Clinical Case Report:

Nutritional Management
of Acute Kidney Injury
Nicole Castro
Queens College Dietetic Internship
September-November 2018
Pathology of Primary Disease

 Acute Kidney Injury

 Before known as acute renal failure
 Abrupt decline in kidney function (24-48 hrs.)
 GFR and tubular function decrease
 Fluid, electrolytes, acid-base imbalance
Kidney Disease Improving Global Outcomes
(KDIGO) Criteria for defining Acute Kidney Injury

AKI is defined as any of the following:

1. Increase in sCr ≥0.3 mg/dL (≥26.5 μmol/L) within 48 hours; or

2. Increase in sCr ≥1.5 times baseline, which is known or presumed to

have occurred within the prior 7 days; or

3. Urine volume <0.5 mL/kg/h for 6 hours.

Classification of Acute Kidney Injury
Classification is determined by
the cause or etiology of the
acute kidney injury. (Where the
injury is occurring)

Prerenal: Reduced blood flow

Before the kidneys

Intrinsic: Within the kidneys

Post-renal: Obstruction to the

urinary tract
 Kidney Disease Improving Global Outcomes
(KDIGO) Criteria for Staging Acute Kidney Injury
AKI is staged for severity according to the following criteria

Stage 1: 1.5–1.9 times baseline OR

Urine volume <0.5 mL/kg/h for 6–12
≥0.3 mg/dL (≥26.5 μmol/L) absolute
hours
increase in sCr

Stage 2: sCr ≥2.0–2.9 times baseline Urine volume <0.5 mL/kg/h for ≥12
sCr ≥3.0 times from baseline OR hours

Stage 3. Increase in sCr to ≥4.0

mg/dL(≥353.6 μmol/L) OR Initiation
Urine volume <0.3 mL/kg/h for ≥24
of renal replacement therapy OR, In
hours OR Anuria for ≥12 hours
patients <18 years, decrease in
eGFR to <35 mL/min per 1.73 m2
Risk Factors for Acute Kidney Injury

 Adults older than 75

 Chronic Kidney Disease
 Cardiac failure
 Liver Disease
 Diabetes Mellitus
 Nephrotoxic medication use
 Hypovolemia
 Sepsis
Signs and Symptoms of AKI

• Nausea
• Vomiting
• Anorexia
• Weakness
• Seizures
• Confusion
• Coma
• Myoclonic twitches
 Evidence Based Recommendations
 Evidence Analysis Library & Nutrition Care Manual
 Energy needs: 20-30 kcalories x kg of body weight
 Protein Recommendations: 1.2-1.5 grams of protein x body weight
 Fluid Recommendations: Dependent on urinary sodium and total fluid output
 Urine Output + 500 ml = fluid needs
 Journal of Parenteral and Enteral Nutrition (Critically Obese Guidelines)
 Energy: 11-14 kcal/kg actual body weight per day (BMI 30-50)
 Protein: range from 2.0 g/kg ideal body weight per day (BMI 30-40)
 Energy: 22-25 kcal/kg ideal body weight per day (BMI >50)
 Protein: 2.5 g/kg ideal body weight (BMI >=40)
 Evidence Based Recommendations
 Journal of Renal Nutrition
 Energy needs: 27 kcal/kg since it does not exceed 1.3 x basal energy expenditure using Harris Benedict
equation
 Protein: 1.4-1.8 g/kg if on RRT; minimum of 1.5 g/kg pro for + nitrogen balance and AA replacement lost
during RRT
 Fluids: adjust accordingly to intake/output

 Nutrition in Clinical Practice Journal-ASPEN

 Energy needs: 25-35 kcal/kg
 Stage I: 20 kcal/kg ; max 25-30 in any stage
 Stage II and III: 27 kcal/kg with mechanical ventilation
 Protein: Non-dialysis 0.8-1.0 g/kg ; 0.6-0.8 g/kg to prevent azotemia
 Stage II and III critically ill: 1.5-2.5 g/kg
 CRRT: 1.8-2.5 g/kg
 Intermittent HD: 1.5-2.0 g/kg
 Fluids: 500-1000 mL + output ; no restriction required on dialysis
Comorbidities
 Acute Respiratory Failure
 Low oxygen levels in the blood
 High levels of carbon dioxide in the blood
 Symptoms: shortness of breath, bluish coloration of skin (cyanosis),
confusion and sleepiness
 Acidity in the blood and brain and heart malfunction that may result
in death.
 Treatment: supplemental oxygen or mechanical ventilation
 Recommendations: 20-25 kcal/kg (prevent overfeeding) 25-30
ambulatory pts. Protein 1.2-1.5 g/kg/day
 Mechanical Ventilation: Penn State 2003b (obese & non-obese);
Penn State 2010 for obese
Comorbidities
 Bipolar Disorder
 Typically begins in adolescence, but also in 20s, 30s
 Alternate episodes of mania and depression
 Unknown causes
 Neurotransmitter changes, psychosocial and hereditary factors
 15 times more incidence of suicide
 Drug induced condition
 Comorbidities
 Drug Induced Acute Kidney Injury
 Acid-base abnormalities
 Electrolyte imbalances and
 Disorders of fluid/water balance
 Increase in serum creatinine
Case Presentation

 42 year (CH-1.1.1) old male (CH-1.1.2)

 Medical history of bipolar disorder
 Admitted 9/3/18 for drug overdose with suicide attempt. Hypotensive,
tachycardic, intubated for airway protection.
 Pneumonia and acute respiratory distress syndrome secondary to
aspiration.
 Acute kidney injury due secondary to nephrotoxic medications.
Assessment: Client History

 Medical History (Hx)

 Admitting Diagnoses: Acute respiratory failure, acute kidney injury,
bipolar disorder, delirium, altered mental status, pneumonia, suicide
attempt, drug overdose, blood loss anemia
 Past medical history: Bipolar disorder

 Social Hx:
 Occupation: unemployed
 Marital Status: Single
 Lives: at home with parents
 Alcohol/drug use: No
Assessment: Food/Nutrition Related
History
 Diet Order (FH-2.1.1): NPO
 Rationale for tube feeding: aspiration precautions; tracheostomy (9/17);
long term nutrition support
 Enteral Nutrition Order (FH-2.1.1):
 Nepro 1.8 @ 45 mL/hr x 24hrs.; 1080 ml, 1944 kcal, 87 g pro, 785
ml free water
 Tolerance of Tube Feeding:
 Tolerating well
 No signs and symptoms of diarrhea, vomiting, dehydration
Assessment: Food/Nutrition Related
History
 Medications (FH-3.1):
IN-PATIENT MEDICATIONS:
Docusate Sodium/Colace
Senna
Famotidine
Amlodipine & Metoprolol
Amiodarone
Chlorpromazine & Fluphenazine
Prednisone
Polymixin & Tobramycin
MECHANISM OF ACTION FOOD-DRUG INTERACTION
Stool softener, Laxative  Alters intestinal absorption of
water and electrolytes
Laxative, stimulant  Electrolyte imbalance with
excessive use
Antiulcer, Anti-GERD, Anti-secretory  Limit caffeine/xanthine; may
decrease B12 and Fe
Antihypertensive  Recommended to decrease Na and
Ca; Avoid licorice
Antiarrhythmic  Avoid grapefruit and SJW; may
cause constipation
Antipsychotic  Take Mg 2 hrs. separate
 Limit caffeine
Corticosteroid  Avoid alcohol
 Caution with grapefruit
 Limit caffeine
 May increase glucose (DM)
Antibiotics used to treat gram-  May cause kidney damage
negative infections
Assessment: Nutrition-Focused Physical
Findings
 Generalized Pitting Edema +3 (PD-1.1.6)
 Skin Intact (PD-1.1.17)
 Morbidly Obese (BMI 48.3)
 Malnutrition: No malnutrition noted.
 Two out of six criteria must be met.
 Only meets 1 criteria (fluid accumulation).
 No decreased energy intake, weight loss, loss of body fat, muscle
mass wasting, reduced grip strength
Assessment: Nutrition Focused Physical Findings
Malnutrition Criteria
Assessment: Anthropometric
Measurements
 Height (AD-1.1.1): 69 inches
 Weight (AD-1.1.2.1): Due to generalized edema/anasarca, no current dry
weight. Measured weight: 148.5 kg; 326.9 lbs. (10/9)
 Body Mass Index (AD-1.1.5.1): 48.3 morbidly obese
 Weight change: since admission: 21%
 Weight Details: Significant weight change/gain of 56.8 lbs. since admission.
 9/6) 126.2 kg, 9/11) 129.8 kg, 9/21) 149.1 kg, 9/26) 150.2 kg, 9/30) 140.1 kg,
10/8) 146.1 kg, 10/9) 148.5 kg, 10/11) no new weights obtained
 IBW Male (+/- 10%): 160 lbs. (72.7 kg)
 Percent Ideal Body Weight: 204%
Biochemical Data, Medical Tests and Procedures
TEST Results 10/9 Interpretation

WBC (10^3/uL) 14.6 H Likely due to inflammation. Infection, pneumonia

Hgb (gm/dl) 8.3 L Blood loss anemia

Hct (%) 25.0 L Blood Loss anemia

Sodium 133L Borderline low (131); electrolyte imbalance

Potassium 4.2 WNL

Glucose 110 H Controlled; 10/8 Glu 145 H likely due to inflammation

and prednisone medication

BUN 72 H 2/2 AKI

Creatinine 5.6 H 2/2 AKI

Calcium 8.3 L Corrected Ca 10.2 WNL

Albumin 1.6 L Indicative of inflammation

Magnesium 1.8 L Renal dysfunction; electrolyte imbalance 2/2 AKI

Phosphorus 4.5 Borderline high due to renal failure

Assessment: Nutrient Needs
 Calories: 1825-2190 kcal
 based on 25-30 kcal/kg using IBW 73 kg for the critically ill obese
patient based in ASPEN recommendations & still falls within
guidelines for AKI
 Protein: 87.6-109.5 g protein/day
 based on 1.2-1.5 g/kg/day due to losses in HD (Nutrition Care
Manual)
 Fluids: 1825 ml
 based on 25 ml/kg (500 mL/day + urine output since on HD)
Diagnoses & Interventions
 1. Inadequate protein-energy (NI-5.2) intake as related to physiological causes of acute
kidney injury, diet prescription, intubation, and sedation as evidenced by NPO status.
 Interventions
 Modify route of enteral nutrition (ND-2.1.6). Recommended long term nutrition
support placement if tube feeding continues.
 Referral to other providers (RC-1.5) Communicated with resident and MICU team
regarding long term nutrition support placement and provision of diet prescription after
PEG placement.
Diagnoses & Interventions (cont’d)

 2. Unintentional weight gain (NC-3.4) as related to intradialytic weight gain and

fluid retention secondary to acute kidney injury as evidenced by generalized
edema, weight fluctuations and BMI 48.3 (morbidly obese).
 Interventions:
 Nutrition Prescription (NP-1.1) Recommended enteral nutrition order post
PEG, initiate Nepro 1.8 formula @ 45 ml/hr x 24 hrs. providing 1080 ml, 1944
kcal, 87 g protein, and 785 ml free water. (27 kcal/kg, 1.2 g pro/kg).
 Team meeting (RC-1.1) Attended white board rounds to have a better
understanding of the patient’s medical and nutritional status.
Monitoring & Evaluation

 Goals:
 EN/PN infusion to meet 75% or more of estimated nutritional needs
 To obtain and maintain electrolytes WNL
 Improve nutrition related labs (renal profile (BD-1.2) and anemia
profile (BD-1.10)) within 3 months.
 To reduce edema +3 edema within 90 days
 To tolerate nutrition Rx
 Obtain glycemic control 140-180 mg/dl
Monitoring & Evaluation
 Recommendations:
 Post PEG, initiate Nepro @ 45 ml/hr x 24 hrs. (FH-1.3.1.1.3)
 Hydration status and electrolytes replacements by MICU team.
 Obtain predialysis weight (AD-1.1.2.1.5) and post dialysis weight
(AD-1.1.2.1.6) and monitor weight changes.
 Improve electrolyte and renal profile (BD-1.2) by reaching
electrolytes balance and BUN/Cr WNL within 3 months.
 Improve anemia profile (BD-1.10) by increasing Hgb/Hct levels
within 3 months.
 Monitor tolerance to nutrition support/formula.
Monitoring & Evaluation
 Previous follow-ups:
 9/6) Vital 1.2 kcal @ 45 ml/hr. + 300 ml free water q. 4hrs.
 9/7) On NPO status for spontaneous breathing trial (SBT);
 9/11) TF currently not meeting estimated needs;
 9/18) TF restarted, initiated Suplena, due to worsening kidney, @ 45 ml/hr meeting 100% of
calorie/ 67% protein needs;
 9/21) TF does not meet protein needs, changing to Nepro 1.8
 9/26) TF meeting 100% nutritional needs;
 10/1) Current TF provides 30 kcal due to propofol but still meets nutritional needs;
 10/8) Current TF is providing 100% of nutritional needs;
 10/11) noted with significant weight gain (21% since admission) related to fluids with generalized
edema.
 10/15) generalized edema +2 improving
 10/24) weight 140.4 kg (reduced 8 kg since 10/11).
Monitoring & Evaluation

 Plan for follow-up care after discharge:

 Patient to continue PEG enteral nutrition support
 Home infusion services (Coram) to help manage nutrition support
and meet needs
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