Newsletter

[ Vol. 12 No. 2 ] (May - August 2011 )
Artificial nutrition in AKI

Enrico Fiaccadori
Department of Internal Medicine & Nephrology, Parma Medical School Hospital Parma, Italy

Patients who develop AKI, especially in the intensive care unit (ICU) are at risk for protein-energy malnutrition, which is a major negative prognostic factor in this clinical condition. Despite the lack of evidence from controlled trials for it’s effect on outcome, nutritional support by the enteral (preferentially) or parenteral route appears clinically indicated in most cases of ICU-acquired AKI, to prevent deterioration in nutritional state with all its known complications. Extrapolating from data in other conditions, it seems intrinsically unlikely that starvation of a catabolic patient is more beneficial than appropriate nutritional support by an expert team with the skills to avoid the potential complications of the EN and PN methodology.

The primary goals of nutritional support in AKI are the same as those for other critically ill patients with normal renal function, i.e., to ensure the delivery of adequate nutrition, to prevent protein-energy wasting with its attendant metabolic complications, to promote wound healing and tissue repair, to support immune system function, to accelerate recovery, and to reduce mortality.

Patients with AKI on RRT should receive a basic intake of at least 1.5 g/Kg/day of protein with an additional 0.2 g/Kg/day to compensate for amino acid / protein loss during RRT. Energy intake should consist of no more than 30 Kcal non-protein calories or 1.3 x BEE (Basal Energy Expenditure) calculated by the Harris-Benedict equation, with about 30 - 35% from lipid, as lipid emulsions. For nutritional support, the enteral route is preferred, although it often needs to be supplemented by the parenteral route in order to meet nutritional requirements. In this session, illustrative cases of critically ill patients with AKI and peculiar nutritional problems will be presented; nutritional support strategies will be also provided by a case-based practical approach.

SUGGESTED READING

1. Druml W. Nutritional management of acute renal failure. J Ren Nutr 2005;15:63-70.
2. Cano N, Fiaccadori E, Tesinski P et al. ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure. Clin Nutr 2006;25:295-310.
3. 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. Kidney Int 2008;73:391-398.
4. Fiaccadori E, Lombardi M, Leonardi S, et al., Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study. J Am Soc Nephrol 1999;10:581-593.
5. Casaer MP, Mesotten D, Schetz MRC. Bench-to bedside review: Metabolism and nutrition. Crit Care 2008;12:222-232.
6. Basi S, Pupim LB, Simmons EM, et al. Insulin resistance in critically ill patients with acute renal failure. Am J Physiol Renal Physiol 2005;289:F259-264.
7. Btaiche IF, Mohammad RA, Alaniz C, Mueller BA. Amino Acid requirements in critically ill patients with acute kidney injury treated with continuous renal replacement therapy. Pharmacotherapy. 2008;28:600-613.
8. Macias WL, Alaka KJ, Murphy MH, Miller ME, Clark WR, Mueller BA. Impact of the nutritional regimen on protein catabolism and nitrogen balance in patients with acute renal failure. JPEN J Parenter Enteral Nutr 1996;20:56-62.
9. Fiaccadori E, Maggiore U, Rotelli C, et al. Effects of different energy intakes on nitrogen balance in patients with acute renal failure: a pilot study. Nephrol Dial Transplant 2005;20:1976-1980.
10. Fiaccadori E, Maggiore U, Giacosa R, et al. Enteral nutrition in patients with acute renal failure. Kidney Int 2004;65:999-1008.

From  
PENSA 2009
“Energizing Nutrition Support Practice for Life”
June 5-7 2009, Shangri-La Hotel, Kuala Lumpur, Malaysia 
Page: 50