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Management of Acute Kidney Injury

Relieving urological obstruction

Refer all adults, children and young people with upper tract
urological obstruction to a urologist. Refer immediately when one
or more of the following is present:
o Pyonephrosis
o an obstructed solitary kidney
o bilateral upper urinary tract obstruction
o complications of acute kidney injury caused by urological
obstruction.
When nephrostomy or stenting is used to treat upper tract
urological obstruction in adults, children and young people with
acute kidney injury, undertake as soon as possible and within 12
hours of diagnosis.

Pharmacological management
Do not routinely offer loop diuretics to treat acute kidney injury.
Consider loop diuretics for treating fluid overload or oedema
while:
o an adult, child or young person is awaiting renal
replacement therapy, or
o renal function is recovering in an adult, child or young
person not receiving renal replacement therapy.
Do not offer low-dose dopamine to treat acute kidney injury.
Referring for renal replacement therapy

Discuss any potential indications for renal replacement therapy


with a nephrologist, paediatric nephrologist and/or critical care
specialist immediately to ensure that the therapy is started as
soon as needed.
When an adult, child or young person has significant
comorbidities, discuss with them and/or their parent or carer and
within the multidisciplinary team whether renal replacement
therapy would offer benefit.

Refer adults, children and young people immediately for renal


replacement therapy if any of the following are not responding to
medical management: (1.5.8)
o Hyperkalaemia
o metabolic acidosis
o symptoms or complications of uraemia (for example,
pericarditis or encephalopathy)
o fluid overload
o pulmonary oedema.
Base the decision to start renal replacement therapy on the
condition of the adult, child or young person as a whole and not
on an isolated urea, creatinine or potassium value.
When there are indications for renal replacement therapy, the
nephrologist and/or critical care specialist should discuss the
treatment with the adult, child or young person and/or their
parent or carer as soon as possible and before starting treatment

Referring to nephrology
Refer adults, children and young people with acute kidney injury
to a nephrologist, paediatric nephrologist or critical care
specialist immediately if they meet criteria for renal replacement
therapy in recommendation 1.5.8.
Do not refer adults, children or young people to a nephrologist or
paediatric nephrologist when there is a clear cause for acute
kidney injury and the condition is responding promptly to medical
management, unless they have a renal transplant.
Consider discussing management with a nephrologist or
paediatric nephrologist when an adult, child or young person with
severe illness might benefit from treatment, but there is
uncertainty as to whether they are nearing the end of their life.
Refer adults, children and young people in intensive care to a
nephrology team when there is uncertainty about the cause of
acute kidney injury or when specialist management of kidney
injury might be needed.

Discuss the management of acute kidney injury with a


nephrologist or paediatric nephrologist as soon as possible and
within 24 hours of detection when one or more of the following is
present:
o a possible diagnosis that may need specialist treatment
(for
example,
vasculitis,
glomerulonephritis,
tubulointerstitial nephritis or myeloma)
o acute kidney injury with no clear cause
o inadequate response to treatment
o complications associated with acute kidney injury
o stage 3 acute kidney injury (according to (p)RIFLE, AKIN or
KDIGO criteria)
o a renal transplant
o chronic kidney disease stage 4 or 5.
Monitor[7] serum creatinine after an episode of acute kidney
injury. Consider referral to a nephrologist or paediatric
nephrologist when eGFR is 30 ml/min/ 1.73 m2 or less in adults,
children and young people who have recovered from an acute
kidney injury.
Consider referral to a paediatric nephrologist for children and
young people who have recovered from an episode of acute
kidney injury but have hypertension, impaired renal function or
1+ or greater proteinuria on dipstick testing of an early morning
urine sample.
HEMODYNAMIC MONITORING AND MANAGEMENT OF AKI
Patients with AKI and at increased risk for AKI require careful attention to
be paid to their hemodynamic status. This is first because hypotension
results in decreased renal perfusion and, if severe or sustained, may
result in kidney injury. Second, the injured kidney loses autoregulation of
blood flow, a mechanism that maintains relatively constant flow despite
changes in pressure above a certain point (roughly, a mean of 65mm
Hg).
Management of blood pressure and cardiac output require careful
titration of fluids and vasoactive medication. Vasopressors can further
reduce blood flow to the tissues if there is insufficient circulating blood
volume.
Fluids

In the absence of hemorrhagic shock, we suggest using isotonic


crystalloids rather than colloids (albumin or starches) as initial
management for expansion of intravascular volume in patients at
risk for AKI or with AKI. (2B)

Vassopressor
We recommend the use of vasopressors in conjunction with fluids
in patients with vasomotor shock with, or at risk for, AKI. (1C)
Protocolized hemodynamic management
We suggest using protocol-based management of hemodynamic
and oxygenation parameters to prevent development or
worsening of AKI in high-risk patients in the perioperative setting
(2C) or in patients with septic shock (2C).
GENERAL SUPPORTIVE MANAGEMENT OF PATIENTS WITH AKI
For many patients, many of the supportive therapies will continue even
if AKI develops. Furthermore, an important goal of early management of
AKI is to prevent further injury and to facilitate recovery of renal
function. These goals can often best be achieved by strict attention to
supportive therapy. However, as renal function deteriorates,
complications arise that require different management.
Particular attention should be given to the assessment of the circulating
volume and fluid administration, the prevention and/or treatment of
hyperkalemia and metabolic acidosis, the knowledge of the changes in
pharmacokinetics of many drugs with discontinuation of all potentially
nephrotoxic drugs, and dose adaptation of drugs excreted by the
kidneys to the patients renal function.
DIURETICS USE IN AKI
Diuretics are frequently used in patients at risk of AKI, and in the
management of those who develop AKI. Since fluid overload is one of
the major symptoms of AKI, diuretics are often used for patients with AKI
to facilitate fluid management.
In addition, oliguric AKI has a worse prognosis than nonoliguric AKI and
physicians often prescribe diuretics to convert oliguric to nonoliguric AKI.
Diuretics are also used to control fluid balance and permit administration
of nutrition and medications. Furthermore, several diuretics have
potentially renoprotective effects that might prevent development of AKI
and hasten its recovery.

However, diuretics can also be harmful, by reducing the circulating


volume excessively and adding a prerenal insult, worsening established
AKI. Therefore, it is essential to evaluate usefulness of diuretics to
improve outcome of patients with AKI, not just for fluid management.

We recommend not using diuretics to prevent AKI. (1B)


We suggest not using diuretics to treat AKI, except in the
management of volume overload. (2C)

VASODILATOR THERAPY, GROWTH FACTOR INTERVENTION &


ADENOSINE RECEPTOR ANTAGONISTS

We recommend not using low-dose dopamine to prevent or treat


AKI
We suggest not using fenoldopam to prevent or treat AKI.
We suggest not using atrial natriuretic peptide (ANP) to prevent
(2C) or treat (2B) AKI.
We recommend not using recombinant human (rh)IGF-1 to
prevent or treat AKI
We suggest that a single dose of theophylline may be given in
neonates with severe perinatal asphyxia, who are at high risk of
AKI

DIALYSIS INTERVENTIONS FOR TREATMENT OF AKI


In the presence of AKI complications such as hypervolemia eg, acute
pulmonary edema or large cumulative positive fluid balance,
hyperkalemia, metabolic acidosis (pH less than 7.1) and uremic
symptoms (persistent nausea and vomiting, pericarditis, neuropathy, or
an otherwise unexplained decline in mental status) dialysis should be
considered as a mainstay therapy.
The main considerations when starting a patient with AKI on dialysis are
the following:
1) timing of initiation of dialysis,
2) the modality of dialysis, and
3) dose of dialysis.
Timing of initiation of dialysis
The optimal timing of dialysis for AKI is not defined. In current practice,
the decision to start RRT is based most often on clinical features of
volume overload and biochemical features of solute imbalance
(azotemia, hyperkalemia, severe acidosis). However, in the absence of
these factors there is generally a tendency to avoid dialysis as

long as possible, a thought process that reflects the decisions made


for patients with CKD Stage 5.
Clinicians tend to delay RRT when they suspect that patients may
recover on their own, and because of concern for the well-known risks
associated with the RRT procedure, including hypotension, arrhythmia,
membrane bioincompatibility, and complications of vascular access and
anticoagulant administration
Initiate RRT emergently when life-threatening changes in fluid,
electrolyte, and acid-base balance exist. (Not Graded)
Consider the broader clinical context, the presence of conditions
that can be modified with RRT, and trends of laboratory tests
rather than single BUN and creatinine thresholds alonewhen
making the decision to start RRT. (Not Graded)
Criteria for stopping RRT
Discontinue RRT when it is no longer required, either because
intrinsic kidney function has recovered to the point that it is
adequate to meet patient needs, or because RRT is no longer
consistent with the goals of care. (Not Graded)
We suggest not using diuretics to enhance kidney function
recovery, or to reduce the duration or frequency of RRT.
Modality of Dialysis
In current clinical practice, the choice of the initial modality for RRT is
primarily based on the availability of, and experience with, a specific
treatment and on the patients hemodynamic status. Modalities of RRT
include intermittent hemodialysis (IHD), continuous renal replacement
therapies (CRRTs), and hybrid therapies, such as sustained low-efficiency
dialysis (SLED).
Use continuous and intermittent RRT as complementary
therapies in AKI patients. (Not Graded)
We suggest using CRRT, rather than standard intermittent RRT,
for hemodynamically unstable patients.
We suggest using CRRT, rather than intermittent RRT, for AKI
patients with acute brain injury or other causes of increased
intracranial pressure or generalized brain edema.

Dose of Dialysis

The dose of RRT to be delivered should be prescribed before


starting each session of RRT. (Not Graded) We recommend
frequent assessment of the actual delivered dose in order to
adjust the prescription. (1B)
Provide RRT to achieve the goals of electrolyte, acid-base, solute,
and fluid balance that will meet the patients needs.
We recommend delivering a Kt/V of 3.9 per week when using
intermittent or extended RRT in AKI. (1A)
We recommend delivering an effluent volume of 2025 ml/kg/h
for CRRT in AKI (1A). This will usually require a higher prescription
of effluent volume. (Not Graded)

Source :
KDIGO Clinical Practice Guideline for Acute Kidney Injury, Volume 2 Issue
1 March 2012
NICE Clinical Guidelines. Prevention, detection and management of
acute kidney injury up to the point of renal replacement therapy, Issued:
August 2013
International Journal of Nephrology and Renovascular Disease : Update
on the diagnosis and management of acute kidney injury