Casaer Michaël P, Mesotten Dieter, Schetz Miet R C
Department of Intensive Care Medicine, University Hospital Leuven, Catholic University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
Crit Care. 2008;12(4):222. doi: 10.1186/cc6945. Epub 2008 Aug 19.
Acute kidney injury (AKI) develops mostly in the context of critical illness and multiple organ failure, characterized by alterations in substrate use, insulin resistance, and hypercatabolism. Optimal nutritional support of intensive care unit patients remains a matter of debate, mainly because of a lack of adequately designed clinical trials. Most guidelines are based on expert opinion rather than on solid evidence and are not fundamentally different for critically ill patients with or without AKI. In patients with a functional gastrointestinal tract, enteral nutrition is preferred over parenteral nutrition. The optimal timing of parenteral nutrition in those patients who cannot be fed enterally remains controversial. All nutritional regimens should include tight glycemic control. The recommended energy intake is 20 to 30 kcal/kg per day with a protein intake of 1.2 to 1.5 g/kg per day. Higher protein intakes have been suggested in patients with AKI on continuous renal replacement therapy (CRRT). However, the inadequate design of the trials does not allow firm conclusions. Nutritional support during CRRT should take into account the extracorporeal losses of glucose, amino acids, and micronutrients. Immunonutrients are the subject of intensive investigation but have not been evaluated specifically in patients with AKI. We suggest a protocolized nutritional strategy delivering enteral nutrition whenever possible and providing at least the daily requirements of trace elements and vitamins.
急性肾损伤（AKI）大多在危重病和多器官功能衰竭的背景下发生，其特征为底物利用、胰岛素抵抗和高分解代谢的改变。重症监护病房患者的最佳营养支持仍是一个有争议的问题，主要是因为缺乏设计充分的临床试验。大多数指南基于专家意见而非确凿证据，对于有或没有AKI的重症患者并无根本差异。对于胃肠道功能正常的患者，肠内营养优于肠外营养。对于无法进行肠内喂养的患者，肠外营养的最佳时机仍存在争议。所有营养方案都应包括严格的血糖控制。推荐的能量摄入量为每天20至30千卡/千克，蛋白质摄入量为每天1.2至1.5克/千克。对于接受持续肾脏替代治疗（CRRT）的AKI患者，有人建议摄入更高的蛋白质。然而，试验设计不完善，无法得出确凿结论。CRRT期间的营养支持应考虑葡萄糖、氨基酸和微量营养素的体外丢失。免疫营养素是深入研究的课题，但尚未在AKI患者中进行专门评估。我们建议采用一种规范化的营养策略，尽可能提供肠内营养，并至少满足微量元素和维生素的每日需求。
