Essential in Nutrition

7/24/2019 Essential in Nutrition

1/47

Internal MedicineBoard Review 2015

Essentials in Clinical Nutrition:Nutritional Requirementsin Renal,Pulmonary, and Hepatic Diseases

..


2/47


3/47


4/47

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


5/47

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 .


6/47

Avoid restriction of protein

intake with the aim ofpreventing or delaying

initiation of RRT.

KDIGO 2012. Kidney Int Suppl. 2012;2:1-138.


7/47

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


8/47


9/47


10/47

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


11/47

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.


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


12/47


13/47

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


1.0.3 g/kg/day

2.0.8 g/kg/day

3.1.3 g/kg/day

4.1.5 g/kg/day


14/47

KDIGO Guidelines 2013. Kidney Int Suppl. 2013;3:1-150.

CKD without RRT


15/47

ESPEN guidelines 2006 & 2009

CKD with RRT


16/47

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


17/47


18/47

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


19/47

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


1.0.3 g/kg/day

2.0.8 g/kg/day

3.1.3 g/kg/day

4.1.5 g/kg/day


20/47

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


21/47


22/47

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%


23/47

Metabolizing Food for Energy

Respiratory quotient

RQ = CO2productionO2consumption

C6H12O6+ 6O2 6H2O + 6CO2 +HEAT


24/47

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


25/47

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


26/47

1.3 REE20% protein

Talpers SS et al. Chest 1992; 102:551-55

Effects on CO2Production :%CHO vs. Total energy


27/47

Malone AM. Nutr Clin Pract 2009 24: 666

Low-carb, high-fat formulas

in COPD & respiratory failure


28/47

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.


29/47

What would you choose if your

patient has hypophosphatemia?

K2HPO4 I.V.

Esafosfina I.V.Acidic phosphate orally/EN

Fleet enemaorally/EN


30/47

Glucose Glucose-6-PO4

Fructose-6-PO4

Fructose-1,6-diPO4

Lactate Pyruvate

Acetyl CoA

Pyruvate dehydrogenaseThiamine pyrophosphate


31/47

or 0.5 mmol/ml

Esafosfina (5g/50 ml) = 22.5 mmol of phosphate


32/47

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%


33/47


34/47

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


35/47

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


36/47

Question 4



Which of the following statements are CORRECT regardinghis nutrition care plan?






37/47

Cahill GF. Starvation in Man. NEJM 1970

Metabolism during Fasting

Restricting protein willincrease proteinbreakdown

Amino acids -keto acids


38/47

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


39/47

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


40/47

Question 4



Which of the following statements are CORRECT regardinghis nutrition care plan?





X

Ascites restrict sodium

Hyponatremia restrict fluid


41/47

Branched-ChainAmino Acids

COOH-

H3

+N--C--H

R

AromaticAmino Acids


42/47

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


43/47

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


44/47

OBrien A et al.Gastroenterology2008;134:17291740

Nutrition in

Cirrhosis:Summary


45/47


46/47

Thank You


47/47

Date post:	20-Feb-2018
Category:	Documents
Upload:	chinnakhet-ketsuwan
View:	215 times
Download:	0 times

Essential in Nutrition

Documents