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

Ju Yeun Kim; Ji-Myung; Yuri Kim

doi:10.4163/jnh.2015.48.3.211

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

Research Article

J Nutr Health 2015;48(3):211-220.

Published online: 19 January 2015

DOI: https://doi.org/10.4163/jnh.2015.48.3.211

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

Ju Yeun Kim¹, Ji-Myung ², Yuri Kim^1,^3,^†

¹Department of Clinical Nutrition, The Graduate School of Clinical Health Sciences, Ewha Womans University, Seoul 120-750, Korea

²Food and Nutrition Major, Division of Food Science and Culinary Arts, Shinhan University, Gyeonggi 480-701, Korea

³Department of Nutritional Science and Food Management, Ewha Womans University, Seoul 120-750, Korea

^†To whom correspondence should be addressed. tel: +82-2-3277-4485, e-mail: yuri.kim@ewha.ac.kr

Received 23 February 2015 Revised 22 March 2015 Accepted 1 June 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: continuous renal replacement therapy, energy support, protein support, clinical outcomes, nutritional status

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Fig. 1.

Study design. ICU, intensive care unit; CRRT, continuous renal replacement therapy.

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)	p value³⁾	< 50% (N = 162)	≧ 50% (N = 77)	p value³⁾
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⁾
Variables¹⁾	< 70% (N = 132)	≧ 70% (N = 107)	p value²⁾	< 50% (N = 162)	≧ 50% (N = 77)	p value²⁾
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

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
Variables	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
Variables	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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