Nutritional support in the patient with acute renal failure

Nutritional support in the patient with acute renal failure is of great importance in lessening the degree of catabolism when energy demands are high and may also result in salutary metabolic effects. Overall treatment considerations in the posttraumatic or postsurgical patient with acute renal failure will be discussed, including fluid and electrolyte balance and energy and nutritional considerations. The application of the Giordano and Giovannetti principles to the field of parenteral nutritional support enables modifications of treatment programs of total parenteral nutrition to be applied to patients with acute renal failure. Utilizing an intravenous mixture of eight essential l-amino acids, hypertonic dextrose, and vitamins, we observed salutary biochemical effects in surgical patients. A prospective, randomized double-blind study of that treatment regimen compared to patients receiving hypertonic dextrose and vitamins alone resulted in improved survival and a decreased duration of renal failure in the treated group. Management considerations of these patients and possible application of these principles to other patients in renal failure will be discussed.     

The effect of intravenous fat emulsions in patients with pancreatic fistula

Three patients with pancreatic fistulae were given parenteral 10% fat emulsion (Intralipid) to study the effect of intravenous fat on pancreatic fistula output. Each patient received nutritional support with isovolumetric, isonitrogenous, and isocaloric solutions containing either hypertonic dextrose and amino acids, or hypertonic dextrose, amino acids, and a fat emulsion. Measurements of fistula volume, fistula amylase, lipase, and chloride concentrations, and fistula trypsin activity were performed. The patients were studied for periods of 10 to 26 days. No significant increases in any of the above parameters were noted during the periods when the fat emulsions were infused. In one patient the fistula closed spontaneously. We conclude that intravenous fat emulsions may be used to provide nutritional support for patients with pancreatic fistula without increasing pancreatic juice volume or enzyme content.     

Does nutritional intervention in protein-energy malnutrition improve morbidity or mortality?

Although there is an association between malnutrition and a poor clinical outcome, it does not necessarily follow that providing nutrients to such patients will improve the outcome. In fact, a number of prospective randomized controlled trials have not been able to demonstrate that nutritional support does, in general, improve morbidity or mortality. Very few such trials have been performed in patients with renal disease. Three studies in patients with acute renal failure have suggested that patients receiving parenteral nutrition using essential amino acids as the nitrogen source have better outcomes than do patients receiving equicaloric amounts of glucose, but these studies cannot exclude the possibility that the intravenous infusion of high concentrations of dextrose is detrimental. Small studies have suggested that the provision of perdialytic nutrient infusions or enteral nutrient supplements can improve measurements of nutritional status, but none of these trials described the effect of the nutritional intervention on morbidity or mortality. Two small trials have raised the possibility that supplemental ketoacids may retard the progression of chronic renal failure. There is a need for large randomized controlled trials to establish or refute the efficacy of nutritional support in renal disease. Such trials should include a control group that is not receiving any nutritional support.     

Vitamins and trace elements: practical aspects of supplementation

The role of micronutrients in parenteral nutrition include the following: (1) Whenever artificial nutrition is indicated, micronutrients, i.e., vitamins and trace elements, should be given from the first day of artificial nutritional support. (2) Testing blood levels of vitamins and trace elements in acutely ill patients is of very limited value. By using sensible clinical judgment, it is possible to manage patients with only a small amount of laboratory testing. (3) Patients with major burns or major trauma and those with acute renal failure who are on continuous renal replacement therapy or dialysis quickly develop acute deficits in some micronutrients, and immediate supplementation is essential. (4) Other groups at risk are cancer patients, but also pregnant women with hyperemesis and people with anorexia nervosa or other malnutrition or malabsorption states. (5) Clinicians need to treat severe deficits before they become clinical deficiencies. If a patient develops a micronutrient deficiency state while in care, then there has been a severe failure of care. (6) In the early acute phase of recovery from critical illness, where artificial nutrition is generally not indicated, there may still be a need to deliver micronutrients to specific categories of very sick patients. (7) Ideally, trace element preparations should provide a low-manganese product for all and a manganese-free product for certain patients with liver disease. (8) High losses through excretion should be minimized by infusing micronutrients slowly, over as long a period as possible. To avoid interactions, it would be ideal to infuse trace elements and vitamins separately: the trace elements over an initial 12-h period and the vitamins over the next 12-h period. (9) Multivitamin and trace element preparations suitable for most patients requiring parenteral nutrition are widely available, but individual patients may require additional supplements or smaller amounts of certain micronutrients, depending on their clinical condition.     

Intradialytic nutritional support

PURPOSE OF REVIEW: Intradialytic nutritional support has been used for more than 30 years both in critically ill patients with acute renal failure and during maintenance hemodialysis. Present knowledge allows better estimation of its metabolic and nutritional efficacy, as well its effect on patient outcome. RECENT FINDINGS: Recent data showed that intradialytic nutritional support is able to counteract these effects of dialysis on protein metabolism and to improve both nitrogen and energy balance. In maintenance hemodialysis patients, the improvement of nutritional status during nutritional support was shown to improve long-term survival. In critically ill patients with acute renal failure, protein sparing is one of the main therapeutic goals. The effect of nutritional support on patient outcome is not demonstrated. Recent data, however, showed that the improvement of nitrogen balance may be associated with a better outcome. SUMMARY: Current information helps to better assess the effects of intradialytic nutritional support, to clarify the nutritional management of renal failure patients and to provide recommendations. Future research should focus on the possible means to improve the efficacy of nutritional support, either by modifying its components of by associating anabolic or anticatabolic agents.     

Parenteral nutrition with essential amino acids in pretransplantation anephrics.

The effect of intravenous hyperalimentation with essential amino acids and hypertonic dextrose on nitrogen metabolism, total body urea and creatinine was studied in 16 patients with end-stage renal disease prior to and after bilateral nephrectomy, splenectomy and appendectomy. Parenteral essential amino acids and hypertonic dextrose are effective in lowering blood urea nitrogen in anephric patients who are incapable of improving renal function. The inclusion of essential amino acids in hypertonic dextrose increases nutritional value far beyond that which can be attributed to the caloric concentration of the amino acids themselves.     

Nutritional management of infants and toddlers with chronic renal failure

Normal renal function is an essential prerequisite for normal nutrition. Renal failure results in malnutrition and growth retardation, which are particularly marked when renal failure has its onset early in life. Conversely, the careful application of nutritional therapy can ameliorate the effects of renal failure and allow improved well being and growth and possibly retard the rate of progression of renal failure. Nutritional therapy includes the provision of an adequate energy intake, appropriate intakes of water, electrolytes, vitamins and minerals and regulation of protein and phosphorus intakes. In this paper the theoretical considerations underlying these objectives are reviewed and practical ways of achieving them with least disruption to the child and his family suggested.     

Total parenteral nutrition in the management of acute renal failure.

Malnutrition is frequently present in patients with acute renal failure and may affect morbidity and mortality in this condition. When adequate nourishment cannot be given through the gastrointestinal tract, total parental nutrition with amino acids and hypertonic glucose may have beneficial results. Total parenteral nutrition has been reported to stabilize or reduce serum urea nitrogen, potassium and phosphorus levels, improve wound healing, enhance survival from acute renal failure, and possibly increase the rate of recovery of renal function. The optimal composition of the total parenteral nutrition infusate is unknown. Preliminary results of a double-blind study are reported in which one man received hypertonic glucose alone, two received glucose with essential amino acids (21 g/day), and three received glucose with essential (21 g/day) and nonessential (21 g/day) amino acids. All infusates were isocaloric. No differences were observed in serum urea nitrogen levels, serum urea nitrogen/creatinine ratios or urea appearance rates. Nitrogen balance was negative in all patients. The ratio of essential amino acids/nonessential amino acids were higher and the tyrosine/phenylalanine ratios were lower in plasma in the two patients receiving glucose with essential amino acids. No patient survived the hospitalization. In view of the markedly negative nitrogen balance frequently observed in these and earlier studies, the use of a different composition or quantity of amino acids, a higher energy intake, and anabolic hormones deserve further investigation.     

Total peripheral parenteral nutrition in pregnancy

Twenty pregnant patients needing nutritional support for various indications received hypercaloric, hyperosmotic, "3 in 1," peripheral parenteral nutrition as a bridge to enteral therapy. This system, named total peripheral parenteral nutrition, was evaluated as to tolerance and efficacy in pregnant patients. Patients were in various stages of pregnancy and had an average weight loss of 10.4 pounds prior to admission. Patients were maintained on total peripheral parenteral nutrition for an average of 5 days and gained an average of 4.1 pounds. Good tolerance with minimal side effects of the treatment was noted. Intravenous sites were changed an average of 1.1 times per patient during the course of therapy and only one serious complication was noted in 20 patients. Patients were followed through delivery and this information is presented. Total peripheral parenteral nutrition appears to be an acceptable alternative to conventional total parenteral nutrition to pregnant patients needing nutritional support. These hypertonic solutions can supply total caloric/metabolic needs without unacceptable side effects.     

Which Diet for Which Renal Failure: Making Sense of the Options

This review describes categories of renal function (normal, renal insufficiency, end-stage renal failure), types of treatment modalities (renal insufficiency management, dialysis, transplantation), and corresponding dietary parameters (protein, energy, fiber, sodium, fluid, potassium, phosphorus, calcium, vitamins, minerals). The focus is directed toward general and nonrenal specialty practitioners, who are encountering a growing number of geriatric patients and patients who have undergone renal transplantation or are in early renal failure. The findings indicate that early intervention may delay or prevent rapid progression of renal disease in some patients, that treatment modalities continue to need individualized dietary support to maintain nutritional status, and that transplant goals should include control of obesity and hyperlipidemia to reduce cardiovascular mortality. J Am Diet Assoc. 1995; 95:898-903.     

Practical implications of nutritional support during continuous renal replacement therapy

Continuous blood membrane interactions during continuous renal replacement therapy cause bioincompatibility and low grade inflammatory reactions with potentially adverse consequences on protein metabolism and immunocompetence. In designing a nutritional program for patients receiving this treatment, these adverse metabolic effects, especially the loss of nutritional substrates, must be considered. This review provides a practical overview of nutritional support in acute renal failure, including assessment techniques, determination of nutrient needs, and appropriate intervention for patient support.     

营养支持治疗在慢性肝功能衰竭病中效果观察

目的探究营养支持治疗在慢性肝衰竭上在治疗上的效果。方法对住入我院的40例慢性肝衰竭患者的营养状况进行综合的分析评价,对这些患者进行治疗时,以现代的内科综合治疗为主,再辅助以相对专业的营养支持治疗,结合患者自身情况选用肠内或肠外或者是两者相结合的方法进行具体的治疗。以生化指标的具体变化以及营养状况作为对比条件,对患者的情况进行治疗前后的比较,进而来判断其临床疗效到底如何。结果在未进行治疗的时候,40例患者中有38例都存在着营养不良的状况,但是这些患者营养不良的程度各自之间都有所差别,经过一段时间的治疗,其营养不良的现象均有所好转,只是好转的程度各有差异。结论在进行对慢性肝病患者的治疗时,要结合患者自身的不同差异,根据患者具体的病情以及病情的发展情况,采取适合于患者的营养支持方案,如果患者能够很好地再配合内科医生进行综合地治疗,就一定会取得相当好的疗效。     

Disease-specific amino acid infusion (F080) in hepatic encephalopathy: a prospective, randomized, double-blind, controlled trial

Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.     

Nutritional therapy for burns in children and adults

Burns are a serious injury that requires optimal nutritional support. This review discusses the nutritional care for adults and children with major burns. A burned patient's metabolism is greatly accelerated with increased requirements for energy, carbohydrates, proteins, fats, vitamins, minerals, and antioxidants. Early nutrition by parenteral and enteral feedings is vital. Careful assessment of the nutritional state of the burn patient is also important to reduce infection, recovery time, and long-term sequelae.     

Parenteral nutrition in acute renal failure

This article reviews the current practice of parenteral feeding in patients with acute renal failure. Assessment of nutritional requirements and the provision of nutrients are discussed. Practical guidelines are provided for dietitians to use in the clinical setting.     

胆道术后并发急性肾衰的营养治疗

报告7例胆道术后并发急性肾衰(ARF),氮质血症病人实施肠外营养(PN)治疗的体会。全组病例均用含8种必需氨基酸(EAA)的肾安,7％Vamin和氨复命等提供氮源,并以20％和10％Intralipid及适量葡萄糖作为主要能源,按“全合一”营养混和液行PN治疗,疗效满意。认为:(1)针对不同原因ARF的PN治疗,应供给足够能量和较最小需要量稍高的EAA,使体内潴留的尿素氮转而用于合成非必需氨基酸(NEAA),进而再被用于合成蛋白质,以减少蛋白质分解,降低氮质血症;(2)在ARF有限的输液量中,20％Intralipid不失为一种低容量、高热卡的有效制剂,应予推崇。     

The nutritional and metabolic support of heart failure in the intensive care unit

PURPOSE OF REVIEW: Heart failure and cardiovascular disease are common causes of morbidity and mortality, contributing to many ICU admissions. Nutritional deficiencies have been associated with the development and worsening of chronic heart failure. Nutritional and metabolic support may improve outcomes in critically ill patients with heart failure. This review analyzes the role of this support in the acute care setting of the ICU. RECENT FINDINGS: Cardiac cachexia is a complex pathophysiologic process. It is characterized by inflammation and anabolic-catabolic imbalance. Nutritional supplements containing selenium, vitamins and antioxidants may provide needed support to the failing myocardium. Evidence shows that there is utility in intensive insulin therapy in the critically ill. Finally, there is an emerging metabolic role for HMG-CoA reductase inhibition, or statin therapy, in the treatment of heart failure. SUMMARY: Shifting the metabolic milieu from catabolic to anabolic, reducing free radicals, and quieting inflammation in addition to caloric supplementation may be the key to nutritional support in the heart failure patient. Tight glycemic control with intensive insulin therapy plays an expanding role in the care of the critically ill. Glucose-insulin-potassium therapy probably does not improve the condition of the patient with heart failure or acute myocardial infarction.     

Nutritional support as an adjunct to radiation therapy

Patients with malignancies which are treated with therapeutic radiation are at risk for nutritional problems, both from their underlying malignancy as well as from their treatment. These effects may be acute or chronic and relate to the site of the tumor and regions irradiated. There is a large experience with nutritional intervention in irradiated patients, including oral feedings and enteral and parenteral nutritional support. The indications for the specific administration of nutritional support during radiotherapy depend on the nutritional status of the patient and the area irradiated, as well as the individual prognosis. Patients who are malnourished at the time of treatment are most likely to profit from nutritional intervention. To date, prospective randomized trials of nutritional support in patients undergoing radiotherapy fail to show a benefit of routine adjuvant nutritional intervention in terms of improved response and tolerance to treatment, improved local control or survival rates, or reduction of complications from therapy.     

Maintenance of pregnancy in a home parenteral nutrition patient

A case is reported of successful conception and completion of pregnancy in a patient with intestinal failure due to Crohn's disease, nourished entirely by home parenteral nutrition. The nutritional regimen included both dextrose and lipid as calorie sources, together with synthetic amino acids and appropriate additives. Nutritional status was monitored by blood biochemistry, anthropometry, urinary nitrogen losses, and measured resting energy expenditure. Obstetric progress was monitored by standard methods, including abdominal ultrasound, maternal weight gain, and measurement of plasma hormone levels. Herein, particular attention is given to the use of intravenous lipid in pregnancy.