What are radiologists doing to prevent contrast-induced nephropathy (CIN) compared with measures supported by current evidence? A survey of European radiologists on CIN associated with computed tomography.
Fishman E K,Reddan D
Acta radiologica (Stockholm, Sweden : 1987)
BACKGROUND:Contrast-induced nephropathy (CIN) is a serious complication of the use of iodinated contrast media (CM), and is associated with increased morbidity and mortality. PURPOSE:To investigate whether radiologists take sufficient measures to prevent CIN in computed tomography (CT). MATERIAL AND METHODS:2005 survey of 509 European radiologists who had > or =3 years' experience and performed > or =50 CT scans/week. RESULTS:The most common methods used to identify patients at risk of CIN were renal function measurements (64%), clinical judgment (55%), and patient questionnaires (31%); 9% made no routine attempt to identify at-risk patients. The most common preventive protocols used in at-risk patients included: intravenous (i.v.) saline volume repletion (59%) or oral hydration (52%) before/after CT; use of low-osmolar CM (LOCM; 40%) or isosmolar CM (IOCM; 36%); and N-acetylcysteine (20%); 8% used no hydration regimen. While 78% of respondents used < or =100 ml of CM in high-risk patients, 14% used < or =150 ml, and 9% set no volume limit. For 57% of respondents, osmolality was the most important attribute in choosing an iodinated CM in at-risk patients; 41% agreed that CIN risk is lower with IOCM versus LOCM (31% disagreed). CONCLUSION:A European radiologist survey identified a need for increased implementation of evidence-based protocols to improve CIN prevention: routine identification of at-risk patients; withdrawal of nephrotoxic drugs; use of volume repletion regimens; lowest possible volume of CM; and appropriate CM.
Imaging protocols for CT urography: results of a consensus conference from the French Society of Genitourinary Imaging.
Renard-Penna Raphaële,Rocher Laurence,Roy Catherine,André Marc,Bellin Marie-France,Boulay Isabelle,Eiss David,Girouin Nicolas,Grenier Nicolas,Hélénon Olivier,Lapray Jean-François,Lefèvre Arnaud,Matillon Xavier,Ménager Jean-Michel,Millet Ingrid,Ronze Sébastien,Sanzalone Thomas,Tourniaire Jean,Brunelle Serge,Rouvière Olivier,
OBJECTIVES:To develop technical guidelines for computed tomography urography. METHODS:The French Society of Genitourinary Imaging organised a Delphi consensus conference with a two-round Delphi survey followed by a face-to-face meeting. Consensus was strictly defined using a priori criteria. RESULTS:Forty-two expert uro-radiologists completed both survey rounds with no attrition between the rounds. Ninety-six (70%) of the initial 138 statements of the questionnaire achieved final consensus. An intravenous injection of 20 mg of furosemide before iodinated contrast medium injection was judged mandatory. Improving the quality of excretory phase imaging through oral or intravenous hydration of the patient or through the use of an abdominal compression device was not deemed necessary. The patient should be imaged in the supine position and placed in the prone position only at the radiologist's request. The choice between single-bolus and split-bolus protocols depends on the context, but split-bolus protocols should be favoured whenever possible to decrease patient irradiation. Repeated single-slice test acquisitions should not be performed to decide of the timing of excretory phase imaging; instead, excretory phase imaging should be performed 7 min after the injection of the contrast medium. The optimal combination of unenhanced, corticomedullary phase and nephrographic phase imaging depends on the context; suggestions of protocols are provided for eight different clinical situations. CONCLUSION:This expert-based consensus conference provides recommendations to standardise the imaging protocol for computed tomography urography. KEY POINTS:• To improve excretory phase imaging, an intravenous injection of furosemide should be performed before the injection of iodinated contrast medium. • Systematic oral or intravenous hydration is not necessary to improve excretory phase imaging. • The choice between single-bolus and split-bolus protocols depends on the context, but split-bolus protocols should be favoured whenever possible to decrease patient irradiation.
KHA-CARI guideline: KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for Acute Kidney Injury.
Langham Robyn G,Bellomo Rinaldo,D' Intini Vincent,Endre Zoltan,Hickey Bernadette B,McGuinness Shay,Phoon Richard K S,Salamon Karen,Woods Julie,Gallagher Martin P, ,
Nephrology (Carlton, Vic.)
Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites.
Angeli Paolo,Gines Pere,Wong Florence,Bernardi Mauro,Boyer Thomas D,Gerbes Alexander,Moreau Richard,Jalan Rajiv,Sarin Shiv K,Piano Salvatore,Moore Kevin,Lee Samuel S,Durand Francois,Salerno Francesco,Caraceni Paolo,Kim W Ray,Arroyo Vicente,Garcia-Tsao Guadalupe,
Acute kidney injury, its definition, and treatment in adults: guidelines and reality.
Matuszkiewicz-Rowińska Joanna,Małyszko Jolanta
Polish archives of internal medicine
In the last decades, much work has been done to improve our understanding of acute kidney injury (AKI) as well to standardize its diagnostic criteria. As a result of many years of work of intensivists and nephrologists, the consensus definitions were established, finally unified in 2012 by the Kidney Disease Improving Global Outcomes (KDIGO) group. These criteria refer to the time of AKI development and base on serum creatinine increase or/and urine output decrease. It is defined as an increase in serum creatinine at least by 0.3 mg/dl within 48 hours or 1.5 times the baseline, which is known or presumed to have occurred within previous seven days, or - according to urine output criterion - urine volume <0.5 ml/kg/hr for at least 6 hours. The present review is based on the discussion during the KDIGO controversy conference, devoted to AKI. In this review, we tried to answer three main questions: is the KDIGO definition of AKI valuable in clinical research and global epidemiology? Is it helpful in everyday clinical practice? As well as in a therapeutic approach to critically ill patients with AKI?
[Prevention of acute kidney injury in critically ill patients : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI].
Joannidis M,Klein S J,John S,Schmitz M,Czock D,Druml W,Jörres A,Kindgen-Milles D,Kielstein J T,Oppert M,Schwenger V,Willam C,Zarbock A
Medizinische Klinik, Intensivmedizin und Notfallmedizin
BACKGROUND:Acute kidney injury (AKI) has both high mortality and morbidity. OBJECTIVES:To prevent the occurrence of AKI, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS:The recommendations stated in this paper are based on the current Kidney Disease Improving Global Outcomes (KDIGO) guidelines, the published statements of the "Working Group on Prevention, AKI section of the European Society of Intensive Care Medicine" and the expert knowledge and clinical experience of the authors. RESULTS:Currently there are no approved clinically effective drugs for the prevention of AKI. Therefore the mainstay of prevention is the optimization of renal perfusion by improving the mean arterial pressure (>65 mm Hg, higher target may be considered in hypertensive patients). This can be done by vasopressors, preferably norepinephrine and achieving or maintaining euvolemia. Hyperhydration that can lead to AKI itself should be avoided. In patients with maintained diuresis this can be done by diuretics that are per se no preventive drug for AKI. Radiocontrast enhanced imaging should not be withheld from patients at risk for AKI; if indicated, however, the contrast media should be limited to the smallest possible volume.
[Acute Kidney Injury - Potentials to Improve AKI-Related Health Care Structure].
Nusshag Christian,Obermann Konrad,Weigand Markus,Schwenger Vedat
Deutsche medizinische Wochenschrift (1946)
Since 2005 the AKI numbers nearly increased threefold. The prevailing health care structure for AKI-management in Germany possesses major potential for improvement. Despite a clear advantage regarding mortality and renal recovery, the cost-intensive CRRT is the predominant procedure in AKI-therapy. Conversion of 85 % of the CRRT-procedures to a dialysis procedure (IHD/SLED) enables annual savings in AKI-therapy by 7.3 million Euros. A reinvestment can finance a strengthened collaboration with licensed nephrologists to improve therapy quality and availability of RRT-units in local hospitals. The the long term aim is the establishment of national therapy guidelines. Lower consequential costs are crucial incentives.
Association of Contrast and Acute Kidney Injury in the Critically Ill: A Propensity-Matched Study.
Williams Lisa-Mae S,Walker Gail R,Loewenherz James W,Gidel Louis T
BACKGROUND:Despite evidence that low osmolar radiocontrast media is not associated with acute kidney injury, it is important to evaluate this association in critically ill patients with normal kidney function. METHODS:This retrospective observational study included 7,333 adults with an ICU stay at a six-hospital health system in south Florida. Patients who received contrast were compared with unexposed control subjects prior to and following propensity score (PS) matching derived from baseline characteristics, admission diagnoses, comorbidities, and severity of illness. Acute kidney injury (AKI), defined as initial onset (stage I) or increased severity, was determined from serum creatinine levels according to Kidney Disease: Improving Global Outcomes guidelines. RESULTS:Based on 2,306 PS-matched pairs obtained from 2,557 patients who received IV contrast and 4,776 unexposed control subjects, the increase in AKI attributable to contrast was 1.3% (19.3% vs 18.0%; P = .273), and no association was found between contrast and the pattern of onset and recovery. Hospital mortality increased by 14.3% subsequent to AKI (18.0 vs 3.6; P < .001), but the risk ratio in relation to patients with stable AKI did not vary when stratified according to contrast. Multivariable regression identified sepsis, metabolic disorders, diabetes, history of renal disease, and severity of illness as factors that were more strongly associated with AKI. CONCLUSIONS:In critically ill adults with normal kidney function, low osmolar radiocontrast media did not substantively increase AKI. Rather than limiting the use of contrast in ICU patients, efforts to prevent AKI should focus on the susceptibility of patients with sepsis, diabetes complications, high Acute Physiology and Chronic Health Evaluation scores, and history of renal disease.
[Update in current care guidelines: acute kidney injury].
Duodecim; laaketieteellinen aikakauskirja
Acute Kidney Injury is an increasing problem. Prevention is based on early detection of risk patients, avoidance of nephrotoxic medications, and adequate fluid therapy with crystalloid solutions. Mortality does not differ between intermittent and continuous renal replacement therapy. Dose above 22 ml/kg/h does not decrease mortality. A working group appointed by the Finnish Medical Society Duodecim, the Finnish Society of Anaesthesiologists, Subdivision of Intensive Care Medicine and the Finnish Society of Nephrology
The optimal definition of contrast-induced acute kidney injury for prediction of inpatient mortality in patients undergoing percutaneous coronary interventions.
Parsh Jessica,Seth Milan,Briguori Carlo,Grossman Paul,Solomon Richard,Gurm Hitinder S
American heart journal
BACKGROUND:It is unknown which definition of contrast-induced acute kidney injury (CI-AKI) in the setting of percutaneous coronary interventions is best associated with inpatient mortality and whether this association is stable across patients with various preprocedural serum creatinine (SCr) values. METHODS:We applied logistic regression models to multiple CI-AKI definitions used by the Kidney Disease Improving Global Outcomes guidelines and previously published studies to examine the impact of preprocedural SCr on a candidate definition's correlation with the adverse outcome of inpatient mortality. We used likelihood ratio tests to examine candidate definitions and identify those where association with inpatient mortality remained constant regardless of preprocedural SCr. These definitions were assessed for specificity, sensitivity, and positive and negative predictive values to identify an optimal definition. RESULTS:Our study cohort included 119,554 patients who underwent percutaneous coronary intervention in Michigan between 2010 and 2014. Most commonly used definitions were not associated with inpatient mortality in a constant fashion across various preprocedural SCr values. Of the 266 candidate definitions examined, 16 definition's association with inpatient mortality was not significantly altered by preprocedural SCr. Contrast-induced acute kidney injury defined as an absolute increase of SCr ≥0.3 mg/dL and a relative SCr increase ≥50% was selected as the optimal candidate using Perkins and Shisterman decision theoretic optimality criteria and was highly predictive of and specific for inpatient mortality. CONCLUSIONS:We identified the optimal definition for CI-AKI to be an absolute increase in SCr ≥0.3 mg/dL and a relative SCr increase ≥50%. Further work is needed to validate this definition in independent studies and to establish its utility for clinical trials and quality improvement efforts.
An overview of NICE guidance: acute kidney injury.
Ellis Peter,Jenkins Karen
British journal of nursing (Mark Allen Publishing)
Acute Kidney Injury (AKI) as a financial, resource and human burden on both the NHS and people with AKI. Clearly if AKI is the cause of much morbidity and mortality and significant amounts of it can be prevented and/or detected earlier, this could only be a good thing. In part, the problem with AKI is that it has historically been regarded as little more than a sequal to other more pressing physical illnesses and therefore not taken as seriously as it might. The 2013 guidance from NICE-clinical guideline 169-and the accompanying pathway, seek to address this with an emphasis on assessment and prevention, identification of disease, management and subsequent chronic disease management ( NICE, 2013a ).
Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference.
Ostermann Marlies,Bellomo Rinaldo,Burdmann Emmanuel A,Doi Kent,Endre Zoltan H,Goldstein Stuart L,Kane-Gill Sandra L,Liu Kathleen D,Prowle John R,Shaw Andrew D,Srisawat Nattachai,Cheung Michael,Jadoul Michel,Winkelmayer Wolfgang C,Kellum John A,
In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.
Acute kidney injury in critically ill cancer patients: an update.
Lameire Norbert,Vanholder Raymond,Van Biesen Wim,Benoit Dominique
Critical care (London, England)
Patients with cancer represent a growing group among actual ICU admissions (up to 20 %). Due to their increased susceptibility to infectious and noninfectious complications related to the underlying cancer itself or its treatment, these patients frequently develop acute kidney injury (AKI). A wide variety of definitions for AKI are still used in the cancer literature, despite existing guidelines on definitions and staging of AKI. Alternative diagnostic investigations such as Cystatin C and urinary biomarkers are discussed briefly. This review summarizes the literature between 2010 and 2015 on epidemiology and prognosis of AKI in this population. Overall, the causes of AKI in the setting of malignancy are similar to those in other clinical settings, including preexisting chronic kidney disease. In addition, nephrotoxicity induced by the anticancer treatments including the more recently introduced targeted therapies is increasingly observed. However, data are sometimes difficult to interpret because they are often presented from the oncological rather than from the nephrological point of view. Because the development of the acute tumor lysis syndrome is one of the major causes of AKI in patients with a high tumor burden or a high cell turnover, the diagnosis, risk factors, and preventive measures of the syndrome will be discussed. Finally, we will briefly discuss renal replacement therapy modalities and the emergence of chronic kidney disease in the growing subgroup of critically ill post-AKI survivors.
Prevention of rhabdomyolysis-induced acute kidney injury - A DASAIM/DSIT clinical practice guideline.
Michelsen Jens,Cordtz Joakim,Liboriussen Lisbeth,Behzadi Meike T,Ibsen Michael,Damholt Mette B,Møller Morten H,Wiis Jørgen
Acta anaesthesiologica Scandinavica
BACKGROUND:Rhabdomyolysis-induced acute kidney injury (AKI) is a common and serious condition. We aimed to summarise the available evidence on this topic and provide recommendations according to current standards for trustworthy guidelines. METHODS:This guideline was developed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The following preventive interventions were assessed: (a) fluids, (b) diuretics, (c) alkalinisation, (d) antioxidants, and (e) renal replacement therapy. Exclusively patient-important outcomes were assessed. RESULTS:We suggest using early rather than late fluid resuscitation (weak recommendation, very low quality of evidence). We suggest using crystalloids rather than colloids (weak recommendation, low quality of evidence). We suggest against routine use of loop diuretics as compared to none (weak recommendation, very low quality of evidence). We suggest against use of mannitol as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of any diuretic as compared to none (weak recommendation, very low quality of evidence). We suggest against routine use of alkalinisation with sodium bicarbonate as compared to none (weak recommendation, low quality of evidence). We suggest against the routine use of any alkalinisation as compared to none (weak recommendation, low quality of evidence). We suggest against routine use of renal replacement therapy as compared to none (weak recommendation, low quality of evidence). For the remaining PICO questions, no recommendations were issued. CONCLUSION:The quantity and quality of evidence supporting preventive interventions for rhabdomyolysis-induced AKI is low/very low. We were able to issue eight weak recommendations and no strong recommendations.
Adherence to guidelines aimed at preventing post-contrast acute kidney injury (PC-AKI) in radiology practices: a survey study.
Dekkers Ilona A,Olchowy Cyprian,Thomsen Henrik S,Molen Aart J van der
Acta radiologica (Stockholm, Sweden : 1987)
BACKGROUND:New insights into post-contrast acute kidney injury (PC-AKI) have recently led to the guidelines on the prevention of PC-AKI being updated. However, little is known about the barriers and facilitators involved in guideline adherence by radiology practices. PURPOSE:To evaluate barriers and facilitators to the adherence of PC-AKI guidelines. MATERIAL AND METHODS:Radiologists visiting the European Society of Urogenital Radiology (ESUR) 2018 meeting, as well as ESUR members were contacted to fill in an electronic questionnaire on the implementation of PC-AKI guidelines applying to their local radiology practices. RESULTS:Of the 145 responding radiologists representing radiology practices, 127 (88%) confirmed having a PC-AKI protocol in place in their radiology practice, of which 61 (48%) used a protocol as specified in a (inter)national guideline. The majority of radiology practices of the respondents used the ESUR guideline (40%). Barriers for not using PC-AKI prevention guidelines were related to a lack of outcome expectancy. Barriers for not using the protocol as specified were related to a lack of agreement with specific recommendations, lack of motivation, guideline-specific factors, and environmental factors. Self-reported facilitators consisted of guideline-specific factors. CONCLUSION:Guidelines for the prevention of PC-AKI seem to be widely implemented among radiology practices, and regularly locally modified because of barriers involved in agreement and behavior. Knowledge of the barriers and facilitators of guideline adherence will aid future efforts aimed at bridging the gap between awareness and implementation of evidence-based guidelines in radiology practices.
Prophylaxis against postcontrast acute kidney injury (PC-AKI): updates in the ESUR guidelines 10.0 and critical review.
Sebastià C,Nicolau C,Martín de Francisco Á L,Poch E,Oleaga L
The European Society of Urogenital Radiology (ESUR) updated its guidelines for prophylaxis against postcontrast acute kidney injury (PC-AKI) in 2018 (ESUR 10.0). These guidelines drastically reduce the indications for prophylaxis against PC-AKI after iodine-based contrast administration, lowering the cutoff for administering prophylaxis to glomerular filtration rates <30ml/min/1.73m and eliminating most of the prior risk factors. Moreover, in cases where prophylaxis is considered necessary, the periods of hydration are shorter than in the previous version. These guidelines have been approved by most radiological societies, although they have also been criticized for excessive relaxation regarding risk factors, especially by the nephrological community. In this article, we critically review the changes to the guidelines.
Outcomes After Kidney injury in Surgery (OAKS): protocol for a multicentre, observational cohort study of acute kidney injury following major gastrointestinal and liver surgery.
INTRODUCTION:Acute kidney injury (AKI) is associated with increased morbidity and mortality following cardiac surgery. Data focusing on the patterns of AKI following major gastrointestinal surgery could inform quality improvement projects and clinical trials, but there is a lack of reliable evidence. This multicentre study aims to determine the incidence and impact of AKI following major gastrointestinal and liver surgery. METHODS AND ANALYSIS:This prospective, collaborative, multicentre cohort study will include consecutive adults undergoing gastrointestinal resection, liver resection or reversal of ileostomy or colostomy. Open and laparoscopic procedures in elective and emergency patients will be included in the study. The primary end point will be the incidence of AKI within 7 days of surgery, identified using an adaptation of the National Algorithm for Detecting Acute Kidney Injury, which is based on the Kidney Disease Improving Global Outcomes (KDIGO) AKI guidelines. Secondary outcomes will include persistent renal dysfunction at discharge and 1 year postoperatively. The 30-day adverse event rate will be measured using the Clavien-Dindo scale. Data on factors that may predispose to the development of AKI will be collected to identify variables associated with AKI. Based on our previous collaborative studies, a minimum of 114 centres are expected to be recruited, contributing over 6500 patients in total. ETHICS AND DISSEMINATION:This study will be registered as clinical audit at each participating hospital. The protocol will be disseminated through local and national medical student networks in the UK and Ireland.
Implementing the Kidney Disease: Improving Global Outcomes/acute kidney injury guidelines in ICU patients.
Hoste Eric A J,De Corte Wouter
Current opinion in critical care
PURPOSE OF REVIEW:Acute kidney injury (AKI) is a frequent finding in critically ill patients and is associated with adverse outcomes. With the purpose of improving outcome of AKI, the Kidney Disease: Improving Global Outcomes (KDIGO) group, a group of experts in critical care nephrology, has presented a set of guidelines in 2012, based on the evidence gathered until mid 2011. This review will update these guidelines with recent evidence. RECENT FINDINGS:Early application of a set of therapeutic measures - a bundle - is advised for the prevention and therapy of AKI. Hemodynamic optimization remains the cornerstone of prevention and treatment of AKI. Fluid resuscitation should be with isotonic crystalloids. Recent evidence demonstrated a higher risk for renal replacement therapy (RRT) and mortality in hydroxyethyl starch-exposed patients. Further, blood pressure should be maintained by the use of vasopressors in vasomotor shock. Nephrotoxic drugs should be avoided or stopped when possible. Contrast-associated AKI should be prevented by prehydration with either NaCl 0.9% or a bicarbonate solution. Other therapies, including intravenous N-acetylcysteine and hemofiltration are not recommended. Optimal timing of RRT remains controversial. Fluid overload remains an important determinant for the initiation of RRT. Continuous therapies are preferred in hemodynamically unstable patients; otherwise, choice of modality does not impact on outcomes. SUMMARY:The KDIGO guidelines as presented in 2012 provide guidelines on the domain of definition of AKI, prevention and treatment, contrast-induced AKI and dialysis interventions for AKI. Especially, early application of a set of measures, the AKI bundle, may prevent AKI and improve outcome.
Haste makes waste-Should current guideline recommendations for initiation of renal replacement therapy for acute kidney injury be changed?
Vanmassenhove Jill,Vanholder Raymond,Van Biesen Wim,Lameire Norbert
Seminars in dialysis
There is broad consensus among guideline organizations that renal replacement therapy (RRT) should not be delayed in case of life-threatening conditions. However, in case of severe acute kidney injury (AKI) without these conditions, it is unclear whether immediate RRT has an advantage over delayed RRT. Two recently published randomized controlled trials (AKIKI and ELAIN) with seemingly opposite results have reignited the discussion whether guideline recommendations on initiation strategies in severe AKI should be adapted. This editorial discusses RRT initiation strategies in severe AKI, based on recent literature and highlights the potential advantages and disadvantages of immediate vs delayed start. Overall, evidence in favor of immediate compared to delayed strategies is sparse and there is wide heterogeneity across studies making it difficult to draw firm conclusions. RRT should not be delayed in case of refractory hyperkalemia, severe metabolic acidosis or pulmonary edema resistant to diuretics. In all other cases, a delayed strategy seems justified and might enhance renal recovery. RRT is not a "it doesn't hurt to try" technique and can expose the patient to a higher risk of bleeding, hemodynamic problems, under-dosing of antibiotics, loss of nutrients, catheter-related complications and the uncertain effects of blood-membrane interactions. There is no compelling reason to change current guideline recommendations and research focus should shift toward the development of algorithms as a decision aid tool for RRT initiation in severe AKI.
Summary of clinical practice guidelines for acute kidney injury.
Walther Carl P,Podoll Amber S,Finkel Kevin W
Hospital practice (1995)
Clinical practice guidelines are intended to standardize the diagnosis and treatment of diseases in order to improve both patient outcomes and resource utilization, using evidence-based criteria. As recently as a decade ago, there was no agreed upon definition of acute kidney injury (AKI), making it difficult to conduct proper clinical studies on the epidemiology and treatment of the disorder. Following the advent of the Risk, Injury, Failure, Loss, and End-stage (RIFLE) criteria for defining AKI, several guidelines for the diagnosis and management of AKI have been developed. In our review, we present a narrative description and comparison of the major published guidelines. Overall, there has been significant agreement among the various guidelines, and each seems well-reasoned and clinically useful. Perhaps the most striking conclusion upon review of the various guidelines is the limited scope of knowledge about optimal management of patients with AKI.
The Japanese clinical practice guideline for acute kidney injury 2016.
Doi Kent,Nishida Osamu,Shigematsu Takashi,Sadahiro Tomohito,Itami Noritomo,Iseki Kunitoshi,Yuzawa Yukio,Okada Hirokazu,Koya Daisuke,Kiyomoto Hideyasu,Shibagaki Yugo,Matsuda Kenichi,Kato Akihiko,Hayashi Terumasa,Ogawa Tomonari,Tsukamoto Tatsuo,Noiri Eisei,Negi Shigeo,Kamei Koichi,Kitayama Hirotsugu,Kashihara Naoki,Moriyama Toshiki,Terada Yoshio,
Clinical and experimental nephrology
Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention is necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.
A European Renal Best Practice (ERBP) position statement on the Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guidelines on Acute Kidney Injury: part 2: renal replacement therapy.
Jörres Achim,John Stefan,Lewington Andrew,ter Wee Pieter M,Vanholder Raymond,Van Biesen Wim,Tattersall James,
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association
This paper provides an endorsement of the KDIGO guideline on acute kidney injury; more specifically, on the part that concerns renal replacement therapy. New evidence that has emerged since the publication of the KDIGO guideline was taken into account, and the guideline is commented on from a European perspective. Advice is given on when to start and stop renal replacement therapy in acute kidney injury; which modalities should be preferentially be applied, and in which conditions; how to gain access to circulation; how to measure adequacy; and which dose can be recommended.
Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine.
Joannidis M,Druml W,Forni L G,Groeneveld A B J,Honore P M,Hoste E,Ostermann M,Oudemans-van Straaten H M,Schetz M
Intensive care medicine
BACKGROUND:Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES:To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. METHOD:A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. RESULTS:We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. CONCLUSION:The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.
Analysis of the short-term prognosis and risk factors of elderly acute kidney injury patients in different KDIGO diagnostic windows.
Li Qinglin,Mao Zhi,Hu Pan,Kang Hongjun,Zhou Feihu
Aging clinical and experimental research
BACKGROUND AND AIMS:Follow-up observation was performed on elderly acute kidney injury (AKI) patients to analyze the short-term prognosis and risk factors of AKI patients in the 48-h diagnostic window and 7-day diagnostic window of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. METHODS:Inpatients aged ≥ 75 years in the geriatric ward of the People's Liberation Army General Hospital, China, between January 2007 and December 2015 were selected as the research subjects. According to two diagnostic criteria in the KDIGO guidelines, patients were divided into a 48-h diagnostic window group and a 7-day diagnostic window group. The medical data of the patients were divided into the death group and the survival group for analysis based on the survival condition of the patients after 90 days of AKI. Factors that affected the 90-day survival of patients in the 48-h diagnostic window and 7-day diagnostic window groups were analyzed using multivariate Cox regression. RESULTS:During the follow-up period, a total of 652 patients were enrolled in this study. Among them, 623 cases were men, accounting for 95.6% of the patients. The median age was 87 (84-91) years. According to the KDIGO staging criteria, there were 308 (47.2%) cases in AKI stage 1, 164 (25.2%) cases in stage 2, and 180 (27.6%) cases in stage 3. Among the 652 patients, 334 (51.2%) were diagnosed with AKI based on the 48-h diagnostic criteria window, and 318 (48.8%) were diagnosed with AKI based on the baseline 7-day diagnostic criteria. The 90-day mortality of AKI patients was 42.5% in the 48-h diagnostic window and 24.2% in the 7-day diagnostic window. The multivariate Cox analysis results showed that low mean arterial pressure (HR = 0.966; P < 0.001), low serum prealbumin level (HR = 0.932; P < 0.001), infection (HR = 1.448; P = 0.047), mechanical ventilation (HR = 1.485; P = 0.038), high blood urea nitrogen (BUN) level (HR = 1.026; P < 0.001), blood magnesium level (HR = 2.560; P = 0.024), and more severe AKI stage (stage 2: HR = 3.482; P < 0.001 and stage 3: HR = 6.267; P < 0.001) were independent risk factors affecting the 90-day mortality of elderly patients in the 48-h diagnostic window, whereas low body mass index (HR = 0.851; P < 0.001), low mean arterial pressure (HR = 0.980; P = 0.036), low serum prealbumin level (HR = 0.950; P = 0.048), low serum albumin level (HR = 0.936; P = 0.015), high BUN level (HR = 1.046; P < 0.001), and more severe AKI stage (stage 2: HR = 4.249; P = 0.001 and stage 3: HR = 9.230; P < 0.001) were independent risk factors affecting the 90-day mortality of elderly patients in the 7-day diagnostic window. CONCLUSIONS:The clinical differences of AKI and risk factors for 90-day mortality in elderly AKI individuals vary depending on the definition used. An increment of Scr ≥ 26.5 μmol/L in 48 h (48-h KDIGO window) alone predicts adverse clinical outcomes.
[Guidelines for the prevention, diagnosis and treatment of acute kidney injury syndromes: Italian version of KDIGO, integrated with new evidence and international commentaries].
Ronco Claudio,Antonelli Massimo,Capasso Giovambattista,De Gaudio Raffaele,Fiaccadori Enrico,Lorini Luca,Mancini Elena,Monti Gianpaola,Morabito Santo,Nalesso Federico,Piccinni Pasquale,Ricci Zaccaria,Romagnoli Stefano,Santoro Antonio,Aresu Stefania,De Rosa Silvia,Samoni Sara,Spinelli Alessandra,Villa Gianluca,Armignacco Paolo,Basile Carlo,Biancofiore Gianni,Cantaluppi Vincenzo,Cerutti Stefania,De Pascalis Antonio,Fumagalli Roberto,Garzotto Francesco,Gaspardone Achille,Genovesi Simonetta,Guggia Silvia,Inguaggiato Paola,Lorenzin Anna,Marenzi Giancarlo,Mariano Filippo,Neri Mauro,Pani Antonello,Pertosa Giovanni,Pistolesi Valentina,Sartori Marco
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia
Clinical use of [TIMP-2]•[IGFBP7] biomarker testing to assess risk of acute kidney injury in critical care: guidance from an expert panel.
Guzzi Louis M,Bergler Tobias,Binnall Brian,Engelman Daniel T,Forni Lui,Germain Michael J,Gluck Eric,Göcze Ivan,Joannidis Michael,Koyner Jay L,Reddy V Seenu,Rimmelé Thomas,Ronco Claudio,Textoris Julien,Zarbock Alexander,Kellum John A
Critical care (London, England)
BACKGROUND:The first FDA-approved test to assess risk for acute kidney injury (AKI), [TIMP-2]•[IGFBP7], is clinically available in many parts of the world, including the USA and Europe. We sought to understand how the test is currently being used clinically. METHODS:We invited a group of experts knowledgeable on the utility of this test for kidney injury to a panel discussion regarding the appropriate use of the test. Specifically, we wanted to identify which patients would be appropriate for testing, how the results are interpreted, and what actions would be taken based on the results of the test. We used a modified Delphi method to prioritize specific populations for testing and actions based on biomarker test results. No attempt was made to evaluate the evidence in support of various actions however. RESULTS:Our results indicate that clinical experts have developed similar practice patterns for use of the [TIMP-2]•[IGFBP7] test in Europe and North America. Patients undergoing major surgery (both cardiac and non-cardiac), those who were hemodynamically unstable, or those with sepsis appear to be priority patient populations for testing kidney stress. It was agreed that, in patients who tested positive, management of potentially nephrotoxic drugs and fluids would be a priority. Patients who tested negative may be candidates for "fast-track" protocols. CONCLUSION:In the experience of our expert panel, biomarker testing has been a priority after major surgery, hemodynamic instability, or sepsis. Our panel members reported that a positive test prompts management of nephrotoxic drugs as well as fluids, while patients with negative results are considered to be excellent candidates for "fast-track" protocols.
[New KDIGO guidelines on acute kidney injury. Practical recommendations].
Zarbock A,John S,Jörres A,Kindgen-Milles D,
The incidence of acute kidney injury (AKI) in critically ill patients is very high and is associated with an increased morbidity and mortality. In 2012 the Kidney Disease: Improving Global Outcome (KDIGO) guidelines were published in which evidence-based practical recommendations are given for the evaluation and management of patients with AKI. The first section of the KDIGO guidelines deals with the unification of earlier consensus definitions and staging criteria for AKI. The subsequent sections of the guidelines cover the prevention and treatment of AKI as well as the management of renal replacement therapy (RRT) in patients with AKI. In each section the existing evidence is discussed and a specific treatment recommendation is given. The guidelines appreciates that there is insufficient evidence for many of the recommendations. As a specific pharmacological therapy is missing, an early diagnosis, aggressive hemodynamic optimization, tight volume control, and avoidance of nephrotoxic drugs are the only interventions to prevent AKI. If renal replacement therapy is required different modalities are available to provide an effective therapy with a low rate of adverse effects.