Nutritional therapy of intensive care renal

patients

Ione de Brito-Ashurst Trust Nutrition Lead

Overview

RF Definition

Malnutrition in RF

Nutrition recommendations

Low protein diets

Case study

Malnutrition is associated with high mortality in AKI

Fiaccadori et al. JASN 1999; 10:581-593

Malnutrition in CKD

Prevalence of malnutrition circa35% in patients beginning HD

Mostly in CKD stage 4 & 5

Characterised by loss of MM, loss of visceral protein and fat mass

Negative impact on QoL, morbidity and mortality

Malnutrition in CKD

Causes

Reduced oral intake – restrictive

diet

Anorexia of uraemia

Loss of nutrients

MIA syndrome (malnutrition

inflammatory atherosclerosis)

Metabolic abnormalities

Gastrointestinal symptoms

Social – poverty, dentition

Prevalence of malnutrition in HD

N= 7,123

BMI <20kg/m2 24%

LBM <90% centile 62%

Albumin <35g/l 20%

nPNA <1g/kg/d 35%

Normalised protein nitrogen appearance

-protein catabolic rate normalised for

weight

Aparicio M. et al. NDT 1999

ESPEN1 NKF2 EBPG3 ASPEN4

Protein g/kg/day

1.2-1.4 1.2 >1.1 1.2-2.0

Energy Kcal/kg/day

35 <60 yrs - 35 >60 yrs - 30

30-40 25-30

1. Toigo G. et al. CN, 2000

2. NKF. AJKD, 2000

3. Fouque D. et aol., EBPG. NDT 2007

4. McClave S.A. et al. JPEN, 2016

Dietary recommendations for RF

Occurs in 33-66% of all critically ill patients1

Hypercatabolic milieu

>50% mortality rate for severe AKI that needs RRT1

Loss in CRRT are up to 7.5gms/day for proteins + 6-15gm/day for amino acids2

Protein catabolic rate estimated at 1.4g/day2

Protein intake up of 1.5g/kg/day + N balance without increasing Urea generation1

Limited protein and calories provision exacerbates breakdown of protein for fuel

Protein intake ≥2.0g/kg/day leads to increased urea generation and intensified dialysis needs1

Acute Kidney Injury

1. Gervasio, J.M. et a. 2011, NCP

2. Kellum et al. 2013 Critic Care

Glucose

The kidneys contribute to:

15-25% of gluconeogenesis

10-20% of glucose uptake

30% of insulin catabolism

AKI – exacerbated insulin resistance due

to:

reduced gluconeogenesis

Reduced insulin and glucagon

clearance

Proteins

Increased catabolism

Metabolic acidosis

Change in amino acids

concentration

Lipids

Impaired lipolysis

Decrease hepatic triglyceride

lipase

Increase in triglycerides

No advantage

from increased

caloric intake

on Nitrogen

balance and

protein

catabolism

reduction

KDIGO – AKI Work Group

Parrish C.R, Practical Gastroenterology, 2011

Low Protein Diet in CKD

Bringing available evidence to bedside….

CASE STUDY

Case study

Male 65 yrs admitted with Type II RF 2nd to CAP for ECMO

Sedated (Morphine + midazolan) and paralysed (atracurium)

Weight 55kg, height 175cm, BMI= 18

Last weight 64kg (6/12)

Known renal impairment

Creatinine 235µmol (2.66mg/dl), Urea 35mmol, Bicarbonate 17mmol

UOP 10-20ml/hr – CRRT

BS present, BNO for 2/7

On polymeric non-fibre feed – Nutrison

ONS improves albumin levels

Clinical assessment

Establish eGFR

21.6ml/min by Cockroft-Gault Equation

CKD stage 4

Raised phosphate levels (<50% eGFR)

Raised potassium levels (<80% eGFR, ACEis)

Low serum creatinine for CKD stage 4

High Urea levels (catabolic)

High Serum urea:creatinine ratio

Malnutrition

Low muscle mass

U shaped urea curve for mortality (optimum 23-27mmol)

Assessment

Nutrition management

25cal/kg = 1600 cals

1.5g/kg = 96g proteins

1st week:

Nutrison Protein Plus –

1400ml @ 60ml/hr – Continuous

1750 cals

88g proteins

0 g fibre

2nd week:

Change to high protein feed

Nutrison Advanced Protison –

1300ml @ 55ml/hr

1664 cals

97.5g proteins

19.5g fibre

Bowel opening regularly type 5/6

Conclusion

Malnutrition is prevalent in CKD and AKI

Malnutrition is associated with high mortality

AKI REE is similar to other ICU groups

Adequate protein intake is essential

Very high caloric intake has no advantages

Dialysis increases nitrogen requirements to cover for losses

TANK YOU