Impact of Early Parenteral Nutrition on Metabolism and Kidney Injury

Abstract

A poor nutritional state and a caloric deficit associate with increased morbidity and mortality, but a recent multicenter, randomized controlled trial found that early parenteral nutrition to supplement insufficient enteral nutrition increases morbidity in the intensive care unit, including prolonging the duration of renal replacement therapy, compared with withholding parenteral nutrition for 1 week. Whether early versus late parenteral nutrition impacts the incidence and recovery of AKI is unknown. Here, we report a prespecified analysis from this trial, the Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients (EPaNIC) study. The timing of parenteral nutrition did not affect the incidence of AKI, but early initiation seemed to slow renal recovery in patients with stage 2 AKI. Early parenteral nutrition did not affect the time course of creatinine and creatinine clearance but did increase plasma urea, urea/creatinine ratio, and nitrogen excretion beginning on the first day of amino acid infusion. In the group that received late parenteral nutrition, infusing amino acids after the first week also increased ureagenesis. During the first 2 weeks, ureagenesis resulted in net waste of 63% of the extra nitrogen intake from early parenteral nutrition. In conclusion, early parenteral nutrition does not seem to impact AKI incidence, although it may delay recovery in patients with stage 2 AKI. Substantial catabolism of the extra amino acids, which leads to higher levels of plasma urea, might explain the prolonged duration of renal replacement therapy observed with early parenteral nutrition.

Feeding the kidneys in AKI: no appetite for a change in practice

“…Length of stay, duration of mechanical ventilation, rate of infection, pressure ulcers, quality of life, and physical function in 90-day survivors did not show any difference between the two groups. The only measured effect was increased ureagenesis, confirming results from the EPaNIC trial [19].…”

Recovery from AKI in the critically ill: potential confounders in the evaluation

“…The nutritional strategy itself had no significant impact on recovery from AKI [35]. From the original study population, 56 patients were excluded for ESRD, 15 for kidney transplantation, and 9 for missing data required for this study.…”

Non-Thyroidal Illness in the ICU: A Syndrome with Different Faces

“…Recently, it was shown in a large RCT-the Early versus Late Parenteral Nutrition in Critically Ill Adults (EPaNIC) trial-that tolerating the pronounced macronutrient deficit that occurs in ICU patients during the first week, when only relying on enteral feeding, improves outcomes as compared with preventing that macronutrient deficit with early initiation of parenteral nutrition. Indeed, not feeding patients early reduced the incidence of nosocomial infections, reduced the occurrence of liver function abnormalities, prevented rather increased muscle weakness, and accelerated recovery (34)(35)(36)(37). As tolerating a fasting response in ICU patients thus appears to be beneficial, perhaps part of these adaptions are mediated via acute NTI.…”