Considerations in the nutritional management of patients with acute renal failure

Abstract

Despite improvements in medical and dialytic therapies, mortality rates for patients with complicated acute renal failure (ARF) remains tragically high-above 50%. Mortality rates also remain persistently high in patients with ARF and preexisting or hospital-acquired malnutrition. ARF causes significant changes in substrate utilization largely because of the metabolic consequences of acute uremia compounded by underlying stress from acute illness. Alterations in protein or amino acid, carbohydrate, and lipid metabolism as well as fluid, electrolyte, and acid-base balance need to be considered when providing nutritional therapy in patients with ARF. Also, the degree of renal impairment, which influences the need for renal replacement therapy (RRT), impacts nutritional requirements. As medical management is becoming highly aggressive in treating ARF with RRT, the ability to provide adequate nutrition is enhanced; however, no consensus on optimal caloric and macro-/micronutrient requirements is available. More current research is required to clarify nutritional needs of this patient population. Nevertheless, individualizing nutrition care and integrating nutritional therapies within a team setting is essential in providing optimal patient care in the presence of ARF.

Developing and Validating a Renal Nutrition Screening Tool to Effectively Identify Undernutrition Risk Among Renal Inpatients

“…Step 1 consists of 5 compulsory questions (1)(2)(3)(4)(5) including determinants, which are the most predictive of undernutrition (e.g., recent involuntary weight loss and change in eating behavior), and renal specific nutrition indicators (e.g., serum phosphate and potassium and episodes of peritonitis) that may impact on their nutritional status. Although the MST has a threshold score of 2 for the determination of undernutrition risk, the threshold for the R-NSTwas raised by 1 point to 3 points due to the characteristics of renal patients.…”

“…[1][2][3] Decreased nutrient intake caused by loss of appetite is considered as a major contributing factor. [1][2][3][4] The prevalence of malnourished renal patients in the acute setting was found to be 52.6% in an Australian study, compared with a prevalence of 32% in patients admitted to acute care wards in Australia and New Zealand regardless of medical specialty. 5 Several nutrition screening tools have been developed worldwide to identify individuals at risk of undernutrition.…”

Approach to the Metabolic Implications of Peritoneal Dialysis in Acute Kidney Injury

“…This inadequacy in amino acid transport has been associated with insulin resistance and uremia. Other factors that contribute to protein catabolism include endocrine abnormalities, metabolic acidosis, systemic inflammatory response syndrome, protease release, and loss and inadequate supply of nutrition substrates (53,54). Thus, AKI alone cannot be held responsible for such alterations: underlying diseases and renal replacement therapy itself are also involved (2).…”

Nutrition support therapy in acute kidney injury: Distinguishing dogma from good practice

“…Once IHD is initiated in AKI, the recommended protein intake becomes the same as that for patients with CKD on IHD at a minimum of 1.2 g/kg and up to 1.5 g/kg [22][23][24][25]. The technology !…”

“…Folate and pyridoxine are exceptions, and are replaced above the DRI at 1 mg and 10 mg, respectively. Vitamin C should be limited to 100 mg with IHD, or less than 200 mg with CRRT, because it is converted to oxalate, a recognized toxin in renal failure [24,25,33]. The removal of oxalate by RRT is not adequate [34].…”