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Raina R, Suchan A, Soundararajan A, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Vitale VS, Crugnale AS, Keller GL, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE, Sethi SK. Nutrition in critically ill children with acute kidney injury on continuous kidney replacement therapy: a 2023 executive summary. Nutrition 2024; 119:112272. [PMID: 38118382 DOI: 10.1016/j.nut.2023.112272] [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: 06/23/2023] [Revised: 10/04/2023] [Accepted: 10/21/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Nutrition plays a vital role in the outcome of critical illness in children, particularly those with acute kidney injury. Currently, there are no established guidelines for children with acute kidney injury treated with continuous kidney replacement therapy. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with acute kidney injury receiving continuous kidney replacement therapy. METHODS An electronic search using PubMed and an inclusive academic library search (including MEDLINE, Cochrane, and Embase databases) was conducted to find relevant English-language articles on nutrition therapy for children (<18 y of age) receiving continuous kidney replacement therapy. RESULTS The existing literature was reviewed by our work group, comprising pediatric nephrologists and experts in nutrition. The modified Delphi method was then used to develop a total of 45 clinical practice points. The best methods for nutritional assessment are discussed. Indirect calorimetry is the most reliable method of predicting resting energy expenditure in children on continuous kidney replacement therapy. Schofield equations can be used when indirect calorimetry is not available. The non-intentional calories contributed by continuous kidney replacement therapy should also be accounted for during caloric dosing. Protein supplementation should be increased to account for the proteins, peptides, and amino acids lost with continuous kidney replacement therapy. CONCLUSIONS Clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with acute kidney injury and on continuous kidney replacement therapy based on the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, Ohio, USA; Akron Children's Hospital, Akron, Ohio, USA.
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA; Children's Healthcare of Atlanta, Atlanta, Georgia, USA; ECU Health, Greenville, North Carolina, USA
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Weiwen V Shih
- Children's Hospital Colorado, University of Colorado, Section of Pediatric Nephrology, Aurora, Colorado, USA
| | - Arwa Nada
- Division of Pediatric Nephrology, Department of Pediatrics, Le Bonheur Children's Hospital and St. Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sharon Y Irving
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee, USA; Department of Medicine, University of Tennessee, Knoxville, Tennessee, USA
| | | | - Aylin S Crugnale
- Akron Nephrology Associates, Cleveland Clinic Akron General, Akron, Ohio, USA
| | | | - Katarina G Berry
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E Bunchman
- Department of Pediatrics, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sidharth K Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta-The Medicity, Gurgaon, India
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Raina R, Suchan A, Sethi SK, Soundararajan A, Vitale VS, Keller GL, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Crugnale AS, Myneni A, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE. Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations. KIDNEY360 2024; 5:285-309. [PMID: 38112754 PMCID: PMC10914214 DOI: 10.34067/kid.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT. METHODS PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023. RESULTS On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points. CONCLUSIONS Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
- Akron Children's Hospital, Akron, Ohio
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, India
| | - Anvitha Soundararajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | | | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
- ECU Health, Greenville, North Carolina
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, United Kingdom
| | - Weiwen V. Shih
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Arwa Nada
- Department of Pediatrics, Division of Pediatric Nephrology, Le Bonheur Children's & St. Jude Children's Research Hospitals, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sharon Y. Irving
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee
- Department of Medicine, University of Tennessee at Knoxville, Knoxville, Tennessee
| | - Aylin S. Crugnale
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Archana Myneni
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Katarina G. Berry
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Jakub Zieg
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E. Bunchman
- Department of Pediatrics, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
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3
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Nesargi S, Steflik H, Kamath N, Selewski D, Gist KM, Menon S. Optimizing Nutrition in Neonates with Kidney Dysfunction. Neoreviews 2024; 25:e25-e35. [PMID: 38161179 DOI: 10.1542/neo.25-1-e25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
The nutritional management of neonates with kidney disease is complex. There may be significant differences in nutritional needs based on the duration and cause of kidney dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD). Furthermore, the treatment modality, including acute (continuous renal replacement therapy and peritoneal dialysis [PD]) and chronic (intermittent hemodialysis and PD) approaches may differentially affect nutritional losses and dietary needs. In this review, we discuss the pathophysiology of compromised nutrition in neonates with AKI and CKD. We also summarize the existing data and consensus recommendations on the provision of nutrition to neonates with AKI and CKD. We highlight the paucity of data on micronutrient losses and the need for future prospective studies to enhance nutritional supplementation to hopefully improve outcomes in these patients.
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Affiliation(s)
- Saudamini Nesargi
- Department of Neonatology, St. Johns Medical College Hospital, Bangalore, India
| | - Heidi Steflik
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Nivedita Kamath
- Department of Pediatric Nephrology, St. Johns Medical College Hospital, Bangalore, India
| | - David Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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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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5
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Fuhrman DY, Gist KM, Akcan-Arikan A. Current practices in pediatric continuous kidney replacement therapy: a systematic review-guided multinational modified Delphi consensus study. Pediatr Nephrol 2023; 38:2817-2826. [PMID: 36625932 PMCID: PMC11069347 DOI: 10.1007/s00467-022-05864-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/25/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has become an integral part of the care of critically ill children. However, uncertainty exists regarding the current state of how CKRT is prescribed and delivered in children. The main objective of this study was to identify the current practices for pediatric CKRT. METHODS We conducted a systematic review of the literature from 2012 to 2022 to identify data regarding CKRT timing of initiation, dosing, anticoagulation, fluid removal, and quality monitoring. Using this data, we then performed a two-round modified Delphi process using a multinational internet-assisted survey of prescribers of CKRT. RESULTS The survey was constructed using 172 articles that met inclusion criteria (12% of studies were pediatric focused). A total of 147 and 126 practitioners completed the survey in rounds 1 and 2, respectively. Participants represented Europe (9.5-11.6%) and North America including pediatric intensivists, nephrologists, and advance practice providers. Consensus (defined as a ≥ 75% participant response of "sometimes" or "always") was achieved for 26 statements. There was consensus in the practices of CKRT initiation, dosing, method of anticoagulation, and fluid removal. In contrast, there appears to be greater variability in the methods used for monitoring anticoagulation and the quality of the delivered treatment. CONCLUSIONS Our study results suggest that the current state of pediatric CKRT practice is reflective of the literature over the last 10 years, which is largely based on the care of adult patients. This data provides a framework to study best practices to further improve outcomes for children receiving CKRT. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- University of Pittsburgh Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA.
| | - Katja M Gist
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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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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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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Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2022; 11:CD010612. [PMID: 36416787 PMCID: PMC9683115 DOI: 10.1002/14651858.cd010612.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register, ClinicalTrials and LILACS to 1 August 2022. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%). AUTHORS' CONCLUSIONS Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.
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Affiliation(s)
- Alicia Isabel Fayad
- Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Daniel G Buamscha
- Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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9
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Lion RP, Vega MR, Smith EO, Devaraj S, Braun MC, Bryan NS, Desai MS, Coss-Bu JA, Ikizler TA, Akcan Arikan A. The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children. Pediatr Nephrol 2022; 37:433-441. [PMID: 34386851 DOI: 10.1007/s00467-021-05162-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In critically ill children with acute kidney injury (AKI), continuous kidney replacement therapy (CKRT) enables nutrition provision. The magnitude of amino acid loss during continuous venovenous hemodiafiltration (CVVHDF) is unknown and needs accurate quantification. We investigated the mass removal and clearance of amino acids in pediatric CVVHDF. METHODS This is a prospective observational cohort study of patients receiving CVVHDF from August 2014 to January 2016 in the pediatric intensive care unit (PICU) of a tertiary children's hospital. RESULTS Fifteen patients (40% male, median age 2.0 (IQR 0.7, 8.0) years) were enrolled. Median PICU and hospital lengths of stay were 20 (9, 59) and 36 (22, 132) days, respectively. Overall survival to discharge was 66.7%. Median daily protein prescription was 2.00 (1.25, 2.80) g/kg/day. Median daily amino acid mass removal was 299.0 (174.9, 452.0) mg/kg body weight, and median daily amino acid mass clearance was 18.2 (13.5, 27.9) ml/min/m2, resulting in a median 14.6 (8.3, 26.7) % protein loss. The rate of amino acid loss increased with increasing dialysis dose and blood flow rate. CONCLUSION CVVHDF prescription and related amino acid loss impact nutrition provision, with 14.6% of the prescribed protein removed. Current recommendations for protein provision for children requiring CVVHDF should be adjusted to compensate for circuit-related loss. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Richard P Lion
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Molly R Vega
- Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - E O'Brien Smith
- Department of Pediatrics and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Sridevi Devaraj
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Michael C Braun
- Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Nathan S Bryan
- Department of Pediatrics and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Jorge A Coss-Bu
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Talat Alp Ikizler
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ayse Akcan Arikan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA. .,Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA. .,Texas Children's Hospital, 6651 Main Street, Houston, TX, 77030, USA.
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10
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Hames DL, Sleeper LA, Ferguson MA, Mehta NM, Salvin JW, Mills KI. Fluid Restriction Contributes to Poor Nutritional Adequacy in Patients With Congenital Heart Disease Receiving Renal Replacement Therapy. J Ren Nutr 2022; 32:78-86. [PMID: 34625332 PMCID: PMC8991421 DOI: 10.1053/j.jrn.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/24/2021] [Accepted: 08/10/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Critically ill patients receiving renal replacement therapy (RRT) in the pediatric cardiac intensive care unit (CICU) are at high risk for inadequate nutrition delivery. The objective of this study is to evaluate barriers to adequate energy and protein delivery in critically ill patients with congenital heart disease receiving RRT. METHODS This is a single-center retrospective cohort study of patients receiving RRT in the CICU from 2011 to 2019. Energy and protein adequacy was recorded over the first 7 days of RRT. Adequacy was defined as delivery of >80% of the energy and protein targets during this time period. Patients who achieved adequacy were compared to those who did not. Multivariable logistic regression models were constructed to determine factors independently associated with energy and protein adequacy while receiving RRT. RESULTS Sixty patients were included for analysis. Fifty-five patients (92%) achieved energy adequacy and 37 patients (62%) achieved protein adequacy. A higher weight-for-age z-score (WAZ) on admission to the CICU was the only independent predictor of inadequate energy intake (odds ratio 0.07, 95% confidence interval 0.01-0.58, P = .014); median WAZ was -1.17 versus +1.24 for those with adequate versus inadequate energy intake, respectively. Fluid restriction to <80% of maintenance fluid at the time of RRT initiation was more likely in patients with higher WAZ. Fluid restriction was the only independent predictor of inadequate protein intake (odds ratio 0.13, 95% confidence interval 0.02-0.7, P = .018); 5% versus 30% were fluid restricted in those with adequate versus inadequate protein intake, respectively. Azotemia was not associated with inadequate protein intake. Initiation of RRT did not allow for liberalization of fluid intake over the time period evaluated. CONCLUSIONS Protein delivery was inadequate in 38% of children undergoing RRT in the CICU. Fluid restriction was associated with inadequate protein intake and higher WAZ was associated with inadequate energy intake.
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Affiliation(s)
- Daniel L. Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael A. Ferguson
- Division of Nephrology, Department of Medicine, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
| | - Joshua W. Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberly I. Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
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Tsujimoto Y, Miki S, Shimada H, Tsujimoto H, Yasuda H, Kataoka Y, Fujii T. Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 2021; 9:CD013330. [PMID: 34519356 PMCID: PMC8438600 DOI: 10.1002/14651858.cd013330.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication amongst people who are critically ill, and it is associated with an increased risk of death. For people with severe AKI, continuous kidney replacement therapy (CKRT), which is delivered over 24 hours, is needed when they become haemodynamically unstable. When CKRT is interrupted due to clotting of the extracorporeal circuit, the delivered dose is decreased and thus leading to undertreatment. OBJECTIVES This review assessed the efficacy of non-pharmacological measures to maintain circuit patency in CKRT. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 which includes records identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included all randomised controlled trials (RCTs) (parallel-group and cross-over studies), cluster RCTs and quasi-RCTs that examined non-pharmacological interventions to prevent clotting of extracorporeal circuits during CKRT. DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently extracted information including participants, interventions/comparators, outcomes, study methods, and risk of bias. The primary outcomes were circuit lifespan and death due to any cause at day 28. We used a random-effects model to perform quantitative synthesis (meta-analysis). We assessed risk of bias in included studies using the Cochrane Collaboration's tool for assessing risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS A total of 20 studies involving 1143 randomised participants were included in the review. The methodological quality of the included studies was low, mainly due to the unclear randomisation process and blinding of the intervention. We found evidence on the following 11 comparisons: (i) continuous venovenous haemodialysis (CVVHD) versus continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF); (ii) CVVHDF versus CVVH; (iii) higher blood flow (≥ 250 mL/minute) versus standard blood flow (< 250 mL/minute); (iv) AN69 membrane (AN69ST) versus other membranes; (v) pre-dilution versus post-dilution; (vi) a longer catheter (> 20 cm) placing the tip targeting the right atrium versus a shorter catheter (≤ 20 cm) placing the tip in the superior vena cava; (vii) surface-modified double-lumen catheter versus standard double-lumen catheter with identical geometry and flow design; (viii) single-site infusion anticoagulation versus double-site infusion anticoagulation; (ix) flat plate filter versus hollow fibre filter of the same membrane type; (x) a filter with a larger membrane surface area versus a smaller one; and (xi) a filter with more and shorter hollow fibre versus a standard filter of the same membrane type. Circuit lifespan was reported in 9 comparisons. Low certainty evidence indicated that CVVHDF (versus CVVH: MD 10.15 hours, 95% CI 5.15 to 15.15; 1 study, 62 circuits), pre-dilution haemofiltration (versus post-dilution haemofiltration: MD 9.34 hours, 95% CI -2.60 to 21.29; 2 studies, 47 circuits; I² = 13%), placing the tip of a longer catheter targeting the right atrium (versus placing a shorter catheter targeting the tip in the superior vena cava: MD 6.50 hours, 95% CI 1.48 to 11.52; 1 study, 420 circuits), and surface-modified double-lumen catheter (versus standard double-lumen catheter: MD 16.00 hours, 95% CI 13.49 to 18.51; 1 study, 262 circuits) may prolong circuit lifespan. However, higher blood flow may not increase circuit lifespan (versus standard blood flow: MD 0.64, 95% CI -3.37 to 4.64; 2 studies, 499 circuits; I² = 70%). More and shorter hollow fibre filters (versus standard filters: MD -5.87 hours, 95% CI -10.18 to -1.56; 1 study, 6 circuits) may reduce circuit lifespan. Death from any cause was reported in four comparisons We are uncertain whether CVVHDF versus CVVH, CVVHD versus CVVH or CVVHDF, longer versus a shorter catheter, or surface-modified double-lumen catheters versus standard double-lumen catheters reduced death due to any cause, in very low certainty evidence. Recovery of kidney function was reported in three comparisons. We are uncertain whether CVVHDF versus CVVH, CVVHDF versus CVVH, or surface-modified double-lumen catheters versus standard double-lumen catheters increased recovery of kidney function. Vascular access complications were reported in two comparisons. Low certainty evidence indicated using a longer catheter (versus a shorter catheter: RR 0.40, 95% CI 0.22 to 0.74) may reduce vascular access complications, however the use of surface-modified double lumen catheters versus standard double-lumen catheters may make little or no difference to vascular access complications. AUTHORS' CONCLUSIONS The use of CVVHDF as compared with CVVH, pre-dilution haemofiltration, a longer catheter, and surface-modified double-lumen catheter may be useful in prolonging the circuit lifespan, while higher blood flow and more and shorter hollow fibre filter may reduce circuit life. The Overall, the certainty of evidence was assessed to be low to very low due to the small sample size of the included studies. Data from future rigorous and transparent research are much needed in order to fully understand the effects of non-pharmacological interventions in preventing circuit coagulation amongst people with AKI receiving CKRT.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Sho Miki
- Department of Nephrology, Sumitomo Hospital, Osaka, Japan
| | - Hiroki Shimada
- Department of Nephrology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama-shi, Japan
| | - Yuki Kataoka
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoko Fujii
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- ANZIC-RC, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
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12
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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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13
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Kripps KA, Baker PR, Thomas JA, Skillman HE, Bernstein L, Gaughan S, Burns C, Coughlin CR, McCandless SE, Larson AA, Kochar A, Stillman CF, Wymore EM, Hendricks EG, Woontner M, Van Hove JLK. REVIEW: Practical strategies to maintain anabolism by intravenous nutritional management in children with inborn metabolic diseases. Mol Genet Metab 2021; 133:231-241. [PMID: 33985889 DOI: 10.1016/j.ymgme.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 12/31/2022]
Abstract
One of the most vital elements of management for patients with inborn errors of intermediary metabolism is the promotion of anabolism, the state in which the body builds new components, and avoidance of catabolism, the state in which the body breaks down its own stores for energy. Anabolism is maintained through the provision of a sufficient supply of substrates for energy, as well as critical building blocks of essential amino acids, essential fatty acids, and vitamins for synthetic function and growth. Patients with metabolic diseases are at risk for decompensation during prolonged fasting, which often occurs during illnesses in which enteral intake is compromised. During these times, intravenous nutrition must be supplied to fully meet the specific nutritional needs of the patient. We detail our approach to intravenous management for metabolic patients and its underlying rationale. This generally entails a combination of intravenous glucose and lipid as well as early introduction of protein and essential vitamins. We exemplify the utility of our approach in case studies, as well as scenarios and specific disorders which require a more careful administration of nutritional substrates or a modification of macronutrient ratios.
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Affiliation(s)
- Kimberly A Kripps
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA; Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
| | - Peter R Baker
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Janet A Thomas
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Heather E Skillman
- Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, CO, USA
| | - Laurie Bernstein
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Sommer Gaughan
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Casey Burns
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Curtis R Coughlin
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Shawn E McCandless
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Austin A Larson
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Aaina Kochar
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Chelsey F Stillman
- Section of Child Neurology, Department of Pediatrics, University of Colorado, Aurora, CO, USA; Neuroscience Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Erica M Wymore
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Ellie G Hendricks
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael Woontner
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Johan L K Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado, Aurora, CO, USA.
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14
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Murphy HJ, Selewski DT. Nutrition Considerations in Neonatal Extracorporeal Life Support. Neoreviews 2021; 22:e382-e391. [PMID: 34074643 DOI: 10.1542/neo.22-6-e382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Extracorporeal life support (ECLS) is a life-saving therapy, but neonates who require ECLS have unique nutritional needs and require aggressive, early nutritional support. These critically ill neonates are at increased risk for long-term feeding difficulties, malnutrition, and growth failure with associated increased morbidity and mortality. Unfortunately, few studies specific to this population exist. Clinical guidelines published by the American Society for Parenteral and Enteral Nutrition are specific to this population and available to aid clinicians in appropriate nutrition regimens, but studies to date suggest that nutrition provision varies greatly from center to center and often is inadequate. Though enteral feedings are becoming more common, aggressive parenteral nutrition is still needed to ensure nutrition goals are met, including the goal of increased protein provision. Long-term complications, including the need for tube feedings and growth failure, are common in neonatal ECLS survivors, particularly those with congenital diaphragmatic hernia. Oral aversion with poor feeding and growth failure must be anticipated and recognized early if present. The nutritional implications associated with the development of acute kidney injury, fluid overload, or the use of continuous renal replacement therapy must be recognized. In this state-of-the-art review, we examine aspects of nutrition for neonates receiving ECLS including nutritional requirements, nutrition provision, current practices, long-term outcomes, and special population considerations.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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15
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Fiaccadori E, Sabatino A, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Singer P, Cuerda C. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2021; 40:1644-1668. [PMID: 33640205 DOI: 10.1016/j.clnu.2021.01.028] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.
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Affiliation(s)
- Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alice Sabatino
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Adamasco Cupisti
- Nephrology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Intensive Care, University Hospital Brussels (UZB), Department of Nutrition, UZ Brussel, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Bruxelles, Belgium
| | | | - Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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16
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Jenks C, Raman L, Dhar A. Review of acute kidney injury and continuous renal replacement therapy in pediatric extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2020; 37:254-260. [PMID: 33967449 DOI: 10.1007/s12055-020-01071-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose To review the relevant literature of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) as it relates to pediatric extracorporeal membrane oxygenation (ECMO). Methods Available online relevant literature. Results ECMO is a therapeutic modality utilized to support patients with refractory respiratory and/or cardiac failure. AKI and fluid overload (FO) are frequently observed in this patient population. There are multiple modalities that can be utilized for AKI and FO which include the following: diuretics, in-line hemofiltration, and CRRT. There are multiple considerations when using CRRT with ECMO including access, CRRT flows, hemolysis, anticoagulation, and CRRT termination. Conclusion While each ECMO center has its own set of equipment, experiences, and practices, it is imperative that the international ECMO community continues to work together to provide an evidence-based approach to address the morbidity and mortality associated with AKI and FO.
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Affiliation(s)
- Christopher Jenks
- Blair E Batson Children's Hospital, Department of Pediatrics, Section of Critical Care, University of Mississippi Medical Center, Jackson, MS USA
| | - Lakshmi Raman
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
| | - Archana Dhar
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
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17
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Raina R, Chakraborty R, Sethi SK, Bunchman T. Kidney Replacement Therapy in COVID-19 Induced Kidney Failure and Septic Shock: A Pediatric Continuous Renal Replacement Therapy [PCRRT] Position on Emergency Preparedness With Resource Allocation. Front Pediatr 2020; 8:413. [PMID: 32719758 PMCID: PMC7347905 DOI: 10.3389/fped.2020.00413] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/16/2020] [Indexed: 01/08/2023] Open
Abstract
The recent worldwide pandemic of COVID-19 has had a detrimental worldwide impact on people of all ages. Although data from China and the United States indicate that pediatric cases often have a mild course and are less severe in comparison to adults, there have been several cases of kidney failure and multisystem inflammatory syndrome reported. As such, we believe that the world should be prepared if the severity of cases begins to further increase within the pediatric population. Therefore, we provide here a position paper centered on emergency preparation with resource allocation for critical COVID-19 cases within the pediatric population, specifically where renal conditions worsen due to the onset of AKI.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Cleveland Clinic Akron General, Akron Nephrology Associates, Akron, OH, United States
- Department of Nephrology, Akron Children's Hospital, Akron, OH, United States
| | - Ronith Chakraborty
- Department of Nephrology, Cleveland Clinic Akron General, Akron Nephrology Associates, Akron, OH, United States
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, United States
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18
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John JC, Taha S, Bunchman TE. Basics of continuous renal replacement therapy in pediatrics. Kidney Res Clin Pract 2019; 38:455-461. [PMID: 31661760 PMCID: PMC6913589 DOI: 10.23876/j.krcp.19.060] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/23/2019] [Accepted: 08/16/2019] [Indexed: 11/04/2022] Open
Abstract
In the last three decades, significant advances have been made in the care of children requiring renal replacement therapy (RRT). The move from the use of only hemodialysis and peritoneal dialysis to continuous venovenous hemofiltration with or without dialysis (continuous renal replacement therapy, CRRT) has become a mainstay in many intensive care units. The move to CRRT is the result of greater clinical experience as well as advances in equipment, solutions, vascular access, and anticoagulation. CRRT is the mainstay of dialysis in pediatric intensive care unit (PICU) for critically ill children who often have hemodynamic compromise. The advantages of this modality include the ability to promote both solute and fluid clearance in a slow continuous manner. Though data exist suggesting that approximately 25% of children in any PICU may have some degree of renal insufficiency, the true need for RRT is approximately 4% of PICU admissions. This article will review the history as well as the progress being made in the provision of this care in children.
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Affiliation(s)
- Jacob C John
- Department of Pediatric Nephrology, Children's Hospital of Richmond at the Virginia Commonwealth University, Richmond, VA, USA
| | - Sara Taha
- Department of Pediatric Nephrology, Children's Hospital of Richmond at the Virginia Commonwealth University, Richmond, VA, USA
| | - Timothy E Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond at the Virginia Commonwealth University, Richmond, VA, USA
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19
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Stapel SN, de Boer RJ, Thoral PJ, Vervloet MG, Girbes ARJ, Oudemans-van Straaten HM. Amino Acid Loss during Continuous Venovenous Hemofiltration in Critically Ill Patients. Blood Purif 2019; 48:321-329. [PMID: 31291614 DOI: 10.1159/000500998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND/OBJECTIVES During continuous venovenous hemofiltration (CVVH), there is unwanted loss of amino acids (AA) in the ultrafiltrate (UF). Solutes may also be removed by adsorption to the filter membrane. The aim was to quantify the total loss of AA via the CVVH circuit using a high-flux polysulfone membrane and to differentiate between the loss by ultrafiltration and adsorption. METHODS Prospective observational study in ten critically ill patients, receiving predilution CVVH with a new filter, blood flow 180 mL/min, and predilution flow 2,400 mL/h. Arterial blood, postfilter blood, and UF samples were taken at baseline, and 1, 8, and 24-h after CVVH initiation, to determine AA concentrations and hematocrit. Mass transfer calculations were used to determine AA loss in the filter and by UF, and the difference between these 2. RESULTS The median AA loss in the filter was 10.4 g/day, the median AA loss by UF was 13.4 g/day, and the median difference was -2.9 g/day (IQR -5.9 to -1.4 g/day). For the individual AA, the difference ranged from -1 g/day to +0.4 g/day, suggesting that some AA were consumed or adsorbed and others were generated. AA losses did not significantly change over the 24-h study period. CONCLUSION During CVVH with a modern polysulfone membrane, the estimated AA loss was 13.4 g/day, which corresponds to a loss of about 11.2 g of protein per day. Adsorption did not play a major role. However, individual AA behaved differently, suggesting complex interactions and processes at the filter membrane or peripheral AA production.
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Affiliation(s)
- Sandra N Stapel
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands,
| | - Ruben J de Boer
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick J Thoral
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Heleen M Oudemans-van Straaten
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
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Feeding modality is a barrier to adequate protein provision in children receiving continuous renal replacement therapy (CRRT). Pediatr Nephrol 2019; 34:1147-1150. [PMID: 30843114 DOI: 10.1007/s00467-019-04211-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Critically ill children have a high prevalence of malnutrition. Children with acute kidney injury experience high rates of protein debt. Previous research has indicated that protein provision is positively associated with survival. METHODS This was a prospective observational study of all patients receiving CRRT for greater than 48 h at our tertiary care institution. Patients with inborn errors of metabolism were excluded. Data collection included energy, protein, and fluid volume intakes, anthropometrics, feeding modality, and route of nutrition intake. RESULTS Forty-one patients 9 ± 6.8 years of age, 66% male, received CRRT over a 10-month time period. CRRT treatment was 17.3 ± 25 days. Forty-one percent were malnourished via anthropometric criteria at CRRT start. Median protein delivery was 2 g/kg/day (IQR 1.4-2.5). Fifty-one percent received a combination of parenteral nutrition (PN) and enteral/oral feedings (EN), 34% received only PN, and 12% received only EN. Percentage of time meeting protein goals by modality was 27.6%, 34.6%, and 65.3% for those patients receiving solely EN, PN, and EN + PN combination, respectively. When weaned to only EN support from combination PN + EN, the average percentage of time protein goals were met decreased to 20.5% (p < 0.01). CONCLUSIONS Without PN, patients on enteral/oral nutrition support fail to meet appropriate protein prescription. Transition of parenteral to enteral feeds was identified as a period of nutritional risk in children receiving CRRT.
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Metabolitic profiling of amino acids in paraquat-induced acute kidney injury. Clin Exp Nephrol 2019; 23:474-483. [PMID: 30859350 DOI: 10.1007/s10157-019-01702-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/19/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The herbicide paraquat (1, 1'-dimethyl-4, 4'-bipyridylium dichloride; PQ) is a poison well-known to cause delayed mortality due to acute kidney injuries (AKI). This study examines the changes in serum amino acids (AAs) metabolite profiles as surrogate markers of renal cell metabolism and function after paraquat poisoning. METHODS To identify the metabolic profiling of free serum AAs and its metabolites, serum from 40 paraquat-poisoned patients with or without AKI is collected. LC-MS/GC-MS is performed to analyze AA molecules. A Cox proportional hazard model was used to assess for incidence of AKI. Receiver operating characteristic (ROC) curve is applied to evaluate AKI occurrence and prognosis. RESULTS A total of 102 serum AAs and its metabolites were identified. Compared with non-AKI patients, 37 varied significantly in AKI patients. The univariate Cox proportional hazard model analysis revealed that the estimated PQ amount, plasma PQ concentration, urine PQ concentration, APACHE, SOFA scores and 16 amino acids correlated with the incidence of AKI. Further analyses revealed that 3-methylglutarylcarnitine, 1-methylimidazoleacetate, and urea showed higher cumulative hazard ratios for the occurrence of AKI during follow-up (P < 0.05). The area under the curve (AUC) of 3-methylglutarylcarnitine, 1-methylimidazoleacetate and urea were 0.917, 0.857, 0.872, respectively. CONCLUSION 3-methylglutarylcarnitine, 1-methylimidazoleacetate and urea were associated with AKI in patients with paraquat intoxication.
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Wu B, Ji D, Xu B, Fan R, Gong D. New modes of continuous renal replacement therapy using a refiltering technique to reduce micronutrient loss. Hemodial Int 2019; 23:181-188. [PMID: 30740858 DOI: 10.1111/hdi.12709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 09/19/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Micronutrient depletion is a major drawback of high-dose continuous renal replacement therapy (CRRT). We tested two novel CRRT modes, double-filtration hemofiltration (DHF) and dialysate-recycling hemodiafiltration (DHDF), aimed at reducing micronutrient loss while maintaining a high clearance rate of midsized solutes comparable to that of high-volume hemofiltration (HVHF). METHODS Forty patients with renal failure requiring CRRT were randomly assigned to receive predilutional standard-volume hemofiltration (SVHF, effluent rate 35 mL/kg/h), predilutional HVHF (100 mL/kg/h), DHF (35 mL/kg/h), and DHDF (30 mL/kg/h). In the two novel modes of CRRT, part of the high-volume primary effluent fluid produced by a high-flux filter (AV600S) was refiltered by two low-flux filters (15 L) for recycling as replacement fluid in DHF and dialysate in DHDF, while the remainder was discarded as final effluent fluid. Specimens were collected for measurement of trace elements, folic acid, amino acids (AAs), β2-microglobulin, cystatin C, and creatinine and for calculation of solute clearance. FINDINGS The clearance of 17 AAs, phosphorus, folic acid, copper, and zinc by DHF and DHDF was much lower than that by HVHF and comparable to that by SVHF. The estimated amount of AA loss by SVHF, HVHF, DHF, and DHDF was 10.3 (7.2-13.4) g/d, 22.1 (17.8-24.0) g/d, 10.6 (8.6-14.0) g/d, and 10.0 (8.6-11.4) g/d, respectively. Clearance of cystatin C and β2-microglobulin by DHF and DHDF was much greater than that by SVHF and equal to that by HVHF. DISCUSSION Compared to HVHF, DHF, and DHDF have an equal capacity for removal of large solutes but show substantially reduced micronutrient loss.
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Affiliation(s)
- Buyun Wu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Daxi Ji
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Bin Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Rong Fan
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Fayad AII, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018; 12:CD010612. [PMID: 30560582 PMCID: PMC6517263 DOI: 10.1002/14651858.cd010612.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm. AUTHORS' CONCLUSIONS Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.
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Affiliation(s)
- Alicia Isabel I Fayad
- Ricardo Gutierrez Children's HospitalPediatric NephrologyInstitute for Clinical Effectiveness and Health PolicyLos Incas Av 4174Buenos AiresArgentina1427
| | - Daniel G Buamscha
- Juan Garrahan Children's HospitalPediatric Critical Care UnitCombate de Los Pozoz Y PichinchaBuenos AiresArgentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresArgentinaC1414CPV
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Quality Improvement Bedside Rounding Audits Enhance Protein Provision for Pediatric Patients Receiving Continuous Renal Replacement Therapy. Pediatr Crit Care Med 2018; 19:1054-1058. [PMID: 30059478 DOI: 10.1097/pcc.0000000000001698] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Describe quality improvement process improvements in protein delivery of continuous renal replacement therapy initiation. DESIGN Prospective study. SETTING PICU and cardiovascular ICU within a quaternary care children's hospital. PATIENTS PICU and cardiovascular ICU patients receiving continuous renal replacement therapy for greater than 48 hours. Inborn errors of metabolism were excluded. INTERVENTIONS Plan-Do-Study-Act cycles were initiated. Cycle 1 developed interdisciplinary quality improvement group continuously monitoring nutrition care with thrice weekly bedside safety rounds and protein prescriptions within nephrologist's notes. Cycle 2 included education to intensivists. Cycle 3 initiated monthly quality improvement meetings reviewing nutritional care goals. MEASUREMENTS AND MAIN RESULTS Primary outcome was percentage of time patients met protein goals in the first 5 days of continuous renal replacement therapy. Secondary outcome was percentage of time patients met protein goals for duration of continuous renal replacement therapy. Cohort (n = 55) mean age was 8.1 years (SD ± 6.8), 62% male, and 31% malnutrition at baseline. Percent of time meeting protein goals by day 5 was 22%, 33%, and 71% and percent of time meeting protein goals throughout was 35%, 39%, and 75% of groups 1, 2, and 3, respectively. Significant improvement occurred after Plan-Do-Study-Act 3 (group 2 vs group 3; p < 0.01) for primary and secondary outcomes. CONCLUSIONS Implementation of an interprofessional quality improvement team significantly decreased number of continuous renal replacement therapy days with unmet protein goals and improved protein delivery.
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Nystrom EM, Nei AM. Metabolic Support of the Patient on Continuous Renal Replacement Therapy. Nutr Clin Pract 2018; 33:754-766. [PMID: 30320418 DOI: 10.1002/ncp.10208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Continuous renal replacement therapy (CRRT) is the modality of choice in critically ill patients with hemodynamic instability requiring renal replacement therapy. The goal of this review is to discuss an overview of CRRT types, components, and important considerations for nutrition support provision. Evidence basis for guidelines and our recommendations are reviewed. Nutrition support-related implications include the possibility of calorie gain with citrate-based anticoagulation, calorie loss with glucose-free replacement fluids and dialysate, and significant amino acid losses in effluent. We challenge nutrition support clinicians to develop a keen understanding of the specific CRRT modalities that are employed in their intensive care units and to be able to determine how the CRRT prescription may impact a patient's nutrition support prescription.
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Affiliation(s)
- Erin M Nystrom
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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Murphy HJ, Finch CW, Taylor SN. Neonatal Extracorporeal Life Support: A Review of Nutrition Considerations. Nutr Clin Pract 2018; 33:625-632. [PMID: 30004582 DOI: 10.1002/ncp.10111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Critically ill neonates who require extracorporeal life support have particular nutrition needs. These infants require prescription of aggressive, early nutrition support by knowledge providers. Understanding the unique metabolic demands and nutrition requirements of these fragile patients is paramount, particularly if additional therapies such as aggressive diuretic regimens or continuous renal replacement therapy are used concurrently. Although the American Society for Parenteral and Enteral Nutrition has published guidelines for this population, a review of each nutrition component is warranted because few studies exist specific to this population. Long-term complications in survivors of neonatal extracorporeal life support, particularly in patients with select diagnoses such as congenital diaphragmatic hernia, can be significant and must be recognized and anticipated. This review focuses on recognizing the nutrition needs of neonatal patients requiring extracorporeal life support, appraising the available data to guide selection of an appropriate mode of nutrition delivery, and describing the anticipated long-term nutrition implications of extracorporeal life support provision during the neonatal period.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carolyn W Finch
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sarah N Taylor
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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Coss-Bu JA, Hamilton-Reeves J, Patel JJ, Morris CR, Hurt RT. Protein Requirements of the Critically Ill Pediatric Patient. Nutr Clin Pract 2017; 32:128S-141S. [PMID: 28388381 DOI: 10.1177/0884533617693592] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This article includes a review of protein needs in children during health and illness, as well as a detailed discussion of protein metabolism, including nitrogen balance during critical illness, and assessment and prescription/delivery of protein to critically ill children. The determination of protein requirements in children has been difficult and challenging. The protein needs in healthy children should be based on the amount needed to ensure adequate growth during infancy and childhood. Compared with adults, children require a continuous supply of nutrients to maintain growth. The protein requirement is expressed in average requirements and dietary reference intake, which represents values that cover the needs of 97.5% of the population. Critically ill children have an increased protein turnover due to an increase in whole-body protein synthesis and breakdown with protein degradation leading to loss of lean body mass (LBM) and development of growth failure, malnutrition, and worse clinical outcomes. The results of protein balance studies in critically ill children indicate higher protein needs, with infants and younger children requiring higher intakes per body weight compared with older children. Monitoring the side effects of increased protein intake should be performed. Recent studies found a survival benefit in critically ill children who received a higher percentage of prescribed energy and protein goal by the enteral route. Future randomized studies should evaluate the effect of protein dosing in different age groups on patient outcomes, including LBM, muscle structure and function, duration of mechanical ventilation, intensive care unit and hospital length of stay, and mortality.
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Affiliation(s)
- Jorge A Coss-Bu
- 1 Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,2 Texas Children's Hospital, Houston, Texas, USA
| | - Jill Hamilton-Reeves
- 3 Department of Dietetics & Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jayshil J Patel
- 4 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claudia R Morris
- 5 Department of Pediatrics, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ryan T Hurt
- 6 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Lipkin AC, Lenssen P, Dickson BJ. Nutrition Issues in Hematopoietic Stem Cell Transplantation: State of the Art. Nutr Clin Pract 2017; 20:423-39. [PMID: 16207682 DOI: 10.1177/0115426505020004423] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
There have been many changes in hematopoietic stem cell transplantation (HSCT) that affect the patient's nutrition support. In the early 1970s, allogeneic transplants were the most common types of HSCTs; today, autologous transplants are the most common. Bone marrow, peripheral blood, and umbilical cord blood all now serve as sources of stem cells. Conditioning therapies include myeloablative, reduced-intensity myeloablative, and nonmyeloablative regimens. New medications are being developed and used to minimize the toxicities of the conditioning therapy and to minimize infectious complications. Supportive therapies for renal and liver complications have changed. In the past, HSCT patients received parenteral nutrition (PN) throughout their hospitalization and sometimes as home therapy. Because of medical complications and cost issues associated with PN, many centers are now working to use less PN and increase use of enteral nutrition. The immunosuppressed diet has changed from a sterile diet prepared under laminar-flow hoods to a more liberal diet that avoids high-risk foods and emphasizes safety in food handling practices. This article will review these changes in HSCT and the impact of these changes on the nutrition support of the patient.
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Affiliation(s)
- Ann Connell Lipkin
- Children's Hospital and Regional Medical Center, Seattle, Washington 98105-0371, USA.
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Wooley JA, Btaiche IF, Good KL. Metabolic and Nutritional Aspects of Acute Renal Failure in Critically Ill Patients Requiring Continuous Renal Replacement Therapy. Nutr Clin Pract 2017; 20:176-91. [PMID: 16207655 DOI: 10.1177/0115426505020002176] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid-base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.
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Affiliation(s)
- Jennifer A Wooley
- St Joseph Mercy Hospital, Clinical Nutrition/Pharmacy, 5301 East Huron River Dr, PO Box 995, Ann Arbor, MI 48106, USA.
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Bufarah MNB, de Góes CR, Cassani de Oliveira M, Ponce D, Balbi AL. Estimating Catabolism: A Possible Tool for Nutritional Monitoring of Patients With Acute Kidney Injury. J Ren Nutr 2016; 27:1-7. [PMID: 27810170 DOI: 10.1053/j.jrn.2016.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 08/07/2016] [Accepted: 09/02/2016] [Indexed: 11/11/2022] Open
Abstract
Hypercatabolism has been described as the main nutritional change in acute kidney injury. Catabolism may be defined as the excessive release of amino acids from skeletal muscle. Conditions such as fasting, inadequate nutritional support, renal replacement therapy, metabolic acidosis, and secretion of catabolic hormones are the main factors that affect protein catabolism. Given the imprecision of the methods conventionally used to assess and monitor the nutritional status of hospitalized patients, the parameters of protein catabolism, such as nitrogen balance, urea nitrogen appearance, and protein catabolic rate appear to be the main measures in this population. Considering the high prevalence of malnutrition in this population and important limitations in this clinical condition, such as the inflammatory state and altered fluid, catabolism parameters are accurate and reliable methods that could contribute to minimize adverse prognosis in this population.
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Affiliation(s)
| | - Cassiana Regina de Góes
- Department of Internal Medicine, Botucatu Medical School-UNESP, São Paulo State University, São Paulo, Brazil
| | - Mariana Cassani de Oliveira
- Department of Internal Medicine, Botucatu Medical School-UNESP, São Paulo State University, São Paulo, Brazil
| | - Daniela Ponce
- Department of Internal Medicine, Botucatu Medical School-UNESP, São Paulo State University, São Paulo, Brazil
| | - André Luis Balbi
- Department of Internal Medicine, Botucatu Medical School-UNESP, São Paulo State University, São Paulo, Brazil
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Cavagnaro Santa María F, Roque Espinosa J, Guerra Hernández P, Smith Torres M, González Largo I, Ronco Macchiavello R. [Continuous renal replacement therapy in newborns: Experience of a single centre]. REVISTA CHILENA DE PEDIATRIA 2015:S0370-4106(15)00183-7. [PMID: 26460084 DOI: 10.1016/j.rchipe.2015.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 07/24/2015] [Accepted: 07/27/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Felipe Cavagnaro Santa María
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago de Chile, Chile.
| | - Jorge Roque Espinosa
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago de Chile, Chile; Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Pamela Guerra Hernández
- Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Marta Smith Torres
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Isabel González Largo
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Ricardo Ronco Macchiavello
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago de Chile, Chile
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Sgambat K, Moudgil A. Carnitine deficiency in children receiving continuous renal replacement therapy. Hemodial Int 2015; 20:63-7. [DOI: 10.1111/hdi.12341] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Kristen Sgambat
- Department of Nephrology; Children's National Health System; Washington DC USA
| | - Asha Moudgil
- Department of Nephrology; Children's National Health System; Washington DC USA
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Liet JM, Allain-Launay E, Gaillard-LeRoux B, Barrière F, Chenouard A, Dejode JM, Joram N. Regional citrate anticoagulation for pediatric CRRT using integrated citrate software and physiological sodium concentration solutions. Pediatr Nephrol 2014; 29:1625-31. [PMID: 24526097 DOI: 10.1007/s00467-014-2770-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/07/2014] [Accepted: 01/22/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND In continuous renal replacement therapy (CRRT), regional citrate anticoagulation offers an attractive alternative to heparinization, especially for children with a high bleeding risk. METHODS We report on a new management approach to CRRT using integrated citrate software and physiological sodium concentration solutions. Convective filtration was performed with pre-filter citrate anticoagulation using an 18 mmol/L citrate solution and a post-filter replacement fluid. The citrate flow rate was automatically adjusted to the blood flow rate by means of integrated citrate software. Similarly, calcium was automatically infused into children to maintain their blood calcium levels within normal range. RESULTS Eleven CRRT sessions were performed (330 h) in seven critically ill children aged 3-15 years (extreme values 15-66 kg). Disease categories included sepsis with multiorgan dysfunction (n = 2) and hemolytic uremic syndrome (n = 5). Median effluent dose was 2.1 (extreme values 1.7-3.3) L/h/1.73 m2. No session had to be stopped because of metabolic complications. Calcium levels, both in the circuits and in the circulating blood of the children, remained stable and secure. CONCLUSIONS Regional citrate anticoagulation can be used in children with a body weight of >15 kg using integrated citrate software and commercially available solutions with physiological sodium concentrations in a safe, effective and convenient procedure.
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Affiliation(s)
- Jean-Michel Liet
- Unité de Réanimation Pédiatrique, Pôle Femme-Enfant-Adolescent, Centre hospitalier universitaire (CHU) de Nantes, 38 Boulevard Jean-Monnet, 44093, Nantes, France,
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Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lee J, Lo S, McArthur C, McGuinness S, Norton R, Myburgh J, Sheinkestel C. Daily Protein Intake and Patient Outcomes in Severe Acute Kidney Injury: Findings of the Randomized Evaluation of Normal versus Augmented Level of Replacement Therapy (RENAL) Trial. Blood Purif 2014; 37:325-34. [DOI: 10.1159/000363175] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 04/18/2014] [Indexed: 11/19/2022]
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Sabatino A, Regolisti G, Maggiore U, Fiaccadori E. Protein/energy debt in critically ill children in the pediatric intensive care unit: acute kidney injury as a major risk factor. J Ren Nutr 2013; 24:209-18. [PMID: 24216255 DOI: 10.1053/j.jrn.2013.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 08/11/2013] [Accepted: 08/22/2013] [Indexed: 01/15/2023] Open
Abstract
Acute kidney injury (AKI) is common in pediatric intensive care unit (PICU) patients. In this clinical setting, the risk of protein-energy wasting is high because of the metabolic derangements of the uremic syndrome, the difficulties in nutrient needs estimation, and the possible negative effects of renal replacement therapy itself on nutrient balance. No specific guidelines on nutritional support in PICU patients with AKI are currently available. The present review is aimed at evaluating the role of AKI as a risk condition for inadequate protein/energy intake in these patients, on the basis of literature data on quantitative aspects of nutritional support in PICU. Current evidence suggests that a relevant protein/energy debt, a widely accepted concept in the literature on adult intensive care unit patients with its negative implications for patients' major outcomes, is also likely to develop in pediatric critically ill patients, and that AKI represents a key factor for its development.
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Affiliation(s)
- Alice Sabatino
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Medical School, Parma, Italy
| | - Giuseppe Regolisti
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Medical School, Parma, Italy
| | - Umberto Maggiore
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Medical School, Parma, Italy
| | - Enrico Fiaccadori
- Department of Clinical and Experimental Medicine, Acute and Chronic Renal Failure Unit, Parma University Medical School, Parma, Italy.
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Abstract
This article provides the bedside clinician an overview of the unique renal complications that are seen commonly in the pediatric intensive care unit. These sections are purposely succinct to give a quick guide to the clinician for the care of these children. We have identified four major areas that should result in discussion and cooperative care between intensive care physicians and nephrologists for the care of these children: (1) hypertension, (2) chronic kidney failure, (3) acute kidney injury, and (4) renal replacement therapy.
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Bunchman TE. Nutrition as Medical Therapy in Pediatric Critical Illness. Clin J Am Soc Nephrol 2013; 8:513-4. [DOI: 10.2215/cjn.01800213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rimmelé T, Kaynar AM, McLaughlin JN, Bishop JV, Fedorchak MV, Chuasuwan A, Peng Z, Singbartl K, Frederick DR, Zhu L, Carter M, Federspiel WJ, Zeevi A, Kellum JA. Leukocyte capture and modulation of cell-mediated immunity during human sepsis: an ex vivo study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R59. [PMID: 23531333 PMCID: PMC3672497 DOI: 10.1186/cc12587] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 03/18/2013] [Indexed: 01/06/2023]
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Affiliation(s)
- Byong Sop Lee
- Division of Neonatology, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Bridges BC, Askenazi DJ, Smith J, Goldstein SL. Pediatric renal replacement therapy in the intensive care unit. Blood Purif 2012; 34:138-48. [PMID: 23095413 DOI: 10.1159/000342129] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Renal replacement therapy (RRT) is used in a wide variety of pediatric populations. In this article, we will review the advantages and disadvantages of the different RRT modalities and the technical aspects of providing pediatric RRT. In addition, we will review the use of RRT with extracorporeal membrane oxygenation, the use of continuous RRT in the critically ill child with acute kidney injury and fluid overload, and the use of RRT for the removal of toxins and treatment of inborn errors of metabolism.
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Affiliation(s)
- Brian C Bridges
- Division of Pediatric Critical Care, Vanderbilt University School of Medicine, Nashville, TN 37232-9075, USA.
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Friedrich JO, Wald R, Bagshaw SM, Burns KEA, Adhikari NKJ. Hemofiltration compared to hemodialysis for acute kidney injury: systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R146. [PMID: 22867021 PMCID: PMC3580734 DOI: 10.1186/cc11458] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/06/2012] [Indexed: 11/29/2022]
Abstract
Introduction The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in patients with acute kidney injury (AKI). Methods MEDLINE, EMBASE and CENTRAL databases and conference abstracts were searched to June 2012 for parallel-group or crossover randomized and quasi-randomized controlled trials (RCTs) evaluating hemofiltration vs. hemodialysis in patients with AKI. Two authors independently selected studies and abstracted data on study quality and outcomes. Additional information was obtained from trial authors. We pooled data using random-effects models. Results Of 6,657 citations, 19 RCTs (10 parallel-group and 9 crossover) met inclusion criteria. Sixteen trials used continuous RRT. Study quality was variable. The primary analysis included three parallel-group trials comparing similar doses of hemofiltration and hemodialysis; sensitivity analyses included trials comparing combined hemofiltration-hemodialysis or dissimilar doses. We found no effect of hemofiltration on mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.25, P = 0.76; three trials, n = 121 (primary analysis); RR 1.10, 95% CI 0.88 to 1.38, P = 0.38; eight trials, n = 540 (sensitivity analysis)) or other clinical outcomes (RRT dependence in survivors, vasopressor use, organ dysfunction) compared to hemodialysis. Hemofiltration appeared to shorten time to filter failure (mean difference (MD) -7 hours, 95% CI (-19,+5), P = 0.24; two trials, n = 50 (primary analysis); MD -5 hours, 95% CI (-10, -1), P = 0.01; three trials, n = 113 (including combined hemofiltration-hemodialysis trials comparing similar doses); MD -6 hours, 95% CI (-10, -1), P = 0.02; five trials, n = 383 (sensitivity analysis)). Data primarily from crossover RCTs suggested that hemofiltration increased clearance of medium to larger molecules, including inflammatory cytokines, compared to hemodialysis, although almost no studies measured changes in serum concentrations. Meta-analyses were based on very limited data. Conclusions Data from small RCTs do not suggest beneficial clinical outcomes from hemofiltration, but confidence intervals were wide. Hemofiltration may increase clearance of medium to larger molecules. Larger trials are required to evaluate effects on clinical outcomes.
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Davison JE, Davies NP, Wilson M, Sun Y, Chakrapani A, McKiernan PJ, Walter JH, Gissen P, Peet AC. MR spectroscopy-based brain metabolite profiling in propionic acidaemia: metabolic changes in the basal ganglia during acute decompensation and effect of liver transplantation. Orphanet J Rare Dis 2011; 6:19. [PMID: 21554693 PMCID: PMC3113316 DOI: 10.1186/1750-1172-6-19] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 05/09/2011] [Indexed: 01/21/2023] Open
Abstract
Background Propionic acidaemia (PA) results from deficiency of Propionyl CoA carboxylase, the commonest form presenting in the neonatal period. Despite best current management, PA is associated with severe neurological sequelae, in particular movement disorders resulting from basal ganglia infarction, although the pathogenesis remains poorly understood. The role of liver transplantation remains controversial but may confer some neuro-protection. The present study utilises quantitative magnetic resonance spectroscopy (MRS) to investigate brain metabolite alterations in propionic acidaemia during metabolic stability and acute encephalopathic episodes. Methods Quantitative MRS was used to evaluate brain metabolites in eight children with neonatal onset propionic acidaemia, with six elective studies acquired during metabolic stability and five studies during acute encephalopathic episodes. MRS studies were acquired concurrently with clinically indicated MR imaging studies at 1.5 Tesla. LCModel software was used to provide metabolite quantification. Comparison was made with a dataset of MRS metabolite concentrations from a cohort of children with normal appearing MR imaging. Results MRI findings confirm the vulnerability of basal ganglia to infarction during acute encephalopathy. We identified statistically significant decreases in basal ganglia glutamate+glutamine and N-Acetylaspartate, and increase in lactate, during encephalopathic episodes. In white matter lactate was significantly elevated but other metabolites not significantly altered. Metabolite data from two children who had received liver transplantation were not significantly different from the comparator group. Conclusions The metabolite alterations seen in propionic acidaemia in the basal ganglia during acute encephalopathy reflect loss of viable neurons, and a switch to anaerobic respiration. The decrease in glutamine + glutamate supports the hypothesis that they are consumed to replenish a compromised Krebs cycle and that this is a marker of compromised aerobic respiration within brain tissue. Thus there is a need for improved brain protective strategies during acute metabolic decompensations. MRS provides a non-invasive tool for which could be employed to evaluate novel treatments aimed at restoring basal ganglia homeostasis. The results from the liver transplantation sub-group supports the hypothesis that liver transplantation provides systemic metabolic stability by providing a hepatic pool of functional propionyl CoA carboxylase, thus preventing further acute decompensations which are associated with the risk of brain infarction.
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Affiliation(s)
- James E Davison
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.
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Pasko DA, Churchwell MD, Salama NN, Mueller BA. Longitudinal hemodiafilter performance in modeled continuous renal replacement therapy. Blood Purif 2011; 32:82-8. [PMID: 21372565 DOI: 10.1159/000324191] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 01/06/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS With advanced anticoagulation, many institutions operate continuous renal replacement therapy (CRRT) circuits longer than manufacturers' recommendations. This extended use may change hemodiafilter performance and clearance properties. However, hemodiafilter performance over time has not been assessed. We investigated solute clearance over time in modeled CRRT. METHODS In vitro continuous hemofiltration (CH) and continuous hemodialysis (CD) were operated for 48 h using AN69 polyacrylonitrile, cellulose triacetate, F70 polysulfone, and Optiflux F160NR polysulfone hemodiafilters with citrated bovine blood. Urea, creatinine, gentamicin, vancomycin, and albumin clearances were assessed in CH (ultrafiltration rates = 1 and 3 l/h). Clearances of urea, creatinine, gentamicin, and albumin, were assessed in CD with dialysate flow rate of 2 l/h. RESULTS Solute CH clearances were significantly higher at 3 l/h. Only creatinine and gentamicin clearances were affected by time. Creatinine CD clearance significantly declined at 48 h for all hemodiafilters, especially polysulfone hemodiafilters. CONCLUSIONS CRRT duration affects solute transmembrane clearance. Clinicians should consider hemodiafilter age when assessing hemodialysis dose or drug clearance.
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Affiliation(s)
- Deborah A Pasko
- Department of Clinical, Social and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, Mich., USA
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Fiaccadori E, Regolisti G, Cabassi A. Specific nutritional problems in acute kidney injury, treated with non-dialysis and dialytic modalities. NDT Plus 2010; 3:1-7. [PMID: 25949400 PMCID: PMC4421537 DOI: 10.1093/ndtplus/sfp017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Accepted: 01/21/2009] [Indexed: 01/04/2023] Open
Abstract
Patients who develop AKI, especially in the intensive care unit (ICU), are at risk of protein-energy malnutrition, which is a major negative prognostic factor in this clinical condition. Despite the lack of evidence from controlled trials of its effect on outcome, nutritional support by the enteral (preferentially) and/or parenteral route appears clinically indicated in most cases of ICU-acquired AKI, independently of the actual nutritional status of the patient, in order to prevent deterioration in the nutritional state with all its known complications. Extrapolating from data in other conditions, it seems intrinsically unlikely that starvation of a catabolic patient is more beneficial than appropriate nutritional support by an expert team with the skills to avoid the potential complications of the enteral and parenteral nutrition methodologies. By the same token, it is ethically impossible to conduct a trial in which the control group undergoes prolonged starvation. The primary goals of nutritional support in AKI, which represents a well-known inflammatory and pro-oxidative condition, are the same as those for other critically ill patients with normal renal function, i.e. to ensure the delivery of adequate nutrition, to prevent protein-energy wasting with its attendant metabolic complications, to promote wound healing and tissue repair, to support immune system function, to accelerate recovery and to reduce mortality. Patients with AKI on RRT should receive a basic intake of at least 1.5 g/kg/day of protein with an additional 0.2 g/kg/day to compensate for amino acid/protein loss during RRT, especially when daily treatments and/or high efficiecy modalities are used. Energy intake should consist of no more than 30 kcal non-protein calories or 1.3 × BEE (Basal Energy Expenditure) calculated by the Harris-Benedict equation, with ∼30-35% from lipid, as lipid emulsions. For nutritional support, the enteral route is preferred, although it often needs to be supplemented through the parenteral route in order to meet nutritional requirements.
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Affiliation(s)
- Enrico Fiaccadori
- Internal Medicine and Nephrology Department , Parma University Medical School , Parma , Italy
| | - Giuseppe Regolisti
- Internal Medicine and Nephrology Department , Parma University Medical School , Parma , Italy
| | - Aderville Cabassi
- Internal Medicine and Nephrology Department , Parma University Medical School , Parma , Italy
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ESPEN Guidelines on Parenteral Nutrition: Adult Renal Failure. Clin Nutr 2009; 28:401-14. [DOI: 10.1016/j.clnu.2009.05.016] [Citation(s) in RCA: 208] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 05/11/2009] [Indexed: 12/21/2022]
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Rimmelé T, Wey PF, Bernard N, Monchi M, Semenzato N, Benatir F, Boselli E, Etienne J, Goudable J, Chassard D, Bricca G, Allaouchiche B. Hemofiltration with the Cascade system in an experimental porcine model of septic shock. Ther Apher Dial 2009; 13:63-70. [PMID: 19379172 DOI: 10.1111/j.1744-9987.2009.00655.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
High-volume hemofiltration (HVHF) has been suggested as an adjuvant treatment of septic shock because of its capacities to remove inflammatory mediators from blood. Nevertheless, HVHF presents some important drawbacks, such as the depletion of low molecular weight molecules (nutriments, vitamins, trace elements and antibiotics) due to the high ultrafiltration rate, or the significant financial cost and nursing workload due to the frequent changes of large amounts of expensive sterile substitution fluids. A new hemofiltration system called "Cascade" has been developed, allowing very high ultrafiltration rates (120 mL/kg/h) limiting these drawbacks by using a special extracorporeal circuit. The objective of this study was to assess the technical feasibility of the Cascade system and to compare its hemodynamic impact to that of the standard HVHF system. Twenty sepsis-induced pigs were randomized in two groups: one group was hemofiltered with the standard HVHF system and the other with the Cascade system during a six-hour session. No technical problems were observed with the Cascade system during the experiment. At the end of the experiment, colloid requirements (989 +/- 355 mL vs. 1913 +/- 538 mL, P = 0.006), epinephrine requirements (0.82 +/- 0.42 mg vs. 3.27 +/- 3.02 mg, P < 0.001), lactic acidosis (pH = 7.33 +/- 0.08 vs. 7.10 +/- 0.07, P < 0.001) and mean pulmonary arterial pressure were less pronounced in the Cascade group. These results suggest that Cascade hemofiltration is technically feasible and safe. Moreover, compared with standard HVHF, it can reduce the severity of porcine septic shock.
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Affiliation(s)
- Thomas Rimmelé
- Department of Anesthesiology and Intensive Care, Edouard Herriot Hospital, Lyon, France.
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Continuous venovenous hemodiafiltration trace element clearance in pediatric patients: a case series. Pediatr Nephrol 2009; 24:807-13. [PMID: 19156445 DOI: 10.1007/s00467-008-1083-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 11/14/2008] [Accepted: 11/18/2008] [Indexed: 10/21/2022]
Abstract
Continuous renal replacement therapy (CRRT) is used to treat critically ill children with acute kidney injury. The effect of CRRT on trace element clearance is poorly characterized. The purpose of this study was to quantify the transmembrane clearance of chromium, copper, manganese, selenium and zinc during continuous venovenous hemodiafiltration (CVVHDF). The transmembrane clearance of trace elements was assessed prospectively in five critically ill children receiving CVVHDF at the pediatric intensive care unit of a tertiary care university hospital. Pre-filter blood and effluent samples were measured for trace element concentrations. Transmembrane clearance of trace elements was calculated, and daily loss of each trace element was determined. Daily trace element loss via CVVHDF was compared with daily standard supplementation of trace elements in pediatric parenteral nutrition. Five patients (age range 23 months to 15 years) with a body weight range of 10.5-53 kg completed the study. The median transmembrane clearance of chromium, copper, manganese, selenium and zinc during CVVHDF was calculated as 0 ml, 0.59 ml, 2.48 ml, 1.22 ml, and 1.90 ml, respectively, per 1.73 m(2) body surface area per minute. The calculated CVVHDF losses were substantially smaller than the daily parenteral supplementation for all trace elements.
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