Manual of Clinical Nutrition

Management of Acute Kidney Injury and Chronic Kidney Disease

Manual of Clinical Nutrition Management III- 114 Copyright © 2013 Compass Group, Inc.

whereas a serum creatinine level of 10 mg/dL suggests a 90% nephron loss or end-stage renal disease. Serial
serum creatinine levels can be used to determine the consistency of dialytic therapy. Eventually, a normal
creatinine level can be established for each dialysis patient based on the patient’s muscle mass and dialysis
prescription. The predialysis or stabilized serum creatinine and the creatinine index reflect the sum of
dietary intake of foods rich in creatine and endogenous creatinine production minus the urinary excretion,
dialytic removal, and endogenous degradation of creatinine. Individuals who have low levels of predialysis or
stabilized serum creatinine (less than 10 mg/dL) should be evaluated for protein-energy malnutrition and
skeletal muscle wasting (12). Sudden increases in serum creatinine levels usually can be traced to changes in
the dialysis regimen, such as skipped treatments, decreased dialysis time, or poor blood flow through an
access. Increased blood urea nitrogen and serum potassium levels accompanied by a sudden increase in the
serum creatinine level and a decrease in carbon dioxide level usually indicate decreased waste product
removal.

Glucose: Normal glucose levels should be maintained in all dialysis patients to prevent the complications of
hypoglycemia and hyperglycemia. Abnormal carbohydrate metabolism resulting in hyperglycemia occurs in
individuals who are approaching end-stage renal disease. Although the cause of this abnormal carbohydrate
metabolism is not known, the abnormality resolves after several weeks of dialysis therapy or after
transplantation. High blood glucose levels can increase thirst, decrease serum sodium levels, and increase
serum potassium levels. Acidosis, which is indicated by decreased carbon dioxide levels and an increased
anion gap, increases protein catabolism and often accompanies increased blood glucose levels in patients
who have chronic renal failure (17,18).

Glomerular Filtration Rate (Creatinine Clearance) (2,5,19)
Creatinine clearance is the most commonly used measurement of GFR. The normal GFR is 125 mL/min.
Direct urinary clearance measurements are useful in determining the degree of renal dysfunction at lower
levels of clearance (5). The estimated GFR provides a useful approximation value (ie, <25 mL/min) (12).

In principle, there is a reciprocal relationship between serum creatinine and creatinine clearance. To
estimate creatinine clearance, factors such as body weight, age, and sex must be considered since
creatinine increases with body weight and musculature and decreases with age. The relationship between
serum creatinine and creatinine clearance is not valid for patients who receive dialysis, patients who have
acute renal failure, or patients in a catabolic state in which muscle mass is being destroyed.

The most widely used method for estimating GFR is the Cockcroft-Gault equation (2,19):

GFR (Men) =

Weight (kg)  (140 – Age)

72  Serum creatinine (mg/dL)

GFR (Women) =

Weight (kg)  (140 – Age) (^) × 0.85
72  Serum creatinine (mg/dL)
For comprehensive guidance on the nutrition assessment, nutrition diagnosis, and nutrition intervention
and the monitoring parameters in the acute care setting refer to Morrison Nutrition Practice Guideline –
Chronic Kidney Disease (CKD) (20).
References

1. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A, for Acute Kidney Injury Network. Acute Kidney Injury
   Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31. Available at:
   http://ccforum.com/content/11/2/R31. Accessed January 12, 2009.


2. Renal failure and Chronic Kidney Disease. In: Nutrition Care Manual. Academy of Nutrition and Dieteics; Updated annually.
   Available at: http://www.nutritioncaremanual.org. Accessed January 31, 2013.


3. Paton M. Continuous renal replacement therapy: slow but steady. Nursing. 2003;33:48-50.


4. Marin A, Hardy G. Practical implications of nutritional support during continuous renal replacement therapy. Curr Opin Clin Nutr
   Metab Care. 2001;4:219-225.


5. Wiggins KL, ed. Guidelines for Nutrition Care of Renal Patients. Chicago, Ill: American Dietetic Association; 2002.


6. Kopple JD, Massry SG, eds. Nutrition Management of Renal Disease. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004.


7. Morrison Nutrition Practice Guideline – Acute Kidney Injury. In: Inman-Felton A, Smith KG. Morrison Nutrition Practice Guidelines.
   Atlanta, Ga: Morrison Management Specialists Inc; 2012. Available at:
   http://www.morrisontoday.com/Documents/Nutrition/MHFS Nutrition


8. Byham-Gray L, Wiesen K, eds. A Clinical Guide to Nutrition Care in Kidney Diseases. Chicago, Ill: American Dietetic Association;
   2004.


9. Wooley JA, Btaiche IF, Good KL. Metabolic and nutritional aspects of acute renal failure in critically ill patients requiring
   continuous renal replacement therapy. Nutr Clin Pract. 2005;20:176- 191.


10. Klein CJ, Moser-Veillon PB, Schweitzer A, Douglass LW, Reynolds HN, Patterson KY, Veillon C. Magnesium, calcium, zinc, and
    nitrogen loss in trauma patients during continuous renal replacement therapy. J Parenter Enteral Nutr. 2002;26:77-92.