Table 1 Nutritional strategy in patients with acute kidney injury in the Department of Intensive Care Medicine, University Hospital Leuven

Protocolized prescription for artificial nutrition

Caloric target: 24, 30, and 36 kcal/kg protein included, based on age, gender, and corrected ideal body weight.

Target and energy provisions of previous day shown in Patient Data Management System. Energy from sources other than PN is included.

'Early' EN

EN is initiated within 36 hours from admission unless (a) formal contraindication (for example, high gastrointestinal fistula, intestinal ischemia, and high-dose vasopressor) or (b) the patient is starting to eat.

Progressive increase of EN dose during hospitalization

Day 2: 200 to 500 kcal

Day 3: 700 to 900 kcal

Day 4: 1,100 to 1,300 kcal

Day 5: 1,500 to 1,700 kcal

PN: according to randomization in ongoing EPaNIC trial

Early PN: within 48 hours of initiation of standard PN to complement EN up to 100% of caloric target, unless patient is starting to eat.

Late PN: no PN during the first week after admission on the ICU.

Standardized formulations

Commercially available ready-to-use EN and PN preparations.

Composition of EN and PN

60% to 70% dextrose, 30% to 40% lipids.

Lipids less than 1 g lipids/kg body weight per day.

Proteins: 0.8 to 1.2 g/kg body weight per day.

No adaptation for acute renal failure and/or CRRT.

Use of glucose-containing replacement fluid (physiological concentration) in CRRT.

Parenteral lipid restriction

If plasma triglycerides are greater than 300 mg/dL. Lipid-free PN is administered and lipids are added once weekly.

Glucose administration in binary PN should not exceed 5 g/kg per day.

Volume and electrolyte restriction

In case of fluid overload, renal replacement therapy will be started rather than PN or EN volume reduced.

Concentrated EN is used only during prolonged critical illness with intermittent hemodialysis.

Electrolyte-free standard formulations are used on indication.

Strict glycemic control

All patients in the ICU receive insulin targeted at blood glucose levels of 80 to 110 mg/dL.

Vitamins and trace elements

All patients requiring nutritional support receive recommended daily allowances of parenteral trace elements and vitamins until they receive more than 1,600 kcal standard enteral formulation.

During severe hepatic failure, doses of manganese and copper are reduced to once weekly.

Immunonutrition

No routine use of enteral or parenteral immunonutrients.

Frequent monitoring of electrolytes and lactate

Potassium, bicarbonate, and lactate every 4 hours.

Sodium, chlorine, magnesium, and phosphorous every 24 hours.