RIFLE. (renal replacement therapy, RRT)

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1 P *,** ** ** ** * ** (acute renal failure)(acute kidney injury) RIFLE [1] ( 1) 3 10% [2] (renal replacement therapy, RRT) (European Society for Clinical Nutrition and Metabolism) (American Society for Parenteral and Enteral Nutrition, ASPEN) (lean body mass) (catabolism) (protein-energy wasting, PEW) ( ) 386 (07) hmchung@vghks.gov.tw (catabolic status) (internal milieu) (insulin resistance) (negative nitrogen balance) [3]

2 1. RIFLE RIFLE GFR () Risk ml6 GFR25% Injury ml12 GFR50% Failure 3GFR75% 40.5 mg/dl 0.3 ml24 12 Loss ESRD ( ) RIFLERisk, Injury, Failure, Loss, ESRD GFR Glomerular filtration rate (1) (glucagon, epinephrine, cortisol, growth hormone) (insulin resistance) (gluconeogenesis) [4] (2)(3) (glucocorticoid, adrenergic agents) [5] [6,7] 30% (acute phase protein) C(CRP) (catabolic status), [5] ( tyrosine histidine ) (impaired lipolysis)(lipoprotein lipase)(hepatic triglyceride lipase)50% (triglyceride,tg) (very-lowdensity lipoprotein, VLDL)(total cholesterol)(high-density lipoprotein, HDL) (parenteral) (fat emulsions) (fatty acid oxida

3 tion) (underlying disease) [3] (basal energy expenditure, BEE) 130% [8,9] [10] ( 5 g) (20 25 kcal/kg) (0.6 1 g/kg/day) [5] ( 5 10g) (10 g) 100 mg/dl 60 80% g/kg [11~14] 2 g/kg [15] 2.5 g/kg [16] [17] 1.5 g/kg 40 kcal/kg 30 kcal/kg ( ) [17] 2009 ESPEN 1.5 g/kg kcal/kg 1.3 [18](high-flux) (continuous renal replacement therapy, CRRT) 0.2 g/kg 2010ASPEN (indirect calorimetry) g/kg[19] % g/kg/day 10 30%(lipid emulsions) mg/dl glutamine glutamine [20] glutamine ω-3 [18] (1)

4 2. Drum, kcal/kg kcal/kg kcal/kg g/kg g/kg g/kg ESPEN, kcal/kg ( ) g/kg 1 g/kg g/kg (0.2g 1.7g) ASPEN, g/kg Berger CRRT (2) (3) (4) (selenium)(chromium)(copper)(zinc) ( ) [21] CVVHDF [22] C B1 (thiamine) CVVH 600 umol (100 mg)c 600 nmol (265 ug) [23,24] CVVHDF B1 1.5 A E D3 K [5] [18] C (secondary oxalosis)c mg mg Berger CRRT B1 [25] [26] [27] [28] [16,29] (1) (2)

5 [30] (gastric residual volume) [30] 24 ( 20 25%) (refeeding syndrome) jejunal tube5 10 [19,20] [19] (standard formulas for enteral nutrition) () (1.5 2 kcal/ml) (70 g/l) (amino acid solutions)(commercial 3-in-1 nutrient admixtures) (1) (2)(3)(4) (5) (6)(7) (8)(9) [31] (20 25 kcal/kg/day) (0.6 1 g/kg/day) kcal/kg ( ) g1 2.5 g/kg 1. Himmelfarb J, Ikizler TA: Acute Kidney Injury: changing lexicography, definitions and epidemiology. Kidney Int 2007; 71: Nolan C, Anderson R: Hospital-acquired acute renal failure. J Am Soc Nephrol 1998; 9: Cano N, Fiaccadori E, Tesinsky P, Toigo G, Druml W, et al: ESPEN Guidelines on Enteral Nutrition: Adult renal failure. Clin Nutr 2006 Apr; 25(2): Nasraway SA Jr: Hyperglycemia during critical illness. JPEN J Parenter Enteral Nutr 2006; 30: Druml W. Nutritional management of acute renal failure. J

6 Ren Nutr2005 Jan; 15(1): Ritchie-McLean S, Kirwan C, Levy JB: Is there a role for intensive insulin therapy in patients with kidney disease. Am J Kidney Dis 2007; 50: Finney JSJ, Zekveld CZ, Elia A, Evans TW: Glucose control and mortality in critically ill patients. JAMA 2003; 290: Kreymann KG, Berger MM, Deutz NE, et al: ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006; 25: Raurich JM, Ibanez J, Marse P, Riera M, Homar X: Resting energy expenditure during mechanical ventilation and its relationship with the type of lesion. JPEN J Parenter Enteral Nutr 2007; 31: Valencia E, Marin A, Hardy G: Nutrition therapy for acute renal failure: a new approach based on 'risk, injury, failure, loss, and end-stage kidney' classification (RIFLE).Curr Opin Clin Nutr Metab Care 2009 May; 12(3): Chima CS, Meyer L, Hummell AC, et al: Protein catabolic rate in patients with acute renal failure on continuous arteriovenous hemofiltration and total parenteral nutrition. J Am Soc Nephrol 1993; 3: Leblanc M, Garred LJ, Cardinal J, et al: Catabolism in critical illness: estimation from urea nitrogen appearance and creatinine production during continuous renal replacement therapy. Am J Kidney Dis 1998; 32: Marshall MR, Golper TA, Shaver MJ, Alam MG, Chatoth DK: Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy. Am J Kidney Dis 2002; 39: Macias WL, Alaka KJ, Murphy MH, Miller ME, Clark WR, Mueller BA: Impact of the nutritional regimen on protein catabolism and nitrogen balance in patients with acute renal failure. JPEN J Parenter Enteral Nutr 1996; 20: Scheinkestel CD, Kar L, Marshall K, et al: Prospective randomized trial to assess caloric and protein needs of critically ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003; 19: Bellomo R, Tan HK, Bhonagiri S, et al: High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance. Int J Artif Organs 2002; 25: Fiaccadori E, Maggiore U, Rotelli C, et al: Effects of different energy intakes on nitrogen balance in patients with acute renal failure: a pilot study. Nephrol Dial Transplant 2005; 20: Cano N, Aparicio M, Brunori G, et al: ESPEN guidelines on parenteral nutrition: adult renal failure. Clin Nutr 2009; 28: Brown RO, Compher C, et al: A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr 2010 Jul-Aug; 34(4): Druml W, Kierdorf HP: Parenteral nutrition in patients with renal failure Guidelines on Parenteral Nutrition, Chapter 17. Ger Med Sci 2009 Nov 18; 7: Doc Klein CJ, Moser-Veillon PB, Schweitzer A, et al: Magnesium, calcium, zinc, and nitrogen loss in trauma patients during continuous renal replacement therapy. JPEN J Parenter Enteral Nutr 2002; 26: Metnitz GH, Fischer M, Bartens C, Steltzer H, Lang T, Druml W: Impact of acute renal failure on antioxidant status in multiple organ failure. Acta Anaesthesiol Scand. 2000; 44: Story DA, Ronco C, Bellomo R: Trace element and vitamin concentration and losses in critically ill patients treated with continuous venovenous hemofiltration. Crit Care Med 1999; 27: Fortin MC, Amyot SL, Geadah D, Leblanc M: Serum concentrations and clearances of folic acid and pyridoxal- 5-phosphate during venovenous continuous renal replacement therapy. Intensive Care Med 1999; 25: Berger MM, Shenkin A, Revelly JP, et al: Copper, selenium, zinc, and thiamine balances during continuous venovenous hemodiafiltration in critically ill patients. Am J Clin Nutr 2004; 80: Jill M: STREJC. Considerations in the nutritional management of patients with acute renal failure. Hemodialysis International 2005; 9: Fiaccadori E, Lombardi M, Leonardi S, Rotelli CF, Tortorella G, Borghetti A: Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study. J Am Soc Nephrol 1999; 10: Li Y, Tang X, Zhang J, Wu T: Nutritional support for acute kidney injury. Cochrane Database Syst Rev 2010 Jan 20; (1): CD Metnitz PG, Krenn CG, Steltzer H, et al: Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002; 30: Fiaccadori E, Maggiore U, Giacosa R, et al: Enteral nutrition in patients with acute renal failure. Kidney Int 2004; 65: Fiaccadori E, Cremaschi E: Nutritional assessment and support in acute kidney injury. Curr Opin Crit Care 2009 Dec; 15(6):

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