J Nutr Health.  2015 Jun;48(3):211-220. 10.4163/jnh.2015.48.3.211.

The effect of nutritional supply on clinical outcomes and nutritional status in critically ill patients receiving continuous renal replacement therapy

• Kim JY
• Kim JM
• Kim Y

• KMID: 2327191
• DOI: http://doi.org/10.4163/jnh.2015.48.3.211

Abstract

PURPOSE
This study was designed to investigate whether nutritional supply influences biochemical markers and clinical outcomes in patients who received continuous renal replacement therapy (CRRT) by evaluating adequacy of nutritional supply for patients.
METHODS
From January 2012 to December 2013, 239 adult patients who received CRRT in the intensive care unit for more than 3 days were included. General information from electronic medical records and nutritional status related biochemical data and clinical outcomes on the first day of CRRT and 2 weeks after CRRT were collected.
RESULTS
The rate of delivered energy and protein was 68.06% and 43.13% which was much lower than energy and protein supply based on their requirement. When the patients were divided into two groups according to 70% of energy received rate and 50% of protein received rate, the group with more than 70% of energy received rate showed significant decrease of length of hospital stay (p = 0.007), length of stay in intensive care unit (ICU) (p = 0.008), duration of CRRT (p < 0.001), and APACHE II score (p < 0.001) compared to less than 70% of energy received rate after adjusting for age. In addition, the group with more than 50% of protein received rate showed decreased mortality (p = 0.031), length of hospital stay (p = 0.008), length of ICU stay (p = 0.035), duration of CRRT (p < 0.001), and APACHE II score (p < 0.001) after adjusting for age. We found that the level of hematocrit (p = 0.006) was significantly improved in the group with more than 70% of energy received rate, and the level of TLC (p = 0.049), hematocrit (p = 0.041) was significantly improved in the group with more than 50% of protein received rate. We also found that energy delivery was negatively correlated with length of stay in ICU (p = 0.049) and positively correlated with level of calcium (p = 0.037). In addition, protein delivery was correlated with the levels of serum total protein (p = 0.021), serum albumin (p = 0.048), hematocrit (p = 0.009), and total cholesterol (p = 0.021) when dead patients were included, but was correlated with the levels of hematocrit (p = 0.034) and calcium (p = 0.024) when dead patients were excluded.
CONCLUSION
Proper nutritional delivery may help patients' clinical outcomes for patients receiving CRRT. However, their actual intakes of energy and protein were not adequate for their requirements. Identification of patients with malnutrition is necessary and a multidisciplinary approach for systemic management is also required.

Keyword

continuous renal replacement therapy; energy support; protein support; clinical outcomes; nutritional status

MeSH Terms

Adult
APACHE
Biomarkers
Calcium
Cholesterol
Critical Illness*
Electronic Health Records
Hematocrit
Humans
Intensive Care Units
Length of Stay
Malnutrition
Mortality
Nutritional Status*
Renal Replacement Therapy*
Serum Albumin
Calcium
Cholesterol
Serum Albumin

Figure

• 

  Fig. 1. Study design. ICU, intensive care unit; CRRT, continuous renal replacement therapy.

Reference

1.Lamb CA., Parr J., Lamb EI., Warren MD. Adult malnutrition screening, prevalence and management in a United Kingdom hospital: cross-sectional study. Br J Nutr. 2009. 102(4):571–575.

2.MacDonald A., Hildebrandt L. Comparison of formulaic equations to determine energy expenditure in the critically ill patient. Nutrition. 2003. 19(3):233–239.

3.Giner M., Laviano A., Meguid MM., Gleason JR. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition. 1996. 12(1):23–29.

4.Heidegger CP., Romand JA., Treggiari MM., Pichard C. Is it now time to promote mixed enteral and parenteral nutrition for the critically ill patient? Intensive Care Med. 2007. 33(6):963–969.

5.Lee S., Choi M., Kim Y., Lee J., Shin C. Nosocomial infection of malnourished patients in an intensive care unit. Yonsei Med J. 2003. 44(2):203–209.

6.Thibault R., Pichard C. Nutrition and clinical outcome in intensive care patients. Curr Opin Clin Nutr Metab Care. 2010. 13(2):177–183.

7.Correia MI., Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003. 22(3):235–239.

8.ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002. 26(1 Suppl):1SA–138SA.

9.Kreymann KG., Berger MM., Deutz NE., Hiesmayr M., Jolliet P., Kazandjiev G., Nitenberg G., van den Berghe G., Wernerman J. DGEM (German Society for Nutritional Medicine), Ebner C, Hartl W, Heymann C, Spies C; ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr. 2006. 25(2):210–223.

10.Rooyackers O., Kouchek-Zadeh R., Tjäder I., Norberg Å., Klaude M., Wernerman J. Whole body protein turnover in critically ill patients with multiple organ failure. Clin Nutr. 2015. 34(1):95–100.

11.Agrawal M., Swartz R. Acute renal failure. Am Fam Physician. 2000. 61(7):2077–2088.

12.Kopple JD. Dietary protein and energy requirements in ESRD patients. Am J Kidney Dis. 1998. 32(6 Suppl 4):S97–S104.

13.Abel RM. Nutritional support in the patient with acute renal failure. J Am Coll Nutr. 1983. 2(1):33–44.

14.Brown RO., Compher C. American Society for Parenteral and Enteral Nutrition Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010. 34(4):366–377.

15.Cano NJ., Aparicio M., Brunori G., Carrero JJ., Cianciaruso B., Fiac-cadori E., Lindholm B., Teplan V., Fouque D., Guarnieri G. ESPEN. ESPEN Guidelines on Parenteral Nutrition: adult renal failure. Clin Nutr. 2009. 28(4):401–414.

16.Susla GM. The impact of continuous renal replacement therapy on drug therapy. Clin Pharmacol Ther. 2009. 86(5):562–565.

17.Kopple JD. The nutrition management of the patient with acute renal failure. JPEN J Parenter Enteral Nutr. 1996. 20(1):3–12.

18.McClave SA., Martindale RG., Vanek VW., McCarthy M., Roberts P., Taylor B., Ochoa JB., Napolitano L., Cresci G. A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009. 33(3):277–316.

19.Barton RG. Nutrition support in critical illness. Nutr Clin Pract. 1994. 9(4):127–139.

20.Wooley JA., Btaiche IF., Good KL. Metabolic and nutritional aspects of acute renal failure in critically ill patients requiring continuous renal replacement therapy. Nutr Clin Pract. 2005. 20(2):176–191.

21.The Korean Dietetic Association. Manual of medical nutrition therapy. 3rd edition.Seoul: The Korean Dietetic Association;2008.

22.World Health Organization Western Pacific Region (PH); IASO International Association for the Study of Obesity (GB); I; International Obesity Task Force (GB). The Asia-Pacific perspective: redefining obesity and its treatment. Seoul: Korean Society for the Study of Obesity;2000.

23.Knaus WA., Draper EA., Wagner DP., Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985. 13(10):818–829.

24.Ahn S., Na SH., Chang CH., Lim H., Lee DC., Shin CS. Effects of APACHE II score and initial nutritional status on prognosis of the critically ill patients. Korean J Crit Care Med. 2012. 27(2):102–107.

25.Chi SN., Ko JY., Lee SH., Lim EH., Kown KH., Yoon MS., Kim ES. Degree of nutritional support and nutritional status in MICU patients. Korean J Nutr. 2011. 44(5):384–393.

26.Moon SS., Lim H., Choi JW., Kim DK., Lee JW., Ko S., Kim DC. Analysis of nutritional support status in the intensive care unit. Korean J Crit Care Med. 2009. 24(3):129–133.

27.Faubel S. Pulmonary complications after acute kidney injury. Adv Chronic Kidney Dis. 2008. 15(3):284–296.

28.Lee SM., Kim SH., Kim Y., Kim E., Baek HJ., Lee S., Lee H., Chang CH., Shin CS. Nutrition support in the intensive care unit of 6 Korean tertiary teaching hospitals: a national multicenter observational study. Korean J Crit Care Med. 2012. 27(3):157–164.

29.Bellomo R. Nutritional management of patients treated with continuous renal replacement therapy. Kopple JD, Massry SG, editors. editors.Kopple and massry's nutritional management of renal disease. 2nd edition.Philadelphia (PA): Lippincott Williams & Wilkins;2004. p. 573–580.

30.Lee MJ. Nutrition support, gastric residual volume and nutritional status of patients receiving enteral nutrition feeding in ICU [dissertation]. Busan: Dong-A University. 2013.

31.Kim WJ. The effect of initial energy and protein delivery on lengths of ICU and hospital stay and ICU and hospital mortality in critically ill patients [dissertation]. Seoul: Yonsei University;2012.

32.Chung HK., Lee SM., Lee JH., Shin CS. Energy deficiency aggravates clinical outcomes of critically ill patients. Korean J Crit Care Med. 2005. 20(1):49–53.

33.Petros S., Horbach M., Seidel F., Weidhase L. Hypocaloric vs Nor-mocaloric nutrition in critically ill patients: a prospective randomized pilot trial. JPEN J Parenter Enteral Nutr. Forthcoming. 2014.

34.Park EK., Lee JH., Lim HS. Degree of enteral tube feeding in the intensive care unit and change in nutritional status. J Korean Diet Assoc. 2001. 7(3):217–226.