Journal List > J Nutr Health > v.48(3) > 1081388

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

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.

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Fig. 1.
Study design. ICU, intensive care unit; CRRT, continuous renal replacement therapy.
jnh-48-211f1.tif
Table 1.
General characteristics of subjects
Variables N = 239
Age (year) 66.2 ± 13.41)
Sex
  Male 148 (61.9)2)
  Female 91 (38.1)
Body weight (kg) 61.7 ± 10.8
BMI (kg/m2) 23.4 ± 3.6
APACHE II score 25.0 ± 8.6
Predicted risk of death (%) 44.6 ± 26.6
Length of hospital stay (day) 45.1 ± 44.9
Length of ICU stay (day) 21.5 ± 21.4
Duration of CRRT (day) 7.3 ± 5.6
Mechanical ventilation 171 (71.5)
Duration of ventilator (day) 11.9 ± 18.8
Mortality 111 (46.4)
Nutrition support
  Enteral Nutrition (EN) 51 (21.4)
  Parenteral Nutrition (PN) 140 (58.6)
  Combined Nutrition (EN + PN) 48 (20.0)
Major diagnosis
  Renal failure 65 (27.2)
  Cardiac failure 37 (15.5)
  Oncologic 22 (9.2)
  Respiratory failure 20 (8.4)
  Gastrointestinal 18 (7.5)
  Infectious 18 (7.5)
  Neuromuscular 18 (7.5)
  Others 41 (17.2)

1) Mean ± SD

2) N (%)

BMI, body mass index; APACHE II score, Acute Physiology an Chronic Health Evaluation II score; ICU, intensive care unit; CRR continuous renal replacement therapy

Table 2.
Mean value of daily energy and protein supply in patients receiving CRRT
Variables N = 239
Estimated nutritional requirements
  Energy (kcal) 1,494.04 ± 231.511)
  Protein (g) 89.50 ± 13.77
Delivered Nutritional Supply
  Energy (kcal) 996.81 ± 355.42
  Protein (g) 41.83 ± 18.00
Rate of nutritional supply2)
  Energy (%) 68.06 ± 25.11
  Protein (%) 43.13 ± 21.54
Nutritional Supply per body weight
  Energy (kcal/kg body weight) 16.62 ± 6.32
  Protein (g/kg body weight) 0.63 ± 0.32

1) Mean ± SD

2) Rate of nutritional supply, energy, protein received/required × 100

Table 3.
Comparisons of clinical outcomes according to rate of energy and protein supply
Rate of energy supply1) p value3) Rate of protein supply2) p value3)
  < 70% (N = 132) ≧ 70%(N = 107) < 50% (N = 162) ≧ 50% (N = 77)
Age (year) 64.4 ± 13.64) 68.4 ± 12.8 0.020 64.9 ± 13.7 68.8 ± 12.4 0.036
Sex, Male 86 (65.2)5) 62 (57.9) 0.254 106 (65.4) 42 (54.5) 0.105
Mortality 63 (47.7) 48 (44.9) 0.658 83 (51.2) 28 (36.4) 0.031
Length of hospital stay (day) 59.0 ± 56.3 51.5 ± 48.8 0.007 54.6 ± 54.7 57.1 ± 50.4 0.008
Length of ICU stay (day) 24.6 ± 22.9 18.2 ± 16.4 0.008 22.4 ±21.7 20.5 ± 18.2 0.035
Duration of CRRT (day) 6.5 ± 3.9 5.8 ± 3.5 < 0.001 6.3 ± 3.8 6.0 ± 3.6 < 0.001
Duration of mechanical ventilator (day) 10.7 ± 15.9 6.6 ± 9.3 0.129 9.4 ± 15.0 7.9 ± 10.2 0.656
APACHE II score 21.2 ± 7.5 21.2 ± 7.2 < 0.001 21.5 ± 7.6 20.7 ± 7.0 < 0.001
Use of mechanical ventilator 93 (70.5) 78 (72.9) 0.677 114 (70.4) 57 (74) 0.558

1) Energy received/required × 100

2) Protein received/required × 100

3) Values are adjusted for age.

4) Mean ± SD n (%)

5) n (%

Excluding dead patients, N = 69 is the group with lower than 70% of energy received rate, N = 59 is the group with higher than 70% o energy received rate, N = 79 is the group with lower than 50% of protein received rate, N = 49 is the group with higher than 50% of protein received rate.

ICU, intensive care unit; CRRT, continuous renal replacement therapy; MV, mechanical ventilator; APACHE II score, acute physiolog and chronic health evaluation II score

Table 4.
Comparisons of changes in biochemical markers according to rate of energy and protein supply between the first day of CRRT and 2 weeks after CRRT
Variables1) Rate of energy supply p value2) Rate of protein supply p value2)
< 70% (N = 132) ≧ 70% (N = 107) < 50% (N = 162) ≧ 50% (N = 77)
N = 239
Total protein (g/dL) -0.01 ± 0.993) 0.10 ± 0.80 0.396 0.02 ± 0.95 0.07 ± 0.81 0.606
Albumin (g/dL) -0.05 ± 0.50 -0.05 ± 0.45 0.817 -0.05 ± 0.49 -0.06 ± 0.47 0.822
Total lymphocyte count (mm3) 201.39 ± 983.66 479.21 ± 1,689.23 0.260 180.76 ± 999.92 630.58 ± 1,857.73 0.049
Hb (g/dL) -0.56 ± 2.20 -0.74 ± 9.55 0.406 -0.42 ± 2.15 -1.11 ± 11.21 0.290
Hct (%) -1.42 ± 6.58 0.98 ± 5.16 0.006 -0.95 ± 6.44 0.94 ± 5.07 0.041
BUN/Cr ratio (%) 0.82 ± 11.73 2.39 ± 21.25 0.760 1.39 ± 14.81 1.80 ± 20.10 0.920
Total Cholesterol (mg/dL) 9.07 ± 49.62 15.20 ± 47.75 0.778 4.23 ± 46.63 26.67 ± 49.62 0.153
Na (mmol/L) -0.48 ± 7.38 -1.31 ± 8.52 0.489 -0.76 ± 8.41 -1.04 ± 6.77 0.688
K (mmol/L) -0.30 ± 1.32 0.06 ± 1.22 0.092 -0.30 ± 1.26 0.20 ± 1.29 0.018
Ca (mg/dL) 0.33 ± 0.94 0.29 ± 1.40 0.046 0.37 ± 0.96 0.19 ± 1.51 0.030
P (mg/dL) -0.77 ± 2.77 -0.62 ± 2.64 0.580 -0.90 ± 2.57 -0.30 ± 2.95 0.180
Mg (mmol/L) -0.07 ± 0.80 -0.03 ± 0.23 0.765 -0.07 ± 0.72 -0.02 ± 0.24 0.714
CRP (mg/L) -37.34 ± 127.39 -26.77 ± 109.92 0.385 -27.89 ± 125.27 -42.05 ± 107.83 0.486
      N = 128
Total protein (g/dL) -0.10 ± 1.533) -0.32 ± 1.69 0.787 0.02 ± 1.61 -0.56 ± 1.54 0.156
Albumin (g/dL) -0.22 ± 0.90 -0.24 ± 0.76 0.765 -0.15 ± 0.94 -0.36 ± 0.62 0.281
Total lymphocyte count (mm3) - -654.73 ± 1,746.67 -50.91 ± 1,272.97 0.070 -567.19 ± 1,676.76 -68.82 ± 1,340.32 0.167
Hb (g/dL) -1.44 ± 3.24 -0.65 ± 2.15 < 0.001 -1.26 ± 3.11 -0.79 ± 2.24 < 0.001
Hct (%) -4.01 ± 9.45 -1.70 ± 6.31 < 0.001 -3.55 ± 9.07 -1.98 ± 6.55 < 0.001
BUN/Cr ratio (%) -1.15 ± 18.84 -2.03 ± 11.47 0.875 -1.80 ± 17.97 -1.16 ± 11.71 0.836
Total Cholesterol (mg/dL) 7.48 ± 45.47 20.81 ± 43.08 0.621 8.36 ± 49.13 20.25 ± 37.09 0.689
Na (mmol/L) 1.12 ± 7.23 -1.25 ± 6.02 0.137 0.80 ± 7.06 -1.22 ± 6.17 0.259
K (mmol/L) -0.67 ± 1.21 -0.62 ± 1.31 0.907 -0.76 ± 1.20 -0.47 ± 1.33 0.333
Ca (mg/dL) 0.02 ± 1.29 0.12 ± 1.30 0.042 0.02 ± 1.23 0.13 ± 1.39 0.045
P (mg/dL) -1.32 ± 2.87 -1.04 ± 2.83 0.319 -1.44 ± 2.84 -0.79 ± 2.83 0.174
Mg (mmol/L) 0.01 ± 0.31 -0.06 ± 0.24 0.312 -0.01 ± 0.32 -0.04 ± 0.22 0.671
CRP (mg/L) -11.83 ± 134.33 -24.77 ± 115.96 0.748 -15.29 ± 133.97 -21.83 ± 112.82 0.799

1) Percent change between CRRT 1d and CRRT 2 weeks.

2) Values are adjusted for age.

3) Mean ± SD

Excluding dead patients, N = 69 is the group with lower than 70% of energy received rate, N = 59 is the group with higher than 70% o energy received rate, N = 79 is the group with lower than 50% of protein received rate, N = 49 is the group with higher than 50% of protein received rate.

Alb, serum albumin; TLC, total lymphocyte count; Hb, hemoglobin; Hct, hematocrit; BUN, blood urea nitrogen; Cr, creatinine; CRP, c eactive protein

Table 5.
Correlations energy and protein intake with clinical outcomes (Excluding dead patients, N = 128)
Variables Energy intake Protein intake
r p1) r p1)
Length of hospital stay -0.076 0.393 -0.023 0.797
Length of ICU stay -0.174 0.049 -0.135 0.131
Duration of CRRT -0.103 0.250 -0.083 0.353
Duration of mechanical ventilator -0.162 0.069 -0.154 0.085

1) Values are adjusted for age.

CU, intensive care unit; CRRT, continuous renal replacement therapy;MV, mechanical ventilator

Table 6.
Correlations energy and protein intake with biochemica markers on 2 weeks after CRRT
Variables Energy intake Protein intake
r p1) r p1)
N = 239
Total protein 0.127 0.299 0.208 0.021
Albumin -0.028 0.821 0.178 0.048
TLC 0.061 0.618 0.087 0.476
Hb -0.176 0.149 -0.106 0.387
Hct -0.004 0.977 0.169 0.009
Total cholesterol 0.174 0.154 0.278 0.021
Na 0.129 0.290 0.099 0.417
K -0.022 0.858 0.165 0.174
Ca 0.235 0.037 0.139 0.254
P 0.161 0.186 -0.004 0.975
Mg -0.103 0.399 -0.067 0.586
N = 128
Total protein 0.033 0.833 0.067 0.483
Albumin -0.097 0.543 0.099 0.301
TLC 0.133 0.402 0.131 0.170
Hb -0.186 0.237 0.151 0.114
Hct -0.090 0.572 0.201 0.034
Total cholesterol 0.267 0.088 0.302 0.052
Na 0.160 0.312 0.062 0.516
K 0.107 0.498 0.160 0.094
Ca -0.007 0.963 0.214 0.024
P 0.279 0.073 0.119 0.213
Mg -0.154 0.330 0.044 0.649

1) Values are adjusted for age.

1) ¶ Excluding dead patients.

TLC, total lymphocyte count; Hb, hemoglobin; Hct, hematocrit

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