This document provides guidelines for the prevention and management of acute kidney injury (AKI) developed by the Kidney Disease: Improving Global Outcomes (KDIGO) organization. It defines AKI and provides recommendations on risk assessment, evaluation and general management, prevention strategies, renal replacement therapy interventions, and specific settings like contrast-induced AKI. The guidelines were developed by an international work group and evidence review team with the aim of standardizing and improving care for AKI globally.
Acute Kidney Injury epidemiology, pathophysiology and management based on current evidence. The presentation is suitable for internal medicine trainees and nephrology fellows.
Acute Kidney Injury epidemiology, pathophysiology and management based on current evidence. The presentation is suitable for internal medicine trainees and nephrology fellows.
Acute kidney injury, previously known as acute renal failure, encompasses a wide spectrum of injury to the kidneys, not just kidney failure. The definition of acute kidney injury has changed in recent years, and detection is now mostly based on monitoring creatinine levels, with or without urine output. Acute kidney injury is increasingly being seen in primary care in people without any acute illness, and awareness of the condition needs to be raised among primary care health professionals.
Acute kidney injury is seen in 13–18% of all people admitted to hospital, with older adults being particularly affected. These patients are usually under the care of healthcare professionals practising in specialties other than nephrology, who may not always be familiar with the optimum care of patients with acute kidney injury. The number of inpatients affected by acute kidney injury means that it has a major impact on healthcare resources. The costs to the NHS of acute kidney injury (excluding costs in the community) are estimated to be between £434 million and £620 million per year, which is more than the costs associated with breast cancer, or lung and skin cancer combined.
Previously termed acute renal failure
Reversible deterioration of renal function over hours to days manifested by:
Increase in BUN
Increase in creatinine
Reduced urine output
Oliguria : <400><100 ml urine output in 24 hours
Acute kidney injury, previously known as acute renal failure, encompasses a wide spectrum of injury to the kidneys, not just kidney failure. The definition of acute kidney injury has changed in recent years, and detection is now mostly based on monitoring creatinine levels, with or without urine output. Acute kidney injury is increasingly being seen in primary care in people without any acute illness, and awareness of the condition needs to be raised among primary care health professionals.
Acute kidney injury is seen in 13–18% of all people admitted to hospital, with older adults being particularly affected. These patients are usually under the care of healthcare professionals practising in specialties other than nephrology, who may not always be familiar with the optimum care of patients with acute kidney injury. The number of inpatients affected by acute kidney injury means that it has a major impact on healthcare resources. The costs to the NHS of acute kidney injury (excluding costs in the community) are estimated to be between £434 million and £620 million per year, which is more than the costs associated with breast cancer, or lung and skin cancer combined.
Previously termed acute renal failure
Reversible deterioration of renal function over hours to days manifested by:
Increase in BUN
Increase in creatinine
Reduced urine output
Oliguria : <400><100 ml urine output in 24 hours
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. Kidney Disease: Improving Global Outcomes
KDIGO AKI GUIDELINE WORK GROUP
Work Group Co-Chairs
Work Group
Peter Aspelin
Stockholm, Sweden
Rashad S Barsoum
Cairo, Egypt
Emmanuel A Burdmann
São Paulo, Brazil
Stuart L Goldstein
Cincinnati, OH, USA
John A Kellum
Pittsburgh, PA
Norbert Lameire
Ghent, Belgium
Alison M MacLeod
Aberdeen, UK
Ravindra L Mehta
San Diego, CA, USA
Patrick T Murray
Dublin, Ireland
Saraladevi Naicker
Jo’burg, South Africa
Steven M Opal
Pawtucket, RI, USA
Franz Schaefer
Heidelberg, Germany
Miet Schetz
Leuven, Belgium
Shigehiko Uchino
Tokyo, Japan
Charles A Herzog
Minneapolis, MN, USA
Michael Joannidis
Innsbruck, Austria
Andreas Kribben
Essen, Germany
Andrew S Levey
Boston, MA, USA
4. Kidney Disease: Improving Global Outcomes
CKD EVIDENCE REVIEW TEAM
Katrin Uhlig, MD, MS, Project Director; Director, Guideline Development
Jose Calvo-Broce, MD, MS, Nephrology Fellow
Aneet Deo, MD, MS, Nephrology Fellow
Amy Earley, BS, Project Coordinator
Tufts Center for Kidney Disease Guideline Development &
Implementation
Tufts Medical Center, Boston, MA, USA
In addition, support and supervision were provided by:
Ethan M Balk, MD, MPH, Program Director, Evidence Based Medicine
6. Kidney Disease: Improving Global Outcomes
2.1.1: AKI is defined as any of the following (Not Graded):
• Increase in SCr by ≥ 0.3 mg/dl (≥ 26.5 µmol/l) within 48 hours; or
• Increase in SCr to ≥ 1.5 times baseline, which is known or
presumed to have occurred within the prior 7 days; or
• Urine volume <0.5 ml/kg/h for 6 hours
AKI DEFINITION
7. Kidney Disease: Improving Global Outcomes
STAGING OF AKI
2.1.2: AKI is staged for severity according to the following criteria (Not Graded):
2.1.3: The cause of AKI should be determined whenever possible. (Not Graded)
9. Kidney Disease: Improving Global Outcomes
RISK ASSESSMENT
2.2.1: We recommend that patients be stratified for risk of AKI according to their
susceptibilities and exposures. (1B)
2.2.2: Manage patients according to their susceptibilities and exposures to
reduce the risk of AKI (see relevant guideline sections). (Not Graded)
2.2.3: Test patients at increased risk for AKI with measurements of SCr and
urine output to detect AKI. (Not Graded) Individualize frequency and duration of
monitoring based on patient risk and clinical course. (Not Graded)
10. Kidney Disease: Improving Global Outcomes
EVALUATION & GENERAL MANAGEMENT
2.3.1: Evaluate patients with AKI promptly to determine the cause, with special
attention to reversible causes. (Not Graded)
2.3.2: Monitor patients with AKI with measurements of SCr and urine output to
stage the severity, according to Recommendation 2.1.2. (Not Graded)
2.3.3: Manage patients with AKI according to the stage (see Figure 4) and cause.
(Not Graded)
2.3.4: Evaluate patients 3 months after AKI for resolution, new onset, or worsening
of pre-existing CKD. (Not Graded)
• If patients have CKD, manage these patients as detailed in the KDOQI CKD
Guideline (Guidelines 7–15). (Not Graded)
• If patients do not have CKD, consider them to be at increased risk for CKD
and care for them as detailed in the KDOQI CKD Guideline 3 for patients at
increased risk for CKD. (Not Graded)
11. Kidney Disease: Improving Global Outcomes
Avoid subclavian catheters if possible
High Risk
Discontinue all nephrotoxic agents when possible
Consider invasive diagnostic workup
Consider Renal Replacement Therapy
1 2 3
Non-invasive diagnostic workup
Ensure volume status and perfusion pressure
Check for changes in drug dosing
Consider functional hemodynamic monitoring
Monitor Serum creatinine and urine output
Consider ICU admission
Avoid hyperglycemia
Consider alternatives to radiocontrast procedures
AKI STAGE
13. Kidney Disease: Improving Global Outcomes
HEMODYNAMIC MONITORING
3.1.1: 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)
3.1.2: We recommend the use of vasopressors in conjunction with fluids in
patients with vasomotor shock with, or at risk for, AKI. (1C)
3.1.3: 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).
14. Kidney Disease: Improving Global Outcomes
GLYCEMIC CONTROL & NUTRITIONAL SUPPORT
3.3.1: In critically ill patients, we suggest insulin therapy targeting plasma glucose
110–149mg/dl (6.1–8.3mmol/l). (2C)
3.3.2: We suggest achieving a total energy intake of 20–30 kcal/kg/d in patients
with any stage of AKI. (2C)
3.3.3: We suggest to avoid restriction of protein intake with the aim of preventing or
delaying initiation of RRT. (2D)
3.3.4: We 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), and up to a maximum of 1.7 g/kg/d in patients on continuous renal
replacement therapy (CRRT) and in hypercatabolic patients. (2D)
3.3.5: We suggest providing nutrition preferentially via the enteral route in patients
with AKI. (2C)
15. Kidney Disease: Improving Global Outcomes
THE USE OF DIURETICS IN AKI
3.4.1: We recommend not using diuretics to prevent AKI. (1B)
3.4.2: We suggest not using diuretics to treat AKI, except in the management of
volume overload. (2C)
16. Kidney Disease: Improving Global Outcomes
VASODILATOR THERAPY
3.5.1: We recommend not using low-dose dopamine to prevent or treat AKI. (1A)
3.5.2: We suggest not using fenoldopam to prevent or treat AKI. (2C)
3.5.3: We suggest not using atrial natriuretic peptide (ANP) to prevent (2C) or
treat (2B) AKI.
17. Kidney Disease: Improving Global Outcomes
GROWTH FACTOR INTERVENTION & ADENOSINE
RECEPTOR ANTAGONISTS
3.6.1: We recommend not using recombinant human (rh)IGF-1 to
prevent or treat AKI. (1B)
3.7.1: We suggest that a single dose of theophylline may be
given in neonates with severe perinatal asphyxia, who are at
high risk of AKI. (2B)
18. Kidney Disease: Improving Global Outcomes
PREVENTION OF AMINOGLYCOSIDE- AND
AMPHOTERICIN-RELATED AKI
3.8.1: We suggest not using aminoglycosides for the treatment of infections
unless no suitable, less nephrotoxic, therapeutic alternatives are available. (2A)
3.8.2: We 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)
3.8.3: We recommend monitoring aminoglycoside drug levels when treatment
with multiple daily dosing is used for more than 24 hours. (1A)
3.8.4: We suggest monitoring aminoglycoside drug levels when treatment with
single-daily dosing is used for more than 48 hours. (2C)
19. Kidney Disease: Improving Global Outcomes
PREVENTION OF AMINOGLYCOSIDE- AND
AMPHOTERICIN-RELATED AKI
3.8.5: We 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)
3.8.6: We suggest using lipid formulations of amphotericin B rather than
conventional formulations of amphotericin B. (2A)
3.8.7: In the treatment of systemic mycoses or parasitic infections, we
recommend using azole antifungal agents and/or the echinocandins rather than
conventional amphotericin B, if equal therapeutic efficacy can be assumed. (1A)
20. Kidney Disease: Improving Global Outcomes
OTHER METHODS OF PREVENTION OF AKI IN
THE CRITICALLY ILL
3.9.1: We 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)
3.9.2: We suggest not using NAC to prevent AKI in critically ill patients
with hypotension. (2D)
3.9.3: We recommend not using oral or i.v. NAC for prevention of
postsurgical AKI. (1A)
22. Kidney Disease: Improving Global Outcomes
CI-AKI: DEFINITION, EPIDEMIOLOGY &
PROGNOSIS
4.1: Define and stage AKI after administration of intravascular contrast media
as per Recommendations 2.1.1–2.1.2. (Not Graded)
• 4.1.1: 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)
23. Kidney Disease: Improving Global Outcomes
ASSESSMENT OF THE POPULATION
AT RISK FOR CI-AKI
4.2.1: 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)
4.2.2: Consider alternative imaging methods in patients at increased risk for
CI-AKI. (Not Graded)
24. Kidney Disease: Improving Global Outcomes
NONPHARMACOLOGICAL PREVENTION
STRATEGIES OF CI-AKI
4.3.1: Use the lowest possible dose of contrast medium in patients at risk for
CI-AKI. (Not Graded)
4.3.2: We 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)
25. Kidney Disease: Improving Global Outcomes
PHARMACOLOGICAL PREVENTION
STRATEGIES OF CI-AKI
4.4.1: We 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)
4.4.2: We recommend not using oral fluids alone in patients at increased risk of
CI-AKI. (1C)
4.4.3: We suggest using oral NAC, together with i.v. isotonic crystalloids, in
patients at increased risk of CI-AKI. (2D)
4.4.4: We suggest not using theophylline to prevent CI-AKI. (2C)
4.4.5: We recommend not using fenoldopam to prevent CI-AKI. (1B)
26. Kidney Disease: Improving Global Outcomes
EFFECTS OF HEMODIALYSIS OR
HEMOFILTRATION
4.5.1: We suggest not using prophylactic intermittent hemodialysis
(IHD) or hemofiltration (HF) for contrast-media removal in patients at
increased risk for CI-AKI. (2C)
28. Kidney Disease: Improving Global Outcomes
TIMING OF RENAL REPLACEMENT THERAPY
5.1.1: Initiate RRT emergently when life-threatening changes in fluid,
electrolyte, and acid-base balance exist. (Not Graded)
5.1.2: 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 alone—when
making the decision to start RRT. (Not Graded)
29. Kidney Disease: Improving Global Outcomes
CRITERIA FOR STOPPING RENAL
REPLACEMENT THERAPY
5.2.1: 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)
5.2.2: We suggest not using diuretics to enhance kidney function
recovery, or to reduce the duration or frequency of RRT. (2B)
30. Kidney Disease: Improving Global Outcomes
5.3.1: In a patient with AKI requiring RRT, base the decision to use
anticoagulation for RRT on assessment of the patient’s potential risks and
benefits from anticoagulation (see Figure 17). (Not Graded)
• 5.3.1.1: We recommend using anticoagulation during RRT in AKI if a
patient does not have an increased bleeding risk or impaired coagulation
and is not already receiving systemic anticoagulation. (1B)
5.3.2: For patients without an increased bleeding risk or impaired coagulation
and not already receiving effective systemic anticoagulation, we suggest the
following:
• 5.3.2.1: For anticoagulation in intermittent RRT, we recommend using
either unfractionated or low-molecular-weight heparin, rather than other
anticoagulants. (1C)
• 5.3.2.2: For anticoagulation in CRRT, we suggest using regional citrate
anticoagulation rather than heparin in patients who do not have
contraindications for citrate. (2B)
ANTICOAGULATION
32. Kidney Disease: Improving Global Outcomes
5.3.2 (cont’d): For patients without an increased bleeding risk or impaired
coagulation and not already receiving effective systemic anticoagulation, we
suggest the following:
• 5.3.2.3: For anticoagulation during CRRT in patients who have
contraindications for citrate, we suggest using either unfractionated or
low-molecular-weight heparin, rather than other anticoagulants. (2C)
5.3.3: For patients with increased bleeding risk who are not receiving
anticoagulation, we suggest the following for anticoagulation during RRT:
• 5.3.3.1: We suggest using regional citrate anticoagulation, rather than
no anticoagulation, during CRRT in a patient without contraindications for
citrate. (2C)
• 5.3.3.2: We suggest avoiding regional heparinization during CRRT in a
patient with increased risk of bleeding. (2C)
ANTICOAGULATION
33. Kidney Disease: Improving Global Outcomes
5.3.4: In a patient with heparin-induced thrombocytopenia (HIT), all heparin
must be stopped and we recommend using direct thrombin inhibitors (such as
argatroban) or Factor Xa inhibitors (such as danaparoid or fondaparinux)
rather than other or no anticoagulation during RRT. (1A)
• 5.3.4.1: In a patient with HIT who does not have severe liver failure,
we suggest using argatroban rather than other thrombin or Factor Xa
inhibitors during RRT. (2C)
ANTICOAGULATION
34. Kidney Disease: Improving Global Outcomes
VASCULAR ACCESS FOR RRT IN AKI
5.4.1: We suggest initiating RRT in patients with AKI via an uncuffed
nontunneled dialysis catheter, rather than a tunneled catheter. (2D)
5.4.2: 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 with preference for the dominant side.
5.4.3: We recommend using ultrasound guidance for dialysis catheter
insertion. (1A)
35. Kidney Disease: Improving Global Outcomes
VASCULAR ACCESS FOR RRT IN AKI
5.4.4: We recommend obtaining a chest radiograph promptly after placement
and before first use of an internal jugular or subclavian dialysis catheter. (1B)
5.4.5: We suggest not using topical antibiotics over the skin insertion site of a
nontunneled dialysis catheter in ICU patients with AKI requiring RRT. (2C)
5.4.6: We suggest not using antibiotic locks for prevention of catheter-related
infections of nontunneled dialysis catheters in AKI requiring RRT. (2C)
36. Kidney Disease: Improving Global Outcomes
DIALYZER MEMBRANES FOR RRT IN AKI
5.5.1: We suggest to use dialyzers with a biocompatible membrane for
IHD and CRRT in patients with AKI. (2C)
37. Kidney Disease: Improving Global Outcomes
MODALITY OF RRT FOR PATIENTS
WITH AKI
5.6.1: Use continuous and intermittent RRT as complementary
therapies in AKI patients. (Not Graded)
5.6.2: We suggest using CRRT, rather than standard intermittent RRT,
for hemodynamically unstable patients. (2B)
5.6.3: 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. (2B)
38. Kidney Disease: Improving Global Outcomes
BUFFER SOLUTIONS FOR RRT IN
PATIENTS WITH AKI
5.7.1: We suggest using bicarbonate, rather than lactate, as a buffer in dialysate
and replacement fluid for RRT in patients with AKI. (2C)
5.7.2: We recommend using bicarbonate, rather than lactate, as a buffer in
dialysate and replacement fluid for RRT in patients with AKI and circulatory shock.
(1B)
5.7.3: We suggest using bicarbonate, rather than lactate, as a buffer in dialysate
and replacement fluid for RRT in patients with AKI and liver failure and/or lactic
acidemia. (2B)
5.7.4: We recommend that dialysis fluids and replacement fluids in patients with
AKI, at a minimum, comply with American Association of Medical Instrumentation
(AAMI) standards regarding contamination with bacteria and endotoxins. (1B)
39. Kidney Disease: Improving Global Outcomes
DOSE OF RRT IN AKI
5.8.1: 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)
5.8.2: Provide RRT to achieve the goals of electrolyte, acid-base, solute, and
fluid balance that will meet the patient’s needs. (Not Graded)
5.8.3: We recommend delivering a Kt/V of 3.9 per week when using
intermittent or extended RRT in AKI. (1A)
5.8.4: We recommend delivering an effluent volume of 20–25 ml/kg/h for
CRRT in AKI. (1A) This will usually require a higher prescription of effluent
volume. (Not Graded)