Modification of Nutrition Therapy During Continuous Renal Replacement Therapy in Critically Ill Pediatric Patients: A Narrative Review and Recommendations

Abstract

Introduction Nutrition is an important part of treatment in critically ill children. Clinical guidelines for nutrition adaptations during continuous renal replacement therapy (CRRT) are lacking. We collected and evaluated current knowledge on this topic and provide recommendations. Methods Questions were produced to guide the literature search in the PubMed database. Results Evidence is scarce and extrapolation from adult data was often required. CRRT has a direct and substantial impact on metabolism. Indirect calorimetry is the preferred method to assess resting energy expenditure (REE). Moderate underestimation of REE is common but not clinically relevant. Formula‐based calculation of REE is inaccurate and not validated in critically ill children on CRRT. The nutrition impact of nonintentional calories delivered as citrate, lactate, and glucose during CRRT must be considered. Quantifying nitrogen balance is not feasible during CRRT. Protein delivery should be increased by 25% to compensate for losses in the effluent. Fats are not removed by CRRT and should not be adapted during CRRT. Electrolyte disturbances are frequently present and should be treated accordingly. Vitamins B1, B6, B9, and C are lost in the effluent and should be adapted to the effluent dose. Trace elements, with the exception of selenium, are not cleared in relevant quantities. Manganese accumulation is of concern because of potential neurotoxicity. Conclusion Current recommendations regarding nutrition support in pediatric CRRT must be extrapolated from adult studies. Recommendations are provided, based on the weak level of evidence. Additional research on this topic is warranted.

Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic

“…Attention should be given to the glucose content because it affects caloric calculation and nutritional management during CKRT. 12 Pharmacy-compounded CKRT fluids reduce the dependency on commercially available options, but intensive safety checks are essential. 13,14 Filters CKRT filters and lines may be specific for certain machine types based on unique connectors; this restricts their diversification.…”

Micronutrient status during paediatric critical illness: A scoping review

“… 0–1 yr 1-1 yr 0.2–2.1 mg/dl 0.6–1.4 mg/dl 5–50 μmol/l 14.5–30 μmol/l 15.3 μmol/l (13.9, 16.7) Low No change ≈ Low serum vitamin E was reported in critically ill children with oxidative stress [ 44 ]serum levels unchanged children [ 52 ] or neonates [ 43 ] Zinc (p) Zinc is a trace element involved in numerous functions including anti-oxidant function, and during the acute inflammatory response with zinc redistribution of zinc in tissues involved in protein synthesis and immune cell proliferation which is associated with reduced serum levels [ 48 ]. 11–24 μmol/l 7.1 μmol/l (4.6, 7.8) Low Serum zinc levels during the first few days of admission are low in children [ 22 , 50 ] with severe pneumonia [ 48 , 49 ], sepsis [ 50 ] and in those with Iinflammation [ 44 , 48 , 49 ], oxidative stress [ 44 ] and following CRRT [ 38 , 80 ] Selenium(s) Selenium is a trace element is involved in anti-oxidant, immunological and endocrine pathways, in addition to helping to maintain membrane and assist in thyroid production [ 50 ]. <1 year >1 year 45–130 ng/mL 70–150 ng/mL 39.5 ng/mL (5.5, 165) Low Serum selenium levels are reported to be low during the first few days of admission [ 11 , 22 , 37 , 44 , 50 , 53 , 56 ], sepsis [ 50 ] in those with inflammation and oxidative stress [ 44 , 56 ], following CRRT [ 38 , 80 ...…”

“… 11–24 μmol/l 7.1 μmol/l (4.6, 7.8) Low Serum zinc levels during the first few days of admission are low in children [ 22 , 50 ] with severe pneumonia [ 48 , 49 ], sepsis [ 50 ] and in those with Iinflammation [ 44 , 48 , 49 ], oxidative stress [ 44 ] and following CRRT [ 38 , 80 ] Selenium(s) Selenium is a trace element is involved in anti-oxidant, immunological and endocrine pathways, in addition to helping to maintain membrane and assist in thyroid production [ 50 ]. <1 year >1 year 45–130 ng/mL 70–150 ng/mL 39.5 ng/mL (5.5, 165) Low Serum selenium levels are reported to be low during the first few days of admission [ 11 , 22 , 37 , 44 , 50 , 53 , 56 ], sepsis [ 50 ] in those with inflammation and oxidative stress [ 44 , 56 ], following CRRT [ 38 , 80 ] and cardiac surgery [ 54 ] Copper (s) Copper is required for redox pathway, energy production, glucose and cholesterol metabolism [ 101 ]. 12–29 μmol/l 12.1 μmol/l (9.5, 14.6) Low No change ≈ High Low serum copper was reported in critically ill children with oxidative stress [ 44 ] Levels unchanged in critical ill children [ 49 ] High in children requiring renal replacement therapy [ 38 ] Iron (p) Iron is r...…”

“… Inflammatory response Low serum levels of thiamine [ 31 ], iron, zinc and selenium [ 11 , 37 , 56 ] and zinc [ 48 , 49 ] are associated with the magnitude of acute phase inflammatory response Oxidative stress With increasing oxidative stress plasma levels of six micronutrients decreased vitamin A, C, E, β, selenium, copper and zinc [ 44 ]. Medication Low thiamine levels was not associated with diuretic use [ 47 ] CCRT Low levels of selenium, zinc and chromium [ 38 ] Dilution effects of dialysate in renal replacement therapy result in losses of selenium, thiamine, folate, pyridoxine and vitamin C and accumulation of manganese [ 80 ]. Cardiac surgery In case study reports thiamine deficiency was associated with lactic acidosis in septic shock [ 32 ], extracorporeal membrane oxygenation [ 33 ], haematological malignancies [ 65 ] and following cardiac surgery [ 34 ].…”

“…Dilution effects of dialysate in renal replacement therapy result in losses of selenium, thiamine, folate, pyridoxine and vitamin C and accumulation of manganese [ 80 ].…”