An European survey of structure and organisation of nutrition support teams in Germany, Austria and Switzerland.

BACKGROUND & AIMS: Nutritional support teams (NST) have been demonstrated to be an excellent mechanism for identifying patients in need of nutrition support, improving the efficacy of nutrition support in a variety of hospital environments. Focus of this study was the investigation of function, structure and organisation of NST in Germany (D), Austria (A) and Switzerland (CH). METHODS: Prospective investigation of the function, structure and organisation of NST in D, A and CH, using standardised questionnaires. RESULTS: From a total of 3071 hospitals in D, A and CH, NST have been established at 98 hospitals (3.2%). Their main activities were creating nutritional regimes (100%), education (87%) and monitoring nutrition therapy (92%). In general, the NST are not independently operating units but are affiliated to a special discipline. Seventy-one per cent of the physicians, 40% of the nurses and 69% of the dieticians in the NST held a nutrition-specific additional qualification. A total of 12% of the physicians, 37% of the nurses and 46% of the dieticians are exclusively responsible for the NST. A reduction of complications (88%) and cost saving (98%) were indicated since their establishment. The NST received in 32% funding support. CONCLUSION: In D, A, CH neither a uniform nor comprehensive patient care by NST existed in 2004. Standards of practice, development of guidelines in clinical nutrition and better documentation in NSTs are necessary. Special efforts should be aimed at education of NST members and financing of teams.

Nutritional management of acute renal failure.

The principles of nutritional therapy (ie, maintain lean body mass, stimulate immunocompetence, and repair functions, such as wound healing) are similar for patients with acute renal failure (ARF) and with other catabolic clinical conditions. However, if a patient with ARF requires nutritional support, the multiple metabolic consequences of acute uremia must be taken into account. These do not only affect fluid, electrolyte, and acid-base balance but also the metabolism of amino acids, proteins, carbohydrates, and lipids. In addition, these metabolic alterations are modified by the acute disease process per se, by associated complications (such as severe infections), and last but not least, by the type and intensity of renal replacement therapy. Whenever possible, enteral nutrition should be provided in patients with ARF because even small amounts of luminal nutrients will help to maintain intestinal functions. Nevertheless, in many patients a parenteral nutrition, at least supplementary and/or temporarily, will become necessary. Metabolic complications of nutritional support frequently occur in patients with ARF because tolerance to volume load and electrolytes is limited and the use of various nutrients is impaired. Despite the notorious difficulty to demonstrate clear-cut benefits of nutritional interventions and especially, of parenteral nutrition on prognosis in critically ill patients, there can be no doubt that nutritional therapy presents a cornerstone in the treatment of patients with ARF. Preexisting and/or hospital-acquired malnutrition have been identified as important factors contributing to the persisting high mortality in acutely ill patients with ARF.

Impact of acute renal failure on antioxidant status in multiple organ failure.

BACKGROUND: Acute renal failure (ARF) can be triggered or aggravated by reactive oxygen species (ROS) but established ARF per se might also affect the antioxidant defence mechanisms of the organism. We evaluated a broad pattern of antioxidants in critically ill patients with multiple organ failure with (MOF-ARF) and without acute renal failure (MOF) to identify any potential involvement of renal dysfunction in the depletion of the antioxidant system. METHODS: Observational study; 13 patients with MOF were investigated (9 with and 4 without ARF), and 17 healthy subjects served as controls. Blood samples were drawn after establishment of MOF. Plasma levels of ascorbate, alpha-tocopherol, retinol, beta-carotene, selenium and lipid peroxidation products (MDA) were determined and the activities of the antioxidant enzymes catalase (CAT), superoxide dismutase (SOD) and glutathione-peroxidase (GSH-PX) in erythrocytes were measured. In addition, ROS production (superoxide anion and hydrogen peroxide) in activated neutrophils was assessed. RESULTS: Plasma levels of ascorbate, beta-carotene and selenium were reduced in both patient groups, when compared to controls. Decrease in selenium was more pronounced in the MOF-ARF group. MDA levels were increased in both groups, again being more pronounced in MOF-ARF patients compared to MOF patients. Hydrogen peroxide production by neutrophils from both patient groups was lower than from controls. CONCLUSION: A depression of the antioxidative system is present in critically ill patients with MOF. In patients with associated ARF this was even more pronounced and plasma MDA levels were higher, suggesting an additional effect on the antioxidative potential in the presence of renal dysfunction and/or renal replacement therapy.

Fat-soluble vitamins in patients with acute renal failure.

OBJECTIVE: Systematic investigations on the status of fat-soluble vitamins in patients with acute renal failure (ARF) are lacking and hence no recommendations for vitamin supply can be defined for these subjects. Thus we compared the status of fat-soluble vitamins, of transport molecules and some vitamin-dependent proteins in patients with ARF and healthy controls. SETTING: Nephrology unit of a university hospital. PATIENTS AND METHODS: Eight patients with ARF requiring hemodialysis therapy were investigated and 28 healthy volunteers served as controls. Plasma concentrations of retinol (vitamin A) and retinol-binding protein (RBP), 25-OH and 1,25-(OH)2 vitamin D3, of parathyroid hormone (PTH), of alpha-tocopherol (vitamin E) and of phylloquinone (vitamin K), osteocalcin and noncarboxylated osteocalcin, respectively, were measured and plasma lipoprotein fractions (as vitamin transport vehicle) were evaluated. RESULTS: Vitamin A levels were decreased (p < 0.001), but RBP levels were normal in ARF patients. Vitamin D3 metabolites 25-OH and 1,25-(OH)2 vitamin D3 plasma levels were profoundly depressed, and PTH was elevated (p < 0.001). Vitamin E plasma concentration was reduced (p < 0.001) but this cannot be accounted for by decreased LDL cholesterol or triglyceride levels. In contrast, vitamin K plasma level was rather elevated in ARF patients with a broad range of individual values. Blood coagulation was normal but total and carboxylated osteocalcin were decreased. No correlation of vitamin K concentrations and any of the plasma lipoprotein fractions could be identified. CONCLUSION: With the exception of vitamin K, profound deficiencies of fat-soluble vitamins develop in patients with ARF. Current recommendations for vitamin supplementation are inadequate and should be reevaluated for these patients.

Antioxidant status in patients on chronic hemodialysis therapy: impact of parenteral selenium supplementation.

Reactive oxygen species may be involved in a broad pattern of tissue injury in patients on regular hemodialysis therapy and, in fact, increasing evidence suggests that the antioxidative system is compromized in these patients. One factor contributing to this reduction of antioxidative capacity is selenium deficiency. The present investigation was undertaken to further define the extent and type of impairment of the oxygen radical scavenger system in chronic hemodialysis patients and to evaluate the impact of selenium supplementation. Twelve non-wasted patients (6 male, 6 female, mean age of 58 years) on chronic hemodialysis for a minimum of 5 months (mean 46 months) were supplemented intravenously with 400 mg selenium (as sodium selenite) thrice weekly after each hemodialysis session over 8 weeks. Blood samples were taken before the start, at intervals of 2 weeks during, and 4 weeks after termination of supplementation. Concentrations were evaluated of selenium and alpha-tocopherol in plasma and erythrocytes, of retinol and ascorbic acid in plasma, of glutathione and the activities of glutathione peroxidase (GSH-Px), superoxide dismutase (SOD) and, catalase (CAT) in erythrocytes. Lipid peroxidation endproducts were measured as malondialdehyde (MDA) in plasma. In patients on hemodialysis multiple alterations of the antioxidative system were present and the concentrations of selenium in plasma, of glutathione and the activity of GSH-Px in erythrocytes were profoundly decreased (p < 0.001). Selenium supplementation improved the selenium status of the patients, as indicated by an increase in selenium concentrations in plasma and erythrocytes and erythrocyte GSH-Px activity. Improvement in antioxidative capacity was further documented by an increase in alpha-tocopherol in erythrocytes. Plasma MDA showed a transient decrease after 6 weeks and increased activities of SOD and CAT were dampened. No effect was seen on plasma concentrations of ascorbic acid, a-tocopherol and retinol. We conclude that patients on chronic hemodialysis therapy manifest a profound depression in antioxidative potential and a selenium deficiency. Selenium supplementation improves the oxygen radical scavenger system and increases selenium concentrations in plasma and erythrocytes and the activity of selenium dependent glutathione peroxidase. Thus, selenium should also be considered for micronutrient supplementation in patients on chronic hemodialysis therapy.

Intradialytic parenteral nutrition in malnourished patients on chronic haemodialysis therapy.

BACKGROUND: Malnutrition is frequently encountered in patients on regular haemodialysis therapy and presents an important determinant of morbidity and mortality. Usual therapeutic approaches to alleviate malnutrition have been unsuccessful. The objective of this study was to assess the impact of intradialytic parenteral nutrition (IDPN) with amino acids (in combination with a glucose-containing dialysate) on nutritional parameters and immunocompetence in patients on regular haemodialysis treatment. METHODS: Effects of IDPN were evaluated in 16 malnourished patients. After a run-in period of 4 weeks (to define stable baseline conditions) 0.8 g amino acids/kg bodyweight using a novel amino-acid solution (adapted to metabolic alteration of uraemia and including the dipeptide glycyl-tyrosine as tyrosine source) was infused thrice weekly during each haemodialysis session for 16 weeks. RESULTS: Intradialytic amino-acid infusion was well tolerated and the dipeptide was rapidly utilized with only traces being detectable in plasma after dialysis. Visceral protein synthesis was improved, serum albumin, prealbumin, and cholinesterase increased during IDPN (P < 0.05). As indicators of augmented immunocompetence skin test reactivity against multiple antigens was improved (P < 0.02) and total lymphocyte count was raised (P < 0.05). Plasma amino acid pattern did not deteriorate but failed to normalize during IDPN and phenylalanine/tyrosine ratio remained stable. Anthropometric measurements and eating behaviour as assessed by dietary records were not altered during IDPN. CONCLUSIONS: Even using a simple and limited intradialytic nutritional support with amino acids can improve visceral protein status and stimulate immunocompetence in malnourished patients on regular haemodialysis therapy.

Lactic acidosis in thiamine deficiency.

Two chronically ill patients with limited nutritional intake during several weeks developed prolonged lactic acidosis. As no other causes of hyperlactaemia could be identified, thiamine deficiency was suspected. Supplementation of 600 mg thiamine resulted in a rapid normalisation of serum lactate levels (in patient 1 from 10.9-2.4 mmol/l; in patient 2 from 11.8-2.0 mmol/l) and acid base status (patient 1: pH from 7.11-7.30, bicarbonate from 8.6-21.2 mmol/l; patient 2: pH from 7.24-7.46, bicarbonate from 16-28 mmol/l; before and after treatment, respectively). Thiamine deficiency was confirmed by the degree of stimulation of erythrocyte transketolase activation by adding thiamine pyrophosphate, evaluated before and after thiamine replacement therapy. Stimulation decreased in patient 1 from 170% to 17% and in patient 2 from 20% to 0%, respectively. In addition to the metabolic derangement right ventricular heart failure was confirmed by echocardiography in both patients and again this was rapidly reversible by thiamine supplementation. We conclude that in malnourished patients unexplained prolonged lactic acidosis may result from thiamine deficiency, which is rapidly reversible by thiamine replacement therapy.

[Administration of a new fat emulsion in intensive care]. / Intensivmedizinischer Einsatz einer neuen Fettemulsion.

A new lipid emulsion for parenteral nutrition, Elolipid, was evaluated for in vitro stability as a component of an all-in-one nutrition solution and, in an open prospective investigation, for clinical tolerance and utilisation in intensive care patients with a broad spectrum of underlying diseases and organ dysfunctions. In vitro stability was determined by photon correlation spectroscopy (mean particle diameter) and Coulter Counter cell sizing (particle size distribution) after 0, 24, 48, 96 h of storage at temperatures of 4 degrees C and 25 degrees C. Mean particle diameter of 330 nm was not altered at any storage time or temperature. The portion of particles with an diameter of greater than 1,000 nm increased mildly during storage of 96 h at room temperature. 31 critically ill patients (mean age 55 +/- 3 years) entered the clinical study: 23 subjects were on artificial ventilation, 15 acquired septicemia, 9 renal insufficiency, and 7 acute or chronic hepatic failure. Fat was given as a component of an all-in-one solution at a rate of 1 g/kg b.w./day for a mean duration of 10 +/- 2 days. Plasma triglycerice concentrations rose mildly between days 3 and 5 only, but in none of the patients the infusion had to be stopped. Lipid-related disturbances of glucose or electrolyte metabolism, hepatic function, cholestasis, induction of disseminated coagulation, impairment of pulmonary gas exchange or renal function were not seen. 7 of 31 patients (22%) died. Side effects of complications attributable to the fat infusion could not be identified. It is concluded that the new lipid emulsion Elolipid is stable as a component of an all-in-one parenteral nutrition solution, is free of side effects and is well-tolerated and utilized even in critically ill patients with multiple organ dysfunctions.

Phenylalanine and tyrosine metabolism in renal failure: dipeptides as tyrosine source.

Several lines of evidence suggest that tyrosine formation is impaired in renal failure. The concentration of tyrosine is decreased and the phenylalanine/tyrosine ratio is increased in plasma and in skeletal muscle cells. After an oral or intravenous load, the rise of plasma phenylalanine is augmented, the clearance is decreased, oxidation is diminished and the corresponding rise of plasma tyrosine level is blunted. Tyrosine elimination and oxidation are not altered in uremia. The defect in tyrosine formation may be especially important in uremic patients on a low protein diet supplemented with tyrosine-free essential amino acid preparations and in subjects on artificial nutritional support. Thus, tyrosine should be regarded as a conditionally essential amino acid in renal failure and should be supplied exogenously, at least in these patient groups. Oral tyrosine supplementation was shown to replete plasma and intracellular pools and improve nitrogen balance in chronic renal failure patients on a low protein diet. However, because of poor solubility in aqueous solutions, tyrosine cannot be included in the free form in amino acid solutions for parenteral nutrition. To circumvent stability or solubility problems, tyrosine containing dipeptides and/or N-acetyl-tyrosine may serve as tyrosine sources for parenteral supply. Renal failure does not affect alanyl-tyrosine hydrolysis, and there is an immediate increase of plasma tyrosine concentration after peptide infusion. Elimination and hydrolysis of glycine-tyrosine is retarded in renal failure, but the clearance exceeds clinically relevant infusion rates. After infusion of N-acetyl-tyrosine, no increase in plasma tyrosine is seen, and the half-life N-acetyl-tyrosine is grossly prolonged in uremia.(ABSTRACT TRUNCATED AT 250 WORDS)

Protein-restricted diets and progression of renal failure.

Interest in dietary therapy of chronic uremia has reawakened because such therapy may slow or halt progression of renal insufficiency. The efficacies of three regimens: 0.6 g protein/kg/day; 0.3 g protein/kg/day plus essential amino acids, and 0.3 g protein/kg/day plus keto acid regimens, have been tested. Each can maintain nitrogen balance if properly administered but if dietary protein and/or the supplement are inadequate, muscle wasting will occur. Data showing that each can slow the rise in serum creatinine are presented. The problems with using serum creatinine, potential mechanisms for the effect on progression and methods for monitoring compliance are discussed.

[Partial parenteral nutrition in severe virus hepatitis]. / Partielle parenterale Ernährung bei schwerer Virushepatitis.

Patients with severe virus hepatitis and a prothrombin concentration below 25% have a bad prognosis. This is due to direct consequences of hepatic failure and to the rather frequent complications of this disease. The clinical course of such patients is essentially dependent upon the degree of liver regeneration, which again is dependent upon the mass of hepatocytes which are able to regenerate and upon the so called hepatotrophic factors. Patients with severe hepatitis suffer during the first weeks rather frequently from nausea and loss of appetite and for that reason their nutrition is insufficient. In the study recorded here 9 cases were investigated (7 patients with hepatitis B, 2 patients with hepatitis non A non B). The question was asked, if partial parenteral nutrition in addition to a liver diet not containing meat would improve liver function. It could be shown that the prothrombin concentration, which could not be improved by vitamine K1 supplements, was increased during a 7 day parenteral nutrition period from 19,3 +/- 2,9% to 41,5 +/- 8,1% (p less than 0,05), serum albumine and cholinesterase activity improved as well. During the first day of treatment there was a significant fall of ammoniac from 115 +/- 10 mumol to 73 +/- 10 mumol/l (p less than 0,05), at the same time production of urea did not increase. All patients survived. The results show, that parenteral nutrition can improve liver function and decrease the catabolic status of metabolism.