essential in nutrition
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Internal MedicineBoard Review 2015
Essentials in Clinical Nutrition:Nutritional Requirementsin Renal,Pulmonary, and Hepatic Diseases
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Question 1
65-year-old man with CKD (baseline BUN 46mg/dL, Cr 2.4 mg/dL) was admitted due toCHF & respiratory failure. Todays labs: BUN
76 mg/dL, Cr 5.4 mg/dL. Acute HD isscheduled later today.
How much protein would you prescribe ?
1.0.3-0.6 g/kg/day2.0.6-0.8 g/kg/day
3.0.8-1.0 g/kg/day
4.1.0-1.5 g/kg/day
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Metabolic Derangements in AKI
Hypermetabolism and hypercatabolism
Glucose intolerance : insulin resistance
Protein and amino acids abnormalities : protein
catabolism, azotemiaLipid metabolism : hypertriglyceridemia
Acid-base disturbance : metabolic acidosis
Fluid imbalance : hyper- / hypovolumia
Electrolytes imbalance :hyper- / hyponatremia,
hyper- / hypokalemia, hyperphosphatemia,
hypocalcemia
Energy and protein requirements are
influenced moreby nature of the illness causing AKI
rather than AKI itself
e.g. severe seps is vs. neph roto xic d rugs .
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Avoid restriction of protein
intake with the aim ofpreventing or delaying
initiation of RRT.
KDIGO 2012. Kidney Int Suppl. 2012;2:1-138.
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Renal Replacement Therapy
Intermittenthemodialysis
CRRT
Peritoneal dialysis
Up to 10-15 g of aminoacids may be lost
Glucose absorbed duringPD & CRRT
Loss of water solublevitamins
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ARF, non ARF, RRT CRRTstress high stress
Protein/AA 0.8-1.0 1.5-2.0 1.8-2.5
(g/kg/d) 0.8-1.0 1.0-1.5 up to 1.7
Energy 25-30 25-30 25-30
(kcal/kg/d) 20-30 20-30 20-30
Water, elytes --- --- --- --- as tolerated --- --- --- --- ---
--- --- supplement with --- --- water soluble vitamins
ASPEN Guidelines 2010. Brown KO et al. JPEN 2010 34: 366KDIGO 2012. Kidney Int Suppl. 2012;2:1-138.
Nutritional Requirements in Patients with
Acute Kidney Injury
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Question 1
65-year-old man with CKD (baseline BUN 46mg/dL, Cr 2.4 mg/dL) was admitted due toCHF & respiratory failure. Todays labs: BUN
76 mg/dL, Cr 5.4 mg/dL. Acute HD isscheduled later today.
How much protein would you prescribe ?
1.0.3-0.6 g/kg/day
2.0.6-0.8 g/kg/day
3.0.8-1.0 g/kg/day
4.1.0-1.5 g/kg/day
Energy
20-30 kcal/kg/day
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Question 2
The patients conditions improved. AKIresolved. He is discharged home withoutRRT.
BUN 46 mg/dL, Cr 2.9 mg/dL
GFR 27 ml/min/1.73 m2
How much protein would you prescribe ?
1.0.3 g/kg/day
2.0.8 g/kg/day
3.1.3 g/kg/day
4.1.5 g/kg/day
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KDIGO Guidelines 2013. Kidney Int Suppl. 2013;3:1-150.
CKD without RRT
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ESPEN guidelines 2006 & 2009
CKD with RRT
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Protein Intake in Kidney Diseases(g/kg/day)
0.8 (RDA)
CKD, no RRTGFR 1.3
CKD+RRT
CAPD 1.2 - 1.5
HD 1.2 - 1.4
AKI: KDIGO 2012. Kidney Int Suppl. 2012;2:1-138. CKD: KDIGO Guidelines 2013. Kidney Int Suppl.2013;3:1-150. CAPD & HD: ESPEN guidelines 2006 & 2009
Low-protein diet (LPD)
CKD no RRT
0.3-0.4
VLPD
EAA/KAsupplement
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Protein Restriction in Practice Meat 1 portion (2)
contains 7 g of protein
Rice/CHO 1 portion ( 1)contains 2 gm of protein
Protein 0.8 g/day in 50 Kg patient
= Protein 40 gm/day
= ?? portions of rice
= ?? portions of meat
Patient Education is Needed to
Prevent Malnutrition
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Question 2
The patients conditions improved. AKIresolved. He is discharged home withoutRRT.
BUN 46 mg/dL, Cr 2.9 mg/dL
GFR 27 ml/min/1.73 m2
How much protein would you prescribe ?
1.0.3 g/kg/day
2.0.8 g/kg/day
3.1.3 g/kg/day
4.1.5 g/kg/day
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Disease-Specific EnteralNutrition & Supplements for
Renal Patients
200 ml, 2:1 (400 kcal)
Low K & Phos Protein 35 g/1000 kcal
Concentrated (possible diarrhea)
BW 60 kg, 1800 kcal/day, all from Nepro Protein 63 g which is 1.1 g/kg/day
>0.8 g/kg/day recommended for CKD patients
with GFR
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Question 3
A 59 year-old man with COPD whoweighs 50 kg is being weaned fromrespiratory support. Which of the
following EN is the MOST appropriate ?
1. 2200 kcal, CHO 45%, prot 15-20%, fat 35-40%
2. 2200 kcal, CHO 60%, prot 15-20%, fat 20-25%
3. 2200 kcal, CHO 60%, prot 15-20%, fat 20-25%
4. 1500 kcal, CHO 60%, prot 15-20%, fat 20-25%
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Metabolizing Food for Energy
Respiratory quotient
RQ = CO2productionO2consumption
C6H12O6+ 6O2 6H2O + 6CO2 +HEAT
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FOOD+ O2 CO2+ H2O + HEAT
C6H12O6+ 6 O2 6 CO2+ 673 kcalCHORQ = 6/6 =1
2(C55H106O6) + 157 O2110 CO2+ 106 H20 + 16,357 kcal
FatRQ = 110/157 = 0.7
1 amino acid + 5.1 O2
4.1 CO2+ 0.7 urea + 2.8 H20 + 475 kcal
ProteinRQ =4.1/5.1 = 0.8
HighestRQ
LowestRQ
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Lower %CHO
2200 kcal, CHO 45%, prot 15-20%, fat 35-40% 2200 kcal, CHO 60%, prot 15-20%, fat 20-25%
Less energy 2200 kcal, CHO 60%, prot 15-20%, fat 20-25%
1500 kcal, CHO 60%, prot 15-20%, fat 20-25%
CO2Production :%CHO vs. Total energy
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1.3 REE20% protein
Talpers SS et al. Chest 1992; 102:551-55
Effects on CO2Production :%CHO vs. Total energy
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Malone AM. Nutr Clin Pract 2009 24: 666
Low-carb, high-fat formulas
in COPD & respiratory failure
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Nutrition Support inChronic Pulmonary Diseases
Prescribe energy intake < estimated needs inpatients with CO2retention. Avoid overfeeding.
Routine use of modified CHO and high fatformulations is not warranted.
Consider its use in pts with ventilatory challengesor ambulatory patients who is being overfed.
High fat diet may delay gastric emptying timeand interfere with respiratory reserve.
Serum P levels should be monitored closely.
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What would you choose if your
patient has hypophosphatemia?
K2HPO4 I.V.
Esafosfina I.V.Acidic phosphate orally/EN
Fleet enemaorally/EN
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Glucose Glucose-6-PO4
Fructose-6-PO4
Fructose-1,6-diPO4
Lactate Pyruvate
Acetyl CoA
Pyruvate dehydrogenaseThiamine pyrophosphate
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or 0.5 mmol/ml
Esafosfina (5g/50 ml) = 22.5 mmol of phosphate
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Question 3
A 59 year-old man with COPD whoweighs 50 kg is being weaned fromrespiratory support. Which of the
following EN is the MOST appropriate ?1. 2200 kcal, CHO 45%, prot 15-20%, fat 35-40%
2. 2200 kcal, CHO 60%, prot 15-20%, fat 20-25%
3. 2200 kcal, CHO 60%, prot 15-20%, fat 20-25%4. 1500 kcal, CHO 60%, prot 15-20%, fat 20-
25%
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Question 4
60-year-old man with hepatitis B cirrhosis (Child-Pugh B)was admitted 2 days ago with fever & drowsiness.
Dx: SBP & hepatic encephalopathy. Na 128.
Which of the following statements are CORRECT regardinghis nutrition care plan? (T/F)
1. When fasting >12 hr, consider IV glucose 2-3 g/kg/day
2. Energy 30-35 kcal/kg/day
3. Protein should be restricted to 0.5 g/kg/day4. Restrict sodium to < 2 g/day
5. Restrict fluid to 1.5 L/day
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Cahill GF. Starvation in Man. NEJM 1970
Metabolism during Fasting
Patients with cirrhosislose muscle protein quicklyduring fasting
Give glucose 2-3 mg/kg/day withprolonged fasting >12h
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Question 4
60-year-old man with hepatitis B cirrhosis (Child-Pugh B)was admitted 2 days ago with fever & drowsiness.
Dx: SBP & hepatic encephalopathy. Na 128.
Which of the following statements are CORRECT regardinghis nutrition care plan?
1. When fasting >12 hr, consider IV glucose 2-3 g/kg/day
2. Energy 30-35 kcal/kg/day
3. Protein should be restricted to 0.5 g/kg/day4. Restrict sodium to < 2 g/day
5. Restrict fluid to 1.5 L/day
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Cahill GF. Starvation in Man. NEJM 1970
Metabolism during Fasting
Restricting protein willincrease proteinbreakdown
Amino acids -keto acids
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COOH-
H3+N--C--H
R
COOH-
OH--C
H + NH4+
R
De-amination
Amino acids -keto acids
Urea Cycle
LiverKidney
More proteinbreakdownmore metabolic
waste
P t i t i ti i NOT
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Protein restriction is NOTrecommended in cirrhosis
with encephalopathy Results in malnutrition & poor outcome
Patients need 1.2-1.5 g/kg/dayExceptions:
Protein intolerance (rare)
Hepatic encephalopathy (stages 3-4)not responding to medical treatment
Restrict protein to 0.5 g/kg/day no more
than 48 hours
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Question 4
60-year-old man with hepatitis B cirrhosis (Child-Pugh B)was admitted 2 days ago with fever & drowsiness.
Dx: SBP & hepatic encephalopathy. Na 128.
Which of the following statements are CORRECT regardinghis nutrition care plan?
1. When fasting >12 hr, consider IV glucose 2-3 g/kg/day
2. Energy 30-35 kcal/kg/day
3. Protein should be restricted to 0.5 g/kg/day4. Restrict sodium to < 2 g/day
5. Restrict fluid to 1.5 L/day
X
Ascites restrict sodium
Hyponatremia restrict fluid
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Branched-ChainAmino Acids
COOH-
H3
+N--C--H
R
AromaticAmino Acids
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BCAAs in Cirrhosis
During hepatic encephalopathy
Consider enteral formulas with BCAA if
patient is not responding to medical Rx IV BCAA solutions benefits not clearly
shown
Consider EN or oral supplements withBCAAs in stable cirrhosis patients
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BCAA-rich Enteral Formulain Patients with Stable Cirrhosis
5 spoons 200 ml
210 kcal, 610 mOsm/kg
(possible diarrhea) 2-3 servings/day including
at bedtime
BCAA about 6 g/serving
Recommended BCAA dose: 0.25g/kg/day or12-30 g/day
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OBrien A et al.Gastroenterology2008;134:17291740
Nutrition in
Cirrhosis:Summary
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Thank You
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