Nutritional management of children with acute kidney injury—clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Abstract

The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.

Nutrition for critically ill children and neonates requiring dialysis: Application of clinical practice recommendations

“…The most recent nutrition management guidelines for children with AKI were published by the Pediatric Renal Nutrition Taskforce (PRNT); as such, we will be referring to these throughout this review. 15 PRNT is an international group of pediatric dietitians and nephrologists who have come together to develop evidence-based (where possible) clinical practice recommendations through the Delphi process. The PRNT provided a full evidence review of each aspect of nutrition care for children with AKI, including key challenges in nutrition assessment and estimation of nutrition needs.…”

“…The PRNT guidelines provide comprehensive statements on nutrition assessment focusing on the hospitalized child with AKI and thus acknowledge the necessary use of nutrition screening workflows by which dietitians are triggered for nutrition assessment based on screening criteria. 15 Clinical dietitians primarily rely on risk screening to define which patients are assessed. Notably, the authors acknowledge that there are no specific nutrition risk screening tools that assign risk level to patients with AKI.…”

“…Adequate protein provision in the setting of other dialytic modalities is also discussed in the PRNT AKI nutrition guidelines, in which the goal remains to prevent negative nitrogen balances. 15 Protein recommendations are extrapolated from chronic dialysis settings. However, in the ICU, it is possible that exact protein losses may vary substantially from chronic settings, given the differences in how dialysis may be prescribed.…”

“…Lastly, the PRNT clinical practice recommendations specifically provide guidance on protein restrictions. 15 In total, pediatric nephrology rarely recommends protein restrictions. However, protein restrictions are occasionally used in special patient situations.…”

“…The PRNT AKI nutrition guidelines discuss the importance of adequate protein provision to limit negative nitrogen balances. 15 No specific statement recommendations have been made regarding the optimal protein provision. They acknowledge that critically ill infants and children have a baseline higher protein need and that when dialytic modalities are added, there are likely greater protein losses.…”