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Nutritional Considerations

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Guidance in this section applies to adults aged 18 years and over. For specific guidance on caring for babies, children, and young people with AKI, please see the “Paediatrics” section.

Acute Kidney Injury (AKI) is characterised by a rapid reduction in kidney function resulting in a failure to maintain fluid, electrolyte and acid-base homeostasis (Segaran et al, 2015). The term AKI encompasses a spectrum of injury from moderate to severe deterioration of kidney function where patients may require renal replacement therapy (RRT) (NICE 2023). Patients with AKI represent a heterogenous group rarely presenting with an isolated disease process and as such the clinical status and treatment of patients with AKI can vary greatly. As a result, nutritional requirements of a patient can vary significantly depending on the degree of AKI, underlying clinical condition, metabolic state, inflammatory status and treatment employed. AKI is often present when there is sepsis and multi organ failure (Kanagasundaram et al, 2019). Patients require an individualised dietetic approach with close monitoring and review, especially if they require RRT (Kopple et al, 2013; Fiaccadori et al 2021).

Malnutrition, specifically protein energy wasting (PEW), is an important predictor of in-hospital mortality in patients with AKI, independent of complications and co-morbidities (Fiaccadori et al, 2021; Li et al 2012, Meyer et al, 2020). Between 24 and 60% of all hospitalised patients with AKI present with a degree of malnutrition (Meyer et al, 2020) with up to 42% presenting with signs of severe malnutrition on admission (Cano et al, 2009; Sabatino et al, 2017). In the critical care setting the prevalence of malnutrition increases to as high as 73% (Oh et al, 2019). Moreover, patients with malnutrition and AKI who survive to hospital discharge have poor clinical outcomes (Meyer et al, 2020). It is therefore important that patients with AKI at risk of malnutrition are identified and where appropriate, referred to the dietitian so that nutritional support and/or dietary electrolyte manipulation can be tailored to meet individual needs.

Nutritional support for patients with AKI must take into account not only the specific metabolic disturbances associated with the kidney injury but also the underlying disease process, inflammatory markers, the potential nutritional losses and gains during RRT, fluid retention (including gut oedema) and retention of uraemic toxins(Mercado et al, 2019; Ostermann et al, 2019; Fiaccadori et al 2021).

The aim of this section is to provide an overview of nutritional considerations with patients affected by AKI. It is not intended to replace the role of health care professionals. To date there are no randomised controlled trials on nutrition and AKI, which remains an under researched area. In view of the lack of systematic reviews and high-quality studies in the current literature, the recommendations provided are limited to current guidelines and the expert opinions of the authors of this document.

This section provides an overview of key nutritional principles in AKI. It is not intended to replace specialist assessment. Evidence in this area remains limited, and recommendations are based on existing guidelines and expert consensus.

Thank you to the Parenteral and Enteral Nutrition Group (PENG) specialist group of the British Dietetic Association (BDA) for allowing use and adaptation of extracts from the “Pocket Guide for Clinical Nutrition.”

Thank you to the Renal Nutrition Group and Critical Care specialist groups of the BDA for their participation and comments.

Thank you to Maria Barrett for her input in the previous editions.

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AKI Guide
Identifying people with AKI at risk of malnutrition