Acute Kidney Injury Guidelines Dr. Fazal Akhtar Sindh Institute of Urology and Transplantation (SIUT)

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Renal replacement therapy

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

Definition and staging of AKI RIFLE Classification AKIN Classification KDIGO Classification

RIFLE Classification

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

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

KDIGO Classification

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.

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Renal replacement therapy

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

Causes of acute kidney injury: exposures and susceptibilities for nonspecific acute kidney injury Exposure Susceptibility Sepsis Dehydration or volume depletion Critical illness Advanced age Circulatory shock Female gender Burns Black race Trauma Chronic kidney disease Cardiac surgery Chronic diseases (heart, lung, liver) Major noncardiac surgery Diabetes mellitus Nephrotoxic drugs Cancer Radiocontrast agents Anemia Poisonous plants and animals Kellum et al. Critical Care 2013 17:204   doi:10.1186/cc11454

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

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Renal replacement therapy

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)

Cause of AKI and Diagnostic tests

Evaluation of AKI

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Fluid and Vasopressure Nutrition and glycemic control Diuretic Renal replacement therapy

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

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.

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

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.

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.

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Fluid and Vasopressure Nutrition and glycemic control Diuretic Renal replacement therapy

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

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Fluid and Vasopressure Nutrition and glycemic control Diuretic Renal replacement therapy

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

AKI Guideline Definition and classification Risk assessment Evaluation and general management Prevention and treatment of AKI Pharmacological treatment Fluid and Vasopressure Nutrition and glycemic control Diuretic Renal replacement therapy

Renal Replacement therapy Vascular Access for Renal Replacement Therapy in AKI Use 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 vein 3rd 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.

Renal Replacement Therapy When? How Much? Which?

Renal Replacement therapy Timing Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist. In absence of risk factor No clear cut answer How often Daily vs alternate days Modality of RRT Use 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.

These are a guidelines not rules

The End