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中华重症医学电子杂志 ›› 2022, Vol. 08 ›› Issue (04) : 347 -352. doi: 10.3877/cma.j.issn.2096-1537.2022.04.012

重症医学研究

重症AKI患者营养支持治疗中氮排量监测的意义
李小荷1, 岳金凤2, 翟茜1,()   
  1. 1. 250012 济南,山东大学齐鲁医院心脏外科重症监护室
    2. 250012 济南,山东大学齐鲁医院重症医学科
  • 收稿日期:2022-10-31 出版日期:2022-11-28
  • 通信作者: 翟茜

The significance of nitrogen excretion monitoring in nutritional therapy in ICU AKI patients

Xiaohe Li1, Jinfeng Yue2, Qian Zhai1,()   

  1. 1. Department of Intensive Care Unit of Cardiovascular Surgery, Qilu Hospital of Shandong University, Jinan 250012, China
    2. Department of Intensive Care Unit, Qilu Hospital of Shandong University, Jinan 250012, China
  • Received:2022-10-31 Published:2022-11-28
  • Corresponding author: Qian Zhai
引用本文:

李小荷, 岳金凤, 翟茜. 重症AKI患者营养支持治疗中氮排量监测的意义[J]. 中华重症医学电子杂志, 2022, 08(04): 347-352.

Xiaohe Li, Jinfeng Yue, Qian Zhai. The significance of nitrogen excretion monitoring in nutritional therapy in ICU AKI patients[J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2022, 08(04): 347-352.

目的

检索并获取合并急性肾损伤(AKI)的重症患者进行营养治疗时监测氮排量的相关临床证据,为临床实践提供参考意见。

方法

通过计算机完整地检索PubMed、Embase、Web of Science、Cochrane Library、中国知网、万方、维普等数据库,收集关于氮排量与进行营养治疗的AKI重症患者预后相关性的临床研究,包括系统评价/meta分析、随机对照试验(RCT)/非RCT、观察性研究(回顾性/前瞻性研究)、病例对照研究等,同时追索纳入文献的参考文献。文献检索起止时间为自建库至2022年8月,为保证研究质量,仅纳入2000年1月以后的文献。由两名研究者各自独立完成文献筛选及质量评价,并对文献能否支持最终结果做出判定。

结果

最终入选7项研究,共收集709例患者数据。包含2项RCT研究、1项前瞻干预研究及4项观察性研究。定性分析发现,持续的负氮平衡可能影响AKI患者的预后,肾功能损伤可能导致氮排量减低,而行肾脏替代治疗(RRT)可能增加额外的氮丢失,进行RRT的AKI患者增加氮摄入可以促进正氮平衡,改善患者预后。

结论

合并AKI的重症患者营养治疗时尤其需要关注氮平衡;监测氮平衡可以对营养治疗方案的制定提供参考。

Objective

To retrieve and obtain clinical evidence of whether nitrogen excretion should be monitored in critically ill patients with acute kidney injury (AKI) during nutritional therapy, so as to provide evidence to clinical practice.

Methods

Available published data (2000.01—2022.08) was retrieved from PubMed, Embase, Web of science, Cochrane Collaboration, CNKI and Wan Fang Data with keywords related with nitrogen excretion in critically ill patients with AKI during nutritional treatment. Further search was performed to identify all available studies. Literature selection and quality assessment of all included studies were performed by two researchers independently.

Results

Seven studies with data for 709 patients were included showing that nitrogen balance could be interfered by renal dysfunction or renal replacement therapy, and negative nitrogen balance may have bad affect on critically ill patients with AKI.

Conclusions

we should pay special attention to nitrogen balance in those patients. Monitoring nitrogen excretion is useful to maintain nitrogen balance and provide evidence for nutritional therapy.

图1 文献筛选流程及结果
表1 纳入文献的基本信息
研究 作者(年份) 例数 研究对象 干预措施 质量评价 结局
RRT对患者氮平衡的影响
前瞻性干预试验 Scheinkestel等7(2003) 11 需要RRT及机械通气的危重症患者 给予RRT治疗及全肠外营养,同等能量供应下蛋白质量以0.25 g的增量变化[1~2.5 g/(kg·d)] MINORS 10分 废液中平均丢失17%(95% CI:13%~24%)的输注氨基酸和4%的输注葡萄糖
病例系列研究 Chua等8(2012) 7 合并AKI的危重症患者 每日透析,1~3号患者经口饮食或禁食,4~7号患者接受肠内营养

JBI系统

8项为“是”

该7例患者平均负氮平衡:-10.7(-16.6~-1.4)g/d
病例系列研究 Ganesan等9(2009) 25 急性肾衰竭的危重患者 给予RRT治疗,肠内肠外营养根据团队评估患者所需要的剂量提供

JBI系统

9项为“是”

该25例CRRT患者平均净负氮平衡为(-1.0±0.6)g/(kg·d)
病例系列研究 Bellomo等14(2002) 7 急性肾衰竭的重症患者 RRT治疗,静脉输注氨基酸2.5 g/(kg·d)

JBI系统

8项为“是”

20个研究日的总氮平衡中位数为-1.8 g/d
营养治疗改善AKI-RRT患者氮平衡
RCT Scheinkestel等13(2003) 50 肾功能衰竭的重症患者 RRT治疗,对照组给予氨基酸2.0 g/(kg·d)补充,试验组给予氨基酸1.5 g/(kg·d)×2 d+2.0 g/(kg·d)×2 d+2.5 g/(kg·d)×2 d补充

RoB

高风险

氮平衡与蛋白质摄入量呈正相关(P=0.0075),且当蛋白摄入量>2 g/(kg·d)时更可能正氮平衡(r2=0.065,P=0.0001)
RCT Singer等12(2007) 14 合并AKI的重症患者,肌酐清除率<50 ml/min RRT治疗,2组给予不同剂量氨基酸补充(150 g/d vs 75 g/d)

RoB

风险不明

正常剂量氨基酸组的日氮平衡与基线无显著差异,而高剂量氨基酸组的日氮平衡显著增加[(-10.5±17)g/d vs(9±8.3)g/d,P<0.01]
氮平衡与AKI重症患者预后相关
RCT Scheinkestel等13(2003) 50 肾功能衰竭的重症患者 RRT,对照组给予氨基酸2.0 g/(kg·d)补充,试验组给予氨基酸1.5 g/(kg·d)×2 d+2.0 g/(kg·d)×2 d+2.5 g/(kg·d)×2 d补充

RoB

高风险

氮平衡每增加1g/d,生存率增加21%(OR=1.211,95% CI:1.017~1.443,P=0.03)
前瞻性观察研究 Bufarah等15(2018) 595 AKI患者部分为重症、部分需透析 肠内或肠外营养治疗

NOS

7分

ROC曲线显示负氮平衡<-6.47 g/d与病死率相关(AUC=0.745,95% CI:0.704~0.786,P<0.001)
1
Gunst J, Vanhorebeek I, Casaer MP, et al. Impact of early parenteral nutrition on metabolism and kidney injury [J]. J Am Soc Nephrol, 2013, 24 (6): 995-1005.
2
Inaguma D, Koide S, Ito E, et al. Ratio of blood urea nitrogen to serum creatinine at initiation of dialysis is associated with mortality: a multicenter prospective cohort study [J]. Clin Exp Nephrol, 2018, 22 (2): 353-364.
3
Berbel MN, Goes CR, Balbi AL, et al. Nutritional parameters are associated with mortality in acute kidney injury [J]. Clinics, 2014, 69 (7): 476-482.
4
Kim TJ, Park SH, Jeong HB, et al. Optimizing nitrogen balance is associated with better outcomes in neurocritically ill patients [J]. Nutrients, 2020, 12 (10): 3037.
5
Canaud B, Leblanc M, Leray-Moragues H, et al. Acute renal insufficiency: nutrition disorders and therapeutic consequences [J]. Nephrologie, 1998, 19 (2): 75-81.
6
Ponce D, Berbel MN, Regina de Goes C, et al. High-volume peritoneal dialysis in acute kidney injury: indications and limitations [J]. Clin J Am Soc Nephrol, 2012, 7 (6): 887-894.
7
Scheinkestel CD, Adams F, Mahony L, et al. Impact of increasing parenteral protein loads on amino acid levels and balance in critically ill anuric patients on continuous renal replacement therapy [J]. Nutrition, 2003, 19 (9): 733-740.
8
Chua HR, Baldwin I, Fealy N, et al. Amino acid balance with extended daily diafiltration in acute kidney injury [J]. Blood Purif, 2012, 33 (4): 292-299.
9
Ganesan MV, Annigeri RA, Shankar B, et al. The protein equivalent of nitrogen appearance in critically ill acute renal failure patients undergoing continuous renal replacement therapy [J]. J Ren Nutr, 2009, 19 (2): 161-166.
10
Bellomo R, Martin H, Parkin G, et al. Continuous arteriovenous haemodiafiltration in the critically ill: influence on major nutrient balances [J]. Intensive Care Med, 1991, 17 (7): 399-402.
11
Balasubramanian S, Tran DH, Serra M, et al. Assessing calorie and protein recommendations for survivors of critical illness weaning from prolonged mechanical ventilation - can we find a proper balance? [J]. Clin Nutr ESPEN, 2021, 45: 449-453.
12
Voerman BJ, Strack van Schijndel RJ, Groeneveld AB, et al. Effects of human growth hormone in critically ill nonseptic patients: results from a prospective, randomized, placebo-controlled trial [J]. Crit Care Med, 1995, 23 (4): 665-673.
13
Wan X, Wang W, Liu J, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range [J]. BMC Med Res Methodol, 2014, 14: 135.
14
Singer P. High-dose amino acid infusion preserves diuresis and improves nitrogen balance in non-oliguric acute renal failure [J]. Wien Klin Wochenschr, 2007, 119 (7-8): 218-222.
15
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 [J]. Nutrition, 2003, 19 (11-12): 909-916.
16
Bellomo R, Tan HK, Bhonagiri S, et al. High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance [J]. Int J Artif Organs, 2002, 25 (4): 261-268.
17
Bufarah MNB, Costa NA, Losilla M, et al. Low caloric and protein intake is associated with mortality in patients with acute kidney injury [J]. Clin Nutr ESPEN, 2018, 24: 66-70.
18
Stapel SN, de Boer RJ, Thoral PJ, et al. Amino acid loss during continuous venovenous hemofiltration in critically ill patients [J]. Blood Purif, 2019, 48 (4): 321-329.
19
Fiaccadori E, Sabatino A, Barazzoni R, et al. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease [J]. Clin Nutr, 2021, 40 (4): 1644-1668.
20
Reaich D, Channon SM, Scrimgeour CM, et al. Correction of acidosis in humans with CRF decreases protein degradation and amino acid oxidation [J]. Am J Physiol, 1993, 265 (2 Pt 1): E230-235.
21
Scialla JJ, Appel LJ, Astor BC, et al. Net endogenous acid production is associated with a faster decline in GFR in African Americans [J]. Kidney Int, 2012, 82 (1): 106-112.
22
Wesson DE, Simoni J. Acid retention during kidney failure induces endothelin and aldosterone production which lead to progressive GFR decline, a situation ameliorated by alkali diet [J]. Kidney Int, 2010, 78 (11): 1128-1135.
23
Banerjee T, Crews DC, Wesson DE, et al. High dietary acid load predicts ESRD among adults with CKD [J]. J Am Soc Nephrol, 2015, 26 (7): 1693-1700.
24
Ikizler TA, Cano NJ, Franch H, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism [J]. Kidney Int, 2013, 84 (6): 1096-1107.
25
Fouque D, Kalantar-Zadeh K, Kopple J, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease [J]. Kidney Int, 2008, 73 (4): 391-398.
26
Btaiche IF, Mohammad RA, Alaniz C, et al. Amino acid requirements in critically ill patients with acute kidney injury treated with continuous renal replacement therapy [J]. Pharmacotherapy, 2008, 28 (5): 600-613.
27
Hung KY, Chen ST, Chu YY, et al. Nutrition support for acute kidney injury 2020-consensus of the Taiwan AKI task force [J]. J Chin Med Assoc, 2022, 85 (2): 252-258.
28
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]. J Am Soc Nephrol, 1993, 3 (8): 1516-1521.
29
Quandt CM, Horst HM, Obeid FN, et al. Accuracy of two-hour urine urea nitrogen determinations in critically ill patients [J]. Clin Pharm, 1984, 3 (4): 408-411.
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