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The management of acute kidney injuries and chronic kidney disease in the hospital setting can vary greatly, being dependent on the clinical scenario. As with the management of any condition, there is no one-size fits all approach that can be adopted, and with the complexities of renal conditions, this is no exception. While an acute kidney injury often requires aggressive clinical management to address the underlying cause (such as from a major injury or trauma), chronic kidney disease often occurs much less drastically, progressing over time. In an acute kidney injury, creatine levels can spike quickly, and there can be dramatic changes in electrolytes, elevations in urea, creatinine, potassium and phosphate, and reduced urine output (as well as fluid requirements). On the other hand, in chronic kidney disease, biochemical markers tend to be more stable over time, as is observed in a gradual drop in haemoglobin over time with reduced production of EPO (which is not directly impacted in an acute kidney injury).

When considering the clinical relevance of existing nutritional guidelines, Advanced Accredited Practising Dietitian Anthony Meade recommends that these should be used with caution as many of these, such as ESPEN, are more relevant to an ICU setting or to enterally fed patients, rather than a general ward setting. In this conversational presentation, he also explains that elevated energy requirements in clinical guidelines, such as in acute kidney injury, apply to the increased energy expenditure from another underlying condition, such as trauma or sepsis, rather than due to the energy demand of the kidneys themselves. Thus, clinical judgement should be used in calculating energy requirements. This judgement should also apply to protein requirements as the underlying condition, individual muscle mass/ BMI and biochemical markers/trends will impact this.

Overall, the management of acute kidney injury and chronic kidney injury is complex and multifactorial. The nutritional management varies significantly, being dependent on the treatment, including the potential dialysis type provided. As health professionals, it is crucial to address misinformation and prevent unnecessary food restrictions in renal patients to optimise their nutritional status and prevent malnutrition.

Summary:

• The management of acute kidney injuries and chronic kidney disease in the hospital setting can vary greatly, being dependent on the clinical scenario.
• In the acute setting, close monitoring of electrolytes, especially potassium (of main priority due to the risk of heart complications), urea, phosphate, and urine output is required as this will impact on the nutritional management provided.
• It is critical to exercise clinical judgement in calculating energy and protein requirements as current guidelines are often tailored to an ICU setting or enterally fed patients, being dependent on the clinical scenario, rather than a general ward-based setting.
• As health professionals, it is crucial to address misinformation and prevent unnecessary food restrictions in renal patients to optimise their nutritional status and prevent malnutrition.
• It is important to communicate to patients that in an acute kidney injury predicted to resolve quickly, dietary restriction may not be required or may only be required in the short term.

Anthony Meade is an Advanced Renal Dietitian practising at Central and Northern Adelaide Renal and Transplantation Service, based at Royal Adelaide Hospital, SA. Anthony is passionate about individualised, patient-centred care and making renal nutrition easier for people with kidney disease, their families and the clinicians caring for them. Anthony has a broad experience in all areas of renal nutrition and is an experienced clinical educator and convenor of the Renal Nutrition Program. 

To register for the presentation and associated documents including the assessment quiz click here