Skip to main content
SpringerLink
Log in

Management of Acute Kidney Injury

  • Chapter
  • First Online:
Evidence-Based Critical Care

  • 366 Accesses

Abstract

Acute Kidney Injury (AKI) in the ICU is commonly caused by hypotension, shock, inflammation, and microcirculatory dysfunction. Reversal of shock through intravenous fluids and vasopressors while avoiding harm from volume overload is the first step in management of AKI. Ascertainment of other underlying causes such as drug or contrast induced nephrotoxicity, urinary tract obstruction or glomerular disease is important, as specific treatments of those conditions might reverse AKI. Efforts are made to prevent further injury and adjust dosage of renally excreted medications. Complications of AKI include volume overload, hyperkalemia, metabolic acidosis, hyperphosphatemia, hypocalcemia and bleeding disorders. Their management is an integral part of treating AKI. Renal replacement therapy is instituted when or preferably before complications from AKI arise despite medical management. Both intermittent hemodialysis and continuous renal replacement therapy are acceptable modalities for dialysis in AKI. Higher doses of renal replacement therapy do not seem to improve outcomes, and prophylactic use of dialysis continues to be a subject of debate. Crystalloids are the fluid type of choice. Concerns have been raised about the safety of hyperchloremic solutions such as normal saline, but more physiologically balanced solutions such as lactated Ringer’s or plasmalyte have yet to show an improvement in hard outcomes. Nutritional support and tight glycemic control in patients with AKI is important but requires further delineation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Uchino S, et al. Acute renal failure in critically ill patients: a multinational multicenter study. JAMA. 2005;294:813–8.

    Article  CAS  Google Scholar 

  2. Srisawat N, et al. Urinary biomarkers and renal recovery in critically ill patients with renal support. Clin J Am Soc Nephrol. 2011;6:1815–23.

    Article  CAS  Google Scholar 

  3. Bellomo R, Wan L, May C. Vasoactive drugs and acute kidney injury. Crit Care Med. 2008;36:S179–86.

    Article  CAS  Google Scholar 

  4. Bellomo R, Kellum JA, Wisniewski SR, Pinsky MR. Effects of norepinephrine on the renal vasculature in normal and endotoxemic dogs. Am J Respir Crit Care Med. 1999;159:1186–92.

    Article  CAS  Google Scholar 

  5. Nassar Junior AP, Farias AQ, D’Albuquerque LAC, Carrilho FJ, Malbouisson LMS. Terlipressin versus norepinephrine in the treatment of hepatorenal syndrome: a systematic review and meta-analysis. PLoS One. 2014;9:e107466.

    Article  Google Scholar 

  6. Bellomo R. The epidemiology of acute renal failure: 1975 versus 2005. Curr Opin Crit Care. 2006;12:557–60.

    Article  Google Scholar 

  7. Licurse A, et al. Renal ultrasonography in the evaluation of acute kidney injury: developing a risk stratification framework. Arch Intern Med. 2010;170:1900–7.

    PubMed  Google Scholar 

  8. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group. KDIGO clinical practice guideline for glomerulonephritis. Kidney Int Suppl. 2012;2:139–274.

    Article  Google Scholar 

  9. Shaw DR, Kessel DO. The current status of the use of carbon dioxide in diagnostic and interventional angiographic procedures. Cardiovasc Intervent Radiol. 2006;29:323–31.

    Article  Google Scholar 

  10. Cox ZL, et al. Adverse drug events during AKI and its recovery. Clin J Am Soc Nephrol. 2013;8:1070–8.

    Article  CAS  Google Scholar 

  11. Karajala V, Mansour W, Kellum JA. Diuretics in acute kidney injury. Minerva Anestesiol. 2009;75:251–7.

    CAS  PubMed  Google Scholar 

  12. Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1–138.

    Article  Google Scholar 

  13. Mehta RL, Pascual MT, Soroko S, Chertow GM. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA. 2002;288:2547–53.

    Article  CAS  Google Scholar 

  14. Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD. Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol. 2011;6:966–73.

    Article  Google Scholar 

  15. Blumberg A, Weidmann P, Ferrari P. Effect of prolonged bicarbonate administration on plasma potassium in terminal renal failure. Kidney Int. 1992;41:369–74.

    Article  CAS  Google Scholar 

  16. Allon M, Shanklin N. Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. Am J Kidney Dis. 1996;28:508–14.

    Article  CAS  Google Scholar 

  17. Marsh JD, Margolis TI, Kim D. Mechanism of diminished contractile response to catecholamines during acidosis. Am J Phys. 1988;254:H20–7.

    Article  CAS  Google Scholar 

  18. Vinsonneau C, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet (London, England). 2006;368:379–85.

    Article  Google Scholar 

  19. Schneider AG, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med. 2013;39:987–97.

    Article  CAS  Google Scholar 

  20. Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis. 2004;44:1000–7.

    Article  Google Scholar 

  21. Palevsky PM, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359:7–20.

    Article  CAS  Google Scholar 

  22. Finfer S, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350:2247–56.

    Article  CAS  Google Scholar 

  23. Brunkhorst FM, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358:125–39.

    Article  CAS  Google Scholar 

  24. Wiedermann CJ. Systematic review of randomized clinical trials on the use of hydroxyethyl starch for fluid management in sepsis. BMC Emerg Med. 2008;8:1.

    Article  Google Scholar 

  25. Yunos NM, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308:1566–72.

    Article  CAS  Google Scholar 

  26. Young P, et al. Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit. JAMA. 2015;314(16):1701–10. https://doi.org/10.1001/jama.2015.12334.

    Article  CAS  PubMed  Google Scholar 

  27. O’Malley CMN, et al. A randomized, double-blind comparison of lactated Ringer’s solution and 0.9% NaCl during renal transplantation. Anesth Analg. 2005;100:1518–24, table of contents

    Article  Google Scholar 

  28. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264–70.

    Article  CAS  Google Scholar 

  29. Harvey SE, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014;371:1673–84.

    Article  Google Scholar 

  30. Fiaccadori E, et al. Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study. J Am Soc Nephrol. 1999;10:581–93.

    Article  CAS  Google Scholar 

  31. Metnitz PGH, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med. 2002;30:2051–8.

    Article  Google Scholar 

  32. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78:1471–8.

    Article  Google Scholar 

  33. Van den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67.

    Article  Google Scholar 

  34. Finfer S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.

    Article  Google Scholar 

  35. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet (London, England). 2000;356:2139–43.

    Article  CAS  Google Scholar 

  36. Gaudry S, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375:122–33.

    Article  Google Scholar 

  37. Barbar SD, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018;379:1431–42.

    Article  CAS  Google Scholar 

  38. Zarbock A, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury. JAMA. 2016;315:2190.

    Article  CAS  Google Scholar 

  39. Smith OM, et al. Standard versus accelerated initiation of renal replacement therapy in acute kidney injury (STARRT-AKI): study protocol for a randomized controlled trial. Trials. 2013;14:320.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Nephrology Division, Washington University, St. Louis, MO, USA

    Fadi A. Tohme

  2. Critical Care Research, Center for Critical Care Nephrology, Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    John A. Kellum

Authors
  1. Fadi A. Tohme
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. John A. Kellum
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John A. Kellum .

Editor information

Editors and Affiliations

  1. Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA

    Robert C. Hyzy

  2. Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA

    Jakob McSparron

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Tohme, F.A., Kellum, J.A. (2020). Management of Acute Kidney Injury. In: Hyzy, R.C., McSparron, J. (eds) Evidence-Based Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-030-26710-0_46

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-26710-0_46

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-26709-4

  • Online ISBN: 978-3-030-26710-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation