What are the nutritional targets for a critically ill patient in the Intensive Care Unit (ICU) on maintenance hemodialysis (HD) 2 to 4 times per week?

Nutritional Targets for Critically Ill Patients on Maintenance Hemodialysis

For critically ill patients in the ICU on maintenance hemodialysis 2-4 times per week, protein intake should be 1.3-1.5 g/kg/day with energy targets of 25-30 kcal/kg/day during the recovery phase, while limiting to 20-25 kcal/kg/day during the acute initial phase.

Energy Requirements

Acute Initial Phase (First 3-4 days)

• Energy target: 20-25 kcal/kg/day 1
• Avoid excessive energy provision during early critical illness as it may be associated with less favorable outcomes 1
• Hyperalimentation should be avoided in the critically ill, as higher amounts of nutrients during the acute phase may lead to poorer outcomes 1

Recovery/Anabolic Phase

• Energy target: 25-30 kcal/kg/day 1
• During stabilization and recovery, higher energy amounts are required to support anabolic reconstitution 1
• For patients >60 years old: 30 kcal/kg/day
• For patients <60 years old: 35 kcal/kg/day 2

Protein Requirements

• Protein target: 1.3-1.5 g/kg/day 1, 2
• Higher protein intake is needed to overcome anabolic resistance associated with critical illness 1
• Hemodialysis patients require a minimum of 1.2 g/kg/day, but acutely ill dialysis patients benefit from higher protein intake (1.3-1.5 g/kg/day) when receiving intensive dialysis 2
• Protein should be delivered progressively during critical illness 1

Route of Administration

1. Enteral Nutrition (EN): Preferred route when gastrointestinal tract is functioning 1

   • Start EN early (within 24-48 hours) in hemodynamically stable patients 1
   • No significant difference between jejunal versus gastric feeding in critically ill patients 1

2. Parenteral Nutrition (PN):

   • Should not be started until all strategies to maximize EN tolerance have been attempted 1
   • Consider supplemental PN if EN provides <60-70% of target after 3 days 1
   • For patients on hemodialysis, administer PN after hemodialysis sessions to prevent premature removal 2

3. Intradialytic Parenteral Nutrition (IDPN):

   • Consider for malnourished patients on hemodialysis who fail to respond or don't tolerate oral nutritional supplements or EN 1
   • Not superior to oral nutritional supplements but reasonable for patients who fail first-line treatments 1

Monitoring and Adjustments

• Monitor phosphate levels to detect refeeding hypophosphatemia; if it occurs, implement caloric restriction 3
• Regular assessment of nutritional parameters including serum albumin and anthropometric measurements 2
• Consider indirect calorimetry when available to measure actual energy expenditure rather than using predictive equations 1, 4
• Track cumulative energy deficit as deficits exceeding 10,000 kcal are associated with increased complications 1

Special Considerations for Hemodialysis Patients

• Account for non-protein calories from dialysate when calculating total energy intake 2
• Assess residual renal function regularly as it may affect nutritional requirements 2
• Monitor for fluid overload and electrolyte imbalances, particularly potassium, phosphorus, and magnesium
• Supplemental micronutrients should be included in all PN prescriptions 1

Practical Implementation

1. Initial phase (first 3-4 days): Start with 20-25 kcal/kg/day and 1.0-1.2 g/kg/day protein
2. Progress to full targets by day 3-4: 25-30 kcal/kg/day and 1.3-1.5 g/kg/day protein
3. Prioritize enteral route whenever possible
4. Supplement with PN if unable to meet >70% of requirements enterally after 3 days
5. Consider IDPN for patients who fail to respond to conventional nutritional support

This approach balances the need to prevent malnutrition while avoiding the complications of overfeeding in critically ill patients with kidney failure requiring hemodialysis.