2. Epidemiology
5-7% of hospitalized patients
Up to 30% of patients in ICU
Harrison’s principle of Internal medicine 19 th ed.,2015
Volume depletion
Adverse effects of medications
Obstruction of the urinary tract
Common causes of community-acquired AKI
Sepsis
Major surgical procedures
Critical illness :heart or liver failure
CI-AKI
Nephrotoxic medication
Common causes of hospital-acquired AKI
3. Definition
Increased in SCr by ≥ 0.3 mg/dl (≥ 26.5 µmol/l) within 48 hour
Increased in SCr to ≥ 1.5 times baseline, which is known or
presumed to have occurred within the prior 7 days
Urine volume < 0.5 ml/kg/h for 6 hours.
KDIGO AKI,2012
8. Novel biomarker for AKI
NGAL (Neutrophil Gelatinase- Associated Lipocalin)
KIM-1
IL-18
Cystatin C
L – type fatty acid binding protein (L-FABP)
KDIGO AKI,2012
11. IGFBP7 (insulin-like growth factor-binding protein 7)
TIMP-2 (tissue inhibitor of metalloproteinase-2)
Diagnosis : [TIMP-2]・[IGFBP7] > 0.3 (ng/ml)(2)/1,000
predicts moderate to severe AKI (stage 2-3) within 12 h
AKI : Urinary Biomarkers
Kashani K. Crit Care. 2013;6;17(1):R25.
Bihorac A. Am J Respir Crit Care Med. 2014;189(8):932-9.
33. Step to approach azotemia
Step 1: Exclude and correct pseudoazotemia
Step 2: Classification AKI, AKI on top CKD, CKD progression
Step 3: Finding postrenal AKI and correction
Step 4: Find and correct intrinsic renal causes of AKI
Step 5: Prerenal AKI vs ATN
Step 6: Dialysis if indicated
Adapted from KDIGO guidelines 2012
Step approach to AKI
36. Management of AKI
Specific treatment is not available for the majority of forms of AKI.
Supportive therapy to ameliorate derangements of fluid and
electrolyte homeostasis and prevent uremic complications.
Elimination of nephrotoxic agents (ACE inhibitors, ARBs,
NSAIDs, aminoglycoside, amphotericin B)
KDIGO AKI,2012
37. Management of AKI
Initiation of renal replacement therapy when indicated.
The ultimate goals of management are to prevent death,
facilitate recovery of kidney function, and minimize the risk of
CKD.
KDIGO AKI,2012
38. Hemodynamic monitoring and support for
prevention and management of AKI
In the absence of hemorrhagic shock, KDIGO 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)
KDIGO recommend the use of vasopressors in conjunction
with fluids in patients with vasomotor shock with or at risk for
AKI. (1C)
KDIGO AKI,2012
39. Hemodynamic monitoring and support for
prevention and management of AKI
KDIGO 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).
KDIGO AKI,2012
40. Glycemic control and nutritional support
In critically ill patients, KDIGO suggest insulin therapy targeting
plasma glucose 110–149 mg/dl (6.1–8.3 mmol/l). (2C)
KDIGO suggest achieving a total energy intake of 20–30
kcal/kg/d in patients with any stage of AKI. (2C)
KDIGO suggest to avoid restriction of protein intake with the
aim of preventing or delaying initiation of RRT. (2D)
KDIGO AKI,2012
41. KDIGO suggest administering
0.8–1.0 g/kg/d of protein in noncatabolic AKI patients without
need for dialysis (2D)
1.0–1.5 g/kg/d in patients with AKI on RRT (2D)
Up to a maximum of 1.7 g/kg/d in patients on continuous renal
replacement therapy (CRRT) and in hypercatabolic patients.
(2D)
KDIGO suggest providing nutrition preferentially via the enteral
route in patients with AKI. (2C)
KDIGO AKI,2012
Glycemic control and nutritional support
42. Use of diuretic in AKI
KDIGO recommend not using diuretics to prevent AKI. (1B)
Suggest not using diuretics to treat AKI, except in the
management of volume overload. (2C)
KDIGO AKI,2012
43. Vasodilator therapy
KDIGO recommend not using low-dose dopamine to prevent or
treat AKI. (1A)
Suggest not using fenoldopam to prevent or treat AKI. (2C)
Suggest not using atrial natriuretic peptide (ANP) to prevent
(2C) or treat (2B) AKI.
KDIGO AKI,2012
45. Adenosine receptor antagonist
KDIGO suggest that a single dose of theophylline may be given
in neonates with severe perinatal asphyxia who are at high risk
of AKI. (2B)
KDIGO AKI,2012
46. Prevention of aminoglycoside and amphotericin
related AKI
KDIGO suggest not using aminoglycosides for the treatment of
infections unless no suitable, less nephrotoxic, therapeutic
alternatives are available. (2A)
KDIGO suggest that, in patients with normal kidney function in
steady state, aminoglycosides are administered as a single
dose daily rather than multiple-dose daily treatment regimens.
(2B)
KDIGO AKI,2012
47. KDIGO recommend monitoring aminoglycoside drug levels when
treatment with multiple daily dosing is used for more than 24 hours. (1A)
Suggest monitoring aminoglycoside drug levels when treatment with
single-daily dosing is used for more than 48 hours. (2C)
Suggest using topical or local applications of aminoglycosides (e.g.,
respiratory aerosols, instilled antibiotic beads), rather than i.v. application,
when feasible and suitable. (2B)
KDIGO AKI,2012
Prevention of aminoglycoside and amphotericin
related AKI
48. KDIGO suggest using lipid formulations of amphotericin B
rather than conventional formulations of amphotericin B. (2A)
In the treatment of systemic mycoses or parasitic infections,
KDIGO recommend using azole antifungal agents and/or the
echinocandins rather than conventional amphotericin B, if equal
therapeutic efficacy can be assumed. (1A)
KDIGO AKI,2012
Prevention of aminoglycoside and amphotericin
related AKI
49. Other method of prevention of AKI
in the critically ill
KDIGO suggest that off-pump coronary artery bypass graft
surgery not be selected solely for the purpose of reducing
perioperative AKI or need for RRT. (2C)
Suggest not using NAC to prevent AKI in critically ill patients
with hypotension. (2D)
KDIGO recommend not using oral or i.v. NAC for prevention of
postsurgical AKI. (1A)
KDIGO AKI,2012
52. Contrast induced AKI
Define and stage AKI after administration of intravascular
contrast media as per Recommendations (Not Graded)
In individuals who develop changes in kidney function after
administration of intravascular contrast media, evaluate for CI-
AKI as well as for other possible causes of AKI. (Not Graded)
KDIGO AKI,2012
53. Assess the risk for CI-AKI and, in particular, screen for pre-
existing impairment of kidney function in all patients who are
considered for a procedure that requires intravascular (i.v. or i.a.)
administration of iodinated contrast medium. (Not Graded)
Risk factors
Pre-existing CKD
Diabetes mellitus
Advanced CHF
High dose contrast media
Hemodynamic instability
KDIGO AKI,2012
Contrast induced AKI
54. Consider alternative imaging methods in patients at increased
risk for CI-AKI. (Not Graded)
KDIGO AKI,2012
Contrast induced AKI
55. Nonpharmacological prevention
strategies of CI-AKI
Use the lowest possible dose of contrast medium in patients at
risk for CI-AKI. (Not Graded)
KDIGO recommend using either iso-osmolar or low osmolar
iodinated contrast media rather than high- osmolar iodinated
contrast media in patients at increased risk of CI-AKI. (1B)
KDIGO AKI,2012
56. Pharmacological prevention
strategies of CI-AKI
KDIGO recommend i.v. volume expansion with either isotonic
sodium chloride or sodium bicarbonate solutions rather than no i.v.
volume expansion, in patients at increased risk for CI-AKI. (1A)
Recommend not using oral fluids alone in patients at increased risk
of CI-AKI. (1C)
KDIGO AKI,2012
57. KDIGO suggest using oral NAC together with i.v. isotonic
crystalloids in patients at increased risk of CI-AKI. (2D)
Suggest not using theophylline to prevent CI-AKI. (2C)
Recommend not using fenoldopam to prevent CI-AKI. (1B)
Pharmacological prevention
strategies of CI-AKI
KDIGO AKI,2012
58. Effects of hemodialysis
or hemofiltration
KDIGO suggest not using prophylactic intermittent
hemodialysis (IHD) or hemofiltration (HF) for contrast-media
removal in patients at increased risk for CI-AKI. (2C)
KDIGO AKI,2012
59. Indications for acute renal
replacement therapy
A : metabolic Acidosis
E : Electrolyte imbalance
I : Intoxication / Ingestion of toxic substance
O : fluid Overload that is refractory to diuretics
U : signs of Uremia
KDIGO AKI,2012
62. Vascular access for renal replacement
therapy in AKI
When choosing a vein for insertion of a dialysis catheter in
patients with AKI, consider these preferences (Not Graded):
First choice: right jugular vein
Second choice: femoral vein
Third choice: left jugular vein
Last choice: subclavian vein
KDIGO AKI,2012
63. AKI : TREATMENT
Specific Rx : Rx cause of AKI
Supportive Rx
1. Maintain hemodynamic and oxygenation
2. Monitor VS, I/O, BW
3. Monitor BUN, Cr, electrolyte,…
4. Discontinue all nephrotoxic agents
5. Nutrition : prefer enteral route
6. Total energy intake 20-30 kcal/kg/day
7. Protein intake g/kg/day
Non-catabolic 0.8-1.0
RRT 1.0-1.5
CRRT, Hypercatabolic up to a max. of 1.7
8. In critically ill patients : insulin therapy targeting PG 110-149 mg/dL
Take home messages
KDIGO AKI,2012
Brenner and Rector’s The kidney 9th edition
64. 9. HypoNa : free water restriction < 1 L/day
10. Volume overload : salt restriction < 1.0-1.5 g/day, furosemide 200 mg iv bolus or 20 mg/h iv
11. Not using diuretics to enhance kidney function recovery or to reduce the duration or
frequency of RRT
12. Not using low-dose dopamine, fenoldopam, ANP, rh IGF-1
13. HyperK : K diet restriction, off ACEI & ARB & K-sparing diuretics, medical Rx
14. Metabolic acidosis : NaHCO3 if pH < 7.15
15. HypoCa : CaCO3 if symptomatic or NaHCO3 to be administered
16. HyperP : P diet restriction, P binders
17. HyperMg : avoid Mg-containing medications
18. Hyperuricemia : usually mild (< 15 mg/dL),if severe add allopurinol, or recombinant uricase
19. Check for changes of drug dosing
20. RRT when indicated
Take home messages
KDIGO AKI,2012
Brenner and Rector’s The kidney 9th edition
