acute kidney injury guidelines

Acute Kidney Injury GuidelinesDr. Fazal Akhtar

Sindh Institute of Urology and Transplantation (SIUT)

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AKI Guideline

Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatment Renal replacement therapy

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Definition

AKI is defined as any of the following : Increase in serum creatinine (S.Cr) by ≥0.3

mg/dl (≥26.5 µmol/l) within 48 hours; or Increase in SCr to ≥1.5 times baseline, which

is known or presumed to have occurred within the prior 7 days or

Urine volume <0.5 ml/kg/h for 6 hours

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Definition and staging of AKI

RIFLE Classification AKIN Classification KDIGO Classification

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RIFLE Classification

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AKIN Classification

Modification of RIFLE classification by Acute Kidney Injury Network

Recognizes that small change in serum creatinine (>0.3 mg/dl)adversely impact outcome

Uses serum creatinine , urine output and time

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AKIN Classification

*Patients needing RRT are classified stage 3 despite the stage they were before starting RRT

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KDIGO Classification

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Severity of AKI and mortality

Stage 1 AKI (≥0.3 mg/dl or 26.5 μmol/l) increase in SCr but less than a twofold increase) had an odds ratio of 2.2

Stage 2 AKI (corresponding to RIFLE-I) there was an odds ratio of 6.1

Stage 3 AKI patients (RIFLE-F) the odds ratio was 8.6 for hospital mortality.Thakar CV etal Incidence and outcomes of AKI in ICU: a Veterans Administration study.Crit Care Med 2009, 37:2552-2558.

SIUT

AKI Guideline

Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatment Renal replacement therapy

SIUT

Recognised risk factors for AKI• Age >75 years• Pre-existing CKD (eGFR <60 mL/kg/1.73 m2)• Previous episode of AKI• Debility and dementia• Heart failure• Liver disease• Diabetes mellitus• Hypotension (Mean arterial pressure <65 mmHg,

systolic pressure <90 mmHg)• Sepsis• Hypovolaemia• Nephrotoxins, eg gentamicin, NSAIDs, iodinated contrast• Antihypertensives in setting of hypotension, eg ACE inhibitors,

loop diuretics

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Causes of acute kidney injury: exposures and susceptibilities for nonspecific acute

kidney injuryExposure SusceptibilitySepsis Dehydration or volume depletionCritical illness Advanced ageCirculatory shock Female genderBurnsBlack raceTrauma Chronic kidney diseaseCardiac surgery Chronic diseases (heart, lung, liver)Major noncardiac surgery Diabetes mellitusNephrotoxic drugs CancerRadiocontrast agents AnemiaPoisonous plants and animals

Kellum et al. Critical Care 2013 17:204   doi:10.1186/cc11454

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Risk Assessment We recommend that patients be stratified for risk of

AKI according to their susceptibilities and exposures. Manage patients according to their susceptibilities

and exposures to reduce the risk of AKI Test patients at increased risk for AKI with

measurements of S Cr. and urine output to detect AKI. Individualize frequency and duration of monitoring

based on patient risk and clinical course

SIUT

AKI Guideline

Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatment Renal replacement therapy

SIUT

Evaluation   Evaluate patients with AKI promptly to determine

the cause, with special attention to reversible causes.

   Monitor patients with AKI with measurements of SCr and urine output to stage the severity, according to Recommendation

   Manage patients with AKI according to the stage    Evaluate patients 3 months after AKI for

resolution, new onset, or worsening of pre-existing chronic kidney disease (CKD) (not graded)

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Cause of AKI and Diagnostic tests

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Evaluation ofAKI

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AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatmentFluid and VasopressureNutrition and glycemic controlDiuretic

Renal replacement therapy

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Classification of IV fluid therapy

NICE recommends that assessment of a patient’s fluid balance should be part of every ward round

It also recommends that IV fluid therapy is classified as resuscitation, replacement or routine maintenance, and that any prescription should clearly identify which type of IV fluid therapy the patient is receiving

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Volume resuscitation – how much fluid?

Fluid conservative therapy decreased ventilator days and didn’t increase the need for RRT in ARDS patients.

Association between positive fluid balance and increased mortality in AKI patients.Wiedeman H, Wheeler A, Bernard G, et al.: Comparison of two fluid management strategies in acute lung injury. New England Journal of Medicine 2006; 354:2564-2575.

Payen D, de Pont A, Sakr Y, et al.; A positive fluid balance is associated with worse outcome in patients with acute renal failure. Critical Care 2008; 12: R74.

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Volume resuscitation – which fluid?

SAFE study – no statistical difference between volume resuscitation with saline or albumin in survival rates or need for RRT.

Post – hoc analysis – albumin was associated with increased mortality in traumatic brain injury subgroup and improved survival in septic shock patients.

Finfer S, Bellomo R, Boyce N, et al.: A comparison of albumin and saline for fluid resuscitation in the intensive care unit. New England Journal of Medicine 2004; 350: 2247-2256.

Which fluid , Normal saline or low chloride solution

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Renal vasodilators? “Renal” dose dopamine doesn’t reduce the

incidence of AKI, the need for RRT or improve outcomes in AKI.

It may worsen renal perfusion in critically ill adults with AKI.

Side effects of dopamine include increased myocardial oxygen demand, increased incidence of atrial fibrillation and negative immuno-modulating effects.Lauschke A, Teichgraber U, Frei U, et al.: “Low-dose” dopamine worsens renal perfusion in patients with acute renal failure. Kidney 2006; 69:1669-1674.Argalious M, Motta P, Khandwala F, et al.: “Renal dose” dopamine is associated with the risk of new onset atrial fibrillation after cardiac surgery. Critical Care Medicine 2005; 33:1327-1332.

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Which inotrope/vasopressor?

There is no evidence that from a renal protection standpoint, there is a vasopressor agent of choice to improve kidney outcome.

Dennen P, Douglas I, Anderson R,: Acute Kidney Injury in the Intensive Care Unit:

An update and primer for the Intensivist. Critical Care Medicine 2010; 38:261-275.

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AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatmentFluid and VasopressureNutrition and glycemic controlDiuretic

Renal replacement therapy

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Nutrition and glycemic control    In critically ill patients, start insulin therapy

targeting plasma glucose 110 to 149 mg/dl    Achieving a total energy intake of 20 to 30

kcal/kg/day in patients with any stage of AKI   Avoid restriction of protein intake with the aim

of preventing or delaying initiation of RRT    0.8 to 1.0 g/kg/day protein in non catabolic

AKI patients without need for dialysis 1.0 to 1.5 g/kg/day in patients with AKI on RRT Up to a maximum of 1.7 g/kg/day in patients

on CRRT and in hypercatabolic patients    We suggest providing nutrition preferentially

via the enteral route in patients with AKI

SIUT

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatmentFluid and VasopressureNutrition and glycemic controlDiuretic

Renal replacement therapy

SIUT

Diuretics

   We recommend not using diuretics to prevent AKI

   We suggest not using diuretics to treat AKI, except in the management of volume overload

SIUT

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI

Pharmacological treatmentFluid and VasopressureNutrition and glycemic controlDiuretic

Renal replacement therapy

SIUT

Renal Replacement therapyVascular Access for Renal Replacement Therapy in AKIUse uncuffed nontunneled dialysis catheter, rather than a tunneled catheter. When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these preferences :

1st choice: right jugular vein 2nd choice: femoral vein3rd choice: left jugular vein Last choice: subclavian vein

Use ultrasound guidance for dialysis catheter insertion. Obtain a chest radiograph promptly after placement and before first use of an internal jugular or subclavian dialysis catheter. Do not using topical antibiotics over the skin insertion site of a nontunneled dialysis catheter in intensive care unit (ICU) patients with AKI requiring RRT. Do not use antibiotic locks for prevention of catheter-related infections of nontunneled dialysis catheters in AKI requiring RRT.

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Renal Replacement Therapy

When? How Much? Which?

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Renal Replacement therapyTiming Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist. In absence of risk factor No clear cut answerHow oftenDaily vs alternate daysModality of RRTUse continuous and intermittent RRT as complementary therapies in AKI patients. The Work Group suggests using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients. (2B) The Work Group suggests using CRRT, rather than intermittent RRT, for AKI patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema.

SIUTThese are a guidelines not rules

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