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Nutritional Management
of Acute Kidney Injury
Nicole Castro
Queens College Dietetic Internship
September-November 2018
Pathology of Primary Disease
Stage 2: sCr ≥2.0–2.9 times baseline Urine volume <0.5 mL/kg/h for ≥12
sCr ≥3.0 times from baseline OR hours
• Nausea
• Vomiting
• Anorexia
• Weakness
• Seizures
• Confusion
• Coma
• Myoclonic twitches
Evidence Based Recommendations
Evidence Analysis Library & Nutrition Care Manual
Energy needs: 20-30 kcalories x kg of body weight
Protein Recommendations: 1.2-1.5 grams of protein x body weight
Fluid Recommendations: Dependent on urinary sodium and total fluid output
Urine Output + 500 ml = fluid needs
Journal of Parenteral and Enteral Nutrition (Critically Obese Guidelines)
Energy: 11-14 kcal/kg actual body weight per day (BMI 30-50)
Protein: range from 2.0 g/kg ideal body weight per day (BMI 30-40)
Energy: 22-25 kcal/kg ideal body weight per day (BMI >50)
Protein: 2.5 g/kg ideal body weight (BMI >=40)
Evidence Based Recommendations
Journal of Renal Nutrition
Energy needs: 27 kcal/kg since it does not exceed 1.3 x basal energy expenditure using Harris Benedict
equation
Protein: 1.4-1.8 g/kg if on RRT; minimum of 1.5 g/kg pro for + nitrogen balance and AA replacement lost
during RRT
Fluids: adjust accordingly to intake/output
Social Hx:
Occupation: unemployed
Marital Status: Single
Lives: at home with parents
Alcohol/drug use: No
Assessment: Food/Nutrition Related
History
Diet Order (FH-2.1.1): NPO
Rationale for tube feeding: aspiration precautions; tracheostomy (9/17);
long term nutrition support
Enteral Nutrition Order (FH-2.1.1):
Nepro 1.8 @ 45 mL/hr x 24hrs.; 1080 ml, 1944 kcal, 87 g pro, 785
ml free water
Tolerance of Tube Feeding:
Tolerating well
No signs and symptoms of diarrhea, vomiting, dehydration
Assessment: Food/Nutrition Related
History
Medications (FH-3.1):
IN-PATIENT MEDICATIONS: MECHANISM OF ACTION FOOD-DRUG INTERACTION
Docusate Sodium/Colace Stool softener, Laxative Alters intestinal absorption of
water and electrolytes
Senna Laxative, stimulant Electrolyte imbalance with
excessive use
Famotidine Antiulcer, Anti-GERD, Anti-secretory Limit caffeine/xanthine; may
decrease B12 and Fe
Amlodipine & Metoprolol Antihypertensive Recommended to decrease Na and
Ca; Avoid licorice
Amiodarone Antiarrhythmic Avoid grapefruit and SJW; may
cause constipation
Chlorpromazine & Fluphenazine Antipsychotic Take Mg 2 hrs. separate
Limit caffeine
Prednisone Corticosteroid Avoid alcohol
Caution with grapefruit
Limit caffeine
May increase glucose (DM)
Polymixin & Tobramycin Antibiotics used to treat gram- May cause kidney damage
negative infections
Assessment: Nutrition-Focused Physical
Findings
Generalized Pitting Edema +3 (PD-1.1.6)
Skin Intact (PD-1.1.17)
Morbidly Obese (BMI 48.3)
Malnutrition: No malnutrition noted.
Two out of six criteria must be met.
Only meets 1 criteria (fluid accumulation).
No decreased energy intake, weight loss, loss of body fat, muscle
mass wasting, reduced grip strength
Assessment: Nutrition Focused Physical Findings
Malnutrition Criteria
Assessment: Anthropometric
Measurements
Height (AD-1.1.1): 69 inches
Weight (AD-1.1.2.1): Due to generalized edema/anasarca, no current dry
weight. Measured weight: 148.5 kg; 326.9 lbs. (10/9)
Body Mass Index (AD-1.1.5.1): 48.3 morbidly obese
Weight change: since admission: 21%
Weight Details: Significant weight change/gain of 56.8 lbs. since admission.
9/6) 126.2 kg, 9/11) 129.8 kg, 9/21) 149.1 kg, 9/26) 150.2 kg, 9/30) 140.1 kg,
10/8) 146.1 kg, 10/9) 148.5 kg, 10/11) no new weights obtained
IBW Male (+/- 10%): 160 lbs. (72.7 kg)
Percent Ideal Body Weight: 204%
Biochemical Data, Medical Tests and Procedures
TEST Results 10/9 Interpretation
Goals:
EN/PN infusion to meet 75% or more of estimated nutritional needs
To obtain and maintain electrolytes WNL
Improve nutrition related labs (renal profile (BD-1.2) and anemia
profile (BD-1.10)) within 3 months.
To reduce edema +3 edema within 90 days
To tolerate nutrition Rx
Obtain glycemic control 140-180 mg/dl
Monitoring & Evaluation
Recommendations:
Post PEG, initiate Nepro @ 45 ml/hr x 24 hrs. (FH-1.3.1.1.3)
Hydration status and electrolytes replacements by MICU team.
Obtain predialysis weight (AD-1.1.2.1.5) and post dialysis weight
(AD-1.1.2.1.6) and monitor weight changes.
Improve electrolyte and renal profile (BD-1.2) by reaching
electrolytes balance and BUN/Cr WNL within 3 months.
Improve anemia profile (BD-1.10) by increasing Hgb/Hct levels
within 3 months.
Monitor tolerance to nutrition support/formula.
Monitoring & Evaluation
Previous follow-ups:
9/6) Vital 1.2 kcal @ 45 ml/hr. + 300 ml free water q. 4hrs.
9/7) On NPO status for spontaneous breathing trial (SBT);
9/11) TF currently not meeting estimated needs;
9/18) TF restarted, initiated Suplena, due to worsening kidney, @ 45 ml/hr meeting 100% of
calorie/ 67% protein needs;
9/21) TF does not meet protein needs, changing to Nepro 1.8
9/26) TF meeting 100% nutritional needs;
10/1) Current TF provides 30 kcal due to propofol but still meets nutritional needs;
10/8) Current TF is providing 100% of nutritional needs;
10/11) noted with significant weight gain (21% since admission) related to fluids with generalized
edema.
10/15) generalized edema +2 improving
10/24) weight 140.4 kg (reduced 8 kg since 10/11).
Monitoring & Evaluation