Renal dysfunction is common in
critically ill patients and its presence has, in the past, posed serious challenges to
nutritional support. Such challenges were due to the increased
azotemia induced by
protein or
amino acid administration, the fluid overload caused by the administration of nutrients and the difficulties associated with the control of these complications by means of conventional dialytic techniques. The development and increasing application of
continuous renal replacement therapy (CRRT) has removed such concerns, because control of
azotemia and fluid balance can be predictably and reliably achieved in all patients. Accordingly, the presence of
renal failure should in no way influence the amount or type of
nutritional support administered to a
critically ill patient. We recommend that approximately 30-35 kcal/kg/day be administered enterally and begun within the first few hours of admission to the intensive care unit and that
protein intake be kept in the 1.5-2 g/kg/day range. Accumulating evidence also suggests that immune-enhancing enteral preparations decrease the duration of
hospital stay, the number of
infections and perhaps mortality. Such preparations should be used in these patients. Finally adequate
vitamin and
trace element supplementation is recommended to counterbalance the decrease in
antioxidants and the loss of some
vitamins during CRRT. Available evidence suggests that if these steps are applied as part of a protocol-based approach to the
nutritional support of patients with
renal failure, their morbidity and perhaps mortality can be significantly decreased.