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

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

3. 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

4. Definition and staging of AKI
RIFLE Classification
AKIN Classification
KDIGO Classification

5. RIFLE Classification

6. 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

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

8. KDIGO Classification

9. 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:

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

11. 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

12. 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 :204   doi: /cc11454

13. 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

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

15. 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)

16. Cause of AKI and Diagnostic tests

17. Evaluation of
AKI

19. 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

20. 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

21. 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:
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.

22. 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:
Which fluid , Normal saline or low chloride solution

23. 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:
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:

24. 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:

25. 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

26. 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

27. 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

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

29. 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

30. 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.

31. Renal Replacement Therapy
When?
How Much?
Which?

32. 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.

33. These are a guidelines not rules

34. The End