acute kidney injury guidelines
DESCRIPTION
AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Renal replacement therapyTRANSCRIPT
Acute Kidney Injury GuidelinesDr. Fazal Akhtar
Sindh Institute of Urology and Transplantation (SIUT)
SIUT
AKI Guideline
Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI
Pharmacological treatment Renal replacement therapy
SIUT
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
SIUT
Definition and staging of AKI
RIFLE Classification AKIN Classification KDIGO Classification
SIUT
RIFLE Classification
SIUT
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
SIUT
AKIN Classification
*Patients needing RRT are classified stage 3 despite the stage they were before starting RRT
SIUT
KDIGO Classification
SIUT
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
SIUT
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
SIUT
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)
SIUT
Cause of AKI and Diagnostic tests
SIUT
Evaluation ofAKI
SIUT
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
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
SIUT
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.
SIUT
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
SIUT
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.
SIUT
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.
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
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.
SIUT
Renal Replacement Therapy
When? How Much? Which?
SIUT
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
The End