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Management of Acute Kidney Injury

  • Fadi A. Tohme
  • John A. KellumEmail author
Chapter
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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.

Keywords

Acute kidney injury Intravenous fluids Diuretics Dialysis Renal replacement therapy 

References

  1. 1.
    Uchino S, et al. Acute renal failure in critically ill patients: a multinational multicenter study. JAMA. 2005;294:813–8.CrossRefGoogle Scholar
  2. 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.CrossRefGoogle Scholar
  3. 3.
    Bellomo R, Wan L, May C. Vasoactive drugs and acute kidney injury. Crit Care Med. 2008;36:S179–86.CrossRefGoogle Scholar
  4. 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.CrossRefGoogle Scholar
  5. 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.CrossRefGoogle Scholar
  6. 6.
    Bellomo R. The epidemiology of acute renal failure: 1975 versus 2005. Curr Opin Crit Care. 2006;12:557–60.CrossRefGoogle Scholar
  7. 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.PubMedGoogle Scholar
  8. 8.
    Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group. KDIGO clinical practice guideline for glomerulonephritis. Kidney Int Suppl. 2012;2:139–274.CrossRefGoogle Scholar
  9. 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.CrossRefGoogle Scholar
  10. 10.
    Cox ZL, et al. Adverse drug events during AKI and its recovery. Clin J Am Soc Nephrol. 2013;8:1070–8.CrossRefGoogle Scholar
  11. 11.
    Karajala V, Mansour W, Kellum JA. Diuretics in acute kidney injury. Minerva Anestesiol. 2009;75:251–7.PubMedGoogle Scholar
  12. 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.CrossRefGoogle Scholar
  13. 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.CrossRefGoogle Scholar
  14. 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.CrossRefGoogle Scholar
  15. 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.CrossRefGoogle Scholar
  16. 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.CrossRefGoogle Scholar
  17. 17.
    Marsh JD, Margolis TI, Kim D. Mechanism of diminished contractile response to catecholamines during acidosis. Am J Phys. 1988;254:H20–7.CrossRefGoogle Scholar
  18. 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.CrossRefGoogle Scholar
  19. 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.CrossRefGoogle Scholar
  20. 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.CrossRefGoogle Scholar
  21. 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.CrossRefGoogle Scholar
  22. 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.CrossRefGoogle Scholar
  23. 23.
    Brunkhorst FM, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358:125–39.CrossRefGoogle Scholar
  24. 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.CrossRefGoogle Scholar
  25. 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.CrossRefGoogle Scholar
  26. 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.CrossRefPubMedGoogle Scholar
  27. 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 contentsCrossRefGoogle Scholar
  28. 28.
    Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264–70.CrossRefGoogle Scholar
  29. 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.CrossRefGoogle Scholar
  30. 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.PubMedGoogle Scholar
  31. 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.CrossRefGoogle Scholar
  32. 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.CrossRefGoogle Scholar
  33. 33.
    Van den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67.CrossRefGoogle Scholar
  34. 34.
    Finfer S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.CrossRefGoogle Scholar
  35. 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.CrossRefGoogle Scholar
  36. 36.
    Gaudry S, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375:122–33.CrossRefGoogle Scholar
  37. 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.CrossRefGoogle Scholar
  38. 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.CrossRefGoogle Scholar
  39. 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.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Nephrology DivisionWashington UniversitySt. LouisUSA
  2. 2.Critical Care Research, Center for Critical Care Nephrology, Critical Care MedicineUniversity of PittsburghPittsburghUSA

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