Tandem ECMO/CRRT medical nutrition therapy clinical practice points: A literature review and Delphi consensus on clinical practice.

BACKGROUND: Patients who undergo tandem extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have a high risk of metabolic disturbances, malnutrition, and fluid imbalances. ECMO/CRRT tandem therapy is becoming more prevalent in use; however, there are limited evidence-based guidelines for optimizing nutritional management. In this review, we examine the current literature on nutritional strategies for tandem ECMO and CRRT patients and provisional, consensus-informed clinical practice points to support individualized nutritional interventions. METHODS: We present a literature review with provisional, consensus-informed clinical practice points using a modified Delphi process. A literature search was conducted in PubMed and included studies discussing ECMO, CRRT, or tandem nutritional support in all age groups. Data extraction was standardized, and risk bias was assessed using the Newcastle-Ottawa Scale. Statements were considered clinically relevant practice points if more than 70% of respondents assigned them a rating of 3 or higher on a 5-point Likert scale. Statements identified as needing additional evidence were categorized as recommendations for future research. RESULTS: The review identified key areas critical for nutritional management in ECMO/CRRT patients: (1) early malnutrition assessment within 48 h of ICU admission, (2) individualized energy and protein requirement estimations accounting for device-specific challenges, (3) aggressive fluid and electrolyte monitoring, (4) preference for early enteral nutrition with parenteral nutrition as a safe alternative when needed, (5) early timing of nutrition initiation, (6) heightened protein targets (2-2.5 g/kg/day for adults; 3-3.5 g/kg/day for pediatrics), (7) careful carbohydrate and lipid administration to avoid metabolic complications, and (8) proactive replacement of vitamins and trace elements lost through CRRT. These recommendations are summarized in clinical practice points for bedside implementation. CONCLUSIONS: This review presents a structured set of provisional, expert consensus-informed clinical practice points for the nutritional management of patients undergoing tandem ECMO/CRRT therapy. While numerous studies address nutrition in the context of either ECMO or CRRT, none were found to specifically examine nutritional strategies in patients receiving both therapies simultaneously. This gap significantly limits the direct applicability of existing evidence to patients on ECMO and CRRT. Nevertheless, the review highlights the critical role of optimized nutritional interventions in improving outcomes, including survival and complication rates, in these critically ill patients. The findings underscore the urgent need for targeted research to validate these preliminary recommendations and to establish evidence-based nutritional goals for this complex and vulnerable population. REGISTRATION: PROSPERO ID: CRD420250651962.