Optimizing Fluid Balance, Nutrition, and Diet in Acute Kidney Injury

Fluid Management

The Kidney International society recommends using isotonic crystalloids rather than colloids for initial expansion of intravascular volume in patients at risk for or with AKI 4
Diuretics should not be used to prevent AKI but are appropriate for managing volume overload in established AKI, as recommended by the Kidney International society 5, 6
Consider early initiation of renal replacement therapy if conservative fluid management is insufficient to achieve neutral or negative fluid balance in severe fluid overload, as suggested by the Clinical Nutrition society 2, 7

The Clinical Nutrition society recommends providing hypocaloric nutrition (not exceeding 70% of energy expenditure) in the early phase of acute illness, and gradually increasing caloric delivery to 80-100% of measured energy expenditure after day three 1, 3
Avoid early full enteral or parenteral nutrition in critically ill patients with AKI; instead, prescribe full nutrition within 3-7 days, as recommended by the Clinical Nutrition society 1
The Clinical Nutrition society suggests that protein intake should not be restricted to avoid or delay kidney replacement therapy initiation in critically ill patients with AKI, and recommends providing 1.2-2.0 g/kg/day of protein 2, 8

Consider increasing lipid intake and reducing carbohydrate provision based on substrate utilization assessed by indirect calorimetry, as suggested by the Clinical Nutrition society 7
Account for additional calories from citrate, glucose, and lactate in dialysis/hemofiltration solutions to avoid overfeeding, as recommended by the Clinical Nutrition society 7

Monitor and supplement trace elements due to increased requirements during kidney failure and critical illness, and large effluent losses during kidney replacement therapy, as recommended by the Clinical Nutrition society 2, 8
Pay particular attention to selenium, zinc, and copper levels, as suggested by the Clinical Nutrition society 2, 8

Use body composition assessment rather than anthropometry when diagnosing and monitoring malnutrition in AKI patients, as recommended by the Clinical Nutrition society 10, 11
Consider ultrasound for assessment of muscle mass, as it is less influenced by fluid shifts compared to bioelectric impedance analysis, as suggested by the Clinical Nutrition society 11

CKD patients previously on controlled protein intake should not maintain this regimen during hospitalization if acute illness is the reason for admission, as recommended by the Clinical Nutrition society 2, 8
Avoid overfeeding in patients with AKI, as it may lead to increased metabolic complications and more positive fluid balance, as suggested by the Clinical Nutrition society 1, 3