A Comparison of Renal Phosphorus Regulation in Thermally Injured and Multiple Trauma Patients Receiving Specialized Nutrition Support

Abstract

To compare phosphorus intake and renal phosphorus regulation between thermally injured patients and multiple trauma patients, 40 consecutive critically ill patients, 20 with thermal injury and 20 with multiple trauma, who required enteral tube feeding were evaluated. Phosphorus intakes were recorded for 14 days from the initiation of tube feeding which was started 1 to 3 days postinjury. Serum for determination of phosphorus concentrations was collected at days 1, 3, 7, and 14 of the study period. A 24-hour urine collection was obtained during the first and second weeks of nutrition support for urinary phosphorus excretion, fractional excretion of phosphorus, renal threshold phosphate concentration, and phosphorus clearance. Average total daily phosphorus intake during the 14-day study for thermally injured patients and multiple trauma patients was 0.99 ± 0.26 mmol/kg/d vs 0.58 ± 0.21 mmol/kg/d, respectively, p < .001. Serum phosphorus concentration on the third day of observation was significantly lower in the thermally injured group than those with multiple trauma (1.9 ± 0.8 mg/dL vs 3.0 ± 0.8 mg/dL, p ≤ .01). A trend toward hypophosphatemia in the thermally injured group persisted by the seventh day of feeding (2.7 ± 1.2 mg/dL vs 3.3 ± 0.6 mg/dL, p ≤ .04). Differences in urinary phosphorus excretion was not statistically significant between the thermally injured and multiple trauma groups (271 ± 213 mg/d vs 171 ± 181 mg/d for week 1, and 320 ± 289 mg/d vs 258 ± 184 mg/d for week 2, respectively). Urinary phosphorus clearance, fractional excretion of phosphorus, or renal threshold phosphate concentrations were also not significantly different between thermally injured and multiple trauma patients. During nutrition support, serum phosphorus concentrations are lower in thermally injured patients compared with multiple trauma patients despite receiving a significantly greater intake of phosphorus. Renal phosphorus regulation does not significantly contribute to the profound hypophosphatemia observed in thermally injured patients when compared with multiple trauma patients during nutrition support. (Journal of Parenteral and Enteral Nutrition 25:152-159, 2001)

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References

Halevy J. , Bulvik S. : Severe hypophosphatemia in hospitalized patients. Arch Intern Med 148:153-155, 1988

Marik PE , Bedigian MK : Refeeding hypophosphatemia in critically ill patients in an intensive care unit. A prospective study. Arch Surg 131:1043-1047, 1996

Sacks GS , Walker J. , Dickerson RN , et al: Observations of hypophosphatemia and its management in nutrition support. Nutr Clin Pract 9:105-108, 1994

Clark CL , Sacks GS , Dickerson RN , et al: Treatment of hypophosphatemia in patients receiving specialized nutrition support using a graduated doing scheme: Results from a prospective clinical trial. Crit Care Med 23:1504-1511, 1995

Weinsier RL , Krumdieck CL : Death resulting from overzealous total parenteral nutrition (TPN): The refeeding syndrome revisited. Am J Clin Nutr 34:393-399, 1980

Vannatta JB , Andress DL , Whang R. , et al: High-dose intravenous phosphorus therapy for severe complicated hypophosphatemia. South Med J 76:1424-1426, 1983

Zazzo JF , Troche G. , Ruel P. , et al: High incidence of hypophosphatemia in surgical intensive care patients: Efficacy of phosphorus therapy on myocardial function. Intensive Care Med 21:826-831, 1995

Nordstrom H. , Lennquist S. , Lindell B. , et al: Hypophosphataemia in severe burns . Acta Chir Scand 143:395-399, 1977

Lennquist S. , Lindell B. , Nordstrom H. , et al: Hypophosphatemia in severe burns. A prospective study. Acta Chir Scand 145:1-6, 1979

10.

Loven L. , Nordstrom H. , Lennquist S. : Changes in calcium and phosphate and their regulating hormones in patients with severe burn injuries. Scand J Plast Reconstr Surg 18:49-53, 1984

11.

Loven L. , Larsson L. , Nordstrom H. , et al: Serum phosphate and 2,3-diphosphoglycerate in severely burned patients after phosphate supplementation. J Trauma 26:348-352, 1986

12.

Loven L. , Larsson J. , Lennquist S. , et al: Hypophosphataemia and muscle phosphate metabolism in severely injured patients. Acta Chir Scand 149:743-749, 1983

13.

Finsterer U. , Betz J. , Braun S. , et al: Metabolism of phosphate and calcium after severe accidental trauma. Scand J Clin Lab Invest 43(Suppl 165):117, 1983

14.

Daily WH , Tonnesen AS , Allen SJ : Hypophosphatemia-incidence, etiology, and prevention in the trauma patient . Crit Care Med 18:1210-1214, 1990

15.

Berger MM , Rothen C. , Cavadini C. , et al: Exudative mineral losses after serious burns: A clue to the alterations of magnesium and phosphate metabolism. Am J Clin Nutr 65:1473-1481, 1997

16.

Hayek ME , Eisenberg PG : Severe hypophosphatemia following the institution of enteral feedings . Arch Surg 124:1325-1328, 1989

17.

Mostellar ME , Tuttle EP : Effects of alkalosis on plasma concentration and urinary excretion of inorganic phosphate in man. J Clin Invest 43:138-149, 1964

18.

Sherman RA , Hwang ER , Walker JA , et al: Reduction in serum phosphorus due to sucralfate. Am J Gastroenterol 78:210-211, 1983

19.

Brown GR , Greenwood JK : Drug- and nutrition-induced hypophosphatemia: Mechanisms and relevance in the critically ill. Ann Pharmacother 28:626-632, 1994

20.

Puschett JB , Goldberg M. : The acute effects of furosemide on acid and electrolyte excretion in man. J Lab Clin Med 71:666-677, 1968

21.

Tobiasen J. , Hiebert JM , O'Brien R. , et al: A graded risk index of burn severity . J Burn Care Rehabil 1:31-35, 1980

22.

Champion HR , Sacco WJ , Carnazzo AJ , et al: Trauma score . Crit Care Med 9:672-676, 1981

23.

Baker SP , O'Neill B. , Haddon W. et al: The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187-190. 1974

24.

Knaus WA , Draper EA , Wagner DP , et al: APACHE II: A severity of disease classification system. Crit Care Med 13:818-829, 1985

25.

Walton RJ , Bijvoet OLM : Nomogram for derivation of renal phosphate threshold concentration . Lancet 2:309-310, 1975

26.

Avioli LV : Calcium and phosphorus. IN Modern Nutrition in Health and Disease , Shils ME , Young VR (eds). Lea & Febiger , Philadelphia, 1988 (7th ed), pp 142-158

27.

Kurokawa K. , Levine BS , Lee DBN , Massry SG : Physiology of phosphorus metabolism and pathophysiology of hypophosphatemia and hyperphosphatemia. IN Fluid, Electrolyte, and Acid-Base Disorders, Arieff AI , Defronzo RA (eds). New York: Churchill Livingstone, New York, 1985, pp 625-659

28.

Royall D. , Fairholm L. , Peters WJ , et al: Continuous measurement of energy expenditure in ventilated burn patients: An analysis. Crit Care Med 22:399-406, 1994

29.

Mathews JJ , Aleem RF , Gamelli RL : Cost reduction strategies in burn nutrition services: Adjustments in dietary treatment of patients with hyponatremia and hypophosphatemia. J Burn Care Rehabil 20:77-79, 1990

30.

Loven L. , Anersson E. , Lennquist S. : Muscular high-energy phosphates and red-cell 2,3-DPG in post-traumatic hypophosphataemia : An experimental study in pigs. Acta Chir Scand 149:735-741, 1983

31.

Tomera JF , Lilford K. , Kukulka SP : Changes in diaphragm polyinositol phosphates caused by large body surface area burn. Burns 19:35-42, 1993

32.

Tomera JF , Kukulka SP , Lilford K. : Cross-talk of second messengers during the systemic trauma response following burn injury: How, when, and where. Circ Shock 39:128-138, 1993

33.

Tomera JF , Friend KD , Kukulka SP , et al: Modification of calcium flux of twitch skeletal muscle in mice subjected to 20% body surface area burn. J Burn Care Rehabil 13:546-555, 1992

34.

Tomera JF , Friend KD , Lilford K. , et al: Formation of gastrocnemius 3H-polyinositol phosphates in response to burn trauma. Burns 18:381-386, 1992

35.

Tomera JF , Lilford K. , Kukulka SP : Dysfunctional metabolism induced by the systemic effects of burn trauma: The role of rates of polyinositol and glycerophosphate formation in diaphragm . J Burn Care Rehabil 14:639-652, 1993

36.

Aubier M. , Murciano D. , Lecocguic Y. , et al: Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure. N Engl J Med 313:420-424, 1985

37.

O'Connor LR , Wheeler WS , Bethune JE : Effect of hypophosphatemia on myocardial performance in man. N Engl J Med 297:901-903, 1977

38.

Coyle S. , Masters PW , Barnard D. : TmP/GFR and ionized calcium in the management of severe hypophosphatemia . Ann Clin Biochem 29:567-569, 1992

39.

Yu YM , Tompkins RG , Ryan CM , Young VR : The metabolic basis of the increase in energy expenditure in severely burned patients. JPEN 23:160-168, 1999

40.

Saffle JR , Medina E. , Raymond J. , et al: Use of indirect calorimetry in the nutritional management of burn patients. J Trauma 25:32-39, 1985

41.

Cunningham JJ : Factors contributing to increased energy expenditure in thermal injury: A review of studies employing indirect calorimetry . JPEN 14:649-656, 1990

42.

Dickerson RN , Gervasio JM , Riley ML , et al: Accuracy of predictive formulas to estimate resting energy expenditure of thermally injured patients. JPEN 25:S4. 2001

43.

Barak V. , Schwartz A. , Kalickman I. , et al: Prevalence of hypophosphatemia in sepsis and infection: The role of cytokines. Am J Med 104:40-47, 1998

44.

Elledge ES , Smith AA , McManus WF , et al: Heterotopic bone formation in burn patients. J Trauma 28:684-687, 1988