by; ashraf el houfi md ms (pulmonology) mrcp (uk) frcp ...dubainutrition.ae/downloads/ashraf el...

By;

Ashraf El Houfi MD

MS (pulmonology) MRCP (UK)

FRCP (London) EDIC

Consultant ICU Dubai Hospital

Introduction

• The significance of nutrition in hospital setting

(especially the ICU) cannot be overstated.

• Critical illness is typically associated with a

Catabolic Stress State coupled with complications

of

• Increased infections,

Multiple-Organ Dysfunction,

Prolonged Hospitalization, and

Increased Morbidity & Mortality

Introduction

• Renal failure is an extremely heterogeneous disease, whose nutritional requirements can differ widely

• Why Renal Failure patient needs special nutritional attention. ??

• Difference between Acute Renal Failure (Acute Kidney Injury)Chronic Renal failureDialysis (HD, PD, CVVHD…)

Acute Kidney Injury

• Acute kidney injury (AKI) occurs in

approximately 7% of all hospitalized patients and

between 33% and 66% of all intensive care unit

(ICU) patients

• ARF, especially in the ICU,

seldom occurs as isolated organ failure but is

usually one component of more complex changes,

in the setting of multiple organ failure.

Metabolic Storm in

Acute Renal Failure

• In most instances ARF is a complication of

Sepsis, Trauma, or Multiple Organ Failure,

• Metabolic derangements determined by the

Acute Uremic State plus Underlying

Disease Process or by

• Complications such as

Severe infections and

Organ dysfunctions and, the type and frequency

of

• Renal Replacement Therapy (RRT)

Metabolic Storm in

Acute Renal Failure

• ARF does affect

Water, Electrolyte, and acid base

metabolism:

• It induces a global change of the

Metabolic Environment with alterations in

Protein and amino acid,

Carbohydrate, and

lipid metabolism

Goals of Nutritional Support

in Acute Renal Failure

• To prevent protein–energy wasting

• To preserve lean body mass

• To avoid further metabolic derangements

• To avoid complications

• To improve wound healing

• To support immune function

• To minimize inflammation

• To reduce mortality

Does EN Influence

Renal Recovery or Patient Outcome?

• There are indications that tube feeding (TF) is

associated with an

improvement in survival in ICU patients with

ARF

• Several studies have proved that TF is associated

with improved outcome in ICU patients (ESPEN GUIDELINES 2006)

• Metnitz PG, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002;30:2051–8.

• Scheinkestel CD,et al. Prospective randomized trial to assess caloric and protein needs of critically Ill,

anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003;19:909–

16.

Initiate Nutrition

How Early !

• We recommend that nutrition support in the form

of early EN be initiated within

24–48 hours in AKI/ARF (critically ill ICU

patient).

• Can we feed a Shocked patient !

Shocked patients have hypo-perfused tissues,

including the GIT. high lactate !

Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Initiate NutritionHow Early !

• Based on expert consensus, we suggest that in

the setting of

Hemodynamic compromise or instability,

EN should be withheld until the patient is

fully resuscitated and/or Hemodynamically stable

• Initiation/ re-initiation of EN to be considered

with caution in patients

stable on vasopressor support.

Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

NB; Justified warning

• Patients on high vasopressor receiving EN, any

• Signs of intolerance (abdominal distention, increasing

[NGT] output or GRVs, decreased passage of stool and

flatus, hypoactive bowel sounds,

+ increasing metabolic acidosis and/or base deficit)

• Should be closely monitored as possible early signs of

gut ischemia, and EN should be held until symptoms and

interventions stabilize

Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Energy Requirement In

Acute Renal Failure

• Energy (Caloric) requirement mainly depends on

the underlying disease

Critical illness

(Trauma, Burn, Severe Sepsis. MOD…..etc.)

• As well as the RRT

Energy Needs

in the Critically ill ?

• We suggest Indirect Calorimetry (IC) be used to

determine energy requirements, when available

Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

• in the absence of IC, we suggest that a published

predictive equation or a simplistic

weight-based equation (25–30 kcal/kg/d)

be used to determine energy requirements

Energy Needs

in the Critically ill ?

Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Fluid Management

• Fully resuscitated, hemodynamically stable

who is either passing normal

U/O ( > 0.5ml/kg/H) or already on RRT

No fluid restriction

• Otherwise

Intake = Output + Insensible losses

Protein Metabolism

• The hallmark of metabolic derangement

• ARF is activation of protein catabolism with

excessive release of amino acids from

skeletal muscle and

• There also is defective muscle utilization of

amino acids for protein synthesis.

• Sustained negative nitrogen balance

Metabolic Response to Stress

Protein synthesis Protein degradation

Protein Requirement

• Based on expert consensus, we suggest that ICU

patients with acute renal failure (ARF) or AKI be

placed on a standard enteral formulation and that

standard ICU recommendations for protein

(1.2–2 g/kg actual body weight per day)

• A.S.P.E.N February 2016 159–211

Protein Requirement

• We recommend that patients receiving frequent hemodialysis or CRRT receive increased protein, up to 2.5 g/kg/d

• A significant amino acid loss (10–15 g/d) is associated with CRRT

• Protein should not be restricted in patients with renal insufficiency as a means to avoid or delayinitiating dialysis therapy.

• A.S.P.E.N February 2016

Critically ill Patients!

• Can lose as much as 1kg of LBM daily

• Loss of LBM accelerates in critical illness

Demling RH. Eplasty 2009;9:e9.

Carbohydrate Metabolism

• There is hyperglycemia, caused both by insulin resistance and the activation of hepatic gluconeogenesis

• Glycemic control should follow the same protocol of critically ill ICU patient Use insulin infusion 140-180 (150 mg/l)

• A.S.P.E.N February 2016

Lipid Metabolism

• Alterations in lipid metabolism are characterized by hyper-triglyceridemia due to an inhibition of lipolysis;

• Exogenous fat clearance after (enteral or parenteral) delivery of lipids can therefore be reduced

• Lipids should represent ∼30–35% of total non protein energy supply

• Most of the high energy (calorie) formulas are high in lipids

Electrolyte Derangement

Chronic Renal Failure

ESPEN Guidelines

Nutritional Screening

• Nutritional screening should be performed;

o Weekly for inpatients

o 2-3 monthly for outpatients with

GFR <20 but not on dialysis

o Within one month of commencement

of dialysis then 6-8 weeks later

o 4-6 monthly for stable hemodialysis patients

o 4-6 monthly for stable peritoneal dialysis

patients

• UK Renal Association 2010

Chronic Renal Failure

• Compensated CRF (NOT yet on Dialysis)

• Disease-specific formulae for ‘‘renal’’ patients:

characterized by

Reduced protein content and

Low electrolyte concentrations.

• Fluid management (NOT yet on Dialysis)

Intake = Output + Insensible losses

Protein Requirement

CRF on maintenance

Hemodialysis (HD patients)

• In acutely ill HD patients the requirements are the

same as in ARF (critically ill patients)

CAPD Consideration

• Peritoneal dialysis losses of proteins, and

micronutrients (5–15 g/day), as are losses of

protein bound substances, such as

Trace elements and absorption of

Glucose is increased (aggravate DM).

• Protein-energy malnutrition is present in a

significant proportion of patients undergoing

chronic peritoneal dialysis CAPD

CAPD Consideration

• Nutritional support indicated in CAPD patients

• Insufficient oral intake, ONS can help to optimize nutrient intake. TF is indicated when adequate nutrition and ONS are insufficient (C). (ESPEN adult Renal failure)

• Formulae with higher protein & lower carbohydratecontent are to be preferred. Products rich in proteins should be used as ONS (C).(ESPEN adult Renal failure)

CAPD & Critical Illness

• Acutely ill CAPD patients have the same

nutritional requirements as ARF patients.

• The energy, protein and minerals

requirements of ARF in

critically ill ICU patients

• Vitamins,

pyridoxine (10 mg) and vitamin C (100 mg)

supplements are recommended (C).

Conclusions

• Patients with renal failure represent an extremely

heterogeneous group, whose nutritional

requirements can differ widely

• Do Renal Failure patients needs special nutritional

attention. ??

• Difference between

Acute Renal Failure (Acute Kidney Injury)

Chronic Renal failure

Dialysis (HD, PD, CVVHD…)

YES