Manual of Clinical Nutrition Management III- 110 Copyright © 2013 Compass Group, Inc.
MANAGEMENT OF ACUTE KIDNEY INJURY AND CHRONIC KIDNEY
DISEASE (Stage V)
Acute Kidney Injury
An international network of kidney and critical care specialists, the Acute Kidney Injury Network, developed
consensus recommendations for the terminology, diagnostic criteria, and staging of acute kidney injury (AKI).
AKI replaces the term acute renal failure, as the condition does not always result in renal failure (1). The
diagnostic criterion for AKI is an abrupt (within 48 hours) reduction in kidney function defined as an absolute
increase in the serum creatinine level of at least 0.3 mg/dL, a 50% increase in the serum creatinine level, or a
documented urine output of less than 0.5 mL/kg per hour for more than 6 hours (1). (Refer to Table III- 29 )
Table III- 29 : Classification/Staging System for AKI (1)
Stage Creatinine Clearance Urine Output
1 Serum creatinine increase of at least 0.3 mg/dL, or a
150% to 200% increase
<0.5 mL/kg per hour for more
than 6 hours
2 Increase in serum creatinine level to greater than 200%
to 300% of baseline<0.5 mL/kg per hour for more
than 12 hours
3 Increase in serum creatinine level to greater than 300%
of baseline, or serum creatinine level of 4.0 mg/dL
with an acute increase of at least 0.5 mg/dL<0.3 mL/kg per hour for 24
hours or anuria for 12 hrCauses of AKI include:
systemic shock due to a sudden loss of blood supply to the kidneys from trauma, surgical
complications, or sepsis
exposure to a nephrotoxic chemical or drug (eg, radiologic dyes, cleaning solvents, pesticides, and
gentamicin)
streptococcal infection
AKI is often complicated by sepsis, trauma, and multiple organ failure (2). Acute kidney injury (AKI) occurs
in approximately 20% of hospitalized patients and is associated with a 40% to 80% mortality rate (2-4).
Continuous renal replacement therapy (CRRT) is a type of dialysis used for hemodynamically unstable
patients who have AKI, as it is better tolerated than conventional intermittent hemodialysis (2). CRRT
removes fluids and solutes slowly, corrects electrolyte and metabolic abnormalities, and maintains fluid
balance until renal function returns or until the patient can tolerate hemodialysis (3). The primary types of
CRRT include continuous hemofiltration, continuous hemodialysis, continuous hemodiafiltration, and slow
continuous ultrafiltration. Peritoneal dialysis is another option, but it is often contraindicated in critically ill
patients (2).
Nutrition Assessment and Nutrition Intervention in AKI
AKI causes nutritional imbalances including acidosis, hyperkalemia, hyperphosphatemia, fluid disturbances,
impaired glucose utilization, protein catabolism, accumulation of metabolic waste, and a rapid decrease in
urine output (4). Patients who have AKI should receive a comprehensive nutrition assessment to identify
nutrition diagnoses and close monitoring to ensure that nutrition care outcomes and goals of therapy are
achieved. The nutrition interventions should be based on the individualized patient assessment and
identified nutrition diagnosis. Nutrition interventions should complement medical management strategies
such as CRRT to optimize the patient’s treatment response. Patients who have AKI are hypermetabolic and
hypercatabolic as a result of the neurohumoral response associated with acute injury (3-6). The primary goals
of medical nutrition therapy are to provide adequate protein, energy, and nutrients and to minimize
malnutrition (2,6). The Academy of Nutrition and Dietetics, formerly American Dietetic Association, published
Guidelines for Nutrition Care of Renal Patients in 2002; however, this publication has not been updated to
reflect the changes in medical management strategies (5). Specific nutrition intervention strategies for acute
care management of AKI are found in the Morrison Nutrition Practice Guideline – Acute Kidney Injury (AKI)
(7). The following summary includes the most recent management strategies and guidelines for medical
nutrition therapy in patients who have AKI (2,5,6,8).
Energy: Individualize based on level of care (eg, critically ill) or indirect calorimetry. Use 25 to 35 kcal/kg of
actual body weight as an estimation of energy requirements. Energy expenditure and requirements will