Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid-base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.

Heart failure (HF) is a major public health problem in the United States that puts a significant burden on both patients and the healthcare system. The prevalence of malnutrition in HF patients is well-known and correlates with a dramatic decline in quality of life and disease progression, and is associated with high morbidity and mortality rates. The implication of HF on micronutrient status is underrecognized in the quest to offer "best practice" medical, device, and surgical interventions to this population. The micronutrient thiamin is of particular interest in the management of HF for several reasons: (a) HF is a disease of the elderly whose micronutrient status is in need of attention; (b) HF patients tend to have inadequate nutrient intake, which has been associated with thiamin deficiency; (c) thiamin deficiency (wet beriberi) impairs cardiac performance and can mimic the signs and symptoms of HF thereby potentially exacerbating the underlying disease; (d) use of loop diuretics to manage fluid and sodium imbalances associated with HF may cause the hyperexcretion of thiamin, thereby increasing the risk of deficiency; and (e) the prevention of thiamin deficiency should be a routine component in the overall management of this disease.

Nutrient requirements vary substantially between patients with altered metabolic states. A major advantage of indirect calorimetry (IC) over predictive energy expenditure equations is that it allows the clinician to measure a patient's actual energy expenditure and "match" the nutrition support regimen to the individual patient's needs, at a defined time. This promotes adequate support without the negative effects of under-or overfeeding.IC calculates resting energy expenditure (REE) and respiratory quotient (RQ) by measuring whole body oxygen (VO 2 ) and carbon dioxide (VCO 2 ) gas exchange using the abbreviated Weir equation where energy expenditure ϭ (3.94 ϫ VO 2 ) ϩ (1.11 ϫ VCO 2 ). 1-3 Measurement of urinary nitrogen excretion is not essential to ensure accuracy in the determination of REE. 3-7 Even a 100% error in the measurement will only produce an error of approximately 1% to 2% in the true energy expenditure. 1,6 -7 The consumption of oxygen accounts for 80% of REE despite a relatively small body pool of 1.2 L. 7 Carbon dioxide production accounts for 20%, even though the body pool is very large, approximately 16 L. 1-3,7 REE measured by IC has been shown to correlate closely with true REE, which is approximately 10% above basal energy expenditure. 1,8

Background: The Joint Commission has mandated universal screening and assessment of hospitalized patients for malnutrition since 1995. Although various validated and nonvalidated tools are available, implementation of this mandate has not been well characterized. We report results of a survey of hospital-based professionals in the United States describing their perspective on the current range of nutrition screening and assessment practices as well as associated gaps in knowledge. Methods and Materials: Data from a 2012-2013 cross-sectional, web-based survey targeting members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), the Academy of Medical-Surgical Nurses, and the Society of Hospital Medicine were collected with non-hospital-based members excluded. Descriptive statistical analysis was performed. Results: Survey data from 1777 unique email addresses are included in this report. A majority of respondents were dietitians, nearly half were A.S.P.E.N. members, and 69.4% reported caring for a mix of adult and pediatric patients. Most respondents answered affirmatively about nutrition screening being performed in alignment with The Joint Commission mandate, but only 50% were familiar with the 2012 Consensus Statement from the Academy of Nutrition and Dietetics/A.S.P.E.N. on adult malnutrition. In most cases, nurses were primarily responsible for nutrition screening, while dietitians had primary responsibility for assessment. No one specific assessment tool or International Classification of Diseases, Ninth Revision code was identified as being used a majority of the time in assessing or coding a patient for malnutrition. Conclusions: The survey findings affirmed compliance with accreditation standards in completing a nutrition screen within 24 hours of admission, and most hospitals appear to have a process to perform a nutrition assessment once a screen is completed. However, there is considerable heterogeneity in both use of tools and mechanisms for coding capture. Opportunities exist to improve education around nutrition screening and assessment and to identify ideal practices for these processes in hospitalized patients.