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Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...
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Nutrition In Pediatric CRRT - Pediatric Continuous Renal ...

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  • Grey bars represent amino acid clearance achieved by continuous veno-venous hemofiltration [4] and black bars from continuous veno-venous hemodialysis [45].
    K, clearance; Thr, threonine; Glu, glutamic acid; Gln, glutamine; Pro, Proline; Gly, Glycine; Ala, Alanine; Val, Valine; Met, Methionine; Phe, Phenylalanine; Lys, Lysine; His, Histidine; Arg, Arginine. This graph was derived using data from: Crit Care Med 2000 28:1161-1165 and J Am Soc Nephrol 2006 17:767A.
  • Transcript

    • 1. Nutrition In Pediatric CRRT Michael Zappitelli, MD, MSc Nutrition in AKI AND CRRT McGill University Health Center Montreal, Quebec, Canada
    • 2. ObjectivesObjectives Discuss the impact of nutrition in acuteDiscuss the impact of nutrition in acute kidney injury... and vice versakidney injury... and vice versa Discuss clearance of nutrition and nutritionDiscuss clearance of nutrition and nutrition adjustment in pediatric CRRT.adjustment in pediatric CRRT.
    • 3. Critical Illness Acute Kidney Injury Poorer outcome, increased mortality No real prevention/treatment Left with: 1) Modifying the negative effects of AKI 2) Providing adequate nutrition ??? Modify outcome??? X X
    • 4. Critical Illness hormone changes -Acute: increase -Later: decrease ↑ cytokines Altered substrate utilization CH2O: ↑hepatic gluconeogenesis (shift away from glycolysis) ↑lipogenesis - Inefficient glucose oxidation - Insulin resistance - Shift in use of amino acids: gluconeogenesis + APR’s MALNUTRITION Acute Kidney Injury Uremia Acidosis Altered Glucose metab. Cytokines Impaired nutrient transport Inefficient/inadequate supply Impaired A.a. conversion ↓lipid oxidation
    • 5. Critical Illness and NutritionCritical Illness and Nutrition Adequate nutrition needed for recovery +Adequate nutrition needed for recovery + normal functioning of growing child.normal functioning of growing child. Tissue synthesis and immune function.Tissue synthesis and immune function. Desire to avoid over- and under-feeding.Desire to avoid over- and under-feeding. Underfeeding: increase morbidity, mortality,Underfeeding: increase morbidity, mortality, infection, wound healing, length of ventilation.infection, wound healing, length of ventilation.
    • 6. Critical Illness and NutritionCritical Illness and Nutrition Children: high risk of malnutrition.Children: high risk of malnutrition. High basal metabolic rates.High basal metabolic rates. Limited energy reserves.Limited energy reserves. High (15-30%) baseline poor nutrition.High (15-30%) baseline poor nutrition.
    • 7. Malnutrition AND AKIMalnutrition AND AKI Same difficulties/pathophysiology +Same difficulties/pathophysiology + Increased difficulty in nutrition provision.Increased difficulty in nutrition provision. Higher rate of baseline malnutrition/ comorbiditiesHigher rate of baseline malnutrition/ comorbidities Metabolic changes of AKI.Metabolic changes of AKI. Children with AKI – increased risk of malnutrition at PICUChildren with AKI – increased risk of malnutrition at PICU discharge.discharge. RRT – increases nutritional losses.RRT – increases nutritional losses.
    • 8. Nutrition and AKINutrition and AKI Problem: No evidence-based guidelines.Problem: No evidence-based guidelines. Difficulty to show effect on hard outcomes.Difficulty to show effect on hard outcomes. Recommendations based onRecommendations based on 1)1) Adult studiesAdult studies 2)2) Known metabolic alterations with AKIKnown metabolic alterations with AKI 3)3) Nutrition in critically ill childrenNutrition in critically ill children 4)4) Measuring nutritional losses by RRT.Measuring nutritional losses by RRT.
    • 9. Critical Illness – Energy needsCritical Illness – Energy needs Metabolic needs vary according to the injury.Metabolic needs vary according to the injury. RDA versus predictive equations vs directRDA versus predictive equations vs direct measurement (indirect calorimetry).measurement (indirect calorimetry). No single predictive equation shown toNo single predictive equation shown to accurately estimate REE.accurately estimate REE. Limitations to indirect calorimetry in critically illLimitations to indirect calorimetry in critically ill patients.patients.
    • 10. AKI and energy needsAKI and energy needs Controversial – AKI per se may not affectControversial – AKI per se may not affect energy expenditure.energy expenditure. Affected more by coexisting conditions.Affected more by coexisting conditions. Almost no data on pediatric AKI andAlmost no data on pediatric AKI and energy needs.energy needs.
    • 11. Indirect calorimetry AND CRRTIndirect calorimetry AND CRRT IC: measure resting energy expenditure.IC: measure resting energy expenditure. Based on: Expired CO2 and O2 (O2 consumption +Based on: Expired CO2 and O2 (O2 consumption + CO2 production).CO2 production). Potential problem with CRRTPotential problem with CRRT Hemofilter Dialysis fluid Effluent HCO3/CO2 fluxes May affect IC measurements. IC may not be reliable?
    • 12. Critical Illness – Energy needsCritical Illness – Energy needs Controversy: ? RDA ? 25-30% above REE.Controversy: ? RDA ? 25-30% above REE. Mean REE in literature: 35 to 60 kcal/kg/dayMean REE in literature: 35 to 60 kcal/kg/day (0.15-0.27 MJ/kg/day)(0.15-0.27 MJ/kg/day) Adults: 25-35 kcal/kg/day – probably need moreAdults: 25-35 kcal/kg/day – probably need more in children.in children. Almost no studies in AKI.Almost no studies in AKI.
    • 13. CarbohydratesCarbohydrates Patients become hyperglycemic.Patients become hyperglycemic. Insulin resistance,Insulin resistance, ↑↑hepatichepatic gluconeogenesis.gluconeogenesis.  Stress hormonesStress hormones  Inflammatory mediators and cytokinesInflammatory mediators and cytokines  Metabolic acidosisMetabolic acidosis  Pre-existing hyperparathyroidismPre-existing hyperparathyroidism
    • 14. Critical Illness - proteinCritical Illness - protein Protein synthesis AND breakdown areProtein synthesis AND breakdown are increased: breakdown more increased.increased: breakdown more increased. Manifestation: net negative nitrogenManifestation: net negative nitrogen balance, skeletal muscle wasting.balance, skeletal muscle wasting. Nitrogen balance = Nin – Nout.Nitrogen balance = Nin – Nout.
    • 15. Critical Illness & AKI - proteinCritical Illness & AKI - protein Protein metabolism abnormal:Protein metabolism abnormal: - Reduced renal synthesis of amino acidsReduced renal synthesis of amino acids - Altered amino acid uptakeAltered amino acid uptake - Factors related to critical illness (elevated stressFactors related to critical illness (elevated stress hormones, increased hepatic gluconeogenesis,hormones, increased hepatic gluconeogenesis, relative insulin resistance).relative insulin resistance).
    • 16. AKI and proteinAKI and protein Protein synthesis CAN be increased byProtein synthesis CAN be increased by providing more amino acids.providing more amino acids. Bellomo et al, Int J of Artif Organs, 2002Bellomo et al, Int J of Artif Organs, 2002 Scheinkestel et al, Nutrition, 2003Scheinkestel et al, Nutrition, 2003 Still very difficult to achieve positive NStill very difficult to achieve positive N balance.balance.
    • 17. Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted Amino Acid Day 2 (n=15) Day 5 (n=9) K1 CVVHD CVVHD Losses K Renal (n=2) K CVVHD CVVHD Losses K Renal (n=3) (ml/min/1.73m2 ) (mcg/kg/d) (ml/min/1.73m2 ) (ml/min/1.73m2 ) (mcg/kg/d) (ml/min/1.73m2 ) Mean±SD, Median Mean±SD, Median Mean Mean±SD, Median Mean±SD, Median Mean Tau Asp Thr Ser Asn Glu Gln Pro Gly Ala Cit Val Cys Met Ile Leu Tyr Phe Orn Lys His Arg 104.5±179.0, 32.9 8.4±11.1, 4.8 1.0 77.8±111.2, 24.2 4.5±5.4, 1.8 2.1 335.8±483.7, 53.6 3.9±4.1, 3.2 2.6 234.0±349.8, 51.1 5.6±4.4, 2.6 12.0 31.9±25.0, 22.6 15.7±18.5, 9.9 4.1 38.8±25.1, 29.8 11.9±5.9, 12.0 18.9 29.1±25.6, 17.8 8.1±8.6, 5.7 3.6 34.6±27.7, 22.3 6.0±3.3, 5.0 9.2 37.2±32.1, 32.3 7.7±8.1, 4.5 9.8 35.5±19.8, 34.3 5.0±3.4, 5.3 28.6 9.4±10.6, 6.2 2.7±4.0, 1.8 0.6 6.1±5.0, 3.8 1.6±0.7, 1.7 1.0 19.4±20.1, 13.2 47.4±63.7, 23.0 2.2 85.4±152.9, 21.2 44.2±30.7, 34.5 0.7 38.3±32.7, 31.2 24.3±22.2, 17.6 0.2 37.5±21.9, 27.3 19.4±11.2, 20.5 0.8 28.1±25.7, 18.0 16.0±16.1, 7.5 3.9 35.3±30.2, 19.8 12.0±7.1, 14.1 12.9 26.1±24.6, 15.4 23.4±21.2, 13.5 5.2 37.9±38.8, 25.2 20.0±11.5, 24.1 6.9 25.6±24.3, 15.9 2.8±4.5, 1.3 4.1 39.3±50.4, 25.7 1.5±1.1, 1.4 5.7 24.8±22.0, 14.8 16.8±13.4, 12.7 5.2 39.1±37.3, 25.1 14.4±6.9, 13.9 5.5 27.4±54.5, 8.6 0.8±1.2, 0.5 0.5 34.7±29.9, 44.3 1.3±1.1, 1.1 5.2 18.0±19.9, 8.2 5.9±13.5, 12.7 3.6 26.8±31.1, 17.2 2.2±1.8, 2.2 5.1 29.9±29.8, 17.3 6.0±5.7, 4.3 6.9 38.6±34.7, 22.1 5.4±2.7, 4.3 6.6 22.9±20.9, 13.6 11.6±9.2, 7.8 3.9 32.2±28.8, 22.7 10.3±5.2, 10.9 4.4 22.2±23.3, 10.7 9.2±13.5, 4.3 4.4 36.5±41.3, 21.4 5.6±2.7, 5.2 10.5 23.9±20.8, 12.9 18.4±23.1, 7.8 4.5 34.9±29.7, 26.4 11.3±6.2, 10.1 7.0 8.4±8.7, 12.9 3.4±5.0, 1.0 0.3 91.0±249.7, 10.6 2.5±3.4, 1.4 0.7 7.7±9.0, 2.8 10.0±11.1, 4.4 0.3 108.4±299.5, 9.6 8.7±8.9, 5.6 0.9 13.2±15.8, 10.0 8.0±15.9, 2.8 0.7 33.4±66.3, 15.7 4.5±3.8, 5.1 12.1 15.8±17.1, 8.0 11.4±23.4, 3.5 1.8 45.8±68.6, 8.6 6.0±4.8, 4.1 6.2 CVVHD clearance of amino acids measured on Day 2 and Day 5 N=15
    • 18. 0 10 20 30 40 50 60 K ml/min/1.73m 2 Thr Glu Gln Pro Gly Ala Val Met Phe Lys His Arg Amino Acids Combined results of clearance of essential amino acids by CRRT. Zappitelli et al (submitted) and Maxvold et al, Critical Care, 2000 (n=6). Several studies, adult and child: ~ 10-20% intake “lost” through hemofilter. Both studies: Highest losses with Glutamine/Glutamic acid
    • 19. Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted Amino Acid2 CVVHD initiation % low/normal/high3 Day 2 % low/high/normal Day 5 % low/normal/high Tau Asp Thr Ser Asn Glu Gln Pro Gly Ala Cit Val Cys Met Ile Leu Tyr Phe Orn Lys His Arg 43±96, 16 0/ 93.3/6.7 40±102, 14 6.7/ 86.7/ 6.7 18±14, 13 11.1/ 88.9/ 0 4±3, 3 0/ 100.0/ 0 5±5, 3 6.7/ 93.3/ 0 13±16, 8 11.1/ 66.7/ 22.2 100±81, 66 20.0/60.0/20.0 99±54, 109 13.3/ 80.0/ 6.7 105±67, 95 0/ 88.9/ 11.1 53±26, 51 60.0/ 40.0/ 0 65±30, 56 53.3/ 46.7/ 0 66±34, 58 44.4/ 55.6/ 0 37±21, 30 0/ 100.0/ 0 42±23, 43 0/ 93.3/ 6.7 42±27, 41 11.1/ 77.8/ 11.1 57±89, 23 0/ 86.7/ 13.3 55±55, 37 0/ 80.0/ 20.0 119±146, 82 11.1/ 44.4/ 44.4 315±146, 295 46.7/ 53.3/ 0 372±167, 364 0/ 33.3/ 66.7 382±261, 336 33.3/ 55.6/ 11.1 124±66, 111 6.7/ 93.3/ 0 142±69, 127 0/ 100.0/ 0 182±113, 132 0/ 88.9/ 11.1 200±135, 167 26.7/ 66.7/ 6.7 186±89, 177 20.0/ 66.7/ 13.3 190±100, 165 11.1/ 77.8/ 11.1 195±133, 157 13.3/ 80.0/ 6.7 259±149, 210 13.3/ 80.0/ 6.7 283±192, 236 11.1/ 77.8/ 11.1 12±7, 10 13.3/ 86.7/ 0 12±8, 11 20.0/ 80.0/ 0 12±7, 12 22.2/ 77.8/ 0 148±58, 151 20.0/ 80.0/ 0 144±43, 142 6.7/ 93.3/ 0 140±57, 148 11.1/ 88.9/ 0 27±25, 21 20.0/ 60.0/ 20.0 17±24, 10 33.3/ 60.0/ 6.7 24±35, 12 33.3/ 55.6/ 11.1 32±52, 16 6.7/ 80.0/ 13.3 37±39, 25 6.7/ 53.3/ 40.0 25±16, 26 0/ 88.9/ 11.1 31±19, 24 13.3/ 86.7/ 0 43±22, 42 6.7/ 93.3/ 0 45±23, 41 0/ 88.9/ 11.1 78±34, 70 0/ 93.3/ 6.7 97±28, 95 0/ 100.0/ 0 101±41, 100 11.1/ 77.8/ 11.1 57±38, 42 6.7/ 73.3/ 20.0 51±27, 45 6.7/ 86.7/ 6.7 46±27, 45 22.2/ 77.8/ 0 92±59, 71 0/ 73.3/ 26.7 98±63, 79 0/ 46.7/ 53.3 83±45, 87 0/ 44.4/ 55.6 47±37, 38 0/ 86.7/ 13.3 56±41, 51 0/ 86.7/ 13.3 67±84, 52 11.1/ 77.8/ 11.1 152±65, 136 0/ 86.7/ 13.3 173±84, 153 0/ 66.7/ 33.3 153±90, 127 11.1/ 66.7/ 22.2 76±32, 71 6.7/ 80.0/ 13.3 75±38, 65 6.7/ 80.0/ 13.3 65±36, 57 11.1/ 77.8/ 11.1 43±26, 39 20.0/ 80.0/ 0 74±56, 55 0/ 93.3/ 6.7 56±31, 50 11.1/ 88.9/ 0 Amino Acid serum levels measured on Days 1, 2 and 5
    • 20. Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted CVVHD initiation (N=15) Day 2 (N=15) Day 5 (N=9) Mean±SD, Median Mean±SD, Median Mean±SD, Median Protein intake (g/kg/d) N balance (g/kg/d) Caloric intake (kcal/kg/d) Caloric balance (kcal/kg/day) 1.98±1.24, 1.75 2.04±1.02, 2.09 1.85±0.60, 2.08 NA -0.88±1.60, -0.22 -0.23±0.19, -0.24 32.6±27.6, 23.8 40.3±22.3, 33.6 43.2±18.4, 42.7 -0.4±25.4, -8.0 +7.7±21.7, +1.5 +10.6±17.7, +10.8 Protein and energy intake and output at CVVHD1 initiation, Day 2 and Day 5. Maxvold et al, Crit Care Med, 2000 Protein intake was 1.5 g/kg/day – Negative nitrogen balance It’s not easy to achieve a positive nitrogen balance. Logic: bigger filter, higher Qd or Quf = increased clearance
    • 21. Does increasing protein intake help?Does increasing protein intake help? Scheinkestel et al.Scheinkestel et al. 1.1. Nutrition, 2003Nutrition, 2003 In 11 critically ill adults on CRRT, protein intake 2.5In 11 critically ill adults on CRRT, protein intake 2.5 g/kg/day led to a) normal amino acid levels and b)g/kg/day led to a) normal amino acid levels and b) positive nitrogen balance.positive nitrogen balance. 2.2. Nutrition, 2003Nutrition, 2003 50 critically ill adults on CRRT: 1.5 vs 2.0 vs 2.550 critically ill adults on CRRT: 1.5 vs 2.0 vs 2.5 g/kg/day.g/kg/day. NB related to protein intake.NB related to protein intake. NB related to hospital stayNB related to hospital stay Protein intake 2.5 g/kg/d: improved survival!Protein intake 2.5 g/kg/d: improved survival!
    • 22. What are we doing?What are we doing? Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. Age (years) CRRT duration (days) Diagnostic category Sepsis/Infection Renal Respiratory Cardiac Hematology Oncology Gastrointestinal/Hepatic Other CRRT indication Electrolyte imbalance Fluid overload only Fluid overload and electrolytes CRRT modality CVVHD CVVH CVVHDF 8.8 ± 6.8 (8.1, 12.8) 10.2±10.7 (7.0, 11.0) days N (%) 74 (38.1) 29 (15.0) 12 (6.2) 21 (10.8) 35 (18.0) 15 (7.7) 9 (4.6) 31 (15.9) 66 (33.9) 98 (50.3) 94 (48.2) 52 (26.7) 49 (25.1)
    • 23. Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. 012345 1 2 3 4 5 6 7 8 9 10 excludes outside values Protein intake (g/kg/day) Day of CRRT Daily change in protein prescription during treatment with CRRT.
    • 24. Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. 0255075100125150 1 2 3 4 5 6 7 8 9 10 excludes outside values Caloric Intake (kcal/kg/day) Day of CRRT Daily change in caloric prescription during treatment with CRRT.
    • 25. Protein and calorie prescription for children and young adults receiving CRRT: a report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry group. Zappitelli et al, submitted. Characteristics (N) Protein intake (g/kg/day) Initial Maximal Gender Males (111) Females (84) p-value1 Age Group ≤ 1 year (35) 1 to ≤13 years (95) >13 years (65) p-value MODS (155) No MODS (40) p-value Survival Survivors (117) Non-survivors (78) p-value CRRT indication Electrolytes (31) Fluid overload (66) Electrolytes and fluid overload (98) p-value 1.4, 1.0[1.4] 2.0, 1.6[1.6] 1.3, 1.0[1.2] 1.9, 1.8[1.5] 0.7 0.9 1.5, 1.8[1.5] 2.5, 2.4[2.3] 1.3, 1.0[1.2] 2.0, 1.9[1.5] 1.4, 1.0[1.0] 1.6, 1.3[1.1] 0.09 0.009* 1.3, 1.0[1.2] 1.9, 1.8[1.5] 1.5, 1.0[0.8] 2.0, 1.3[1.7] 0.1 0.2 1.4, 1.0[1.2] 2.0, 1.6[1.5] 1.3, 1.0[1.3] 1.8, 1.8[1.7] 0.6 0.9 1.2, 1.0[0.9] 1.6, 1.4[1.1] 1.6, 1.2[1.2] 2.1, 1.8[1.8] 1.2, 1.0[1.3] 2.0, 1.8[1.6] 0.07 0.2 All groups: -Maximal protein>initial Multivariate predictors of maximal protein intake - Younger age - Higher initial protein Rx - #CRRT days Protein Rx >2g/kg/day in 40%
    • 26. Critical Illness & AKI - LipidsCritical Illness & AKI - Lipids  LDL and VLDLLDL and VLDL Cholesterol and HDL-CholesterolCholesterol and HDL-Cholesterol Impaired LipolysisImpaired Lipolysis Lipase Activity ~50%Lipase Activity ~50%  Lipoprotein LipaseLipoprotein Lipase  Hepatic Triglyceride LipaseHepatic Triglyceride Lipase
    • 27. Critical Illness - VitaminsCritical Illness - Vitamins Water SolubleWater Soluble Vit BVit B11 Def Altered Energy Metabolism,Def Altered Energy Metabolism,  Lactic Acid, Tubular damageLactic Acid, Tubular damage Vit BVit B66 Def Altered Amino acid and lipidDef Altered Amino acid and lipid metabolismmetabolism Folate Def AnemiaFolate Def Anemia Vit C Def Limit 200 mg/d as precursor toVit C Def Limit 200 mg/d as precursor to Oxalic acidOxalic acid Potential for losses during CRRT.Potential for losses during CRRT.
    • 28. Critical Illness - VitaminsCritical Illness - Vitamins Fat SolubleFat Soluble Vit D Def HypocalcemiaVit D Def Hypocalcemia Vit A ExcessVit A Excess  renal catabolism ofrenal catabolism of retinol binding proteinretinol binding protein Vit E DefVit E Def  >50% plasma and RBC>50% plasma and RBC
    • 29. CRRT-VitaminsCRRT-Vitamins 0 2 4 6 8 10 12 14 16 Serum folate level (ng/ml) Pre CRRT Day 2 Day 5 Day of CRRT Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted * *
    • 30. Critical Illness – trace metalsCritical Illness – trace metals Deficiencies linked to:Deficiencies linked to: - Lymphocyte dysfunctionLymphocyte dysfunction - Cardiovascular dysfunctionCardiovascular dysfunction - Platelet activityPlatelet activity - Antioxidant functionAntioxidant function - Wound healingWound healing
    • 31. Amino acid, trace metal and folate clearance by continuous renal replacement therapy in critically ill children. Zappitelli et al, submitted K1 Day 2 K Day 5 Serum concentrations­­­­­­­­­­­­­­­­­­_____________________ (ml/min/1.73m2 ) (ml/min/1.73m2 ) Initiation Day 2 Day 5 Reference range2 Selenium Copper Chromium Zinc Manganese Folate 10.1±7.2, 9.5 8.6±3.9, 7.2 55±19, 49 61±24, 59 64±23, 63 23 to 190 (µg/l) 0.4±0.3, 0.3 0.54±0.46, 0.44 88±21, 87 L3 110±27, 106 104±27, 103 90 to 190 (µg/dl) 24.0±10.6, 25.4 24.7±7.1, 26.0 2±1, 2 2±1, 2 2±0.4, 2 0 to 2.1 (µg/l) 4.2±4.1, 3.2 4.0±2.4, 2.9 66±44, 53 L 68±28, 61 76±38, 68 60 to 120 (µg/dl) 9.0±12.9, 4.6 38.2±121.4, 5.1 9±16, 4 H3 8±15, 3 H 8±15, 3 H 0 to 2 (µg/l) 29.4±54.9, 16.2 15.6±3.2, 16.3 16±12, 12 10±4, 9 8±2, 7 5.4 to 40 (ng/l) Churchwell et al, NDT, 2007 Critically ill adults receiving CVVHD and CVVHDF Transmembrane clearances Much lower clearance of selenium and chromium Overall, trace metal clearance negligible.
    • 32. SynthesisSynthesis Nutritional parameter Nutrition modality Energy Protein Vitamins Trace elements Monitoring Consider ­ Early enteral feeding, will often require parenteral nutrition ­ Approximately 25% above basal metabolic needs as measured by metabolic cart or estimated with equations. ­20 to 25% as carbohydrates (insulin as needed) 30 to 40% lipid formulations (20% lipid emulsions) 40 to 50% protein ­ 2 to 3 g/kg/day with AKI ­ Increase intake if on CRRT (by 20%) ­ Daily recommended intake ­ Monitor serum folate, water soluble vitamin levels ± replacement ­ Daily recommended intake ­Resting energy expenditure, nitrogen balance, electrolytes, vitamins, trace elements ­ Glutamine
    • 33. AcknolwedgementsAcknolwedgements Timothy E. BunchmanTimothy E. Bunchman Norma J. MaxvoldNorma J. Maxvold Stuart L. GoldsteinStuart L. Goldstein

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