Renal replacement therapy lacks in protein delivery in pediatric congenital heart disease

October 22, 2021

2 minutes reading

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The authors report no relevant financial disclosures.

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Renal replacement therapy was insufficient for protein delivery in critically ill children with congenital heart disease, according to a retrospective cohort study at one center in the Journal of Renal Nutrition.

“Although several studies have been conducted in critically ill children with AKI, there is limited data evaluating nutritional status and nutrient intake in patients with congenital heart disease (CHD) who [renal replacement therapy] RRT,” Daniel L. Hames, MD, of the Cardiovascular Critical Care Division at Boston Children’s Hospital and the Department of Pediatrics at Harvard Medical School, and colleagues wrote. “In addition, identifying the barriers to providing adequate nutrition in this population could provide clinically relevant information in the assessment and treatment of these patients.”

Hames and co-workers examined data from 60 patients with CHD (median age, 5.2 years; 67% male patients) who were treated with RRT in a pediatric cardiac ICU between January 1, 2011 and December 31, 2019. Apart from 12 patients over 18 years of age, all participants were children. Researchers determined fluid balance and energy and protein targets and adequacy in the first 7 days of RRT, defining adequacy as greater than 80% protein and energy delivery.

The only significant comorbidity unrelated to the diagnosis of CHD in the study population was obstructive sleep apnea, which occurred in one subject.

At baseline, the median weight-for-age z-score (WAZ) was -0.95, height-for-age z-score (HAZ) was -1.23 and BMI z-score was -0.19, indicating malnutrition implies, Hames and colleagues wrote.

Energy adequacy was achieved in 55 patients (92%), and most (63%) achieved adequacy by the time RRT started. These patients had a lower median WAA (–1.17 vs. 1.24) and a lower median BMI z-score (–0.32 vs. 1.65) than patients who did not achieve adequacy. Higher WAZ score was the only predictor of energy insufficiency in multivariate analysis (OR = 0.07; 95% CI, 0.01-0.58).

Patients with insufficient maintenance fluid levels on the day of starting RRT were more likely to fail to achieve energy goals (60% vs. 11% of patients without fluid restriction.

Protein adequacy was achieved in 37 patients (62%), although only 28 patients (47%) achieved adequacy for more than half of their time on RRT. Fluid restriction was the only independent predictor of protein deficiency (OR = 0.13; 95% CI 0.02-0.7); azotemia was not associated with protein intake.

The proportion of fluid-restricted patients did not change during RRT (15%) and 18 patients (30%) were restricted on RRT for more than half of their time. Only 30 patients (50%) achieved a negative fluid balance.

According to the researchers, the limitations include study design, small sample size, calculation methods, non-assessment of nitrogen levels, and evaluation of energy and protein only during RRT.

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