferred to a general hospital. Transferred and not-transferred groups differed significantly with regard to age, presence of dementia, number of comorbid medical disorder, history of arterial hypertension, blood urea nitrogen (BUN), creatinine, albumin, glucose, calcium, hemoglobin, and hematocrit (P < .001). In a multiple logistic regression analysis, blood urea nitrogen (odds ratio [OR], 63.2), hemoglobin (OR, 35.3), albumin (OR, 7.3) and age (OR, 5.73) were independently associated with transfers. Acute medical deteriorations occurred in 46.2% of patients with azotemia (BUN >24 mg/dL), 32.7% of those with anemia (Hb <12 g/L), 37.5 % of those with hypoalbuminemia (albumin <3.7 g/dL), and 37.4% of patients 65 and older. CONCLUSION Medical deterioration of psychiatric inpatients correlates with higher BUN, lower albumin and hemoglobin, and older age. Baseline azotemia, anemia or hypoalbuminemia should trigger prompt medical evaluation and enhanced monitoring to prevent, identify, and treat somatic disorders.
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Affiliation(s)
- Peter Manu
- Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, New York 11004, USA.
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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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Maursetter L, Kight CE, Mennig J, Hofmann RM. Review of the Mechanism and Nutrition Recommendations for Patients Undergoing Continuous Renal Replacement Therapy. Nutr Clin Pract 2011; 26:382-90. [DOI: 10.1177/0884533611413899] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Laura Maursetter
- Section of Nephrology, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Judy Mennig
- Acute Dialysis Services Unit, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - R. Michael Hofmann
- Section of Nephrology, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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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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Elevation of blood urea nitrogen is predictive of long-term mortality in critically ill patients independent of "normal" creatinine. Crit Care Med 2011; 39:305-13. [PMID: 21099426 DOI: 10.1097/ccm.0b013e3181ffe22a] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We hypothesized that elevated blood urea nitrogen can be associated with all-cause mortality independent of creatinine in a heterogeneous critically ill population. DESIGN Multicenter observational study of patients treated in medical and surgical intensive care units. SETTING Twenty intensive care units in two teaching hospitals in Boston, MA. PATIENTS A total of 26,288 patients, age ≥ 18 yrs, hospitalized between 1997 and 2007 with creatinine of 0.80-1.30 mg/dL. INTERVENTIONS None. MEASUREMENTS Blood urea nitrogen at intensive care unit admission was categorized as 10-20, 20-40, and >40 mg/dL. Logistic regression examined death at days 30, 90, and 365 after intensive care unit admission as well as in-hospital mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. MAIN RESULTS Blood urea nitrogen at intensive care unit admission was predictive for short- and long-term mortality independent of creatinine. Thirty days following intensive care unit admission, patients with blood urea nitrogen of >40 mg/dL had an odds ratio for mortality of 5.12 (95% confidence interval, 4.30-6.09; p < .0001) relative to patients with blood urea nitrogen of 10-20 mg/dL. Blood urea nitrogen remained a significant predictor of mortality at 30 days after intensive care unit admission following multivariable adjustment for confounders; patients with blood urea nitrogen of >40 mg/dL had an odds ratio for mortality of 2.78 (95% confidence interval, 2.27-3.39; p < .0001) relative to patients with blood urea nitrogen of 10-20 mg/dL. Thirty days following intensive care unit admission, patients with blood urea nitrogen of 20-40 mg/dL had an odds ratio of 2.15 (95% confidence interval, 1.98-2.33; <.0001) and a multivariable odds ratio of 1.53 (95% confidence interval, 1.40-1.68; p < .0001) relative to patients with blood urea nitrogen of 10-20 mg/dL. Results were similar at 90 and 365 days following intensive care unit admission as well as for in-hospital mortality. A subanalysis of patients with blood cultures (n = 7,482) demonstrated that blood urea nitrogen at intensive care unit admission was associated with the risk of blood culture positivity. CONCLUSION Among critically ill patients with creatinine of 0.8-1.3 mg/dL, an elevated blood urea nitrogen was associated with increased mortality, independent of serum creatinine.
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Wiesen P, Van Overmeire L, Delanaye P, Dubois B, Preiser JC. Nutrition Disorders During Acute Renal Failure and Renal Replacement Therapy. JPEN J Parenter Enteral Nutr 2011; 35:217-22. [DOI: 10.1177/0148607110377205] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Patricia Wiesen
- Department of General Intensive Care, University Hospital Centre of Liege, Belgium
| | | | - Pierre Delanaye
- Department of Nephrology, University Hospital Centre of Liege, Belgium
| | - Bernard Dubois
- Department of Nephrology, University Hospital Centre of Liege, Belgium
| | - Jean-Charles Preiser
- Department of General Intensive Care, University Hospital Centre of Liege, Belgium
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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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Langouche L, Perre SV, Thiessen S, Gunst J, Hermans G, D'Hoore A, Kola B, Korbonits M, Van den Berghe G. Alterations in adipose tissue during critical illness: An adaptive and protective response? Am J Respir Crit Care Med 2010; 182:507-16. [PMID: 20442437 DOI: 10.1164/rccm.200909-1395oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
RATIONALE Critical illness is characterized by lean tissue wasting, whereas adipose tissue is preserved. Overweight and obese critically ill patients may have a lower risk of death than lean patients, suggestive of a protective role for adipose tissue during illness. OBJECTIVES To investigate whether adipose tissue could protectively respond to critical illness by storing potentially toxic metabolites, such as excess circulating glucose and triglycerides. METHODS We studied adipose tissue morphology and metabolic activity markers in postmortem biopsies of 61 critically ill patients and 20 matched control subjects. Adipose morphology was also studied in in vivo biopsies of 27 patients and in a rabbit model of critical illness (n = 22). MEASUREMENTS AND MAIN RESULTS Adipose tissue from critically ill patients revealed a higher number and a smaller size of adipocytes and increased preadipocyte marker levels as compared with control subjects. Virtually all adipose biopsies from critically ill patients displayed positive macrophage staining. The animal model demonstrated similar changes. Glucose transporter levels and glucose content were increased. Glucokinase expression was up-regulated, whereas glycogen and glucose-6-phosphate levels were low. Acetyl CoA carboxylase protein and fatty acid synthase activity were increased. Hormone-sensitive lipase activity was not altered, whereas lipoprotein lipase activity was increased. A substantially increased AMP-activated protein kinase activity may play a crucial role. CONCLUSIONS Postmortem adipose tissue biopsies from critically ill patients displayed a larger number of small adipocytes in response to critical illness, revealing an increased ability to take up circulating glucose and triglycerides. Similar morphologic changes were present in vivo. Such changes may render adipose tissue biologically active as a functional storage depot for potentially toxic metabolites, thereby contributing to survival.
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Affiliation(s)
- Lies Langouche
- Department and Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Belgium.
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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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