Microsoft PowerPoint - ARF 2010 北部淑子修正版

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笛孵俞
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1 99 ARF 急性腎衰竭醫學營養治療 Medical Nutrition Therapy for Acute Renal Failure (Acute kidney injury) CRRT EN Nutrition PN 台灣營養學會臨床營養委員會腎臟專科小組召集人陳淑子 Introduction Metabolic Alterations & its effects on nutrients metabolism Implications of renal replacement therapy Nutritional Requirements and interventions Nutrient Administration 2 1

2 Metabolic Alterations Hypercatabolism Lean body mass Immune response Water, electrolyte and acid-base metabolism Protein, carbohydrate, lipid metabolism Metabolic change will be determined by Underlying disease process & Complications Sepsis, trauma, burn, multiple organ failure Organ dysfunctions Type and intensity of renal replacement therapy 3 Mechanism of Protein catabolism Insulin resistance protein synthesis stimulated by insulin muscular protein degradation amino acid oxidation Stress mediators Catabolic hormones Catacholamines, glucagon, glucocorticoids Cytokines IL-1, IL-6, TNF-α hepatic hepatic extraction of amino acid gluconeogensis from amino acid Cannot be effectively suppressed by providing exogenous nutrient substrates glycogenolysis Release of proteases Acidosis 4 2

3 Carbohydrate Metabolism Hyperglycemia Peripheral Insulin resistance Hepatic gluconeogensis from amino acid Insensitive to the negative feed back by glucose load Poor control Diabetes corticosteroids, immunosuppressants Complications Metabolic rate fat synthesis infection Impaired wound healing CO2 5 Lipid Metabolism Impaired lipolysis peripheral lipoprotein lipase hepatic triglyceride lipase Clearance TG HDL-C Hemodialysis International 2005; 9:

4 Continuous renal replacement therapy (CRRT) CVVHD(continuous venovenous hemodialysis ) Diffusion Removal of small molecular weight solutes Dextrose-containing dialysate CVVH(continuous venovenous hemofiltration) Convection Excellent fluid removal Removal of middle molecular weight solutes Loss of nutrients(protein protein) CVVHDF(continuous venovenous hemodiafiltration ) Convection+ Diffusion Greatest efficiency in removal of solutes and fluid Dextrose-containing dialysate Loss of nutrients(protein protein) SCUF(Slow continuous ultrafiltration ) A version of CVVH Nutrition in Clinical Practice 2005;20;176 7 Metabolic impact of replacement therapy 1 Glucose absorption (CVVHD,CVVHDF Glucose concentration of dialysate 1.5%,2.5% (1.5 g/dl, 2.5 g/dl) Absorption rate :35%~45% 0.1%, 0.11%, 0.15% Lactate 45mmol/L 12kcal/L (1mmol/L 0.27 kcal) Dialysate flow rate 1L/hour, 2L/hour Patient s s blood glucose CVVHD,CVVHDF) Protein & amino acid loss (CVVH,CVVHDF Type of membrane 10~17% intake or 10-15g/d 15g/d Activation of protein breakdown CVVH,CVVHDF) 8 4

5 Example for determining energy 43% uptake with 1.5% dialysate at 1000 ml/h 1000 ml/h 24 hr g/ml kcal/g = 526 kcal/24h 9 P:0 K:0, 2, 4 meq/l Ca:0, 2.5, 3.5 meq/l Mg:0.5, 1.0, 1.5 meq/l 10 5

6 Metabolic impact of replacement therapy 2 Effects of anticoagulation Heparin Systemic anticoagulation Trisodium citrate Hypocalcemia Alkalemia or anion-gap metabolic acidosis citrate bicarbonate or accumulate ACD-A (anticoagulant citrate dextrose-formula A) Replacement Fluids (CVVH,CVVHDF) Modify Electrolyte, metabolism acidosis Normal saline, sodium bicarbonate. Hypothermia Heat loss immune defenses, heart rate, arterial pressure O2, Indirect calorimetry 11 Nutritional requirements-energy Determined by the underlying disease, not by renal failure Avoid overfeeding Promote glucose control Requirement Indirect calorimetry <130% BEE Harris-Benedict equation Stress factor: Krause s s Food &Nutrition Therapy: kcal/kg/d (2008) ADA: kcal/kg/d (2004) Druml W.: kcal/kg/d (2005) ESPEN:nonprotein calorie: kcal/kg/d (2009) ASPEN: Indirect calorimetry or Harris-Benedict equation (2005) 12 6

7 Underfeeding are less deleterious than from overfeeding Overfeeding can result in Hyperglycemia Fatty degeneration of the liver stress hormone carbon dioxide 13 Nutritional requirements-protein The optimal amount of protein supplement in ARF is unknown Adjusted according to Catabolic rate, renal function, dialysis losses Krause s s Food &Nutrition Therapy (2008) Nondialysis: g/kg/d dialysed: g/kg/d Stable period before renal function returns: g/kg/d ADA clinical guideline (2004) Noncatabolic & nondialysis: g/kg/d CRRT: g/kg/d ASPEN (2010) HD:1.5 g/kg/d CRRT: g/kg/d ESPEN (2009) Conservative therapy: g/kg/d Serum BUN CRRT: g/kg/d up to 1.7 g/kg/d Druml w. (Journal of renal nutrition ) (2005) Noncabolic, polyuric: g/kg/d CRRT: g/kg/d 14 7

Other protein recommendation (1996) (2001) (2003) Hemodialysis International 2005; 9: 135 142 15 Catabolism

8 Other protein recommendation (1996) (2001) (2003) Hemodialysis International 2005; 9: Catabolism Hypercatabolism BUN/Cr >20 Patient classification Mild stress UNA<6 Moderate stress UNA 6~10 Sever stress Sever stress UNA>

9 Urea nitrogen appearance (UNA) & protein breakdown UNA=UUN+ (BUN 2 -BUN 1 ) 0.6 BW 1 + (BW 2 -BW 1 ) BUN 2 UUN=urinary urea nitrogen (g/24h) BUN1=postdialysis BUN, BUN2=predialysis BW1=postdialysis BW, BW2=predialysis BW Net protein breakdown=una 6.25 Muscle loss= UNA History of protein and energy suggestion Hemodialysis International 2005; 9:

10 Example for Clinical practice (Dr. Druml) Journal of Renal Nutrition, Vol 15, No 1 ( January), 2005: pp ADA Recommendations 20 10

11 Nutritional requirements-micronutrition Vitamin requirements are not well defined Folate & Vit B 6 1mg/dmg/d Vit C ADA:< mg/d ASPEN:<100 mg/d ESPEN:<30-50 mg/d (supplies higher than 50 mg/d during CRRT ) Druml:<250 mg/d Vit C oxalate secondary oxalosis Minerals Se, Zn ( 有研究顯示較低但目前多數研究認為不需補充 ) 21 Objective of Nutritional Interventions Preservation of lean body mass Stimulation of immunocompetence Repair functions Wound healing Reduced mortality 22 11

12 Designing a nutritional program Metabolism consequences associated with renal failure Underlying disease process associated complications Modern replacement therapy 23 Nutrient Administration- Enteral nutrition Oral feeding Nonhypercabolic p t (nondialysis) Initially in Low protein Keep BUN<60~100 Tube feeding Standard formula are adequate for the majority patients Benefiaial effects Glutamine CRRT g/d ( CRRT loss g/d) Controversial Arginine Immune-enhancing & Wound-healing formula Be care for Vit A & Vit C Caution Sign of ileus,, abdomen distention Acute hypotension 24 12

Nutrient Administration- Parenteral nutrition Glucose <3-5 g/kg/d Dextrose infusion rate<3-5 mg/kg/min Insulin is necessary to main normal glycemia Lipid emulsions <1 g fat /kg/d monitoring:tg TG<400

13 Nutrient Administration- Parenteral nutrition Glucose <3-5 g/kg/d Dextrose infusion rate<3-5 mg/kg/min Insulin is necessary to main normal glycemia Lipid emulsions <1 g fat /kg/d monitoring:tg TG<400 mg/dl 20% batter than 10% Essential fatty acid 2-4% of total calorie 20% 300ml lipid per 2weeks Content Vit K & Phosphate Amino acid solutions EAA+NEAA Dependent amino acid Histidine, tyrosine, Serine, Cysteine, Arginine Initiated with low rate Full amount of protein & modest amount of carbohydrate 25 Calorie contribution of Parenteral nutrition components 26 13

Recommended dosages of PN for patients with ARF and CKD by American Medical

requirements are affected by underlying disease Suggestion Energy:25-35

5g/kg) Avoid overfeeding Glucose absorption from dialysate Nutrition therapy

14 Recommended dosages of PN for patients with ARF and CKD by American Medical Association Nutrition Advisory Committee Summary Nutritional requirements are affected by underlying disease Suggestion Energy:25-35 kcal/kg Protein: Protein:(CRRT) g/kg(<2.5g/kg 2.5g/kg) Avoid overfeeding Glucose absorption from dialysate Nutrition therapy must be more closely monitored K, P, Mg Parenteral nutrition:infusion rate & volume Tube feeding:gi symptom 28 14

15 THANK YOU FOR YOUR ATTENTION 29 15

短暫的高血糖之生理異常反應

短暫的高血糖之生理異常反應 Metabolic considerations in critical illness : : 1. (ebb phase): 2. ; (Catabolism): (1)stress hormne,, (2)cortisol.catecholamines, insulin resistant (3) cytokines( IL-1. IL-6. TNF), --------- 1. AGEs AGEs.advanced

Microsoft PowerPoint - ARF 2010 北部 淑子修正版

Microsoft PowerPoint - ARF 2010 北部淑子修正版