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The present review is aimed at illustrating and discussing literature data and recent guidelines concerning artificial nutrition in patients with acute kidney injury (AKI) on renal replacement therapy (RRT). Protein-energy wasting often complicates the clinical course of AKI in critically ill patients, increasing their morbidity and mortality risk. The most severe forms of the syndrome - those observed in ICU patients - are characterized by hypercatabolism with relevant lean body mass loss. In this clinical condition, artificial nutrition (enteral and/or parenteral nutrition) is considered an integral part of the complex therapeutic approach. Even though many issues concerning nutrition in AKI are common to other critically ill patients, the presence of AKI with the ensuing impairment of the kidney homeostatic function introduces specific problems and can make more difficult to give the patient an adequate nutrient provision. Thus, peculiarities of the syndrome - and of RRT itself - must be taken into account in nutritional planning for these patients. Recent guidelines have suggested that the enteral route should be the preferred one, even though parenteral nutrition is often required to target nutritional needs (25-30 kcal/kg body weight/day, and 1.5 + 0.2 g/kg/day to compensate for amino acid losses during RRT). Special attention should be paid to the impact of different forms of RRT on the possible loss of both macro- and micronutrients and vitamins, as well as to the risk of metabolic complications. Finally, close integration between nutritional support and RRT is required, aiming at carefully tailoring both therapies on patient's changing needs., (© 2011 Wiley Periodicals, Inc.)

We report on a patient with biliary sepsis due to Vancomycin-resistant Enterococcus faecium (VRE) treated with linezolid (LNZ), who had both hepatic failure and acute kidney injury requiring daily sustained low-efficiency dialysis (SLED), a new intermittent, prolonged diffusive modality of renal replacement therapy for ICU patients. Following cholecystostomy and peritoneal drain insertion, serum, bile and peritoneal fluid serial samples were simultaneously collected for LNZ concentration measurement (chromatography/mass spectrometry). Unusually high serum antibiotic levels (20 mg/L or more) were achieved as early as 36 hours since the start of LNZ administration, owing to relatively low hepatic clearance. Serum LNZ leveled off after commencing SLED, apparently reaching steady state levels. The lowest values of Cmin in bile was 5.86 mg/L; the average serum and bile AUC0-12 over the observation period were 204 mg/L*h and 276 mg/L*h, with a AUC0-24/MIC ratio of 227 h and 307 h, respectively. The excellent biliary pharmacodynamic exposure suggests that standard-dose LNZ might represent a valuable choice in severe biliary infection, even in the presence of hepatic failure, when the patients receive highly efficient modalities of renal replacement therapy.

Purpose of Review: Acute kidney injury (AKI) in the ICU is associated with an increased risk of protein-energy wasting (PEW), a major negative prognostic factor. This review illustrates recently published data and guidelines concerning nutritional problems in AKI, pointing out complexities and peculiarities of the syndrome., Recent Findings: The main goals of nutritional support in AKI on renal replacement therapy (RRT) are to ensure the provision of adequate amounts of nutrients, to prevent PEW, to promote tissue reparation, to support the immune system, and possibly to reduce mortality. The enteral route should be preferred, even though parenteral nutrition is often required to target nutritional needs. Special attention should be paid both to the impact of RRT on macronutrient and micronutrient losses, and to the risk of complications. In fact, due to both the acute loss of the kidneys' homeostatic function, and the frequent need of RRT, patients with AKI are especially prone to hypoglycemia and hyperglycemia, hypertriglyceridemia, fluid balance alterations, electrolyte and acid-base derangements., Summary: This review highlights the most recent concepts and recommendations for nutritional support in AKI, stressing the need for a close integration between adequate nutrition and RRT in this clinical condition, with the aim of carefully tailoring both therapies on patients' changing needs. Recent findings about the renoprotective role of some nutrients (glutamine, omega-3 fatty acids) are also discussed.