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Huang HX, Hobson K, Benedetti C, Kennedy S. Water-soluble vitamins and trace elements in children with chronic kidney disease stage 5d. Pediatr Nephrol 2024; 39:1405-1419. [PMID: 37698654 DOI: 10.1007/s00467-023-06132-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/13/2023]
Abstract
Children receiving maintenance dialysis (chronic kidney disease (CKD) stage 5d) have unique risk factors for micronutrient deficiency or toxicity. Children receiving chronic dialysis often require specialized diet plans that may provide more than the recommended daily allowance (RDA) of water-soluble vitamins and micronutrients, with or without the addition of a kidney-friendly vitamin. The following is a comprehensive review of current literature on disorders of micronutrients in this population including those of water-soluble vitamins (vitamin C and vitamin B complexes) and trace elements (copper, selenium, and zinc) and has three areas of focus: (1) the risk factors and clinical presentations of disorders of micronutrients, both deficiency and toxicity, (2) the tools to evaluate micronutrient status, and (3) the central role of renal dietitians in optimizing nutritional status from a micronutrient perspective.
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Affiliation(s)
| | - Kimberly Hobson
- Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, USA
| | | | - Sabina Kennedy
- Division of Nephrology, Emory University School of Medicine, 2015 Uppergate Drive, Office 316J, Atlanta, GA, 30322, USA.
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2
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Vega MRW, Cerminara D, Desloovere A, Paglialonga F, Renken-Terhaerdt J, Walle JV, Shaw V, Stabouli S, Anderson CE, Haffner D, Nelms CL, Polderman N, Qizalbash L, Tuokkola J, Warady BA, Shroff R, Greenbaum LA. Nutritional management of children with acute kidney injury-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2023; 38:3559-3580. [PMID: 36939914 PMCID: PMC10514117 DOI: 10.1007/s00467-023-05884-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/21/2023]
Abstract
The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
| | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - José Renken-Terhaerdt
- Wilhemina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Vanessa Shaw
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University, Hippokratio Hospital, Thessaloniki, Greece
| | | | - Dieter Haffner
- Hannover Medical School, Children's Hospital, Hannover, Germany
| | | | | | | | - Jetta Tuokkola
- New Children's Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Larry A Greenbaum
- Emory University, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
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3
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Kung CW, Chou YH. Acute kidney disease: an overview of the epidemiology, pathophysiology, and management. Kidney Res Clin Pract 2023; 42:686-699. [PMID: 37165615 DOI: 10.23876/j.krcp.23.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/20/2023] [Indexed: 05/12/2023] Open
Abstract
Acute kidney injury (AKI) increases the risk of chronic kidney disease (CKD), and AKI and CKD are seen as interconnected syndromes. Acute kidney disease (AKD) is defined as subacute damage and/or loss of kidney function occurring 7 to 90 days after AKI, during which period key interventions may be initiated to hinder the development of CKD. While AKD is usually under-recognized, it is associated with high morbidity and mortality globally. This review article aims to summarize the current knowledge concerning the epidemiology, pathophysiology, and management of AKD with the aim to develop monitoring strategies and therapeutic agents of AKD. Generally, AKD tends to occur more frequently in the elderly and those with chronic diseases, such as hypertension, diabetes mellitus, and metabolic syndrome. In addition, the severity, duration, and frequency of AKI are independent risk factors for AKD. Investigations of several mechanisms of AKD, such as renal tubular epithelium cell-cycle arrest, epigenetic change, chronic inflammation, mitochondria dysfunction, failed regeneration of tubular cells, metabolic reprogramming, and renin-angiotensin system (RAS) activation, have identified additional potential pharmacotherapy targets. Management of AKD includes prevention of repeated AKI, early and regular follow-up by a nephrologist, resumption and adjustment of essential medication, optimization of blood pressure control and nutrition management, and development of new pharmaceutical agents including RAS inhibitors. Finally, we outline a care bundle for AKD patients based on important lessons learned from studies and registries and identify the need for clinical trials of RAS inhibitors or other novel agents to impede ensuing CKD development.
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Affiliation(s)
- Chin-Wei Kung
- Department of Internal Medicine, China Medical University Hospital, China Medical University College of Medicine, Taichung, Taiwan
| | - Yu-Hsiang Chou
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
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4
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Stoppe C, Patel JJ, Zarbock A, Lee ZY, Rice TW, Mafrici B, Wehner R, Chan MHM, Lai PCK, MacEachern K, Myrianthefs P, Tsigou E, Ortiz-Reyes L, Jiang X, Day AG, Hasan MS, Meybohm P, Ke L, Heyland DK. The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial. Crit Care 2023; 27:399. [PMID: 37853490 PMCID: PMC10585921 DOI: 10.1186/s13054-023-04663-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Based on low-quality evidence, current nutrition guidelines recommend the delivery of high-dose protein in critically ill patients. The EFFORT Protein trial showed that higher protein dose is not associated with improved outcomes, whereas the effects in critically ill patients who developed acute kidney injury (AKI) need further evaluation. The overall aim is to evaluate the effects of high-dose protein in critically ill patients who developed different stages of AKI. METHODS In this post hoc analysis of the EFFORT Protein trial, we investigated the effect of high versus usual protein dose (≥ 2.2 vs. ≤ 1.2 g/kg body weight/day) on time-to-discharge alive from the hospital (TTDA) and 60-day mortality and in different subgroups in critically ill patients with AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria within 7 days of ICU admission. The associations of protein dose with incidence and duration of kidney replacement therapy (KRT) were also investigated. RESULTS Of the 1329 randomized patients, 312 developed AKI and were included in this analysis (163 in the high and 149 in the usual protein dose group). High protein was associated with a slower time-to-discharge alive from the hospital (TTDA) (hazard ratio 0.5, 95% CI 0.4-0.8) and higher 60-day mortality (relative risk 1.4 (95% CI 1.1-1.8). Effect modification was not statistically significant for any subgroup, and no subgroups suggested a beneficial effect of higher protein, although the harmful effect of higher protein target appeared to disappear in patients who received kidney replacement therapy (KRT). Protein dose was not significantly associated with the incidence of AKI and KRT or duration of KRT. CONCLUSIONS In critically ill patients with AKI, high protein may be associated with worse outcomes in all AKI stages. Recommendation of higher protein dosing in AKI patients should be carefully re-evaluated to avoid potential harmful effects especially in patients who were not treated with KRT. TRIAL REGISTRATION This study is registered at ClinicalTrials.gov (NCT03160547) on May 17th 2017.
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Affiliation(s)
- Christian Stoppe
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany.
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alex Zarbock
- Department of Anaesthesiology and Intensive Care Medicine, University of Münster, Münster, Germany
| | - Zheng-Yii Lee
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bruno Mafrici
- Renal and Transplantation Unit, Department of Dietetics and Nutrition, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, UK
| | - Rebecca Wehner
- Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Kristen MacEachern
- Intensive Care Unit, Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | | | - Evdoxia Tsigou
- Intensive Care Unit, Agioi Anargiroi Hospital, Athens, Greece
| | - Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Andrew G Day
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada.
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada.
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Xiong J, Yu Z, Huang Y, He T, Yang K, Zhao J. Geriatric Nutritional Risk Index and Risk of Mortality in Critically Ill Patients With Acute Kidney Injury: A Multicenter Cohort Study. J Ren Nutr 2023; 33:639-648. [PMID: 37302721 DOI: 10.1053/j.jrn.2023.06.004] [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: 10/25/2022] [Revised: 05/26/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023] Open
Abstract
OBJECTIVES Malnutrition is associated with adverse outcomes in acute or chronic diseases. However, the prediction value of the Geriatric Nutritional Risk Index (GNRI) in critically ill patients with acute kidney injury (AKI) has not been well studied. METHODS Data was extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) and the electronic intensive care unit database. We used two nutritional indicators, the GNRI and the modified Nutrition Risk in Critically ill (NUTRIC) score, to evaluate the relationship between the nutritional status of patients with AKI and prognosis. The outcome is in-hospital mortality and 90-day mortality. The prediction accuracy of GNRI was compared with the NUTRIC score. RESULTS A total of 4,575 participants with AKI were enrolled in this study. The median age of 68 (interquartile range, 56-79) years, and 1,142 (25.0%) patients experienced in-hospital mortality, and 1,238 (27.1%) patients experienced 90-day mortality. Kaplan-Meier survival analysis indicated that lower GNRI levels and high NUTRIC score are associated with lower in-hospital and 90-day survival of patients with AKI (P < .001 by log-rank test). After multivariate adjustment, Cox regression analysis demonstrated a 2-fold increased risk of in-hospital (hazard ratio = 2.019, 95% confidence interval: 1.699-2.400, P < .001) and 90-day (hazard ratio = 2.023, 95% confidence interval: 1.715-2.387, P < .001) mortality in the low GNRI group. Moreover, the multivariate-adjusted Cox model containing GNRI had higher prediction accuracy for the prognosis of patients with AKI than that with NUTRIC score (AUCGNRI model vs. AUCNUTRIC model for in-hospital mortality = 0.738 vs. 0.726, AUCGNRI model vs. AUCNUTRIC model for 90-day mortality = 0.748 vs. 0.726). In addition, the prediction value of GNRI was validated by the electronic intensive care unit database (7,881 patients with AKI) with satisfying performance (AUCGNRI model = 0.680). CONCLUSIONS Our results demonstrated that GNRI is strongly associated with survival in patients in the intensive care unit coexisting with AKI, and the GNRI has a superior predictive value than the NUTRIC score.
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Affiliation(s)
- Jiachuan Xiong
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, PR China
| | - Zhikai Yu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, PR China
| | - Yinghui Huang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, PR China
| | - Ting He
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, PR China
| | - Ke Yang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, PR China
| | - Jinghong Zhao
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, PR China.
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6
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Lumlertgul N, Cameron LK, Bear DE, Ostermann M. Micronutrient Losses during Continuous Renal Replacement Therapy. Nephron Clin Pract 2023; 147:759-765. [PMID: 37611551 DOI: 10.1159/000531947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/09/2023] [Indexed: 08/25/2023] Open
Abstract
Acute kidney injury impacts the micronutrient status by various mechanisms including decreased enteral absorption, changes in redistribution, altered metabolism, and increased consumption. When renal replacement therapy (RRT) is applied, there are additional losses of vitamins, trace elements, and amino acids, and their derivatives due to diffusion or adhesion. Varied data exist regarding the degree of micronutrient losses and plasma concentrations in patients who receive RRT, and these differ by RRT modality, dose, duration, and type of micronutrient. Water-soluble vitamins, selenium, copper, and carnitine are among the most frequently reported depleted nutrients. The role of micronutrient supplementation in critically ill patients undergoing RRT and the optimal dose and mode of administration are yet to be determined.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand,
- Faculty of Medicine, Centre of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand,
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK,
| | - Lynda K Cameron
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College London, London, UK
| | - Danielle E Bear
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, Guy's and St Thomas' NHS Foundation Trust, Department of Critical Care, London, UK
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7
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Fishman G, Singer P. Metabolic and nutritional aspects in continuous renal replacement therapy. JOURNAL OF INTENSIVE MEDICINE 2023; 3:228-238. [PMID: 37533807 PMCID: PMC10391575 DOI: 10.1016/j.jointm.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 08/04/2023]
Abstract
Nutrition is one of the foundations for supporting and treating critically ill patients. Nutritional support provides calories, protein, electrolytes, vitamins, and trace elements via the enteral or parenteral route. Acute kidney injury (AKI) is a common and devastating problem in critically ill patients and has significant metabolic and nutritional consequences. Moreover, renal replacement therapy (RRT), whatever the modality used, also profoundly impacts metabolism. RRT and of the extracorporeal circuit impede 'effect the evaluation of a patient's energy requirements by clinicians. Substrates added and removed within the extracorporeal treatment are not always taken into consideration, making treatment even more challenging. Furthermore, evidence on nutritional support during continuous renal replacement therapy (CRRT) is scarce, and there are no clinical guidelines for nutrition adaptations during CRRT in critically ill patients. Most recommendations are based on expert opinions. This review discusses the complex interaction between nutritional support and CRRT and presents some milestones for nutritional support in critically ill patients on CRRT.
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Affiliation(s)
- Guy Fishman
- Corresponding author at: General Intensive Care and Institute for Nutrition Research.
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8
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Teixeira JP, Griffin BR, Pal CA, González-Seguel F, Jenkins N, Jones BM, Yoshida Y, George N, Israel HP, Ghazi L, Neyra JA, Mayer KP. Critical illness myopathy and trajectory of recovery in acute kidney injury requiring continuous renal replacement therapy: a prospective observational trial protocol. BMJ Open 2023; 13:e072448. [PMID: 37217272 PMCID: PMC10230984 DOI: 10.1136/bmjopen-2023-072448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Acute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors. METHODS AND ANALYSIS This protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1-3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling. ETHICS AND DISSEMINATION We anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions. TRIAL REGISTRATION NUMBER NCT05287204.
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Affiliation(s)
- J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Benjamin R Griffin
- Division of Nephrology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Chaitanya Anil Pal
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Felipe González-Seguel
- Servicio Medicina Física y Rehabilitación, Clinica Alemana de Santiago SA, Santiago, Región Metropolitana, Chile
- Facultad de Medicina, Universidad del Desarrollo, Santiago, Región Metropolitana, Chile
| | - Nathanial Jenkins
- Department of Health and Human Physiology, The University of Iowa, Iowa City, Iowa, USA
| | - Beth M Jones
- Department of Orthopedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Yuri Yoshida
- Department of Orthopedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Hayley Puffer Israel
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Lama Ghazi
- Department of Epidemiology, The University of Alabama School of Public Health, Birmingham, Alabama, USA
| | - Javier A Neyra
- Division of Nephrology, The University of Alabama Heersink School of Medicine, Birmingham, Alabama, USA
| | - Kirby P Mayer
- Department of Physical Therapy, University of Kentucky College of Health Sciences, Lexington, Kentucky, USA
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9
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Czempik PF, Wiórek A. Iron deficiency in sepsis patients managed with divided doses of iron dextran: a prospective cohort study. Sci Rep 2023; 13:5264. [PMID: 37002279 PMCID: PMC10066317 DOI: 10.1038/s41598-023-32002-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Iron deficiency (ID) impairs hemoglobin (Hb) synthesis and immune function, both crucial for sepsis patients. We assessed the impact of iron dextran on reticulocyte (Ret) Hb equivalent (Ret-He) and Ret subpopulations in iron-deficient sepsis patients. In this prospective clinical study we enrolled patients with sepsis or septic shock with procalcitonin concentration > 0.5 ng/mL, diagnosed with ID based on Ret-He. Study subjects received divided doses of iron dextran until normalization of Ret-He. The study population included 35 subjects. The median Ret-He increase after 2 doses of iron dextran was 3.0 (IQR 1.9-6.1) pg (p < 0.01) with median time to normalization 4 (IQR 3-5) days. Although no change in Ret percentage [Me 1.5 (IQR 1.1-2.1) vs. Me 1.4 (IQR 1.1-2.4) %, p = 0.39] and number [Me 0.05 (IQR 0.04-0.07) vs. Me 0.05 (IQR 0.03-0.06) 106/µL, p = 0.88] was noted, Ret subpopulations changed significantly (p for all < 0.01). Divided doses of iron dextran relatively quickly normalize Ret-He in iron-deficient sepsis patients. Changes in Ret subpopulations suggest increased erythropoietic activity. Further research is needed to explore the role of intravenous iron in this clinical setting.
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Affiliation(s)
- Piotr F Czempik
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland.
- Transfusion Committee, University Clinical Center of Medical University of Silesia in Katowice, Katowice, Poland.
| | - Agnieszka Wiórek
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland
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10
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Teixeira JP, Mayer KP, Griffin BR, George N, Jenkins N, Pal CA, González-Seguel F, Neyra JA. Intensive Care Unit-Acquired Weakness in Patients With Acute Kidney Injury: A Contemporary Review. Am J Kidney Dis 2023; 81:336-351. [PMID: 36332719 PMCID: PMC9974577 DOI: 10.1053/j.ajkd.2022.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
Acute kidney injury (AKI) and intensive care unit-acquired weakness (ICU-AW) are 2 frequent complications of critical illness that, until recently, have been considered unrelated processes. The adverse impact of AKI on ICU mortality is clear, but its relationship with muscle weakness-a major source of ICU morbidity-has not been fully elucidated. Furthermore, improving ICU survival rates have refocused the field of intensive care toward improving long-term functional outcomes of ICU survivors. We begin our review with the epidemiology of AKI in the ICU and of ICU-AW, highlighting emerging data suggesting that AKI and AKI treated with kidney replacement therapy (AKI-KRT) may independently contribute to the development of ICU-AW. We then delve into human and animal data exploring the pathophysiologic mechanisms linking AKI and acute KRT to muscle wasting, including altered amino acid and protein metabolism, inflammatory signaling, and deleterious removal of micronutrients by KRT. We next discuss the currently available interventions that may mitigate the risk of ICU-AW in patients with AKI and AKI-KRT. We conclude that additional studies are needed to better characterize the epidemiologic and pathophysiologic relationship between AKI, AKI-KRT, and ICU-AW and to prospectively test interventions to improve the long-term functional status and quality of life of AKI survivors.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico.
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Kentucky
| | - Benjamin R Griffin
- Division of Nephrology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Naomi George
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico; Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Nathaniel Jenkins
- Department of Health and Human Physiology, University of Iowa, Iowa City, Iowa
| | - C Anil Pal
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Felipe González-Seguel
- Servicio de Medicina Física y Rehabilitación, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
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11
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Role of Fat-Free Mass Index on Amino Acid Loss during CRRT in Critically Ill Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020389. [PMID: 36837590 PMCID: PMC9966592 DOI: 10.3390/medicina59020389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023]
Abstract
Background and objectives: Amino acid (AA) loss is a prevalent unwanted effect of continuous renal replacement therapy (CRRT) in critical care patients, determined both by the machine set-up and individual characteristics. The aim of this study was to evaluate the bioelectrical impedance analysis-derived fat-free mass index (FFMI) effect on amino acid loss. Materials and methods: This was a prospective, observational, single sample study of critical care patients upon initiation of CRRT. AA loss during a 24 h period was estimated. Conventional determinants of AA loss (type and dose of CRRT, concentration of AA) and FFMI were entered into the multivariate regression analysis to determine the individual predictive value. Results: Fifty-two patients were included in the study. The average age was 66.06 ± 13.60 years; most patients had a high mortality risk with APAHCE II values of 22.92 ± 8.15 and SOFA values of 12.11 ± 3.60. Mean AA loss in 24 h was 14.73 ± 9.83 g. There was a significant correlation between the lost AA and FFMI (R = 0.445, B = 0.445 CI95%: 0.541-1.793 p = 0.02). Multivariate regression analysis revealed the independent predictors of lost AA to be the systemic concentration of AA (B = 6.99 95% CI:4.96-9.04 p = 0.001), dose of CRRT (B = 0.48 95% CI:0.27-0.70 p < 0.001) and FFMI (B = 0.91 95% CI:0.42-1.41 p < 0.001). The type of CRRT was eliminated in the final model due to co-linearity with the dose of CRRT. Conclusions: A substantial amount of AA is lost during CRRT. The amount lost is increased by the conventional factors as well as by higher FFMI. Insights from our study highlight the FFMI as a novel research object during CRRT, both when prescribing the dosage and evaluating the nutritional support needed.
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Kurlak LO, Scaife PJ, Briggs LV, Broughton Pipkin F, Gardner DS, Mistry HD. Alterations in Antioxidant Micronutrient Concentrations in Placental Tissue, Maternal Blood and Urine and the Fetal Circulation in Pre-eclampsia. Int J Mol Sci 2023; 24:3579. [PMID: 36834991 PMCID: PMC9958563 DOI: 10.3390/ijms24043579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Trace elements such as selenium and zinc are vital components of many enzymes, including endogenous antioxidants, and can interact with each other. Women with pre-eclampsia, the hypertensive disease of pregnancy, have been reported as having changes in some individual antioxidant trace elements during pregnancy, which are related to maternal and fetal mortality and morbidity. We hypothesised that examination of the three compartments of (a) maternal plasma and urine, (b) placental tissue and (c) fetal plasma in normotensive and hypertensive pregnant women would allow identification of biologically significant changes and interactions in selenium, zinc, manganese and copper. Furthermore, these would be related to changes in the angiogenic markers, placental growth factor (PlGF) and Soluble Fms-Like Tyrosine Kinase-1 (sFlt-1) concentrations. Venous plasma and urine were collected from healthy non-pregnant women (n = 30), normotensive pregnant controls (n = 60) and women with pre-eclampsia (n = 50) in the third trimester. Where possible, matched placental tissue samples and umbilical venous (fetal) plasma were also collected. Antioxidant micronutrient concentrations were measured by inductively coupled plasma mass-spectrometry. Urinary levels were normalised to creatinine concentration. Plasma active PlGF and sFlt-1 concentrations were measured by ELISA. Maternal plasma selenium, zinc and manganese were all lower in women with pre-eclampsia (p < 0.05), as were fetal plasma selenium and manganese (p < 0.05 for all); maternal urinary concentrations were lower for selenium and zinc (p < 0.05). Conversely, maternal and fetal plasma and urinary copper concentrations were higher in women with pre-eclampsia (p < 0.05). Differences in placental concentrations varied, with lower overall levels of selenium and zinc (p < 0.05) in women with pre-eclampsia. Maternal and fetal PlGF were lower and sFlt-1 higher in women with pre-eclampsia; maternal plasma zinc was positively correlated with maternal plasma sFlt-1 (p < 0.05). Because of perceptions that early- and late-onset pre-eclampsia have differing aetiologies, we subdivided maternal and fetal data accordingly. No major differences were observed, but fetal sample sizes were small following early-onset. Disruption in these antioxidant micronutrients may be responsible for some of the manifestations of pre-eclampsia, including contributing to an antiangiogenic state. The potential benefits of mineral supplementation, in women with deficient intakes, during pregnancy to reduce pre-eclampsia remain an important area for experimental and clinical research.
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Affiliation(s)
- Lesia O. Kurlak
- School of Medicine (Stroke Research), University of Nottingham, Nottingham NG7 2UH, UK
| | - Paula J. Scaife
- Clinical, Metabolic and Molecular Physiology Research Group, University of Nottingham, Derby DE22 3DT, UK
| | - Louise V. Briggs
- School of Engineering, University of Nottingham, Nottingham NG7 2RD, UK
| | - Fiona Broughton Pipkin
- Department of Obstetrics & Gynaecology, University of Nottingham, Nottingham NG5 1PB, UK
| | - David S. Gardner
- School of Veterinary Medicine and Science, University of Nottingham, Loughborough LE12 5RD, UK
| | - Hiten D. Mistry
- Department of Women and Children’s Health, School of Life Course and Population Sciences, King’s College London, London SE1 1UL, UK
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13
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Emuron D, Thomas K, Mullane R. The Nutritional Risk Index as a Predictor of 90-Day Dialysis Dependence After Acute Renal Failure: A Pilot Study. J Ren Nutr 2023; 33:29-34. [PMID: 35447334 DOI: 10.1053/j.jrn.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/28/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Return of sufficient renal function to discontinue dialysis following acute renal failure is an important clinical and patient-oriented outcome. Our study sought to develop a model using the Nutritional Risk Index (NRI) to predict 90-day dialysis dependence. METHODS We retrospectively analyzed 77 patients with acute renal failure admitted to a single university medical center's intensive care units between January 2015 and January 2019 with the need for continuous renal replacement therapy. We assessed the predictive ability of the NRI for 90-day dialysis dependence using age, serum total protein, number of vasopressor days, baseline predialysis estimated glomerular filtration rate (eGFR), and Sequential Organ Failure Assessment (SOFA) score as covariates. RESULTS Of the analytic group, 20 (25.9%) had severe nutritional risk, and 16 (20.8%) recovered from acute renal failure at 90 days. The mean age was 57.1 years. The clinical model comprising the NRI, age, serum total protein, number of vasopressor days, SOFA score, and baseline predialysis eGFR had an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.81-0.97), sensitivity 56.3%, and specificity 95%. Exclusion of baseline predialysis eGFR and SOFA score did not significantly decrease model discrimination, AUC 0.87 (95% CI, 0.78-0.97). The AUC was least when serum total protein was dropped from the final model, 0.79 (95% CI, 0.66-0.92). CONCLUSIONS The NRI when used together with other clinical parameters, including serum total protein, may improve the accuracy of predicting renal recovery and independence from dialysis at 90 days.
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Affiliation(s)
- Dennis Emuron
- Fellow, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kaleb Thomas
- Resident, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ryan Mullane
- Assistant Professor, Division of Nephrology, University of Nebraska Medical Center, Omaha, Nebraska.
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14
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Miškinis J, Ramonas E, Gurevičienė V, Razumienė J, Dagys M, Ratautas D. Capacitance-Based Biosensor for the Measurement of Total Loss of L-Amino Acids in Human Serum during Hemodialysis. ACS Sens 2022; 7:3352-3359. [PMID: 36268654 PMCID: PMC9706805 DOI: 10.1021/acssensors.2c01342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In this paper, we present a biosensor based on a gold nanoparticle (AuNP)-modified Pt electrode with an adjusted membrane containing cross-linked L-amino acid oxidase for the detection and quantification of total L-amino acids. The designed biosensor was tested and characterized using the capacitance-based principle, capacitance measurements after electrode polarization, disconnection from the circuit, and addition of the respective amount of the analyte. The method was implemented using the capacitive and catalytic properties of the Pt/AuNP electrode; nanostructures were able to store electric charge while at the same time catalyzing the oxidation of the redox reaction intermediate H2O2. In this way, the Pt/AuNP layer was charged after the addition of analytes, allowing for much more accurate measurements for samples with low amino acid concentrations. The combined biosensor electrode with the capacitance-based measurement method resulted in high sensitivity and a low limit of detection (LOD) for hydrogen peroxide (4.15 μC/μM and 0.86 μM, respectively) and high sensitivity, a low LOD, and a wide linear range for L-amino acids (0.73 μC/μM, 5.5 μM and 25-1500 μM, respectively). The designed biosensor was applied to measure the relative loss of amino acids in patients undergoing renal replacement therapy by analyzing amino acid levels in diluted serum samples before and after entering/leaving the hemodialysis apparatus. In general, the designed biosensor in conjunction with the proposed capacitance-based method was clinically tested and could also be applied for the detection of other analytes using analyte-specific oxidases.
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15
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Nadamuni M, Venable AH, Huen SC. When a calorie isn't just a calorie: a revised look at nutrition in critically ill patients with sepsis and acute kidney injury. Curr Opin Nephrol Hypertens 2022; 31:358-366. [PMID: 35703214 PMCID: PMC9248034 DOI: 10.1097/mnh.0000000000000801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To discuss how nutritional management could be optimized to promote protective metabolism in sepsis and associated acute kidney injury. RECENT FINDINGS Recent evidence suggests that sepsis is a metabolically distinct critical illness and that certain metabolic alterations, such as activation of fasting metabolism, may be protective in bacterial sepsis. These findings may explain the lack of survival benefit in recent randomized controlled trials of nutrition therapy for critical illness. These trials are limited by cohort heterogeneity, combining both septic and nonseptic critical illness, and the use of inaccurate caloric estimates to determine energy requirements. These energy estimates are also unable to provide information on specific substrate preferences or the capacity for substrate utilization. As a result, high protein feeding beyond the capacity for protein synthesis could cause harm in septic patients. Excess glucose and insulin exposures suppress fatty acid oxidation, ketogenesis and autophagy, of which emerging evidence suggest are protective against sepsis associated organ damage such as acute kidney injury. SUMMARY Distinguishing pathogenic and protective sepsis-related metabolic changes are critical to enhancing and individualizing nutrition management for critically ill patients.
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Affiliation(s)
| | | | - Sarah C Huen
- Department of Internal Medicine
- Department of Pharmacology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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16
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Berger MM, Shenkin A, Schweinlin A, Amrein K, Augsburger M, Biesalski HK, Bischoff SC, Casaer MP, Gundogan K, Lepp HL, de Man AME, Muscogiuri G, Pietka M, Pironi L, Rezzi S, Cuerda C. ESPEN micronutrient guideline. Clin Nutr 2022; 41:1357-1424. [PMID: 35365361 DOI: 10.1016/j.clnu.2022.02.015] [Citation(s) in RCA: 167] [Impact Index Per Article: 83.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome. OBJECTIVE This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement". METHODS The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations. RESULTS There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed. CONCLUSION This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.
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Affiliation(s)
- Mette M Berger
- Department of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Alan Shenkin
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Anna Schweinlin
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Karin Amrein
- Medical University of Graz, Department of Internal Medicine, Division of Endocrinology and Diabetology, Austria.
| | - Marc Augsburger
- University Centre of Legal Medicine Lausanne-Geneva, Lausanne University Hospital and University of Lausanne, Geneva University Hospital and University of Geneva, Lausanne-Geneva, Switzerland.
| | | | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Michael P Casaer
- KU Leuven, Department of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, Leuven, Belgium.
| | - Kursat Gundogan
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey.
| | | | - Angélique M E de Man
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Giovanna Muscogiuri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy; United Nations Educational, Scientific and Cultural Organization (UNESCO) Chair for Health Education and Sustainable Development, Federico II, University, Naples, Italy.
| | - Magdalena Pietka
- Pharmacy Department, Stanley Dudrick's Memorial Hospital, Skawina, Poland.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy.
| | - Serge Rezzi
- Swiss Nutrition and Health Foundation (SNHf), Epalinges, Switzerland.
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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17
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Fah M, Van Althuis LE, Ohnuma T, Winthrop HM, Haines KL, Williams DG, Krishnamoorthy V, Raghunathan K, Wischmeyer PE. Micronutrient deficiencies in critically ill patients receiving continuous renal replacement therapy. Clin Nutr ESPEN 2022; 50:247-254. [DOI: 10.1016/j.clnesp.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
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18
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Gardner DS, Allen JC, Goodson D, Harvey D, Sharman A, Skinner H, Szafranek A, Young JS, Bailey EH, Devonald MA. Urinary trace elements are biomarkers for early detection of acute kidney injury. Kidney Int Rep 2022; 7:1524-1538. [PMID: 35812272 PMCID: PMC9263416 DOI: 10.1016/j.ekir.2022.04.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/27/2022] [Accepted: 04/18/2022] [Indexed: 12/11/2022] Open
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Breik L, Tatucu-Babet OA, Ridley EJ. Micronutrient intake from enteral nutrition in critically ill adults: A systematic review of randomised controlled trials. Aust Crit Care 2021; 35:564-574. [PMID: 34756550 DOI: 10.1016/j.aucc.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 08/29/2021] [Accepted: 09/03/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES The primary objective was to compare the intake of important micronutrients provided from enteral nutrition to critically ill patients with the Australia and New Zealand recommended dietary intakes. A secondary objective was to compare the upper levels of intake and investigate prespecified subgroups. REVIEW METHOD USED A systematic literature review was performed. DATA SOURCES MEDLINE, EMBASE, CINAHL, and CENTRAL were used. REVIEW METHODS Databases were searched for randomised controlled trials that investigated an enteral nutrition intervention as the sole source of nutrition, were published in English between January 2000 and January 8th, 2021, and provided data to calculate micronutrient intake. The primary outcome was the % recommended dietary intake. The quality of individual trials was assessed using the Cochrane Risk of Bias Tool. Outcomes are presented as either mean ± standard deviation or median [interquartile range], with a p < 0.05 considered statistically significant. RESULTS Thirteen trials were included (n = 1538 patients). Trials investigating hypocaloric nutrition were excluded from the primary outcome assessment (conducted in nine trials (n = 1220)). All nine trials delivered ≥104% of the recommended dietary intakes and <100% of the upper level of intakes of all micronutrients. In subgroup analyses, trials with ≥80% target energy delivered a higher % of the recommended dietary intake of vitamin B12, thiamine, zinc, and vitamin C. Acute Physiology and Chronic Health Evaluation scores ≥20 delivered a higher % of the recommended dietary intake of vitamin B12 and vitamin A. Antioxidant formulas compared with standard formulas delivered a higher % recommended dietary intake of vitamin C and thiamine. In the four trials that investigated hypocaloric feeding compared with control, there was no difference in micronutrient intake. The quality was low. CONCLUSIONS Enteral nutrition delivery frequently met the recommended dietary intakes for all micronutrients investigated and did not exceed the upper levels of intake set for health. PROSPERO REGISTRATION CRD42020178333.
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Affiliation(s)
- Lina Breik
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 555 St Kilda Rd, Melbourne, VIC, 3004, Australia; Nutrition and Dietetics Department, Box Hill Hospital, Eastern Health, 8 Arnold Street, Box Hill, Melbourne, VIC, 3128, Australia
| | - Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 555 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 555 St Kilda Rd, Melbourne, VIC, 3004, Australia; Nutrition Department, Alfred Hospital, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
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20
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Berger MM, Broman M, Forni L, Ostermann M, De Waele E, Wischmeyer PE. Nutrients and micronutrients at risk during renal replacement therapy: a scoping review. Curr Opin Crit Care 2021; 27:367-377. [PMID: 34039873 PMCID: PMC8270509 DOI: 10.1097/mcc.0000000000000851] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Malnutrition is frequent in patients with acute kidney injury. Nutrient clearance during renal replacement therapy (RRT) potentially contributes to this complication. Although losses of amino acid, trace elements and vitamins have been described, there is no clear guidance regarding the role of micronutrient supplementation. RECENT FINDINGS A scoping review was conducted with the aim to review the existing literature on micronutrients status during RRT: 35 publications including data on effluent losses and blood concentrations were considered relevant and analysed. For completeness, we also included data on amino acids. Among trace elements, negative balances have been shown for copper and selenium: low blood levels seem to indicate potential deficiency. Smaller size water soluble vitamins were found in the effluent, but not larger size liposoluble vitamins. Low blood values were frequently reported for thiamine, folate and vitamin C, as well as for carnitine. All amino acids were detectable in effluent fluid. Duration of RRT was associated with decreasing blood values. SUMMARY Losses of several micronutrients and amino acids associated with low blood levels represent a real risk of deficiency for vitamins B1 and C, copper and selenium: they should be monitored in prolonged RRT. Further Research is urgently required as the data are insufficient to generate strong conclusions and prescription recommendations for clinical practice.
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Affiliation(s)
- Mette M. Berger
- Lausanne University Hospital (CHUV) & University of Lausanne, Lausanne, Switzerland
| | - Marcus Broman
- Perioperative and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Lui Forni
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Department of Clinical & Experimental Medicine, School of Biosciences & Medicine, University of Surrey, Surrey
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas’ Foundation Hospital, Department of Critical Care, London, UK
| | | | - Paul E. Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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21
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Ostermann M, Lumlertgul N, Mehta R. Nutritional assessment and support during continuous renal replacement therapy. Semin Dial 2021; 34:449-456. [PMID: 33909935 DOI: 10.1111/sdi.12973] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/24/2021] [Accepted: 03/19/2021] [Indexed: 01/03/2023]
Abstract
Malnutrition is highly prevalent in patients with acute kidney injury, especially in those receiving renal replacement therapy (RRT). For the assessment of nutritional status, a combination of screening tools, anthropometry, and laboratory parameters is recommended rather than a single test. To avoid underfeeding and overfeeding during RRT, energy expenditure should be measured by indirect calorimetry or calculated using predictive equations. Nitrogen balance should be periodically measured to assess the degree of catabolism and to evaluate protein intake. However, there is limited data for nutritional targets specifically for patients on RRT, such as protein intake. The composition of commercial solutions for continuous renal replacement therapy (CRRT) varies. CRRT itself can be associated with both, nutrient losses into the effluent fluid and caloric gain from dextrose, lactate, and citrate. The role of micronutrient supplementation, and potential use of micronutrient enriched CRRT solutions in this setting is unknown, too. This review provides an overview of existing knowledge and uncertainties related to nutritional aspects in patients on CRRT and emphasizes the need for more research in this area.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' Hospital, London, UK
| | - Nuttha Lumlertgul
- Department of Critical Care, Guy's & St Thomas' Hospital, London, UK.,Division of Nephrology, Department of Internal Medicine and Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Ravindra Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA, USA
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22
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Amino acids and vitamins status during continuous renal replacement therapy: An ancillary prospective observational study of a randomised control trial. Anaesth Crit Care Pain Med 2021; 40:100813. [PMID: 33588088 DOI: 10.1016/j.accpm.2021.100813] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/11/2020] [Accepted: 11/23/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is associated with micronutrients loss. Current recommendations are to administer 1-1.5g/kg/day of proteins during CRRT. We aim to evaluate the net effect of CRRT on amino acids (AA), vitamins A and C (Vit A, Vit C) levels. METHODS This is a prospective observational study embedded within a randomised controlled trial comparing two CRRT doses in patients with septic shock. CRRT was provided in continuous veno-venous haemofiltration mode at a dose of either 35ml/kg/h or 70ml/kg/h. All patients received parenteral nutrition with standard trace elements and vitamins (protein intake 1g/kg/d). We measured serum levels of glutamine, valine and alanine as well as Vit A and Vit C upon randomisation, study day four and eight. In addition, we measured a larger panel of AA in a subset of 11 patients. RESULTS We included 30 patients (17 allocated to 70ml/kg/h and 13 to 35ml/kg/h CRRT). Before CRRT initiation, mean plasma levels of glutamine and valine, Vit A and Vit C were low. CRRT was not associated with any significant change in AA levels except for a decrease in cystein. It was associated with an increase in Vit A and a decrease in Vit C levels. CRRT dose had no impact on those nutrients blood levels. CONCLUSIONS Irrespective of dose, CRRT was associated with a decrease in cysteine and Vit C and an increase in Vit A with no significant change in other AA. Further studies should focus on lean mass wasting during CRRT.
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Meyer D, Mohan A, Subev E, Sarav M, Sturgill D. Acute Kidney Injury Incidence in Hospitalized Patients and Implications for Nutrition Support. Nutr Clin Pract 2020; 35:987-1000. [DOI: 10.1002/ncp.10595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Daniel Meyer
- Division of Nephrology Department of Medicine Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Anju Mohan
- Division of Nephrology, Department of Medicine North Shore University Healthsystem Evanston Illinois USA
| | - Emiliya Subev
- Department of Clinical Nutrition North Shore University Healthsystem Evanston Illinois USA
| | - Menaka Sarav
- Division of Nephrology, Department of Medicine North Shore University Healthsystem Evanston Illinois USA
| | - Daniel Sturgill
- Division of Nephrology Department of Medicine Medical College of Wisconsin Milwaukee Wisconsin USA
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24
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Lumlertgul N, Bear DE, Ostermann M. Clearance of micronutrients during continuous renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:616. [PMID: 33076937 PMCID: PMC7574342 DOI: 10.1186/s13054-020-03347-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/14/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK.,Division of Nephrology, Department of Internal Medicine and Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, 1873 Rama IV Road, Bangkok, 10330, Thailand.,Research Unit in Critical Care Nephrology, Chulalongkorn University, 1873 Rama IV Road, Bangkok, 10330, Thailand
| | - Danielle E Bear
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK.,Department of Nutrition and Dietetics, Guy's & St Thomas' NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Trust, 249 Westminster Bridge Road, London, SE1 7EH, UK.
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Abstract
PURPOSE OF REVIEW Trace elements are vital components involved in major body functions. Cases of trace elements deficiencies are increasingly encountered in clinical practice, although often underrecognized. This review gives a thorough insight into the newest findings on clinical situations associated with trace elements deficiencies in children and adults, their recognition and management. RECENT FINDINGS Trace elements deficiencies are frequently found in various conditions, most commonly in burns, bariatric surgery, intestinal failure, renal replacement therapy, oncology, critical illness and cardiac surgery. The main trace elements involved are selenium, zinc, copper and iron. Trace elements deficiencies are associated with increased risk of morbidity and mortality. Recognition of clinical signs of trace elements deficiencies can be challenging. Although trace elements supplementation is indisputable in many circumstances, it is still debatable in other situations such as sepsis and cardiac surgery. SUMMARY Recent findings on trace elements deficiencies could have important implications on health outcomes. Trace elements delivery is a core component of nutritional care. Front-line clinicians should be aware of at-risk clinical situations to provide correct and timely intervention. Future research should be directed towards investigating the potential benefits of antioxidant trace elements supplementation in children in whom studies are scarce, especially in critical conditions such as burns, sepsis and cardiac surgery.
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Serum Levels and Removal by Haemodialysis and Haemodiafiltration of Tryptophan-Derived Uremic Toxins in ESKD Patients. Int J Mol Sci 2020; 21:ijms21041522. [PMID: 32102247 PMCID: PMC7073230 DOI: 10.3390/ijms21041522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 12/30/2022] Open
Abstract
Tryptophan is an essential dietary amino acid that originates uremic toxins that contribute to end-stage kidney disease (ESKD) patient outcomes. We evaluated serum levels and removal during haemodialysis and haemodiafiltration of tryptophan and tryptophan-derived uremic toxins, indoxyl sulfate (IS) and indole acetic acid (IAA), in ESKD patients in different dialysis treatment settings. This prospective multicentre study in four European dialysis centres enrolled 78 patients with ESKD. Blood and spent dialysate samples obtained during dialysis were analysed with high-performance liquid chromatography to assess uremic solutes, their reduction ratio (RR) and total removed solute (TRS). Mean free serum tryptophan and IS concentrations increased, and concentration of IAA decreased over pre-dialysis levels (67%, 49%, −0.8%, respectively) during the first hour of dialysis. While mean serum total urea, IS and IAA concentrations decreased during dialysis (−72%, −39%, −43%, respectively), serum tryptophan levels increased, resulting in negative RR (−8%) towards the end of the dialysis session (p < 0.001), despite remarkable Trp losses in dialysate. RR and TRS values based on serum (total, free) and dialysate solute concentrations were lower for conventional low-flux dialysis (p < 0.001). High-efficiency haemodiafiltration resulted in 80% higher Trp losses than conventional low-flux dialysis, despite similar neutral Trp RR values. In conclusion, serum Trp concentrations and RR behave differently from uremic solutes IS, IAA and urea and Trp RR did not reflect dialysis Trp losses. Conventional low-flux dialysis may not adequately clear Trp-related uremic toxins while high efficiency haemodiafiltration increased Trp losses.
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