Total parenteral nutrition in the management of acute renal failure

Abstract

Malnutrition is frequently present in patients with acute renal failure and may affect morbidity and mortality in this condition. When adequate nourishment cannot be given through the gastrointestinal tract, total parental nutrition with amino acids and hypertonic glucose may have beneficial results. Total parenteral nutrition has been reported to stabilize or reduce serum urea nitrogen, potassium and phosphorus levels, improve wound healing, enhance survival from acute renal failure, and possibly increase the rate of recovery of renal function. The optimal composition of the total parenteral nutrition infusate is unknown. Preliminary results of a double-blind study are reported in which one man received hypertonic glucose alone, two received glucose with essential amino acids (21 g/day), and three received glucose with essential (21 g/day) and nonessential (21 g/day) amino acids. All infusates were isocaloric. No differences were observed in serum urea nitrogen levels, serum urea nitrogen/creatinine ratios or urea appearance rates. Nitrogen balance was negative in all patients. The ratio of essential amino acids/nonessential amino acids were higher and the tyrosine/phenylalanine ratios were lower in plasma in the two patients receiving glucose with essential amino acids. No patient survived the hospitalization. In view of the markedly negative nitrogen balance frequently observed in these and earlier studies, the use of a different composition or quantity of amino acids, a higher energy intake, and anabolic hormones deserve further investigation.

Proteolytic Activity in Patients with Hypercatabolic Renal Failure

“…However, nitrogen balance remains negative in all patients 2 suggesting that decreased protein synthesis is not the sole cause of loss of body nitrogen. Several studies have shown that proteinases participate in protein catabolism of patients with hypercatabolic ARF3-6.…”

Nutrition and the Dialysis Prescription

“…An early study compared hypertonic glucose alone with a solution containing essential amino acids and demonstrated increased survival and return of renal func tion in the latter group [52], However, no significant dif ferences in survival, renal recovery, or laboratory evi dence of nitrogen balance were seen in several subsequent studies that examined modifications of the type (essential versus nonessential) and quantity of amino acid supple mentation provided [53][54][55]. These negative findings could be attributed to the overwhelming effects of severe underlying disease [56]; furthermore, each study had lim ited statistical power to detect intra-group differences due to small sample size (range: 6-45).…”

Nutrition in Acute Renal Failure

“…[19] proposes a ratio of EAA to non-EAA of about 3:1 to 4:1. Generally, in hypercatabolic ARF, there seems to be an increased requirement for branched-chain amino acids [12], moreover, they are sup posed to have a pharmacologically anabolic effect [4,12,21], Therefore, Kopple and Cianciaruso [40] think that about 40% of the administered EAA should be provided as branched-chain amino acids. Perhaps, this regimen will provide better the requirement of amino acids in catabolic ARF with follow ing reduction of negative nitrogen balance; up to now, there are no controlled studies demonstrating this effect.…”

“…In the early postaggressive phase, only 30% of infused lipid can be utilized for generation of energy, indicating that lipid emulsions are not a suit able source to fulfill energy demands in the early phase of illness [46], If the patient is on TPN for a longer period, lipid infusions are necessary in order to prevent essential fatty acid deficiency [46], The administration of 250-500 g of lipid emulsion at least twice weekly is generally recommended [40] with infusion in small doses due to the fact that lipid emulsions are composed primarily of triglycerides for which clearance is generally decreased in uremia [12]. Additionally, lipid emulsions have been reported to block the reticuloendothelial system, resulting in di minished resistance to infection and induc tion of dissiminated intravascular coagulopa thy [46], The daily vitamin requirement in ARF treated with TPN is not well defined and data have been derived predominantly based on studies of chronic uremia [40].…”

“…The state of nutrition represents a signifi cant clinical parameter influencing the mor tality of these patients [ 12], as they frequently suffer from malnutrition and wasting [26] which have adverse effects on the outcome of the illness. Thus, the primary goal of nutri tional therapy in ARF is to provide nutri tions to maintain or improve the nutritional status of the patient [20].…”