By; Ashraf El Houfi MD MS (pulmonology) MRCP (UK) FRCP (London) EDIC Consultant ICU Dubai Hospital

By; Ashraf El Houfi MD MS (pulmonology) MRCP (UK) FRCP (London) EDIC Consultant ICU Dubai Hospital

Introduction The significance of nutrition in hospital setting (especially the ICU) cannot be overstated. Critical illness is typically associated with a Catabolic Stress State coupled with complications of Increased infections, Multiple-Organ Dysfunction, Prolonged Hospitalization, and Increased Morbidity & Mortality

Introduction Renal failure is an extremely heterogeneous disease, whose nutritional requirements can differ widely Why Renal Failure patient needs special nutritional attention.?? Difference between Acute Renal Failure (Acute Kidney Injury) Chronic Renal failure Dialysis (HD, PD, CVVHD )

Acute Kidney Injury Acute kidney injury (AKI) occurs in approximately 7% of all hospitalized patients and between 33% and 66% of all intensive care unit (ICU) patients ARF, especially in the ICU, seldom occurs as isolated organ failure but is usually one component of more complex changes, in the setting of multiple organ failure.

Metabolic Storm in Acute Renal Failure In most instances ARF is a complication of Sepsis, Trauma, or Multiple Organ Failure, Metabolic derangements determined by the Acute Uremic State plus Underlying Disease Process or by Complications such as Severe infections and Organ dysfunctions and, the type and frequency of Renal Replacement Therapy (RRT)

Metabolic Storm in Acute Renal Failure ARF does affect Water, Electrolyte, and acid base metabolism: It induces a global change of the Metabolic Environment with alterations in Protein and amino acid, Carbohydrate, and lipid metabolism

Goals of Nutritional Support in Acute Renal Failure To prevent protein energy wasting To preserve lean body mass To avoid further metabolic derangements To avoid complications To improve wound healing To support immune function To minimize inflammation To reduce mortality

Does EN Influence Renal Recovery or Patient Outcome? There are indications that tube feeding (TF) is associated with an improvement in survival in ICU patients with ARF Several studies have proved that TF is associated with improved outcome in ICU patients (ESPEN GUIDELINES 2006) Metnitz PG, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002;30:2051 8. Scheinkestel CD,et al. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003;19:909 16.

Initiate Nutrition How Early! We recommend that nutrition support in the form of early EN be initiated within 24 48 hours in AKI/ARF (critically ill ICU patient). Can we feed a Shocked patient! Shocked patients have hypo-perfused tissues, including the GIT. high lactate! Journal of Parenteral and Enteral Nutrition February 2016 American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Initiate Nutrition How Early! Based on expert consensus, we suggest that in the setting of Hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or Hemodynamically stable Initiation/ re-initiation of EN to be considered with caution in patients stable on vasopressor support. Journal of Parenteral and Enteral Nutrition February 2016 American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

NB; Justified warning Patients on high vasopressor receiving EN, any Signs of intolerance (abdominal distention, increasing [NGT] output or GRVs, decreased passage of stool and flatus, hypoactive bowel sounds, + increasing metabolic acidosis and/or base deficit) Should be closely monitored as possible early signs of gut ischemia, and EN should be held until symptoms and interventions stabilize Journal of Parenteral and Enteral Nutrition February 2016 American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Energy Requirement In Acute Renal Failure Energy (Caloric) requirement mainly depends on the underlying disease Critical illness (Trauma, Burn, Severe Sepsis. MOD..etc.) As well as the RRT

Energy Needs in the Critically ill? We suggest Indirect Calorimetry (IC) be used to determine energy requirements, when available Journal of Parenteral and Enteral Nutrition February 2016 American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Energy Needs in the Critically ill? in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (25 30 kcal/kg/d) be used to determine energy requirements Journal of Parenteral and Enteral Nutrition February 2016 American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine

Fluid Management Fully resuscitated, hemodynamically stable who is either passing normal U/O ( > 0.5ml/kg/H) or already on RRT No fluid restriction Otherwise Intake = Output + Insensible losses

Protein Metabolism The hallmark of metabolic derangement ARF is activation of protein catabolism with excessive release of amino acids from skeletal muscle and There also is defective muscle utilization of amino acids for protein synthesis. Sustained negative nitrogen balance

Metabolic Response to Stress

Protein synthesis Protein degradation

Protein Requirement Based on expert consensus, we suggest that ICU patients with acute renal failure (ARF) or AKI be placed on a standard enteral formulation and that standard ICU recommendations for protein (1.2 2 g/kg actual body weight per day) A.S.P.E.N February 2016 159 211

Protein Requirement We recommend that patients receiving frequent hemodialysis or CRRT receive increased protein, up to 2.5 g/kg/d A significant amino acid loss (10 15 g/d) is associated with CRRT Protein should not be restricted in patients with renal insufficiency as a means to avoid or delay initiating dialysis therapy. A.S.P.E.N February 2016

Critically ill Patients! Can lose as much as 1kg of LBM daily Loss of LBM accelerates in critical illness Demling RH. Eplasty 2009;9:e9.

Carbohydrate Metabolism There is hyperglycemia, caused both by insulin resistance and the activation of hepatic gluconeogenesis Glycemic control should follow the same protocol of critically ill ICU patient Use insulin infusion 140-180 (150 mg/l) A.S.P.E.N February 2016

Lipid Metabolism Alterations in lipid metabolism are characterized by hyper-triglyceridemia due to an inhibition of lipolysis; Exogenous fat clearance after (enteral or parenteral) delivery of lipids can therefore be reduced Lipids should represent 30 35% of total non protein energy supply Most of the high energy (calorie) formulas are high in lipids

Electrolyte Derangement

Chronic Renal Failure ESPEN Guidelines

Nutritional Screening Nutritional screening should be performed; o Weekly for inpatients o 2-3 monthly for outpatients with GFR <20 but not on dialysis o Within one month of commencement of dialysis then 6-8 weeks later o 4-6 monthly for stable hemodialysis patients o 4-6 monthly for stable peritoneal dialysis patients UK Renal Association 2010

Chronic Renal Failure Compensated CRF (NOT yet on Dialysis) Disease-specific formulae for renal patients: characterized by Reduced protein content and Low electrolyte concentrations. Fluid management (NOT yet on Dialysis) Intake = Output + Insensible losses

Protein Requirement

CRF on maintenance Hemodialysis (HD patients) In acutely ill HD patients the requirements are the same as in ARF (critically ill patients)

CAPD Consideration Peritoneal dialysis losses of proteins, and micronutrients (5 15 g/day), as are losses of protein bound substances, such as Trace elements and absorption of Glucose is increased (aggravate DM). Protein-energy malnutrition is present in a significant proportion of patients undergoing chronic peritoneal dialysis CAPD

CAPD Consideration Nutritional support indicated in CAPD patients Insufficient oral intake, ONS can help to optimize nutrient intake. TF is indicated when adequate nutrition and ONS are insufficient (C). (ESPEN adult Renal failure) Formulae with higher protein & lower carbohydrate content are to be preferred. Products rich in proteins should be used as ONS (C). (ESPEN adult Renal failure)

CAPD & Critical Illness Acutely ill CAPD patients have the same nutritional requirements as ARF patients. The energy, protein and minerals requirements of ARF in critically ill ICU patients Vitamins, pyridoxine (10 mg) and vitamin C (100 mg) supplements are recommended (C).

Conclusions Patients with renal failure represent an extremely heterogeneous group, whose nutritional requirements can differ widely YES Do Renal Failure patients needs special nutritional attention.?? Difference between Acute Renal Failure (Acute Kidney Injury) Chronic Renal failure Dialysis (HD, PD, CVVHD )