Metabolic Support of the Patient on Continuous Renal Replacement Therapy

Abstract

Continuous renal replacement therapy (CRRT) is the modality of choice in critically ill patients with hemodynamic instability requiring renal replacement therapy. The goal of this review is to discuss an overview of CRRT types, components, and important considerations for nutrition support provision. Evidence basis for guidelines and our recommendations are reviewed. Nutrition support-related implications include the possibility of calorie gain with citrate-based anticoagulation, calorie loss with glucosefree replacement fluids and dialysate, and significant amino acid losses in effluent. We challenge nutrition support clinicians to develop a keen understanding of the specific CRRT modalities that are employed in their intensive care units and to be able to determine how the CRRT prescription may impact a patient's nutrition support prescription. (Nutr Clin Pract. 2018;33:754-766)

ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

“…In Western countries and the US, PD is not routinely utilized for critically ill adult patients in the ICU. Thus, in this clinical setting, extracorporeal KRT represents the gold standard, and in the case of acutely/critically ill, AKI/AKD patients are usually classified based on its duration [21]. Each of the principal modalities of KRT used in the ICU (intermittent, prolonged intermittent, and continuous) carries advantages and disadvantages in this specific patient setting.…”

“…In the ICU, the more prolonged modalities are preferred, such as CKRT or Prolonged Intermittent Kidney Replacement (PIKRT). This latter term encompasses the group of the so-called "hybrid" therapies since it combines the characteristics of intermittent and continuous KRT concerning the prolonged duration and increased frequency of treatment, along with the main advantages of both [21].…”

Parenteral Provision of Micronutrients to Adult Patients: An Expert Consensus Paper

“…The decision to monitor micronutrient status biochemically may be considered in clinical situations that represent follow up after micronutrient replacement therapies are provided, routine surveillance of patients receiving long‐term HPN patients, in cases of organ failure (liver or kidney), danger of toxicity necessitates monitoring . Renal function should be considered when vitamins and TEs are supplemented, in case of prolonged (>2 weeks) CRRT, a monthly monitoring of hydrosoluble micronutrients may be considered …”

“…4,24 Renal function should be considered when vitamins and TEs are supplemented, 59 r in case of prolonged (>2 weeks) CRRT, 21,23 a monthly monitoring of hydrosoluble micronutrients may be considered. 93,94 If micronutrients are included with macronutrient provision (i.e., each day PN is provided) and have been prescribed in consideration of the individual clinical requirements, the risk of developing micronutrient complications is low, and isolated micronutrient monitoring may be of limited value in otherwise stable patients in the acute setting. 19,20 Therefore, careful consideration of the clinical significance of micronutrient testing needs to be considered in the acutely unwell patient, and routine measurement of serum vitamin levels is not usually recommended in critical care.…”

Body Composition Analysis as a Predictor of Prognosis for Patients With Acute Kidney Injury Requiring Kidney Replacement Therapy

“…4 KRT patients can experience nutrient loss, altered body temperature, and increased hemodynamic disturbances due to the modification of volume status, requiring complex management and difficulty with accurate assessment of nutritional needs. 5 As a nutritional status marker, decreased muscle mass is one of the main diagnostic criteria for protein energy wasting which occurs in up to 42% of the population upon ICU admission. 6,7 A popular term sarcopenia is defined as a progressive loss of skeletal muscle mass and poor quality of life in older age.…”