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1、Implications of nutritional support during continuous veno-venous haemofiltrationPresent by Ri 陳宇光Introduction :CVVH CVVH lWide accepted therapy for acute renal failure in intensive carelCorrect uremia , fluid overload and eliminate metabolic wastes.lIn the application of clearance by convectionlOne
2、 type of the CRRT (continuous renal replacement therapy) AdvantageslImprove hamodynamic stabilitylPossibility for unlimited nutrition, optimal fluid balancelGradual toxin removal without fluctuationsIndicationlARF ,CRI and hemodynamic unstable PtlRespiratory distress syndromelMultiple organ failurel
3、CHF or hepatic failurelARF after organ transplantationlIntoxicationNutrient loss by CRRT Loss of Nutrients during CVVHlWater-soluble nutrients with low molecular size and low protein binding : amino acids or vitaminslLipids and liposoluble vitamins : nearly no losslCholesterol and/or triglycerides :
4、 only trace amount lossAmino acids losseslLosses : approximately 10-15 g/dayl10% of infused amino acids are lostlDepend upon the rate of ultrafiltration and free serum amino acid levelslNot upon molecular size or chargelAmino acid supply : increased by 0.2 g/kg/dayCarbohydrateslDextrose-containing d
5、ialysate: significant amount can be absorbed (35-45 %)lFluid replacement with dextrose containing electrolyte : significant gains of energy Possible HyperglycemialTogether with the energy derived from the metabolism of lactate (45 mmol of lactate yields 12 kcal /l): take into account when designing
6、regimentsGains of energy in CVVHWater-soluble vitamin and trace element losseslParticipate in a variety of physiological functionslMay attenuate the effects of the inflammatory cascade, particularly the effects of oxygen-derived free radicalslSignificant lower vitamins and trace elements during the
7、first 24 h of CVVHlActual micronutrient requirement : unknown Blood concentrations of micronutrients in critically ill patients receiving CVVH compared with controlsProposed vitamin supplementation in acute renal failureGlutamine losses ()lEssential amino acid during illnesslMaintenance of musclelPr
8、eservation of gastrointestinal tract integritylAcid base balancelEnhancement of the immune systemlAn energy source in rapidly growing tissues( gut mucosa and immune cells)Glutamine losses ()lLinked to multiple organ failure (MOF)lReceived 20g/day intravenous glutamine supplementation: decrease death
9、s lCVVHD induces changes in glutamine metabolism : initial decrease of up to 33%lSubsequent losses during CRRT : 25- 35%(3000mg/day)Glutamine losses ()lA dosage of 0.3-0.5 g/kg/day (30-35 g /day for adult) lThe stability of a glutamine vitamin replacement solution : L-glutamine(4g), vitamin C (100mg
10、) and folic acid (400ug) in 160 ml sterile waterEffect of glutamine supplementation on critically ill patientsAntioxidant losses()lReactive oxygen species: pathogenesis of renal diseases lCRRT: Aggravate deprivation of the oxygen radical scavenger system by elimination of water-soluble antioxidantsE
11、nhance lipid peroxidation, increase malondialdehydeAntioxidant losses()lAntioxidant losses can be observed in ARF patients treated with intermittent haemodialysis and CRRTlIncreased demand for the liposoluble antioxidant vitamin E and intracellular antioxidant glutathione (against lipid peroxidation
12、)Plasma levels of antioxidants in multiple organ failure and acute renal failure patients on continuous renal replacement therapy compared with controlsConclusionlCVVH is associated with a broad spectrum of metabolic side effects, including:the loss of amino acids such as glutamine, water- soluble v
13、itamin, minerals , and antioxidantslNutrition in conjunction with aggressive treatment of the underlying disease process to increase recovery of renal function could improve survival ratelProtein restriction is unnecessary in patients with ARF receiving CRRT, optimal amount of daily protein and tota
14、l energy require further research.ReferenceslAngela Marin and Gil Hardy ,Practical implications of nutritional support during continuous renal replacement therapy, lLingtak-Neander Chan .Nutritional support in acute renal failure, Curr Opin Clin Nutr Metab Care 7:207-212lStory, David A. MBBS (Hons),
15、 BMedSci(Hons), FANZCA; Ronco, Claudio MD; Bellomo, Rinaldo MBBS (Hons), MD, FRACP Trace element and vitamin concentrations and losses in critically ill patients treated with continuous venovenous hemofiltrationlDemling RH,DeBiasse MA: Micronutrients in critical illness. Crit Care Clin 1997;11:651-673Curr Opin Clin Nutr Metab Care 4:219225Thanks for Your Attention !
