Chapter 20: Renal Disorders

KIDNEY INJURY, ACUTE

Population

• – Adults and children.

Recommendations

NICE 2019, VA/DoD 2019, KDIGO 2012

• – General care of the acutely ill patient.

  • In the absence of hemorrhagic shock, use of isotonic crystalloids rather than colloids for intravascular volume expansion.

  • Do not use diuretics to prevent or treat AKI except in the management of volume overload.

  • Do not use low-dose dopamine in either the prevention or treatment of AKI.

  • Use vasopressors in addition to fluids for management of vasomotor shock with or at risk for AKI.

• – Adults receiving intravenous iodinated contrast

  • Consider IV volume expansion to at-risk adults, including those with:

    • CKD with eGFR <30 mL/min.

    • Heart failure.

    • Age 75 y or older.

    • History of Renal transplant.

    • Use of a large volume of contrast medium.

    • Intra-arterial administration of contrast medium with first-pass renal exposure.

  • Consider temporarily stopping ACE inhibitors and ARBs in adults having iodine-based contrast media if they have chronic kidney disease with an eGFR less than 40 mL/min.

  • Inconsistent evidence for N-acetylcysteine use to prevent contrast-induced nephropathy.

• – Consult a pharmacist to assist with drug dosing in adults or children at risk for AK.

Sources

• – NICE. Acute Kidney Injury: Prevention, Detection and Management of Acute Kidney Injury up to the Point of Renal Replacement Therapy. London (UK): National Institute for Health and Care Excellence (NICE); 2019. https://www.nice.org.uk/guidance/ng148

• – VA/DoD. Clinical Practice Guideline for the Management of Chronic Kidney Disease in Primary Care. Washington (DC): Department of Veterans Affairs, Department of Defense; 2019.

• – Kidney Disease Improving Global Outcomes (KDIGO). KDIGO Clinical Practice Guideline for Acute Kidney Injury: Kidney International Supplements; March 2012;2(1).

Comments

1. Acute kidney injury (AKI) is defined as any of the following

   • the increase in SCr by ≥0.3 mg/dL over 48 h,

   • increase in SCr to ≥1.5 times baseline within the past 7 d

   • or urine volume <0.5 mL/kg/h for 6 h.