【medical-news】ESPEN2009 欧洲临床营养指南: 成人肾衰竭
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Acute renal failure
ARF not only affects water, electrolyte and acid–base metabolism but also induces global changes in the ‘‘milieu interieur’’, with specific alterations in protein, amino acid, carbohydrate and lipid metabolisms. Additionally, it exerts a pro-inflammatory reaction and has a profound effect on the anti-oxidative system. ARF, especially in the ICU setting, rarely represents an isolated disease process. Metabolic changes in these patients are also determined by the underlying disease and/or co-morbidities, by other organ dysfunction, as well as by the modality and intensity of renal replacement therapy (RRT).
B
Renal replacement therapies have profound effects on metabolism and nutrient balances. C
Poor nutritional status is a major risk factor for morbidity and mortality, thus determining
outcomes. B
Goals of nutritional support
The primary nutritional goals of PN in ARF should be the same as those in other catabolic conditions in the ICU, such as ensuring the provision of optimal amount of energy, protein and micronutrients, with the aims of prevention of PEW, preservation of lean body mass, maintenance of nutritional status, avoidance of further metabolic derangements, enhancement of wound healing, support of immune function, and reduction in mortality. In the case of ARF patients, nutritional goals could also include the attenuation of their inflammatory status and improvement of the oxygen radical scavenging system and of endothelial function.
C
Outcomes
Due to the lack of well-designed randomized controlled trials the evidence regarding the effects of PN on survival and renal recovery remains inconclusive.
C
Indications
The indications for and contraindications to PN in ARF are comparable to those in other critically ill patients (see ICU guidelines). PN is appropriate in ARF when the GI tract cannot be used for enteral feeding, or when EN is not enough to reach nutrient intake goals.
C
Requirements
Macronutrient requirements are more influenced by the severity of underlying disease, type and intensity of extracorporeal RRT, nutritional status and associated complications, rather than by the ARF itself.
C
Micronutrient requirements have been poorly investigated in ARF patients. In ICU patients with ARF, the enhanced requirements for water-soluble vitamins induced by extracorporeal therapy should be met by supplementing multivitamin products. In line with standard recommendations, because of the possibility of accumulation, patients should be carefully monitored for signs of vitamin A toxicity. Similarly, it has been recommended that vitamin C should not exceed 30–50 mg/day, because inappropriate supplementation may result in secondary oxalosis. Recent data show that prolonged CRRT results in selenium and thiamine depletions despite supplementation at recommended amount.
C
ARF is associated with major fluid, electrolyte and acid–base equilibrium derangements, such as hypo- and hypernatremia, hyperkalemia, hyperphosphatemia, and metabolic acidosis. Restrictions of potassium, magnesium and phosphate in PN are however usually unnecessary if the patients are on daily RRT (CRRT, hemodialysis or SLED). Serum electrolyte levels largely depend on the electrolyte composition of the dialysate/reinfusate solutions, and the intensity of RRT. Hypophosphatemia and hypomagnesaemia can frequently be observed during CRRT or SLED, and should be anticipated.
C
Formula and route
Standard formulae are adequate for the majority of patients. However, requirements can differ and have to be assessed individually. When there are electrolyte derangements, three-in-one formulae without electrolytes or customized formulae can be advantageous.
C
For short time periods, peripheral PN can be used in ARF patients, according to fluid restriction needs and calorie/protein goals, but due to the need for fluid restriction and the high osmolarity of more concentrated commercial three-in-one admixtures, PN in ARF patients, especially those in the ICU, often needs to be infused centrally.
C
Chronic renal failure
An energy intake ≥30–35 kcal/kg/day is associated with better nitrogen balance and is recommended in stable CKD patients. B
Indications
Conservatively treated patients with CKD seldom need PN. Potential indications of PN in CKD patients are similar to the indications for PN in non-renal patients. Malnourished CKD patients requiring nutritional support should only be considered for PN when ONS and EN are impossible or fail to reach nutritional goals. Special attention should be given to CKD requiring PN during perioperative periods.
C
When nutritional requirements cannot be met by dietary intake (with or without ONS), in combination with EN or by the enteral route alone, the goals of PN in CKD patients are (a) prevention and treatment of PEW leading to cachexia; (b) ensuring the provision of optimal levels of energy, essential nutrients and trace elements; and (c) attenuation of disease (CKD) progression through protein or phosphate restriction.
C
Formula
Because no data are available on specific PN formulae, standard PN mixtures should be used if PN is indicated. In patients receiving PN without any oral or enteral supply, vitamins and trace elements should also be administered intravenously. If the patients need PN for a period exceeding two weeks, accumulation of vitamin A and trace elements should be considered.
C
Monitoring
Reports in the literature regarding the use of PN in non-dialyzed CKD patients are scarce. Positive nitrogen balance can however be demonstrated in CKD patients submitted to surgery. Because of the risk of electrolyte disturbances, stringent monitoring of the electrolytes, especially during the first weeks of PN support, is recommended.
C
PEW is very common in patients undergoing maintenance hemodialysis; its prevalence varies from 20% to 70% according to the nutritional parameters considered.
B
Although initiation of dialysis results in an initial improvement in nutritional indices, some dialysis-specific factors, like impairment of subjective well-being, loss of nutrients, protein catabolism and inflammation are relevant for the high incidence of PEW.
C
In acutely ill HD patients the requirements are the same as in ARF patients. Macronutrient requirements of metabolically stable patients include nitrogen delivery of 1.1–1.5 g/kg per day and energy of 30–40 kcal/kg per day.
C
Mineral requirements include needs for 800–1000 mg phosphate, 2–2.5 g potassium and 1.8–2.5 g sodium per day. C
Due to dialysis-induced losses, water-soluble vitamins should be supplied: folic acid (1 mg/day), pyridoxine (10–20 mg/day) and vitamin C (30–60 mg/day). Vitamin D should be given according to serum calcium, phosphorus and parathyroid hormone levels.
Routine hemodialysis does not induce significant trace-element losses. However, in depleted patients, zinc (15 mg/day) and selenium (50–70 mg/day) supplementation may be useful.
C
Outcomes
PEW is recognized as an independent determinant of morbidity and mortality in HD patients. B
Large randomized, controlled trials are needed to evaluate the effects of IDPN on quality of life, hospitalization rate and survival. Retrospective studies suggest that IDPN may reduce hospitalization rate and survival. Randomized controlled trials evaluating the effect of IDPN are needed.
B
Acutely ill patients with CKD on dialysis should be treated in a similar manner to those with ARF. Standard amino acid solutions can be used for IDPN in non-acutely ill malnourished HD patients. The energy supply should combine carbohydrate and fat. The use of specific parenteral solutions is not yet supported by controlled data.
C
In acutely ill patients with CKD on dialysis the route for PN should be the same as in ARF patients. In non-acutely ill malnourished HD patients, IDPN is infused through the venous line during dialysis.
C
Chronically dialyzed patients
In acutely ill patients with CKD on dialysis the decision to use PN should be based on the same criteria as in ARF patients. C
In non-acutely ill malnourished HD patients with mild PEW as defined by insufficient spontaneous intake, dietary counseling, and, if necessary, ONS should be prescribed. In patients exhibiting severe PEW, with spontaneous intakes more than 20 kcal/day: dietary counseling and ONS should be prescribed; IDPN is indicated in patients unable to comply with ONS; EN can be necessary when ONS or IDPN fail to improve nutritional status. In patients exhibiting severe PEW, with spontaneous intakes less than 20 kcal/day, or in stress conditions: both ONS and IDPN are generally unable to provide satisfactory nutritional supply and are not recommended; daily nutritional support is necessary and EN should be preferred to PN; central venous PN is indicated when EN is impossible or insufficient.
C
Since CAPD patients usually have better residual renal function, several uremic symptoms and metabolic abnormalities are less pronounced than in patients on HD therapy. However peritoneal losses of various nutrients are significant while absorption of glucose from the dialysate is enhanced.
C
The enhanced loss of proteins or amino acids can induce protein PEW and deficiencies of micronutrients. Due to the increased glucose load, body weight may even increase in CAPD patients but this reflects an increase in body fat mass only and masks a loss in lean body mass. The high glucose load is also responsible for induction or aggravation of diabetes, hypertriglyceridemia in 60% of patients, and increased LDL and VLDL cholesterol.
C
Acutely ill CAPD patients have the same nutritional requirements as ARF patients. Macronutrient requirements of metabolically stable patients include nitrogen delivery of 1.1–1.5 g/kg per day and energy of 30–40 kcal/kg per day.
C
Indications
Intravenous PN has been poorly investigated in CAPD patients. Present data suggest that PN should be limited to malnourished and stressed CAPD patients, or patients with severe encapsulating peritonitis, when nutritional requirements cannot be ensured by oral or enteral routes. In acutely ill patients with CKD on dialysis the decision to use PN should be the same as in ARF patients. In CAPD patients presenting with mild PEW as defined by insufficient spontaneous intakes, dietary counseling, and, if necessary, ONS should be prescribed. In patients exhibiting severe PEW, with spontaneous intakes more than 20 kcal/day: dietary counseling and ONS should be prescribed; IPPN may be considered in patients unable to comply with ONS; EN can be necessary when ONS are unable to improve nutritional status. In patients exhibiting severe PEW, with spontaneous intakes less than 20 kcal/day, or in stress conditions: daily nutritional support is necessary and EN should be preferred to PN; central venous PN is indicated when EN is impossible or insufficient.
C
Goals of PN
In acutely ill patients with CKD on dialysis, the goal of PN is to reduce protein catabolism and nutritional depletion-associated morbidity and mortality. In chronically undernourished CAPD patients IPPN aims to improve quality of life and to reduce PEW-related complications, hospitalization rate and mortality.
C
Formula
During central venous PN the energy supply should combine carbohydrate and fat. Amino acid based PD solutions can be used for IPPN in non-acutely ill malnourished CAPD patients. The use of specific formulae for parenteral mixtures is not yet supported by controlled data.
C
Route
The special form of PN unique to CAPD patients is Intraperitoneal Parenteral Nutrition (IPPN). IPPN is shown to improve nitrogen balance and nutritional parameters. When nutritional requirements cannot be ensured by oral or enteral routes, IPPN can be proposed in stable CAPD patients. In acutely ill patients with CKD on CAPD the route for PN should be the same as in ARF patients. In these patients a combined use of PN and IPPD, using an amino acid based PD solution can be suggested. In non-acutely ill malnourished CAPD patients, the preferred route is via the peritoneum.
B
ARF not only affects water, electrolyte and acid–base metabolism but also induces global changes in the ‘‘milieu interieur’’, with specific alterations in protein, amino acid, carbohydrate and lipid metabolisms. Additionally, it exerts a pro-inflammatory reaction and has a profound effect on the anti-oxidative system. ARF, especially in the ICU setting, rarely represents an isolated disease process. Metabolic changes in these patients are also determined by the underlying disease and/or co-morbidities, by other organ dysfunction, as well as by the modality and intensity of renal replacement therapy (RRT).
B
Renal replacement therapies have profound effects on metabolism and nutrient balances. C
Poor nutritional status is a major risk factor for morbidity and mortality, thus determining
outcomes. B
Goals of nutritional support
The primary nutritional goals of PN in ARF should be the same as those in other catabolic conditions in the ICU, such as ensuring the provision of optimal amount of energy, protein and micronutrients, with the aims of prevention of PEW, preservation of lean body mass, maintenance of nutritional status, avoidance of further metabolic derangements, enhancement of wound healing, support of immune function, and reduction in mortality. In the case of ARF patients, nutritional goals could also include the attenuation of their inflammatory status and improvement of the oxygen radical scavenging system and of endothelial function.
C
Outcomes
Due to the lack of well-designed randomized controlled trials the evidence regarding the effects of PN on survival and renal recovery remains inconclusive.
C
Indications
The indications for and contraindications to PN in ARF are comparable to those in other critically ill patients (see ICU guidelines). PN is appropriate in ARF when the GI tract cannot be used for enteral feeding, or when EN is not enough to reach nutrient intake goals.
C
Requirements
Macronutrient requirements are more influenced by the severity of underlying disease, type and intensity of extracorporeal RRT, nutritional status and associated complications, rather than by the ARF itself.
C
Micronutrient requirements have been poorly investigated in ARF patients. In ICU patients with ARF, the enhanced requirements for water-soluble vitamins induced by extracorporeal therapy should be met by supplementing multivitamin products. In line with standard recommendations, because of the possibility of accumulation, patients should be carefully monitored for signs of vitamin A toxicity. Similarly, it has been recommended that vitamin C should not exceed 30–50 mg/day, because inappropriate supplementation may result in secondary oxalosis. Recent data show that prolonged CRRT results in selenium and thiamine depletions despite supplementation at recommended amount.
C
ARF is associated with major fluid, electrolyte and acid–base equilibrium derangements, such as hypo- and hypernatremia, hyperkalemia, hyperphosphatemia, and metabolic acidosis. Restrictions of potassium, magnesium and phosphate in PN are however usually unnecessary if the patients are on daily RRT (CRRT, hemodialysis or SLED). Serum electrolyte levels largely depend on the electrolyte composition of the dialysate/reinfusate solutions, and the intensity of RRT. Hypophosphatemia and hypomagnesaemia can frequently be observed during CRRT or SLED, and should be anticipated.
C
Formula and route
Standard formulae are adequate for the majority of patients. However, requirements can differ and have to be assessed individually. When there are electrolyte derangements, three-in-one formulae without electrolytes or customized formulae can be advantageous.
C
For short time periods, peripheral PN can be used in ARF patients, according to fluid restriction needs and calorie/protein goals, but due to the need for fluid restriction and the high osmolarity of more concentrated commercial three-in-one admixtures, PN in ARF patients, especially those in the ICU, often needs to be infused centrally.
C
Chronic renal failure
An energy intake ≥30–35 kcal/kg/day is associated with better nitrogen balance and is recommended in stable CKD patients. B
Indications
Conservatively treated patients with CKD seldom need PN. Potential indications of PN in CKD patients are similar to the indications for PN in non-renal patients. Malnourished CKD patients requiring nutritional support should only be considered for PN when ONS and EN are impossible or fail to reach nutritional goals. Special attention should be given to CKD requiring PN during perioperative periods.
C
When nutritional requirements cannot be met by dietary intake (with or without ONS), in combination with EN or by the enteral route alone, the goals of PN in CKD patients are (a) prevention and treatment of PEW leading to cachexia; (b) ensuring the provision of optimal levels of energy, essential nutrients and trace elements; and (c) attenuation of disease (CKD) progression through protein or phosphate restriction.
C
Formula
Because no data are available on specific PN formulae, standard PN mixtures should be used if PN is indicated. In patients receiving PN without any oral or enteral supply, vitamins and trace elements should also be administered intravenously. If the patients need PN for a period exceeding two weeks, accumulation of vitamin A and trace elements should be considered.
C
Monitoring
Reports in the literature regarding the use of PN in non-dialyzed CKD patients are scarce. Positive nitrogen balance can however be demonstrated in CKD patients submitted to surgery. Because of the risk of electrolyte disturbances, stringent monitoring of the electrolytes, especially during the first weeks of PN support, is recommended.
C
PEW is very common in patients undergoing maintenance hemodialysis; its prevalence varies from 20% to 70% according to the nutritional parameters considered.
B
Although initiation of dialysis results in an initial improvement in nutritional indices, some dialysis-specific factors, like impairment of subjective well-being, loss of nutrients, protein catabolism and inflammation are relevant for the high incidence of PEW.
C
In acutely ill HD patients the requirements are the same as in ARF patients. Macronutrient requirements of metabolically stable patients include nitrogen delivery of 1.1–1.5 g/kg per day and energy of 30–40 kcal/kg per day.
C
Mineral requirements include needs for 800–1000 mg phosphate, 2–2.5 g potassium and 1.8–2.5 g sodium per day. C
Due to dialysis-induced losses, water-soluble vitamins should be supplied: folic acid (1 mg/day), pyridoxine (10–20 mg/day) and vitamin C (30–60 mg/day). Vitamin D should be given according to serum calcium, phosphorus and parathyroid hormone levels.
Routine hemodialysis does not induce significant trace-element losses. However, in depleted patients, zinc (15 mg/day) and selenium (50–70 mg/day) supplementation may be useful.
C
Outcomes
PEW is recognized as an independent determinant of morbidity and mortality in HD patients. B
Large randomized, controlled trials are needed to evaluate the effects of IDPN on quality of life, hospitalization rate and survival. Retrospective studies suggest that IDPN may reduce hospitalization rate and survival. Randomized controlled trials evaluating the effect of IDPN are needed.
B
Acutely ill patients with CKD on dialysis should be treated in a similar manner to those with ARF. Standard amino acid solutions can be used for IDPN in non-acutely ill malnourished HD patients. The energy supply should combine carbohydrate and fat. The use of specific parenteral solutions is not yet supported by controlled data.
C
In acutely ill patients with CKD on dialysis the route for PN should be the same as in ARF patients. In non-acutely ill malnourished HD patients, IDPN is infused through the venous line during dialysis.
C
Chronically dialyzed patients
In acutely ill patients with CKD on dialysis the decision to use PN should be based on the same criteria as in ARF patients. C
In non-acutely ill malnourished HD patients with mild PEW as defined by insufficient spontaneous intake, dietary counseling, and, if necessary, ONS should be prescribed. In patients exhibiting severe PEW, with spontaneous intakes more than 20 kcal/day: dietary counseling and ONS should be prescribed; IDPN is indicated in patients unable to comply with ONS; EN can be necessary when ONS or IDPN fail to improve nutritional status. In patients exhibiting severe PEW, with spontaneous intakes less than 20 kcal/day, or in stress conditions: both ONS and IDPN are generally unable to provide satisfactory nutritional supply and are not recommended; daily nutritional support is necessary and EN should be preferred to PN; central venous PN is indicated when EN is impossible or insufficient.
C
Since CAPD patients usually have better residual renal function, several uremic symptoms and metabolic abnormalities are less pronounced than in patients on HD therapy. However peritoneal losses of various nutrients are significant while absorption of glucose from the dialysate is enhanced.
C
The enhanced loss of proteins or amino acids can induce protein PEW and deficiencies of micronutrients. Due to the increased glucose load, body weight may even increase in CAPD patients but this reflects an increase in body fat mass only and masks a loss in lean body mass. The high glucose load is also responsible for induction or aggravation of diabetes, hypertriglyceridemia in 60% of patients, and increased LDL and VLDL cholesterol.
C
Acutely ill CAPD patients have the same nutritional requirements as ARF patients. Macronutrient requirements of metabolically stable patients include nitrogen delivery of 1.1–1.5 g/kg per day and energy of 30–40 kcal/kg per day.
C
Indications
Intravenous PN has been poorly investigated in CAPD patients. Present data suggest that PN should be limited to malnourished and stressed CAPD patients, or patients with severe encapsulating peritonitis, when nutritional requirements cannot be ensured by oral or enteral routes. In acutely ill patients with CKD on dialysis the decision to use PN should be the same as in ARF patients. In CAPD patients presenting with mild PEW as defined by insufficient spontaneous intakes, dietary counseling, and, if necessary, ONS should be prescribed. In patients exhibiting severe PEW, with spontaneous intakes more than 20 kcal/day: dietary counseling and ONS should be prescribed; IPPN may be considered in patients unable to comply with ONS; EN can be necessary when ONS are unable to improve nutritional status. In patients exhibiting severe PEW, with spontaneous intakes less than 20 kcal/day, or in stress conditions: daily nutritional support is necessary and EN should be preferred to PN; central venous PN is indicated when EN is impossible or insufficient.
C
Goals of PN
In acutely ill patients with CKD on dialysis, the goal of PN is to reduce protein catabolism and nutritional depletion-associated morbidity and mortality. In chronically undernourished CAPD patients IPPN aims to improve quality of life and to reduce PEW-related complications, hospitalization rate and mortality.
C
Formula
During central venous PN the energy supply should combine carbohydrate and fat. Amino acid based PD solutions can be used for IPPN in non-acutely ill malnourished CAPD patients. The use of specific formulae for parenteral mixtures is not yet supported by controlled data.
C
Route
The special form of PN unique to CAPD patients is Intraperitoneal Parenteral Nutrition (IPPN). IPPN is shown to improve nitrogen balance and nutritional parameters. When nutritional requirements cannot be ensured by oral or enteral routes, IPPN can be proposed in stable CAPD patients. In acutely ill patients with CKD on CAPD the route for PN should be the same as in ARF patients. In these patients a combined use of PN and IPPD, using an amino acid based PD solution can be suggested. In non-acutely ill malnourished CAPD patients, the preferred route is via the peritoneum.
B
