Renal Disorders

KIDNEY INJURY, ACUTE (AKI)

Adults, Acute Illness

► NICE 2023, VA/DoD 2019, KDIGO 2012

–General care of the acutely ill patient.
- In the absence of hemorrhagic shock, use 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. Avoid the combination of ACE/ARB, diuretics, and nonsteroidal anti-inflammatory drugs. This combination is more likely to cause AKI, especially in those >75 y of age and with preexisting renal impairment.

Practice Pearls

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.
- - Urine volume < 0.5 mL/kg/h for 6 h.
Stages of AKI and corresponding lab values (Table 13–1).

Table 13–1Stages of Acute Kidney Injury

Table 13–1 Stages of Acute Kidney Injury

Stage 1

Stage 2

Stage 3

Creatinine increase over 48 h

0.3 mg/dL or 1.5–2 × above baseline

2–3 × baseline

3 × baseline, or Cr > 4.0 mg/dL with acute rise of 0.5 mg/dL

Urine output: less than 0.5 mg/kg/h for at least

6 h

12 h

24 h (or, anuria > 12 h)

Adapted from KDIGO 2012, Table 3.

–NICE. Acute Kidney Injury: Prevention, Detection and Management. London, UK: National Institute for Health and Care Excellence (NICE); 2023. 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. 2012;2(1).

Adults Receiving Intravenous Iodine-Based Contrast

► NICE 2023, VA/DoD 2019, KDIGO 2012

–Encourage oral hydration before and after contrast administration if increased risk¹ of kidney injury.
–Consider temporarily stopping ACE inhibitors and ARBs if eGFR < 40 mL/min/1.73 m².
–For patients receiving renal replacement therapy, involve the nephrologist before administering contrast.
–Measure estimated GFR prior to contrast only in patients at increased risk for kidney injury.
–Consider IV volume expansion to at-risk adults, including those with:
- Chronic kidney disease (CKD) with eGFR < 30 mL/min/1.73 m².
- 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 ...

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