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Kdigo aki guideline

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Universidad nacional de Piura

This document provides clinical practice guidelines for the diagnosis, evaluation, and treatment of acute kidney injury (AKI). It was developed by an international work group using a systematic review of the evidence and outlines recommendations for: 1. Defining and classifying AKI according to increases in serum creatinine and decreases in urine output. 2. Evaluating patients at risk for AKI and implementing general management strategies. 3. Preventing AKI through hemodynamic monitoring, glycemic control, and minimizing nephrotoxic medications. 4. Treating established AKI through renal replacement therapy, including criteria for initiation and discontinuation as well as specific modalities and procedures.

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OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF NEPHROLOGY KDIGO Clinical Practice Guideline for Acute Kidney Injury VOLUME 2 | ISSUE 1 | MARCH 2012 http://www.kidney-international.org KI_SuppCover_2.1.indd 1 2/7/12 12:32 PM
http://www.kidney-international.org contents & 2012 KDIGO VOL 2 | SUPPLEMENT 1 | MARCH 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury iv Tables and Figures 1 Notice 2 Work Group Membership 3 KDIGO Board Members 4 Reference Keys 5 Abbreviations and Acronyms 6 Abstract 7 Foreword 8 Summary of Recommendation Statements 13 Section 1: Introduction and Methodology 13 Chapter 1.1: Introduction 17 Chapter 1.2: Methodology 19 Section 2: AKI Definition 19 Chapter 2.1: Definition and classification of AKI 23 Chapter 2.2: Risk assessment 25 Chapter 2.3: Evaluation and general management of patients with and at risk for AKI 28 Chapter 2.4: Clinical applications 33 Chapter 2.5: Diagnostic approach to alterations in kidney function and structure 37 Section 3: Prevention and Treatment of AKI 37 Chapter 3.1: Hemodynamic monitoring and support for prevention and management of AKI 42 Chapter 3.2: General supportive management of patients with AKI, including management of complications 43 Chapter 3.3: Glycemic control and nutritional support 47 Chapter 3.4: The use of diuretics in AKI 50 Chapter 3.5: Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides 57 Chapter 3.6: Growth factor intervention 59 Chapter 3.7: Adenosine receptor antagonists 61 Chapter 3.8: Prevention of aminoglycoside- and amphotericin-related AKI 66 Chapter 3.9: Other methods of prevention of AKI in the critically ill 69 Section 4: Contrast-induced AKI 69 Chapter 4.1: Contrast-induced AKI: definition, epidemiology, and prognosis 72 Chapter 4.2: Assessment of the population at risk for CI-AKI 76 Chapter 4.3: Nonpharmacological prevention strategies of CI-AKI 80 Chapter 4.4: Pharmacological prevention strategies of CI-AKI 87 Chapter 4.5: Effects of hemodialysis or hemofiltration 89 Section 5: Dialysis Interventions for Treatment of AKI 89 Chapter 5.1: Timing of renal replacement therapy in AKI 93 Chapter 5.2: Criteria for stopping renal replacement therapy in AKI 95 Chapter 5.3: Anticoagulation 101 Chapter 5.4: Vascular access for renal replacement therapy in AKI 105 Chapter 5.5: Dialyzer membranes for renal replacement therapy in AKI 107 Chapter 5.6: Modality of renal replacement therapy for patients with AKI 111 Chapter 5.7: Buffer solutions for renal replacement therapy in patients with AKI 113 Chapter 5.8: Dose of renal replacement therapy in AKI 116 Biographic and Disclosure Information 122 Acknowledgments 124 References
contents http://www.kidney-international.org & 2012 KDIGO TABLES 18 Table 1. Implications of the strength of a recommendation 19 Table 2. Staging of AKI 21 Table 3. Comparison of RIFLE and AKIN criteria for diagnosis and classification of AKI 21 Table 4. Cross-tabulation of patients classified by RIFLE vs. AKIN 22 Table 5. Causes of AKI and diagnostic tests 23 Table 6. Causes of AKI: exposures and susceptibilities for non-specific AKI 28 Table 7. AKI diagnosis 29 Table 8. Overview of the approaches to determine baseline SCr in the application of RIFLE classification in previous studies 29 Table 9. Estimated baseline SCr 30 Table 10. AKI staging 33 Table 11. Definitions of AKI, CKD, and AKD 33 Table 12. Examples of AKI, CKD, and AKD based on GFR and increases in SCr 35 Table 13. Markers of kidney damage in AKD and CKD 35 Table 14. Integrated approach to interpret measures of kidney function and structure for diagnosis of AKI, AKD, and CKD 73 Table 15. CI-AKI risk-scoring model for percutaneous coronary intervention 77 Table 16. Additional radiological measures to reduce CI-AKI 91 Table 17. Potential applications for RRT 91 Table 18. Fluid overload and outcome in critically ill children with AKI 97 Table 19. Overview of the advantages and disadvantages of different anticoagulants in AKI patients 104 Table 20. Catheter and patient sizes 107 Table 21. Typical setting of different RRT modalities for AKI (for 70-kg patient) 108 Table 22. Theoretical advantages and disadvantages of CRRT, IHD, SLED, and PD 112 Table 23. Microbiological quality standards of different regulatory agencies FIGURES 14 Figure 1. The RIFLE criteria for AKI 20 Figure 2. Overview of AKI, CKD, and AKD 20 Figure 3. Conceptual model for AKI 25 Figure 4. Stage-based management of AKI 26 Figure 5. Evaluation of AKI according to the stage and cause 34 Figure 6. Chronic Kidney Disease Epidemiology Collaboration cohort changes in eGFR and final eGFR corresponding to KDIGO definition and stages of AKI 34 Figure 7. GFR/SCr algorithm 38 Figure 8. Conceptual model for development and clinical course of AKI 48 Figure 9. Effect of furosemide vs. control on all-cause mortality 48 Figure 10. Effect of furosemide vs. control on need for RRT 51 Figure 11. Effect of low-dose dopamine on mortality 52 Figure 12. Effect of low-dose dopamine on need for RRT 73 Figure 13. Sample questionnaire 78 Figure 14. Risk for contrast-induced nephropathy 81 Figure 15. Bicarbonate vs. saline and risk of CI-AKI 85 Figure 16. NAC and bicarbonate vs. NAC for risk of CI-AKI 96 Figure 17. Flow-chart summary of recommendations Additional information in the form of supplementary materials can be found online at http://www.kdigo.org/clinical_practice_guidelines/AKI.php iv Kidney International Supplements (2012) 2, iv
http://www.kidney-international.org & 2012 KDIGO Notice Kidney International Supplements (2012) 2, 1; doi:10.1038/kisup.2012.1 SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE This Clinical Practice Guideline document is based upon the best information available as of February 2011. It is designed to provide information and assist decision-making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The recommendations for research contained within this document are general and do not imply a specific protocol. SECTION II: DISCLOSURE Kidney Disease: Improving Global Outcomes (KDIGO) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived or actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information is published in its entirety at the end of this document in the Work Group members’ Biographical and Disclosure Information section, and is kept on file at the National Kidney Foundation (NKF), Managing Agent for KDIGO. Kidney International Supplements (2012) 2, 1 1
http://www.kidney-international.org & 2012 KDIGO Work Group Membership Kidney International Supplements (2012) 2, 2; doi:10.1038/kisup.2012.2 WORK GROUP CO-CHAIRS John A Kellum, MD, FCCM, FACP Norbert Lameire, MD, PhD University of Pittsburgh School of Medicine Ghent University Hospital Pittsburgh, PA Ghent, Belgium WORK GROUP Peter Aspelin, MD, PhD Alison M MacLeod, MBChB, MD, FRCP Karolinska University Hospital University of Aberdeen Stockholm, Sweden Aberdeen, United Kingdom Rashad S Barsoum, MD, FRCP, FRCPE Ravindra L Mehta, MD, FACP, FASN, FRCP Cairo University UCSD Medical Center Cairo, Egypt San Diego, CA Emmanuel A Burdmann, MD, PhD Patrick T Murray, MD, FASN, FRCPI, FJFICMI ˜ University of Sao Paulo Medical School UCD School of Medicine and Medical Science ˜ Sao Paulo, Brazil Dublin, Ireland Saraladevi Naicker, MBChB, MRCP, FRCP, Stuart L Goldstein, MD FCP(SA), PhD Cincinnati Children’s Hospital & Medical Center University of the Witwatersrand Cincinnati, OH Johannesburg, South Africa Charles A Herzog, MD Steven M Opal, MD Hennepin County Medical Center Alpert Medical School of Brown University Minneapolis, MN Pawtucket, RI Michael Joannidis, MD Franz Schaefer, MD Medical University of Innsbruck Heidelberg University Hospital Innsbruck, Austria Heidelberg, Germany Andreas Kribben, MD Miet Schetz, MD, PhD University Duisburg-Essen University of Leuven Essen, Germany Leuven, Belgium Andrew S Levey, MD Shigehiko Uchino, MD, PhD Tufts Medical Center Jikei University School of Medicine Boston, MA Tokyo, Japan EVIDENCE REVIEW TEAM Tufts Center for Kidney Disease Guideline Development and Implementation, Tufts Medical Center, Boston, MA, USA: 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 In addition, support and supervision were provided by: Ethan M Balk, MD, MPH, Program Director, Evidence Based Medicine 2 Kidney International Supplements (2012) 2, 2
http://www.kidney-international.org & 2012 KDIGO KDIGO Board Members Kidney International Supplements (2012) 2, 3; doi:10.1038/kisup.2012.3 Garabed Eknoyan, MD Norbert Lameire, MD, PhD Founding KDIGO Co-Chairs Kai-Uwe Eckardt, MD Bertram L Kasiske, MD KDIGO Co-Chair KDIGO Co-Chair Omar I Abboud, MD, FRCP Michel Jadoul, MD Sharon Adler, MD, FASN Simon Jenkins, MBE, FRCGP Rajiv Agarwal, MD Suhnggwon Kim, MD, PhD Sharon P Andreoli, MD Martin K Kuhlmann, MD Gavin J Becker, MD, FRACP Nathan W Levin, MD, FACP Fred Brown, MBA, FACHE Philip K-T Li, MD, FRCP, FACP Daniel C Cattran, MD, FRCPC Zhi-Hong Liu, MD Allan J Collins, MD, FACP Pablo Massari, MD Rosanna Coppo, MD Peter A McCullough, MD, MPH, FACC, FACP Josef Coresh, MD, PhD Rafique Moosa, MD Ricardo Correa-Rotter, MD Miguel C Riella, MD Adrian Covic, MD, PhD Adibul Hasan Rizvi, MBBS, FRCP Jonathan C Craig, MBChB, MM (Clin Epi), DCH, FRACP, PhD Bernardo Rodriquez-Iturbe, MD Angel de Francisco, MD Robert Schrier, MD Paul de Jong, MD, PhD Justin Silver, MD, PhD Ana Figueiredo, RN, MSc, PhD Marcello Tonelli, MD, SM, FRCPC Mohammed Benghanem Gharbi, MD Yusuke Tsukamoto, MD Gordon Guyatt, MD, MSc, BSc, FRCPC Theodor Vogels, MSW David Harris, MD Angela Yee-Moon Wang, MD, PhD, FRCP Lai Seong Hooi, MD Christoph Wanner, MD Enyu Imai, MD, PhD David C Wheeler, MD, FRCP Lesley A Inker, MD, MS, FRCP Elena Zakharova, MD, PhD NKF-KDIGO GUIDELINE DEVELOPMENT STAFF Kerry Willis, PhD, Senior Vice-President for Scientific Activities Michael Cheung, MA, Guideline Development Director Sean Slifer, BA, Guideline Development Manager Kidney International Supplements (2012) 2, 3 3
http://www.kidney-international.org & 2012 KDIGO Reference Keys Kidney International Supplements (2012) 2, 4; doi:10.1038/kisup.2012.4 NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D. Implications Grade* Patients Clinicians Policy Level 1 Most people in your situation would Most patients should receive the The recommendation can be evaluated ‘‘We recommend’’ want the recommended course of action recommended course of action. as a candidate for developing a policy and only a small proportion would not. or a performance measure. Level 2 The majority of people in your situation Different choices will be appropriate for The recommendation is likely to require ‘‘We suggest’’ would want the recommended course different patients. Each patient needs substantial debate and involvement of action, but many would not. help to arrive at a management decision of stakeholders before policy can be consistent with her or his values and determined. preferences. *The additional category ‘‘Not Graded’’ was used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence. The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other clinical specialists. The ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations. Grade Quality of evidence Meaning A High We are confident that the true effect lies close to that of the estimate of the effect. B Moderate The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. C Low The true effect may be substantially different from the estimate of the effect. D Very low The estimate of effect is very uncertain, and often will be far from the truth. CONVERSION FACTORS OF METRIC UNITS TO SI UNITS Parameter Metric units Conversion factor SI units Amikacin (serum, plasma) mg/ml 1.708 mmol/l Blood urea nitrogen mg/dl 0.357 mmol/l Calcium, ionized (serum) mg/dl 0.25 mmol/l Creatinine (serum) mg/dl 88.4 mmol/l Creatinine clearance ml/min 0.01667 ml/s Gentamicin (serum) mg/ml 2.09 mmol/l Glucose mg/dl 0.0555 mmol/l Lactate (plasma) mg/dl 0.111 mmol/l Tobramycin (serum, plasma) mg/ml 2.139 mmol/l Urea (plasma) mg/ml 0.167 mmol/l Note: Metric unit  conversion factor = SI unit. 4 Kidney International Supplements (2012) 2, 4
http://www.kidney-international.org & 2012 KDIGO Abbreviations and Acronyms Kidney International Supplements (2012) 2, 5; doi:10.1038/kisup.2012.5 AAMI American Association of Medical HF Hemofiltration Instrumentation HIT Heparin-induced thrombocytopenia ACCP American College of Chest Physicians HR Hazard ratio ACD-A Anticoagulant dextrose solution A i.a. Intraarterial ACE-I Angiotensin-converting enzyme inhibitor(s) ICU Intensive-care unit ADQI Acute Dialysis Quality Initiative IGF-1 Insulin-like growth factor-1 AHCPR Agency for Health Care Policy and Research IHD Intermittent hemodialysis AKD Acute kidney diseases and disorders IIT Intensive insulin therapy AKI Acute kidney injury i.v. Intravenous AKIN Acute Kidney Injury Network KDIGO Kidney Disease: Improving Global Outcomes ANP Atrial natriuretic peptide KDOQI Kidney Disease Outcomes Quality Initiative aPTT Activated partial thromboplastin time LOS Length of stay ARB Angiotensin-receptor blocker(s) MDRD Modification of Diet in Renal Disease ARF Acute renal failure MI Myocardial infarction ARFTN Acute Renal Failure Trial Network MIC Minimum inhibitory concentration ATN Acute tubular necrosis MRI Magnetic resonance imaging AUC Area under the curve MW Molecular weight BMI Body mass index NAC N-acetylcysteine BUN Blood urea nitrogen NICE-SUGAR Normoglycemia in Intensive Care Evaluation CDC Centers for Disease Control and Survival Using Glucose Algorithm CHF Congestive heart failure Regulation CI Confidence interval NKD No known kidney disease CI-AKI Contrast-induced acute kidney injury NKF National Kidney Foundation CIT Conventional insulin therapy NSF Nephrogenic Systemic Fibrosis CKD Chronic kidney disease OR Odds ratio CrCl Creatinine clearance PD Peritoneal dialysis CRF Chronic renal failure PICARD Program to Improve Care in Acute Renal CRRT Continuous renal replacement therapy Disease CT Computed tomography RCT Randomized controlled trial CVC Central venous catheters RIFLE Risk, Injury, Failure; Loss, End-Stage Renal CVVH Continuous venovenous hemofiltration Disease CVVHDF Continuous venovenous hemodiafiltration RR Relative risk eCrCl Estimated creatinine clearance RRT Renal replacement therapy EGDT Early goal-directed therapy SAFE Saline vs. Albumin Fluid Evaluation eGFR Estimated glomerular filtration rate SCr Serum creatinine ERT Evidence Review Team ScvO2 Central venous oxygen saturation ESRD End-stage renal disease SLED Sustained low-efficiency dialysis FDA Food and Drug Administration TCC Tunneled cuffed catheter GFR Glomerular filtration rate VISEP Efficacy of Volume Substitution and Insulin HDF Hemodiafiltration Therapy in Severe Sepsis HES Hydroxyethylstarch Kidney International Supplements (2012) 2, 5 5
http://www.kidney-international.org & 2012 KDIGO Abstract Kidney International Supplements (2012) 2, 6; doi:10.1038/kisup.2012.6 The 2011 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury (AKI) aims to assist practitioners caring for adults and children at risk for or with AKI, including contrast-induced acute kidney injury (CI-AKI). Guideline development followed an explicit process of evidence review and appraisal. The guideline contains chapters on definition, risk assessment, evaluation, prevention, and treatment. Definition and staging of AKI are based on the Risk, Injury, Failure; Loss, End-Stage Renal Disease (RIFLE) and Acute Kidney Injury Network (AKIN) criteria and studies on risk relationships. The treatment chapters cover pharmacological approaches to prevent or treat AKI, and management of renal replacement for kidney failure from AKI. Guideline recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the GRADE approach. Limitations of the evidence are discussed and specific suggestions are provided for future research. Keywords: Clinical Practice Guideline; KDIGO; acute kidney injury; contrast-induced nephropathy; renal replacement therapy; evidence-based recommendation CITATION In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1–138. 6 Kidney International Supplements (2012) 2, 6
http://www.kidney-international.org & 2012 KDIGO Foreword Kidney International Supplements (2012) 2, 7; doi:10.1038/kisup.2012.8 It is our hope that this document will serve several useful Some argue that recommendations should not be made purposes. Our primary goal is to improve patient care. We when evidence is weak. However, clinicians still need to make hope to accomplish this, in the short term, by helping clinical decisions in their daily practice, and they often ask, clinicians know and better understand the evidence (or lack ‘‘What do the experts do in this setting?’’ We opted to give of evidence) that determines current practice. By providing guidance, rather than remain silent. These recommendations comprehensive evidence-based recommendations, this guide- are often rated with a low strength of recommendation and a line will also help define areas where evidence is lacking and low strength of evidence, or were not graded. It is important research is needed. Helping to define a research agenda is an for the users of this guideline to be cognizant of this (see often neglected, but very important, function of clinical Notice). In every case these recommendations are meant to practice guideline development. be a place for clinicians to start, not stop, their inquiries into We used the GRADE system to rate the strength of evidence specific management questions pertinent to the patients they and the strength of recommendations. In all, there were only see in daily practice. 11 (18%) recommendations in this guideline for which the We wish to thank the Work Group Co-Chairs, Drs John overall quality of evidence was graded ‘A,’ whereas 20 (32.8%) Kellum and Norbert Lameire, along with all of the Work were graded ‘B,’ 23 (37.7%) were graded ‘C,’ and 7 (11.5%) Group members who volunteered countless hours of their were graded ‘D.’ Although there are reasons other than quality time developing this guideline. We also thank the Evidence of evidence to make a grade 1 or 2 recommendation, in Review Team members and staff of the National Kidney general, there is a correlation between the quality of overall Foundation who made this project possible. Finally, we owe a evidence and the strength of the recommendation. Thus, there special debt of gratitude to the many KDIGO Board members were 22 (36.1%) recommendations graded ‘1’ and 39 (63.9%) and individuals who volunteered time reviewing the guide- graded ‘2.’ There were 9 (14.8%) recommendations graded line, and making very helpful suggestions. ‘1A,’ 10 (16.4%) were ‘1B,’ 3 (4.9%) were ‘1C,’ and 0 (0%) were ‘1D.’ There were 2 (3.3%) graded ‘2A,’ 10 (16.4%) were ‘2B,’ 20 (32.8%) were ‘2C,’ and 7 (11.5%) were ‘2D.’ There were Kai-Uwe Eckardt, MD Bertram L. Kasiske, MD 26 (29.9%) statements that were not graded. KDIGO Co-Chair KDIGO Co-Chair Kidney International Supplements (2012) 2, 7 7
http://www.kidney-international.org & 2012 KDIGO Summary of Recommendation Statements Kidney International Supplements (2012) 2, 8–12; doi:10.1038/kisup.2012.7 Section 2: AKI Definition 2.1.1: AKI is defined as any of the following (Not Graded): K Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) within 48 hours; or K Increase in SCr to X1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or K Urine volume o0.5 ml/kg/h for 6 hours. 2.1.2: AKI is staged for severity according to the following criteria (Table 2). (Not Graded) Table 2 | Staging of AKI Stage Serum creatinine Urine output 1 1.5–1.9 times baseline o0.5 ml/kg/h for 6–12 hours OR X0.3 mg/dl (X26.5 mmol/l) increase 2 2.0–2.9 times baseline o0.5 ml/kg/h for X12 hours 3 3.0 times baseline o0.3 ml/kg/h for X24 hours OR OR Increase in serum creatinine to X4.0 mg/dl (X353.6 mmol/l) Anuria for X12 hours OR Initiation of renal replacement therapy OR, In patients o18 years, decrease in eGFR to o35 ml/min per 1.73 m2 2.1.3: The cause of AKI should be determined whenever possible. (Not Graded) 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) 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) K If patients have CKD, manage these patients as detailed in the KDOQI CKD Guideline (Guidelines 7–15). (Not Graded) K 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) Section 3: Prevention and Treatment of AKI 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) 8 Kidney International Supplements (2012) 2, 8–12
summary of recommendation statements Figure 4 | Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive- care unit. 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). 3.3.1: In critically ill patients, we suggest insulin therapy targeting plasma glucose 110–149 mg/dl (6.1–8.3 mmol/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) 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) 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. 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) 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) 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) Kidney International Supplements (2012) 2, 8–12 9
summary of recommendation statements 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) Section 4: Contrast-induced AKI 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) 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) 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) 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) 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) Section 5: Dialysis Interventions for Treatment of AKI 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) 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) 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) 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) 10 Kidney International Supplements (2012) 2, 8–12
summary of recommendation statements Impaired Yes Proceed without coagulation? anticoagulation Rec No 5.3.1.1 Underlying Yes Use anticoagulation condition requires adapted to this systemic anticoagulation? condition No Choose RRT CRRT Intermittent RRT Modality Recs No 5.3.2.2 Contraindication Regional Citrate & to Citrate? Anticoagulation 5.3.3.1 Yes No Rec Increased Heparin 5.3.2.3 Bleeding Risk? Yes Rec Proceed without 5.3.3.2 anticoagulation No Increased Heparin Bleeding Risk? Rec 5.3.2.1 Yes Proceed without anticoagulation Figure 17 | Flow-chart summary of recommendations. Heparin includes low-molecular-weight or unfractionated heparin. CRRT, continuous renal replacement therapy; RRT, renal replacement therapy. 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) Kidney International Supplements (2012) 2, 8–12 11
summary of recommendation statements 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) 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): K First choice: right jugular vein; K Second choice: femoral vein; K Third choice: left jugular vein; K Last choice: subclavian vein with preference for the dominant side. 5.4.3: We recommend using ultrasound guidance for dialysis catheter insertion. (1A) 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) 5.5.1: We suggest to use dialyzers with a biocompatible membrane for IHD and CRRT in patients with AKI. (2C) 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) 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) 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) 12 Kidney International Supplements (2012) 2, 8–12
http://www.kidney-international.org chapter 1.1 & 2012 KDIGO Section 1: Introduction and Methodology Kidney International Supplements (2012) 2, 13–18; doi:10.1038/kisup.2011.31 Chapter 1.1: Introduction The concept of acute renal failure (ARF) has undergone Volume depletion and hypotension are profound stimuli for significant re-examination in recent years. Mounting evi- vasopressin secretion. As a consequence the distal tubules and dence suggests that acute, relatively mild injury to the kidney collecting ducts become fully permeable to water. Concen- or impairment of kidney function, manifest by changes in trating mechanisms in the inner medulla are also aided urine output and blood chemistries, portend serious clinical by low flow through the loops of Henle and thus, urine consequences.1–5 Traditionally, most reviews and textbook volume is minimized and urine concentration maximized chapters emphasize the most severe reduction in kidney (4500 m Osmol/kg). Conversely, when the tubules are function, with severe azotemia and often with oliguria or injured, maximal concentrating ability is impaired and urine anuria. It has only been in the past few years that moderate volume may even be normal (i.e., nonoliguric renal failure). decreases of kidney function have been recognized as Analysis of the urine to determine tubular function has a potentially important, in the critically ill,2 and in studies long history in clinical medicine. Indeed, a high urine on contrast-induced nephropathy.4 osmolality coupled with a low urine sodium in the face of oliguria and azotemia is strong evidence of intact tubular Glomerular filtration rate and serum creatinine function. However, this should not be interpreted as The glomerular filtration rate (GFR) is widely accepted as the ‘‘benign’’ or even prerenal azotemia. Intact tubular function, best overall index of kidney function in health and disease. particularly early on, may be seen with various forms of renal However, GFR is difficult to measure and is commonly disease (e.g., glomerulonephritis). Sepsis, the most common estimated from the serum level of endogenous filtration condition associated with ARF in the intensive-care unit markers, such as creatinine. Recently, Chertow et al.1 found (ICU)7 may alter renal function without any characteristic that an increase of serum creatinine (SCr) of 40.3 mg/dl changes in urine indices.8,9 Automatically classifying these (426.5 mmol/l) was independently associated with mortality. abnormalities as ‘‘prerenal’’ will undoubtedly lead to Similarly, Lassnigg et al.3 saw, in a cohort of patients who incorrect management decisions. Classification as ‘‘benign underwent cardiac surgery, that either an increase of SCr azotemia’’ or ‘‘acute renal success’’ is not consistent with X0.5 mg/dl (X44.2 mmol/l) or a decrease 40.3 mg/dl available evidence. Finally, although severe oliguria and even (426.5 mmol/l) was associated with worse survival. The anuria may result from renal tubular damage, it can also be reasons why small alterations in SCr lead to increases in caused by urinary tract obstruction and by total arterial or hospital mortality are not entirely clear. Possible explanations venous occlusion. These conditions will result in rapid and include the untoward effects of decreased kidney function irreversible damage to the kidney and require prompt such as volume overload, retention of uremic compounds, recognition and management. acidosis, electrolyte disorders, increased risk for infection, and anemia.6 Although, these changes in SCr could simply be Acute tubular necrosis (ATN) colinear with unmeasured variables that lead to increased When mammalian kidneys are subjected to prolonged warm mortality, multiple attempts to control for known clinical ischemia followed by reperfusion, there is extensive necrosis variables has led to the consistent conclusion that decreased destroying the proximal tubules of the outer stripe of the kidney function is independently associated with outcome. medulla, and the proximal convoluted tubules become Furthermore, more severe reductions in kidney function tend necrotic as well.10 Distal nephron involvement in these to be associated with even worse outcome as compared to animal experiments is minimal, unless medullary oxygena- milder reductions. tion is specifically targeted.11 Although these animals develop severe ARF, as noted by Rosen and Heyman, not much else Oliguria and anuria resembles the clinical syndrome in humans.12 Indeed these Although urine output is both a reasonably sensitive authors correctly point out that the term ‘‘acute tubular functional index for the kidney as well as a biomarker of necrosis does not accurately reflect the morphological tubular injury, the relationship between urine output and changes in this condition’’.12 Instead, the term ATN is used GFR, and tubular injury is complex. For example, oliguria to describe a clinical situation in which there is adequate may be more profound when tubular function is intact. renal perfusion to largely maintain tubular integrity, but not Kidney International Supplements (2012) 2, 13–18 13
chapter 1.1 to sustain glomerular filtration. Data from renal biopsies in patients with ATN dating back to the 1950s13 confirm the limited parenchymal compromise in spite of severe organ dysfunction.12 Thus, the syndrome of ATN has very little to do with the animal models traditionally used to study it. More recently, investigators have emphasized the role of endothelial dysfunction, coagulation abnormalities, systemic inflammation, endothelial dysfunction, and oxidative stress in causing renal injury, particularly in the setting of sepsis.14,15 True ATN does, in fact, occur. For example, patients with arterial catastrophes (ruptured aneurysms, acute dissection) can suffer prolonged periods of warm ischemia just like animal models. However, these cases comprise only a small fraction of patients with AKI, and ironically, these patients are often excluded from studies seeking to enroll patients with the more common clinical Figure 1 | The RIFLE criteria for AKI. ARF, acute renal failure; GFR, syndrome known as ATN. glomerular filtration rate; Screat, serum creatinine concentration; UO, urine output. Reprinted from Bellomo R, Ronco C, Kellum JA, ARF et al. Acute renal failure—definition, outcome measures, animal In a recent review, Eknoyan notes that the first description of models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis ARF, then termed ischuria renalis, was by William Heberden Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-212 with in 1802.16 At the beginning of the twentieth century, ARF, permission from Bellomo R et al.;22 accessed http://ccforum.com/ then named Acute Bright’s disease, was well described in content/8/4/R204 William Osler’s Textbook for Medicine (1909), as a consequence of toxic agents, pregnancy, burns, trauma, or operations on the kidneys. During the First World War the syndrome was named AKI: acute kidney injury/impairment ‘‘war nephritis’’,17 and was reported in several publications. Importantly, by defining the syndrome of acute changes in The syndrome was forgotten until the Second World War, renal function more broadly, RIFLE criteria move beyond when Bywaters and Beall published their classical paper on ARF. The term ‘‘acute kidney injury/impairment’’ has been crush syndrome.18 However, it is Homer W. Smith who is proposed to encompass the entire spectrum of the syndrome credited for the introduction of the term ‘‘acute renal failure’’, from minor changes in markers of renal function to in a chapter on ‘‘Acute renal failure related to traumatic requirement for renal replacement therapy (RRT).23 Thus, injuries’’ in his textbook The kidney-structure and function in the concept of AKI, as defined by RIFLE creates a new health and disease (1951). Unfortunately, a precise biochemical paradigm. AKI is not ATN, nor is it renal failure. Instead, it definition of ARF was never proposed and, until recently, there encompasses both and also includes other, less severe was no consensus on the diagnostic criteria or clinical conditions. Indeed, as a syndrome, it includes patients definition of ARF, resulting in multiple different definitions. without actual damage to the kidney but with functional A recent survey revealed the use of at least 35 definitions in the impairment relative to physiologic demand. Including such literature.19 This state of confusion has given rise to wide patients in the classification of AKI is conceptually attractive variation in reported incidence and clinical significance of because these are precisely the patients that may benefit from ARF. Depending on the definition used, ARF has been early intervention. However, it means that AKI includes both reported to affect from 1% to 25% of ICU patients and has injury and/or impairment. Rather than focusing exclusively lead to mortality rates from 15–60%.7,20,21 on patients with renal failure or on those who receive dialysis or on those that have a clinical syndrome defined by RIFLE criteria pathology, which is usually absent (ATN), the strong The Acute Dialysis Quality Initiative (ADQI) group developed association of AKI with hospital mortality demands that we a system for diagnosis and classification of a broad range of change the way we think about this disorder. In a study by acute impairment of kidney function through a broad Hoste et al.,2 only 14% of patients reaching RIFLE ‘‘F’’ consensus of experts.22 The characteristics of this system are received RRT, yet these patients experienced a hospital summarized in Figure 1. The acronym RIFLE stands for the mortality rate more than five times that of the same ICU increasing severity classes Risk, Injury, and Failure; and the two population without AKI. Is renal support underutilized or outcome classes, Loss and End-Stage Renal Disease (ESRD). delayed? Are there other supportive measures that should be The three severity grades are defined on the basis of the employed for these patients? Sustained AKI leads to profound changes in SCr or urine output where the worst of each alterations in fluid, electrolyte, acid-base and hormonal criterion is used. The two outcome criteria, Loss and ESRD, regulation. AKI results in abnormalities in the central are defined by the duration of loss of kidney function. nervous, immune, and coagulation systems. Many patients 14 Kidney International Supplements (2012) 2, 13–18
chapter 1.1 with AKI already have multisystem organ failure. What is the (X0.3 mg/dl or X26.5 mmol/l) when they occur within a incremental influence of AKI on remote organ function and 48-hour period.23 Two recent studies examining large how does it affect outcome? A recent study by Levy et al. databases in the USA28 and Europe29 validated these examined outcomes for over 1000 patients enrolled in the modified criteria. Thakar et al. found that increased severity control arms of two large sepsis trials.24 Early improvement of AKI was associated with an increased risk of death (within 24 hours) in cardiovascular (P ¼ 0.0010), renal independent of comorbidity.28 Patients with Stage 1 (Po0.0001), or respiratory (P ¼ 0.0469) function was (X0.3 mg/dl or X26.5 mmol/l) increase in SCr but less than significantly related to survival. This study suggests that a two-fold increase had an odds ratio of 2.2; with Stage 2 outcomes for patients with severe sepsis in the ICU are (corresponding to RIFLE-I), there was an odds ratio of 6.1; closely related to early resolution of AKI. While rapid and in Stage 3 (RIFLE-F), an odds ratio of 8.6 for hospital resolution of AKI may simply be a marker of a good mortality was calculated. An additional modification to the prognosis, it may also indicate a window of therapeutic RIFLE criteria has been proposed for pediatric patients in opportunity to improve outcome in such patients. order to better classify small children with acute-on-chronic disease.32 Validation studies using RIFLE As of early 2010, over half a million patients have been Limitations to current definitions for AKI studied to evaluate the RIFLE criteria as a means of Unfortunately, the existing criteria—while extremely useful classifying patients with AKI.25–28 Large series from the and widely validated—are still limited. First, despite efforts to USA,28 Europe,29,30 and Australia,25 each including several standardize the definition and classification of AKI, there is thousand patients, have provided a consistent picture. AKI still inconsistency in application.26,27 A minority of studies defined by RIFLE is associated with significantly decreased have included urinary output criteria despite its apparent survival and furthermore, increasing severity of AKI defined ability to identify additional cases6,29 and many studies have by RIFLE stage leads to increased risk of death. excluded patients whose initial SCr is already elevated. An early study from Uchino et al. focused on the Preliminary data from a 20 000-patient database from the predictive ability of the RIFLE classification in a cohort University of Pittsburgh suggests that roughly a third of AKI of 20 126 patients admitted to a teaching hospital for cases are community-acquired33 and many cases may be 424 hours over a 3-year period.5 The authors used an missed by limiting analysis to documented increases in SCr. electronic laboratory database to classify patients into Indeed, the majority of cases of AKI in the developing world RIFLE-R, I, and F and followed them to hospital discharge are likely to be community-acquired. Thus, few studies can or death. Nearly 10% of patients achieved a maximum provide accurate incidence data. An additional problem RIFLE-R, 5% I, and 3.5% F. There was a nearly linear relates to the limitations of SCr and urine output for increase in hospital mortality with increasing RIFLE class, detecting AKI. In the future, biomarkers of renal cell injury with patients at R having more than three times the mortality may identify additional patients with AKI and may identify rate of patients without AKI. Patients with I had close to the majority of patients at an earlier stage. twice the mortality of R and patients with F had 10 times the mortality rate of hospitalized patients without AKI. Rationale for a guideline on AKI The investigators performed multivariate logistic regression AKI is a global problem and occurs in the community, in the analysis to test whether RIFLE classification was an hospital where it is common on medical, surgical, pediatric, independent predictor of hospital mortality. They found and oncology wards, and in ICUs. Irrespective of its nature, that class R carried an odds ratio of hospital mortality of 2.5, AKI is a predictor of immediate and long-term adverse I of 5.4, and F of 10.1. outcomes. AKI is more prevalent in (and a significant risk Ali et al. studied the incidence of AKI in Northern factor for) patients with chronic kidney disease (CKD). Scotland, a geographical population base of 523 390. The Individuals with CKD are especially susceptible to AKI incidence of AKI was 2147 per million population.31 Sepsis which, in turn, may act as a promoter of progression of the was a precipitating factor in 47% of patients. RIFLE underlying CKD. The burden of AKI may be most significant classification was useful for predicting recovery of renal in developing countries34,35 with limited resources for the function (Po0.001), requirement for RRT (Po0.001), length care of these patients once the disease progresses to kidney of hospital stay for survivors (Po0.001), and in-hospital failure necessitating RRT. Addressing the unique circum- mortality (P ¼ 0.035). Although no longer statistically stances and needs of developing countries, especially in the significant, subjects with AKI had a high mortality at 3 and detection of AKI in its early and potentially reversible stages 6 months as well. to prevent its progression to kidney failure requiring dialysis, More recently, the Acute Kidney Injury Network (AKIN), is of paramount importance. an international network of AKI researchers, organized a Research over the past decade has identified numerous summit of nephrology and critical care societies from around preventable risk factors for AKI and the potential of the world. The group endorsed the RIFLE criteria with improving their management and outcomes. Unfortunately, a small modification to include small changes in SCr these are not widely known and are variably practiced Kidney International Supplements (2012) 2, 13–18 15
chapter 1.1 worldwide, resulting in lost opportunities to improve the care These criteria were formulated as follows: and outcomes of patients with AKI. Importantly, there is no K AKI is common. unifying approach to the diagnosis and care of these patients. K AKI imposes a heavy burden of illness (morbidity and There is a worldwide need to recognize, detect, and intervene mortality). to circumvent the need for dialysis and to improve outcomes K The cost per person of managing AKI is high. of AKI. The difficulties and disadvantages associated with an K AKI is amenable to early detection and potential prevention. increasing variation in management and treatment of K There is considerable variability in practice to prevent, diseases that were amplified in the years after the Second diagnose, treat, and achieve outcomes of AKI. World War, led in 1989 to the creation in the USA of the K Clinical practice guidelines in the field have the potential Agency for Health Care Policy and Research (now the Agency to reduce variations, improve outcomes, and reduce costs. for Healthcare Research and Quality). This agency was K Formal guidelines do not exist on this topic. created to provide objective, science-based information to improve decision making in health-care delivery. A major contribution of this agency was the establishment of a Summary systematic process for developing evidence-based guidelines. Small changes in kidney function in hospitalized patients are It is now well accepted that rigorously developed, evidence- important and associated with significant changes in short- based guidelines, when implemented, have improved quality, and long-term outcomes. The shift of terminology from ATN cost, variability, and outcomes.36,37 and ARF to AKI has been well received by the research and Realizing that there is an increasing prevalence of acute clinical communities. RIFLE/AKIN criteria provide a uni- (and chronic) kidney disease worldwide and that the form definition of AKI, and have become the standard for complications and problems of patients with kidney disease diagnostic criteria. AKI severity grades represent patient are universal, Kidney Disease: Improving Global Outcomes groups with increasing severity of illness as illustrated by an (KDIGO), a nonprofit foundation, was established in 2003 increasing proportion of patients treated with RRT, and ‘‘to improve the care and outcomes of kidney disease patients increasing mortality. Thus, AKI as defined by the RIFLE worldwide through promoting coordination, collaboration, criteria is now recognized as an important syndrome, and integration of initiatives to develop and implement alongside other syndromes such as acute coronary syndrome, clinical practice guidelines’’.38 acute lung injury, and severe sepsis and septic shock. The Besides developing guidelines on a number of other RIFLE/AKIN classification for AKI is quite analogous to the important areas of nephrology, the Board of Directors Kidney Disease Outcomes Quality Initiative (KDOQI) for of KDIGO quickly realized that there is room for improving CKD staging, which is well known to correlate disease international cooperation in the development, dissemi- severity with cardiovascular complications and other mor- nation, and implementation of clinical practice guide- bidities.39 As CKD stages have been linked to specific lines in the field of AKI. At its meeting in December of treatment recommendations, which have proved extremely 2006, the KDIGO Board of Directors determined that the useful in managing this disease,39 we have developed topic of AKI meets the criteria for developing clinical practice recommendations for evaluation and management of guidelines. patients with AKI using this stage-based approach. 16 Kidney International Supplements (2012) 2, 13–18
http://www.kidney-international.org chapter 1.2 & 2012 KDIGO Chapter 1.2: Methodology INTRODUCTION surgery. We excluded studies on AKI from rhabdomyolysis, This chapter provides a very brief summary of the methods specific infections, and poisoning or drug overdose. Overall, used to develop this guideline. Detailed methods are we screened 18 385 citations. provided in Appendix F. The overall aim of the project was to create a clinical practice guideline with recommendations Outcome selection judgments, values, and preferences for AKI using an evidence-based approach. After topics and We limited outcomes to those important for decision making, relevant clinical questions were identified, the pertinent including development of AKI, need for or dependence on scientific literature on those topics was systematically RRT, and all-cause mortality. When weighting the evidence searched and summarized. across different outcomes, we selected as the ‘‘crucial’’ outcome that which weighed most heavily in the assessment of the Group member selection and meeting process overall quality of evidence. Values and preferences articulated The KDIGO Co-Chairs appointed the Co-Chairs of the Work by the Work Group included: i) a desire to be inclusive in Group, who then assembled the Work Group to be responsible terms of meeting criteria for AKI; ii) a progressive approach to for the development of the guideline. The Work Group consisted risk and cost such that, as severity increased, the group put of domain experts, including individuals with expertise in greater value on possible effectiveness of strategies, but nephrology, critical care medicine, internal medicine, pediatrics, maintained high value for avoidance of harm; iii) intent to cardiology, radiology, infectious diseases and epidemiology. For guide practice but not limit future research. support in evidence review, expertise in methods, and guideline development, the NKF contracted with the Evidence Review Grading the quality of evidence and the strength of Team (ERT) based primarily at the Tufts Center for Kidney recommendations Disease Guideline Development and Implementation at Tufts The grading approach followed in this guideline is adopted Medical Center in Boston, Massachusetts, USA. The ERT from the GRADE system.40,41 The strength of each recom- consisted of physician-methodologists with expertise in nephrol- mendation is rated as level 1 which means ‘‘strong’’ or level 2 ogy and internal medicine, and research associates and assistants. which means ‘‘weak’’ or discretionary. The wording corres- The ERT instructed and advised Work Group members in all ponding to a level 1 recommendation is ‘‘We recommend y steps of literature review, critical literature appraisal, and should’’ and implies that most patients should receive the guideline development. The Work Group and the ERT course of action. The wording for a level 2 recommendation collaborated closely throughout the project. The Work Group, is ‘‘We suggest y might’’ which implies that different choices KDIGO Co-Chairs, ERT, liaisons, and NKF support staff met for will be appropriate for different patients, with the suggested four 2-day meetings for training in the guideline development course of action being a reasonable choice in many patients. process, topic discussion, and consensus development. In addition, each statement is assigned a grade for the quality of the supporting evidence, A (high), B (moderate), C (low), Evidence selection, appraisal, and presentation or D (very low). Table 1 shows the implications of the We first defined the topics and goals for the guideline and guideline grades and describes how the strength of the identified key clinical questions for review. The ERT recommendations should be interpreted by guideline users. performed literature searches, organized abstract and article Furthermore, on topics that cannot be subjected to screening, coordinated methodological and analytic processes systematic evidence review, the Work Group could issue of the report, defined and standardized the search methodol- statements that are not graded. Typically, these provide ogy, performed data extraction, and summarized the guidance that is based on common sense, e.g., reminders of evidence. The Work Group members reviewed all included the obvious and/or recommendations that are not sufficiently articles, data extraction forms, summary tables, and evidence specific enough to allow the application of evidence. The profiles for accuracy and completeness. The four major topic GRADE system is best suited to evaluate evidence on areas of interest for AKI included: i) definition and comparative effectiveness. Some of our most important classification; ii) prevention; iii) pharmacologic treatment; guideline topics involve diagnosis and staging or AKI, and and iv) RRT. Populations of interest were those at risk for here the Work Group chose to provide ungraded statements. AKI (including those after intravascular contrast-media These statements are indirectly supported by evidence on risk exposure, aminoglycosides, and amphotericin) and those relationships and resulted from unanimous consensus of the with or at risk for AKI with a focus on patients with sepsis or Work Group. Thus, the Work Group feels they should not be trauma, receiving critical care, or undergoing cardiothoracic viewed as weaker than graded recommendations. Kidney International Supplements (2012) 2, 13–18 17
chapter 1.2 Table 1 | Implications of the strength of a recommendation Implications Grade* Patients Clinicians Policy Level 1 Most people in your situation Most patients should receive the The recommendation can be evaluated as ‘‘We recommend’’ would want the recommended recommended course of action. a candidate for developing a policy or a course of action and only a performance measure. small proportion would not. Level 2 The majority of people in your Different choices will be appropriate for The recommendation is likely to require ‘‘We suggest’’ situation would want the different patients. Each patient needs help to substantial debate and involvement of recommended course of action, arrive at a management decision consistent stakeholders before policy can be but many would not. with her or his values and preferences. determined. SPONSORSHIP advertisements herein are the responsibility of the contributor, KDIGO gratefully acknowledges the following sponsors that copyright holder, or advertiser concerned. Accordingly, the make our initiatives possible: Abbott, Amgen, Belo Founda- publishers and the ISN, the editorial board and their respective tion, Coca-Cola Company, Dole Food Company, Genzyme, employers, office and agents accept no liability whatsoever for Hoffmann-LaRoche, JC Penney, NATCO—The Organization the consequences of any such inaccurate or misleading data, for Transplant Professionals, NKF—Board of Directors, opinion or statement. While every effort is made to ensure that Novartis, Robert and Jane Cizik Foundation, Shire, drug doses and other quantities are presented accurately, Transwestern Commercial Services, and Wyeth. KDIGO is readers are advised that new methods and techniques supported by a consortium of sponsors and no funding is involving drug usage, and described within this Journal, accepted for the development of specific guidelines. should only be followed in conjunction with the drug manufacturer’s own published literature. DISCLAIMER While every effort is made by the publishers, editorial board, and ISN to see that no inaccurate or misleading data, opinion SUPPLEMENTARY MATERIAL Appendix F: Detailed Methods for Guideline Development. or statement appears in this Journal, they wish to make it clear Supplementary material is linked to the online version of the paper at that the data and opinions appearing in the articles and http://www.kdigo.org/clinical_practice_guidelines/AKI.php 18 Kidney International Supplements (2012) 2, 13–18
http://www.kidney-international.org chapter 2.1 & 2012 KDIGO Section 2: AKI Definition Kidney International Supplements (2012) 2, 19–36; doi:10.1038/kisup.2011.32 Chapter 2.1: Definition and classification of AKI INTRODUCTION Table 2 | Staging of AKI AKI is one of a number of conditions that affect kidney Stage Serum creatinine Urine output structure and function. AKI is defined by an abrupt decrease 1 1.5–1.9 times baseline o0.5 ml/kg/h for in kidney function that includes, but is not limited to, ARF. It OR 6–12 hours is a broad clinical syndrome encompassing various etiologies, X0.3 mg/dl (X26.5 mmol/l) increase including specific kidney diseases (e.g., acute interstitial 2 2.0–2.9 times baseline o0.5 ml/kg/h for nephritis, acute glomerular and vasculitic renal diseases); X12 hours non-specific conditions (e.g, ischemia, toxic injury); as well 3 3.0 times baseline o0.3 ml/kg/h for as extrarenal pathology (e.g., prerenal azotemia, and acute OR X24 hours postrenal obstructive nephropathy)—see Chapters 2.2 and Increase in serum creatinine to OR 2.3 for further discussion. More than one of these conditions X4.0 mg/dl (X353.6 mmol/l) Anuria for X12 hours OR may coexist in the same patient and, more importantly, Initiation of renal replacement therapy epidemiological evidence supports the notion that even mild, OR, In patients o18 years, decrease in reversible AKI has important clinical consequences, including eGFR to o35 ml/min per 1.73 m2 increased risk of death.2,5 Thus, AKI can be thought of more like acute lung injury or acute coronary syndrome. Furthermore, because the manifestations and clinical con- 2.1.2: AKI is staged for severity according to the following sequences of AKI can be quite similar (even indistinguish- criteria (Table 2). (Not Graded) able) regardless of whether the etiology is predominantly 2.1.3: The cause of AKI should be determined whenever within the kidney or predominantly from outside stresses on possible. (Not Graded) the kidney, the syndrome of AKI encompasses both direct injury to the kidney as well as acute impairment of function. RATIONALE Since treatments of AKI are dependent to a large degree on Conditions affecting kidney structure and function can be the underlying etiology, this guideline will focus on specific considered acute or chronic, depending on their duration. diagnostic approaches. However, since general therapeutic AKI is one of a number of acute kidney diseases and and monitoring recommendations can be made regarding all disorders (AKD), and can occur with or without other acute forms of AKI, our approach will be to begin with general or chronic kidney diseases and disorders (Figure 2). Whereas measures. CKD has a well-established conceptual model and definition that has been useful in clinical medicine, research, and public Definition and staging of AKI health,42–44 the definition for AKI is evolving, and the AKI is common, harmful, and potentially treatable. Even concept of AKD is relatively new. An operational definition a minor acute reduction in kidney function has an adverse of AKD for use in the diagnostic approach to alterations prognosis. Early detection and treatment of AKI may in kidney function and structure is included in Chapter 2.5, improve outcomes. Two similar definitions based on SCr with further description in Appendix B. and urine output (RIFLE and AKIN) have been proposed and The conceptual model of AKI (Figure 3) is analogous to validated. There is a need for a single definition for practice, the conceptual model of CKD, and is also applicable to research, and public health. AKD.42,45 Circles on the horizontal axis depict stages in the development (left to right) and recovery (right to left) of 2.1.1: AKI is defined as any of the following (Not Graded): AKI. AKI (in red) is defined as reduction in kidney function, K Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) including decreased GFR and kidney failure. The criteria for within 48 hours; or the diagnosis of AKI and the stage of severity of AKI are K Increase in SCr to X1.5 times baseline, which based on changes in SCr and urine output as depicted in the is known or presumed to have occurred within triangle above the circles. Kidney failure is a stage of AKI the prior 7 days; or highlighted here because of its clinical importance. Kidney K Urine volume o0.5 ml/kg/h for 6 hours. failure is defined as a GFR o15 ml/min per 1.73 m2 body Kidney International Supplements (2012) 2, 19–36 19
chapter 2.1 surface area, or requirement for RRT, although it is Existing evidence supports the validity of both RIFLE and recognized that RRT may be required earlier in the evolution AKIN criteria to identify groups of hospitalized patients with of AKI. Further description is included in Chapter 2.5 and increased risk of death and/or need for RRT.2,5,25,28–30 Appendix A. Epidemiological studies, many multicentered, collectively It is widely accepted that GFR is the most useful overall enrolling more than 500 000 subjects have been used to index of kidney function in health and disease, and changes establish RIFLE and/or AKIN criteria as valid methods to in SCr and urine output are surrogates for changes in GFR. In diagnose and stage AKI. Recently, Joannidis et al.29 directly clinical practice, an abrupt decline in GFR is assessed from an compared RIFLE criteria with and without the AKIN increase in SCr or oliguria. Recognizing the limitations of the modification. While AKI classified by either criteria were use of a decrease in kidney function for the early detection associated with a similarly increased hospital mortality, the and accurate estimation of renal injury (see below), there is a two criteria identified somewhat different patients. The broad consensus that, while more sensitive and specific original RIFLE criteria failed to detect 9% of cases that were biomarkers are needed, changes in SCr and/or urine output detected by AKIN criteria. However, the AKIN criteria missed form the basis of all diagnostic criteria for AKI. The first 26.9% of cases detected by RIFLE. Examination of the cases international interdisciplinary consensus criteria for diag- missed by either criteria (Table 4) shows that cases identified nosis of AKI were the RIFLE criteria32 proposed by the by AKIN but missed by RIFLE were almost exclusively Stage 1 ADQI. Modifications to these criteria have been proposed in (90.7%), while cases missed by AKIN but identified by RIFLE order to better account for pediatric populations (pRIFLE)32 included 30% with RIFLE-I and 18% RIFLE-F; furthermore, and for small changes in SCr not captured by RIFLE (AKIN these cases had hospital mortality similar to cases identified criteria).23 Recommendations 2.1.1 and 2.1.2 represent the by both criteria (37% for I and 41% for F). However, cases combination of RIFLE and AKIN criteria (Table 3). missed by RIFLE but identified as Stage 1 by AKIN also had hospital mortality rates nearly twice that of patients who had no evidence of AKI by either criteria (25% vs. 13%). These data provide strong rationale for use of both RIFLE and AKIN criteria to identify patients with AKI. AKD AKI CKD Staging of AKI (Recommendation 2.1.2) is appropriate because, with increased stage of AKI, the risk for death and need for RRT increases.2,5,25,28–31 Furthermore, there is now Figure 2 | Overview of AKI, CKD, and AKD. Overlapping ovals accumulating evidence of long-term risk of subsequent show the relationships among AKI, AKD, and CKD. AKI is a subset development of cardiovascular disease or CKD and mortality, of AKD. Both AKI and AKD without AKI can be superimposed even after apparent resolution of AKI.47–49 upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases For staging purposes, patients should be staged accord- and disorders; AKI, acute kidney injury; CKD, chronic kidney ing to the criteria that give them the highest stage. Thus disease. when creatinine and urine output map to different stages, Stages defined by Complications creatinine and urine output are surrogates GFR Increased Kidney Normal Damage ↓ GFR Death risk failure Damage Antecedents Markers such Intermediate Stage as NGAL, KIM-1, AKI and IL-18 are Outcomes surrogates Figure 3 | Conceptual model for AKI. Red circles represent stages of AKI. Yellow circles represent potential antecedents of AKI, and the pink circle represents an intermediate stage (not yet defined). Thick arrows between circles represent risk factors associated with the initiation and progression of disease that can be affected or detected by interventions. Purple circles represent outcomes of AKI. ‘‘Complications’’ refers to all complications of AKI, including efforts at prevention and treatment, and complications in other organ systems. AKI, acute kidney injury; GFR, glomerular filtration rate. Adapted from Murray PT, Devarajan P, Levey AS, et al. A framework and key research questions in AKI diagnosis and staging in different environments. Clin J Am Soc Nephrol 2008; 3: 864–868 with permission from American Society of Nephrology45 conveyed through Copyright Clearance Center, Inc.; accessed http://cjasn.asnjournals.org/content/3/3/864.full 20 Kidney International Supplements (2012) 2, 19–36
chapter 2.1 Table 3 | Comparison of RIFLE and AKIN criteria for diagnosis and classification of AKI AKI staging Urine output RIFLE Serum creatinine (common to both) Class Serum creatinine or GFR Stage 1 Increase of more than or equal to 0.3 mg/dl Less than 0.5 ml/kg/h for Risk Increase in serum creatinine  1.5 or GFR (X26.5 mmol/l) or increase to more than or equal to more than 6 hours decrease 425% 150% to 200% (1.5- to 2-fold) from baseline Stage 2 Increased to more than 200% to 300% Less than 0.5 ml/kg per hour Injury Serum creatinine  2 or GFR decreased (42- to 3-fold) from baseline for more than 12 hours 450% Stage 3 Increased to more than 300% (43-fold) Less than 0.3 ml/kg/h for Failure Serum creatinine  3, or serum creatinine from baseline, or more than or equal to 4.0 mg/dl 24 hours or anuria for 44 mg/dl (4354 mmol/l) with an acute (X354 mmol/l) with an acute increase of at least 12 hours rise 40.5 mg/dl (444 mmol/l) or GFR 0.5 mg/dl (44 mmol/l) or on RRT decreased 475% Loss Persistent acute renal failure=complete loss of kidney function 44 weeks End-stage kidney ESRD 43 months disease Note: For conversion of creatinine expressed in SI units to mg/dl, divide by 88.4. For both AKIN stage and RIFLE criteria, only one criterion (creatinine rise or urine output decline) needs to be fulfilled. Class is based on the worst of either GFR or urine output criteria. GFR decrease is calculated from the increase in serum creatinine above baseline. For AKIN, the increase in creatinine must occur in o48 hours. For RIFLE, AKI should be both abrupt (within 1–7 days) and sustained (more than 24 hours). When baseline creatinine is elevated, an abrupt rise of at least 0.5 mg/dl (44 mmol/l) to 44 mg/dl (4354 mmol/l) is sufficient for RIFLE class Failure (modified from Mehta et al.23 and the report of the Acute Dialysis Quality Initiative consortium22). AKI, acute kidney injury; AKIN, Acute Kidney Injury Network; ESRD, end-stage renal disease; GFR, glomerular filtration rate; RIFLE, risk, injury, failure, loss, and end stage; RRT, renal replacement therapy. Reprinted from Endre ZH. Acute kidney injury: definitions and new paradigms. Adv Chronic Kidney Dis 2008; 15: 213–221 with permission from National Kidney Foundation46; accessed http://www.ackdjournal.org/article/S1548-5595(08)00049-9/fulltext Table 4 | Cross-tabulation of patients classified by RIFLE vs. AKIN RIFLE AKIN Non-AKI Risk Injury Failure Total (AKIN) Non-AKI n* 8759 (12.9%) 781 (27.7%) 452 (37.4%) 271 (41.3%) 10 263 (15.9%) Stage1 n* 457 (25.2%) 282 (33.0%) 243 (44.0%) 95 (60.0%) 1077 (34.5%) Stage 2 n* 36 (30.6%) 21 (47.6%) 885 (25.9%) 91 (54.9) 1033 (29.0%) Stage 3 n* 11 (18.2%) 8 (12.5%) 16 (62.5%) 1948 (41.3) 1983 (41.2%) Total (RIFLE) n* 9263 (13.6%) 1092 (29.2%) 1596 (32.3%) 2405 (42.6%) 14 356 (21.7%) *Number of patients classified into the respective stages of AKI by AKIN or RIFLE are cross-tabulated against each other. Hospital mortality of each group is given in parentheses. Shaded fields denote patients assigned to the same degree of AKI by both classification systems. AKI, acute kidney injury; AKIN, Acute Kidney Injury Network; RIFLE, risk, injury, failure, loss, and end stage. With kind permission from Springer Science+Business Media: Intensive Care Med. Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. 35 (2009): 1692–1702. Joannidis M, Metnitz B, Bauer P et al.29; accessed http://www.springerlink.com/content/r177337030550120/ the patient is staged according to the highest (worst) stage. the definition of AKI in Recommendation 2.1.1). This is The changes in GFR that were published with the original problematic for smaller pediatric patients, including infants RIFLE criteria do not correspond precisely to changes in SCr. and children with low muscle mass who may not be able to As SCr is measured and GFR can only be estimated, achieve a SCr of 4.0 mg/dl (354 mmol/l). Thus, the pediatric- creatinine criteria should be used along with urine output modified RIFLE AKI criteria32 were developed using a change for the diagnosis (and staging) of AKI. One additional change in estimated creatinine clearance (eCrCl) based on the in the criteria was made for the sake of clarity and simplicity. Schwartz formula. In pRIFLE, patients automatically reach For patients reaching Stage 3 by SCr 44.0 mg/dl Stage 3 if they develop an eCrCl o35 ml/min per 1.73 m2. (4354 mmol/l), rather than require an acute increase of However, with this automatic pRIFLE threshold, the SCr X0.5 mg/dl (X44 mmol/l) over an unspecified time period, we change based AKI definition (recommendation 2.1.1) is instead require that the patient first achieve the creatinine- applicable to pediatric patients, including an increase of based change specified in the definition (either X0.3 mg/dl 0.3 mg/dl (26.5 mmol/l) SCr.32 [X26.5 mmol/l] within a 48-hour time window or an increase There are important limitations to these recommenda- of X1.5 times baseline). This change brings the definition and tions, including imprecise determination of risk (see Chapter staging criteria to greater parity and simplifies the criteria. 2.2) and incomplete epidemiology of AKI, especially outside Recommendation 2.1.2 is based on the RIFLE and AKIN the ICU. Clinical judgment is required in order to determine criteria that were developed for average-sized adults. The if patients seeming to meet criteria do, in fact, have disease, as creatinine change–based definitions include an auto- well as to determine if patients are likely to have AKI even if matic Stage 3 classification for patients who develop SCr incomplete clinical data are available to apply the diagnostic 44.0 mg/dl (4354 mmol/l) (provided that they first satisfy criteria. The application of the diagnostic and staging criteria Kidney International Supplements (2012) 2, 19–36 21
chapter 2.1 Table 5 | Causes of AKI and diagnostic tests some patients with specific kidney diseases (e.g., glome- Selected causes of AKI requiring rulonephritis) for which a specific treatment is available. As immediate diagnosis and specific such, it is always necessary to search for the underlying cause therapies Recommended diagnostic tests of AKI (see Chapter 2.3). Decreased kidney perfusion Volume status and urinary diagnostic indices Research Recommendations Acute glomerulonephritis, vasculitis, Urine sediment examination, K The role of biomarkers other than SCr in the early interstitial nephritis, thrombotic serologic testing and microangiopathy hematologic testing diagnosis, differential diagnosis, and prognosis of AKI Urinary tract obstruction Kidney ultrasound patients should be explored. Some important areas in AKI, acute kidney injury. which to focus include: J Early detection where the gold standard is AKI by clinical diagnosis after the fact and the biomarker is compared to existing markers (SCr and urine is discussed in greater detail, along with specific examples in output) at the time of presentation. Chapter 2.4. J Prognosis where a biomarker is used to predict risk The use of urine output criteria for diagnosis and staging for AKI or risk for progression of AKI. has been less well validated and in individual patients J Prognosis where a biomarker is used to predict the need for clinical judgment regarding the effects of drugs recovery after AKI vs. death or need for long-term RRT. (e.g., angiotensin-converting enzyme inhibitors [ACE-I]), K The influence of urinary output criteria on AKI staging fluid balance, and other factors must be included. For very needs to be further investigated. Influence of fluid obese patients, urine output criteria for AKI may include balance, percent volume overload, diuretic use, and some patients with normal urine output. However, these differing weights (actual, ideal body weight, lean body recommendations serve as the starting point for further mass) should be considered. Also, it is currently not evaluation, possibly involving subspecialists, for a group of known how urine volume criteria should be applied (e.g., patients recognized to be at increased risk. average vs. persistent reduction for the period specified). Finally, it is axiomatic that patients always be managed K The influence of SCr or eGFR criteria on AKI staging according to the cause of their disease, and thus it is needs to be further investigated. The use of different important to determine the cause of AKI whenever possible. relative and absolute SCr increments or eGFR decrements In particular, patients with decreased kidney perfusion, acute at different time points and with differently ascertained glomerulonephritis, vasculitis, interstitial nephritis, throm- baseline values requires further exploration and valida- botic microangiopathy, and urinary tract obstruction require tion in various populations. immediate diagnosis and specific therapeutic intervention, in addition to the general recommendations for AKI in the SUPPLEMENTARY MATERIAL remainder of this guideline (Table 5). Appendix A: Background. Appendix B: Diagnostic Approach to Alterations in Kidney Function It is recognized that it is frequently not possible to deter- and Structure. mine the cause, and often the exact cause does not dictate a Supplementary material is linked to the online version of the paper at specific therapy. However, the syndrome of AKI includes http://www.kdigo.org/clinical_practice_guidelines/AKI.php 22 Kidney International Supplements (2012) 2, 19–36
http://www.kidney-international.org chapter 2.2 & 2012 KDIGO Chapter 2.2: Risk assessment The kidney is a fairly robust organ that can tolerate exposure to Table 6 | Causes of AKI: exposures and susceptibilities for several insults without suffering significant structural or non-specific AKI functional change. For this reason, any acute change in kidney Exposures Susceptibilities function often indicates severe systemic derangement and predicts a poor prognosis. Risk for AKI is increased by exposure Sepsis Dehydration or volume depletion Critical illness Advanced age to factors that cause AKI or the presence of factors that increase Circulatory shock Female gender susceptibility to AKI. Factors that determine susceptibility of the Burns Black race kidneys to injury include dehydration, certain demographic Trauma CKD characteristics and genetic predispositions, acute and chronic Cardiac surgery (especially Chronic diseases (heart, lung, liver) with CPB) comorbidities, and treatments. It is the interaction between Major noncardiac surgery Diabetes mellitus susceptibility and the type and extent of exposure to insults that Nephrotoxic drugs Cancer determines the risk of occurrence of AKI. Radiocontrast agents Anemia Understanding individual ‘‘risk factors’’ may help in Poisonous plants and animals preventing AKI. This is particularly gratifying in the hospital CKD, chronic kidney disease; CPB, cardiopulmonary bypass. setting, where the patient’s susceptibility can be assessed before certain exposures as surgery or administration of However, the chances of developing AKI after exposure to the potentially nephrotoxic agents. Accordingly, some suscept- same insult differ among different individuals. This is ibility factors may be modified, and contemplated exposures attributed to a number of susceptibility factors which vary avoided or tailored to reduce the risk of AKI. widely from individual to individual. Our understanding of Risk assessment in community-acquired AKI is different susceptibility factors (Table 6) is based on many observa- from hospital-acquired AKI, for two main reasons: i) Available tional studies that address different settings with regards to evidence on risk factors is largely derived from hospital data and the type, severity, duration, and multiplicity of insults. While extrapolation to the community setting is questionable. ii) The this heterogeneity provides insight into some susceptibility opportunity to intervene, prior to exposure, is quite limited. factors that are common across various populations, the Most patients are seen only after having suffered an exposure generalizability of results from one particular setting to the (trauma, infection, poisonous plant, or animal). However, there next is uncertain. is still room to assess such patients, albeit after exposure, in The course and outcome of AKI are modified by other order to identify those who are more likely to develop AKI, factors, but since these are manifested within the context of thereby requiring closer monitoring and general supportive actual disease, they must be categorized as ‘‘prognostic’’ measures. It may also be helpful to identify such patients in rather than ‘‘risk’’ factors, hence being discussed separately in order to avoid additional injury. A more complete discussion of Appendix D. Lastly, the fact that some 30% of patients who the approach to identification and management of risk for AKI recover from AKI remain at increased risk of CKD, is provided in Appendices C and D. cardiovascular disease, and death calls for the identification of the risk factors that can identify such patients in the hopes 2.2.1: We recommend that patients be stratified for risk of AKI of providing them with timely preventive measures.50–52 according to their susceptibilities and exposures. (1B) Finally, it is important to screen patients who have 2.2.2: Manage patients according to their susceptibilities and undergone an exposure (e.g., sepsis, trauma) and to continue exposures to reduce the risk of AKI (see relevant monitor high-risk patients until the risk has subsided. Exact guideline sections). (Not Graded) intervals for checking SCr and in which individuals to 2.2.3: Test patients at increased risk for AKI with measure- monitor urine output remain matters of clinical judgment; ments of SCr and urine output to detect AKI. (Not however, as a general rule, high risk in-patients should have Graded) Individualize frequency and duration of SCr measured at least daily and more frequently after an monitoring based on patient risk and clinical course. exposure, and critically ill patients should have urine output (Not Graded) monitoring. This will necessitate urinary bladder catheteriza- tion in many cases, and the risks of infection should also be considered in the monitoring plan. RATIONALE A recent clinical practice assessment in the UK concluded There are many types of exposures that may cause AKI that only 50% of patients with AKI were considered to have (Table 6) and these are discussed in detail in Appendix C. received a ‘‘good’’ overall standard of care. This figure fell to Kidney International Supplements (2012) 2, 19–36 23
chapter 2.2 just over 30% if AKI developed during a hospital admission K Studies are needed to develop and validate scoring systems rather than being diagnosed before admission.53 The authors for AKI risk prediction in various settings, in addition to also felt that there was an unacceptable delay in recognizing cardiac surgery and exposure to radiocontrast material. AKI in 43% of those that developed the condition after K Genome-wide association studies are needed to deter- admission, and that in a fifth of such patients its develop- mine risk of AKI in different hospital settings and with ment was predictable and avoidable. Their recommendations respect to long-term outcomes. were simple: risk assessment for AKI as part of the initial K Studies are needed on risk factors for the development of, evaluation of emergency admissions, along with appropriate recovery from, and long-term outcomes of community- serum biochemistry on admission and at frequent intervals acquired AKI, including sepsis, trauma, tropical infec- thereafter.53 tions, snake bites, and ingestion of toxic plants, etc. RESEARCH RECOMMENDATIONS SUPPLEMENTARY MATERIAL K Better delineation of risk for hospital- and community- Appendix C: Risk Determination. Appendix D: Evaluation and General Management Guidelines for acquired AKI is needed. Patients with AKI. K Better delineation of the effects of age on the risk for AKI Supplementary material is linked to the online version of the paper at is needed. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 24 Kidney International Supplements (2012) 2, 19–36
http://www.kidney-international.org chapter 2.3 & 2012 KDIGO Chapter 2.3: Evaluation and general management of patients with and at risk for AKI Given that AKI is associated with significant morbidity and with AKI include both reducing kidney injury and complica- mortality, and because no specific treatment is available to tions related to decreased kidney function. reverse AKI, early recognition and management is para- mount. Indeed, recognition of patients at risk for AKI, or 2.3.1: Evaluate patients with AKI promptly to determine with possible AKI but prior to clinical manifestations, is the cause, with special attention to reversible likely to result in better outcomes than treating only causes. (Not Graded) established AKI. Chapter 2.2 introduced the approach to 2.3.2: Monitor patients with AKI with measurements of risk assessment with further detail provided in Appendix C. SCr and urine output to stage the severity, This chapter will concern itself with the evaluation according to Recommendation 2.1.2. (Not Graded) and general management of patients with, or even at risk 2.3.3: Manage patients with AKI according to the stage for, AKI. Further detail is provided in Appendix D. We (see Figure 4) and cause. (Not Graded) highlight the importance of beginning management at the 2.3.4: Evaluate patients 3 months after AKI for resolu- earliest point in the development of AKI—in patients with tion, new onset, or worsening of pre-existing CKD. suspected AKI or even in those at increased risk who have (Not Graded) been exposed to the various factors discussed in Chapters 2.2 K If patients have CKD, manage these patients as and Appendix C. detailed in the KDOQI CKD Guideline (Guide- Although much of the remaining chapters in this guide- lines 7–15). (Not Graded) line pertain to management of specific aspects of AKI, there K If patients do not have CKD, consider them to be are general management principles that are common to all at increased risk for CKD and care for them as patients and these will be discussed here and further detailed in the KDOQI CKD Guideline 3 for expounded upon in Appendix D. Treatment goals in patients patients at increased risk for CKD. (Not Graded) Figure 4 | Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive-care unit. Kidney International Supplements (2012) 2, 19–36 25
chapter 2.3 RATIONALE The clinical evaluation of AKI includes a careful history As emphasized in Chapter 2.2, AKI is not a disease but and physical examination. Drug history should include over- rather a clinical syndrome with multiple etiologies. While the-counter formulations and herbal remedies or recreational much of the literature examining epidemiology and clinical drugs. The social history should include exposure to tropical consequences of AKI appear to treat this syndrome as a diseases (e.g., malaria), waterways or sewage systems, and homogeneous disorder, the reality is that AKI is hetero- exposure to rodents (e.g., leptospirosis, hantavirus). Physical geneous and often is the result of multiple insults. Figure 5 examination should include evaluation of fluid status, signs illustrates an approach to evaluation of AKI. Further for acute and chronic heart failure, infection, and sepsis. discussion of evaluation in clinical practice is provided in Measurement of cardiac output, preload, preload respon- Appendix D. siveness, and intra-abdominal pressure should be considered Figure 5 | Evaluation of AKI according to the stage and cause. 26 Kidney International Supplements (2012) 2, 19–36
chapter 2.3 in the appropriate clinical context. Laboratory parameters— variables like central venous pressure are not nearly as useful including SCr, blood urea nitrogen (BUN), and electrolytes, as dynamic variables, such as pulse-pressure variation, complete blood count and differential—should be obtained. inferior vena cava filling by ultrasound and echocardio- Urine analysis and microscopic examination as well as graphic appearance of the heart (see also Appendix D). urinary chemistries may be helpful in determining the Note that while the actions listed in Figure 4 provide underlying cause of AKI. Imaging tests, especially ultrasound, an overall starting point for stage-based evaluation and are important components of the evaluation for patients with management, they are neither complete not mandatory for AKI. Finally, a number of biomarkers of functional change an individual patient. For example, the measurement of urine and cellular damage are under evaluation for early diagnosis, output does not imply that the urinary bladder catheteriza- risk assessment for, and prognosis of AKI (see Appendix D tion is mandatory for all patients, and clinicians should for detailed discussion). balance the risks of any procedures with the benefits. Individualize frequency and duration of monitoring based Furthermore, clinicians must individualize care decisions on patient risk, exposure and clinical course. Stage is a predictor based on the totality of the clinical situation. However, it is of the risk for mortality and decreased kidney function (see advisable to include AKI stage in these decisions. Chapter 2.4). Dependent on the stage, the intensity of future The evaluation and management of patients with AKI preventive measures and therapy should be performed. requires attention to cause and stage of AKI, as well as factors Because the stage of AKI has clearly been shown to that relate to further injury to the kidney, or complications correlate with short-term2,5,27,29 and even longer-term out- from decreased kidney function. Since AKI is a risk factor for comes,31 it is advisable to tailor management to AKI stage. CKD, it is important to evaluate patients with AKI for new Figure 4 lists a set of actions that should be considered for onset or worsening of pre-existing CKD. If patients have patients with AKI. Note that for patients at increased risk (see CKD, manage patients as detailed in the KDOQI CKD Chapters 2.2 and 2.4), these actions actually begin even Guideline (Guidelines 7–15). If patients do not have CKD, before AKI is diagnosed. consider them to be at increased risk for CKD and care for Note that management and diagnostic steps are both them as detailed in the KDOQI CKD Guideline 3 for patients included in Figure 4. This is because response to therapy is an at increased risk for CKD. important part of the diagnostic approach. There are few specific tests to establish the etiology of AKI. However, a RESEARCH RECOMMENDATIONS patient’s response to treatment (e.g., discontinuation of a K Clinical research aimed at testing early management possible nephrotoxic agent) provides important information strategies is urgently needed. Such trials should also as to the diagnosis. address the risks and benefits of commonly used fluid- Nephrotoxic drugs account for some part of AKI in 20–30% management strategies, including intravenous (i.v.) fluids of patients. Often, agents like antimicrobials (e.g., aminoglyco- and diuretics. sides, amphotericin) and radiocontrast are used in patients that K Methods to better assess fluid status in critically ill and are already at high risk for AKI (e.g., critically ill patients with other hospitalized patients at risk for AKI are needed. sepsis). Thus, it is often difficult to discern exactly what K Research is needed, with follow-up beyond hospital stay, contribution these agents have on the overall course of AKI. to better understand the clinical consequences of AKI in Nevertheless, it seems prudent to limit exposure to these agents patients with and without underlying CKD. whenever possible and to weigh the risk of developing or worsening AKI against the risk associated with not using the SUPPLEMENTARY MATERIAL agent. For example, when alternative therapies or diagnostic Appendix C: Risk Determination. Appendix D: Evaluation and General Management Guidelines for approaches are available they should be considered. Patients with AKI. In order to ensure adequate circulating blood volume, it is Supplementary material is linked to the online version of the paper at sometimes necessary to obtain hemodynamic variables. Static http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 19–36 27
http://www.kidney-international.org chapter 2.4 & 2012 KDIGO Chapter 2.4: Clinical applications This chapter provides a detailed application of the AKI diagnose patients as rapidly as possible. For example, case A definition and staging for clinical diagnosis and management. can be diagnosed with AKI on day 2 by the first criterion, The definitions and classification system discussed in whereas the second criterion is not satisfied until day 3 Chapter 2.1 can be used easily in many patients and requires (increase from 1.3 to 1.9). However, this is only true because little clinical interpretation. However, in real time, clinicians the episode of AKI began prior to medical attention, and thus do not always have a complete dataset to work with the day 1 SCr level was already increased. If creatinine and individual patients present with unique histories. As measurements had available with 48 hours prior to day 1 and discussed in the previous chapter, it is difficult to distinguish if this level had been at baseline (1.0 mg/dl [88.4 mmol/l]), it AKI from CKD in many cases. In addition, as many as would have been possible to diagnose AKI on day 1 using the two-thirds of all cases of AKI begin prior to hospitali- second criterion. zation (community-acquired AKI). Therefore, clinicians Cases F-H do not have a baseline measurement of SCr may be faced with patients in whom kidney function available. Elevated SCr (reduced eGFR) on day 1 of the is already decreased and, during the hospitalization, hospitalization is consistent with either CKD or AKD improves rather than worsens. Finally, many patients without AKI. In Case F, baseline SCr can be inferred do not have a prior measurement of kidney function to be below the day 1 value because of the subsequent available for comparison. This chapter provides detailed clinical course; thus, we can infer the patient has had an examples of the application of these definitions to the clinical episode of AKI. In case G, AKI can be diagnosed by setting. application of criterion 2, but the patient may have under- lying CKD. Case H does not fulfill the definition for Examples of application of AKI definitions AKI based on either criteria, and has either CKD or AKD Table 7 illustrates a number of examples whereby patients without AKI. presenting with possible AKI can be diagnosed. Cases A-F The example of Case A raises several important issues. have a measurement of baseline SCr. To simplify decision- First, frequent monitoring of SCr in patients at increased risk making, baseline estimated glomerular filtration rate (eGFR) of AKI will significantly improve diagnostic time and exceeds 60 ml/min per 1.73 m2 in these patients, so none has accuracy. If Case A had not presented to medical attention pre-existing CKD. Cases A-F can all be diagnosed with AKI (or if SCr had not been checked) until day 7, the case of AKI by applying the first two criteria in Recommendation 2.1.1. (a would likely have been missed. Frequent measurement of SCr documented increase of at least 0.3 mg/dl (426.5 mmol/l) in high-risk patients, or in patients in which AKI is suspected, [within 48 hours or a 50% increase from presumed baseline). is therefore encouraged—see Chapter 2.3. The second issue Note that a patient can be diagnosed with AKI by fulfilling highlighted by Case A is the importance of baseline SCr either criterion 1 or 2 (or 3, urine output) and thus cases measurements. Had no baseline been available it would still B,C,D, and F all fulfill the definition of AKI. Note also that have been possible to diagnose AKI on day 3 (by either using patients may be diagnosed earlier using criterion 1 or 2. Early criterion 2 or by using criterion 1 and accepting the baseline diagnosis may improve outcome so it is advantageous to SCr as 1.3); however, not only would this have resulted in a Table 7 | AKI diagnosis Serum creatinine mg/dl (lmol/l) Diagnosis AKI? Criterion 1 Criterion 2 Case Baseline Day 1 Day 2 Day 3 Day 7 50% from baseline X0.3 mg/dl (X26.5 lmol/l) rise in p48 hours A 1.0 (88) 1.3 (115) 1.5 (133) 2.0 (177) 1.0 (88) Yes Yes B 1.0 (88) 1.1 (97) 1.2 (106) 1.4 (124) 1.0 (88) No Yes C 0.4 (35) 0.5 (44) 0.6 (53) 0.7 (62) 0.4 (35) Yes No D 1.0 (88) 1.1 (97) 1.2 (106) 1.3 (115) 1.5 (133) Yes No E 1.0 (88) 1.3 (115) 1.5 (133) 1.8 (159) 2.2 (195) Yes Yes F ? 3.0 (265) 2.6 (230) 2.2 (195) 1.0 (88) Yes No G ? 1.8 (159) 2.0 (177) 2.2 (195) 1.6 (141) ? Yes H ? 3.0 (265) 3.1 (274) 3.0 (265) 2.9 (256) ? No 28 Kidney International Supplements (2012) 2, 19–36
chapter 2.4 Table 8 | Overview of the approaches to determine baseline SCr in the application of RIFLE classification in previous studies No. of pts Multi-/ Criteria % % Study analyzed single-center used Method to determine baseline SCr recorded estimated Bagshaw25 120123 multi cr+uo estimated by MDRD formula 0 100 Ostermann30 41972 multi cr estimated by MDRD formula 0 100 Uchino5 20126 single cr retrieved from hospital database, or estimated by MDRD formula N/A N/A Bell54 8152 single cr+uo retrieved from hospital database, or estimated by MDRD formula N/A N/A Hoste2 5383 single cr+uo estimated by MDRD formula, or admission creatinine value, N/A N/A whatever was lower Ali31 5321 multi cr retrieved from hospital database, or admission creatinine value 100 0 Cruz55 2164 multi cr+uo retrieved from hospital database, or estimated by MDRD formula 78 22 Perez-Valdivieso56 1008 single cr estimated by MDRD formula 0 100 Kuitunen57 813 single cr+uo preoperative value 100 0 Coca58 304 single cr the lowest s-creatinine value in the first 5 hospital days 100 0 Arnaoutakis59 267 single N/A N/A N/A N/A Abosaif60 247 single cr+uo retrieved from hospital database, or admission creatinine value 100 0 Maccariello61 214 multi cr+uo retrieved from hospital database, or estimated by MDRD formula N/A N/A Jenq62 134 single cr+uo admission creatinine value, or estimated by MDRD formula 90 10 cr, creatinine criteria; MDRD, Modification of Diet in Renal Disease; N/A, not available; pts, patients; SCr, serum creatinine; uo, urine output criteria. Reprinted from Zavada J, Hoste E, Cartin-Ceba R et al. A comparison of three methods to estimate baseline creatinine for RIFLE classification. Nephrol Dial Transplant 2010; 25(12): 3911–3918 (Ref. 64) by permission from The European Renal Association-European Dialysis and Transplant Association; accessed http://ndt.oxfordjournals.org/content/ 25/12/3911.long Table 9 | Estimated baseline SCr Age (years) Black males mg/dl (lmol/l) Other males mg/dl (lmol/l) Black females mg/dl (lmol/l) Other females mg/dl (lmol/l) 20–24 1.5 (133) 1.3 (115) 1.2 (106) 1.0 (88) 25–29 1.5 (133) 1.2 (106) 1.1 (97) 1.0 (88) 30–39 1.4 (124) 1.2 (106) 1.1 (97) 0.9 (80) 40–54 1.3 (115) 1.1 (97) 1.0 (88) 0.9 (80) 55–65 1.3 (115) 1.1 (97) 1.0 (88) 0.8 (71) 465 1.2 (106) 1.0 (88) 0.9 (80) 0.8 (71) Estimated glomerular filtration rate=75 (ml/min per 1.73 m2)=186 Â (serum creatinine [SCr]) À 1.154 Â (age) À 0.203 Â (0.742 if female) Â (1.210 if black)=exp(5.228 À 1.154 Â In [SCr]) À 0.203 Â In(age) À (0.299 if female) + (0.192 if black). Reprinted from Bellomo R, Ronco C, Kellum JA et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-212 with permission from Bellomo R et al.22; accessed http://ccforum.com/content/8/4/R204 delay in diagnosis, it would have resulted in a delay in staging Estimating baseline SCr (see Table 7). On day 7, it can be inferred that the patient’s Many patients will present with AKI without a reliable baseline was no higher than 1.0 mg/dl (88 mmol/l) and thus baseline SCr on record. Baseline SCr can be estimated using correct staging of Case A as Stage 2 (two-fold increase from the Modification of Diet in Renal Disease (MDRD) Study the reference SCr, see below and Table 7) on day 3 could have equation assuming that baseline eGFR is 75 ml/min per 1.73 been determined in retrospect. However, if a baseline SCr was m2 (Table 9).22 This approach has been used in many, but not available to use as the reference, the correct stage could be all, studies of AKI epidemiology using RIFLE2,5,25,30–32,54–63 determined on day 3. (see Table 8) and has recently been validated.64 Hence, most Case B illustrates why criterion 2 can detect cases of AKI current data concerning AKI defined by RIFLE criteria are missed by criterion 1. It also clarifies why these cases are based on estimated baseline SCr for a large proportion of unusual. Had the SCr increased to 1.5 mg/dl (132.6 mmol/l) patients. as opposed to peaking at 1.4 mg/dl (123.8 mmol/l), it would Table 9 shows the range of estimated SCr obtained by have been picked up by criterion 1 as well. By contrast back-calculation for various age, sex, and race categories. Cases C, D, and even F illustrate how criterion 2 may When the baseline SCr is unknown, an estimated SCr can be miss cases identified by criterion 1. Note that Case F can used provided there is no evidence of CKD (see Appendix B). only be diagnosed by inference. By day 7, it can be Fortunately, when there is a history of CKD, a baseline SCr is inferred that the baseline was no higher than 1.0 mg/dl usually available. Unfortunately, many cases of CKD are not (88 mmol/l) and thus it can be determined that the patient identified, and thus estimating the baseline SCr may risk presented with AKI. However, if the baseline SCr could labeling a patient with AKI when in reality the diagnosis was be estimated it would be possible to make this inference as unidentified CKD. As discussed further in Appendix B, it is early as day 1. essential to evaluate a patient with presumed AKI for Kidney International Supplements (2012) 2, 19–36 29
chapter 2.4 Table 10 | AKI staging Serum creatinine mg/dl (lmol/l) Case Baseline Day 1 Day 2 Day 3 Day 7 Reference creatinine Max AKI stage A 1.0 (88) 1.3 (115) 1.5 (133) 2.0 (177) 1.0 (88) 1.0 (88) 2 B 1.0 (88) 1.1 (97) 1.2 (106) 1.4 (124) 1.0 (88) 1.0 (88) 1 C 0.4 (35) 0.5 (44) 0.6 (53) 0.7 (62) 0.4 (35) 0.4 (35) 1 D 1.0 (88) 1.1 (97) 1.2 (106) 1.3 (115) 1.5 (133) 1.0 (88) 1 E 1.0 (88) 1.3 (115) 1.5 (133) 1.8 (159) 2.2 (195) 1.0 (88) 2 F ? 3.0 (265) 2.6 (230) 2.2 (195) 1.0 (88) 1.0 (88) 3 G ? 1.8 (159) 2.0 (177) 2.2 (195) 1.6 (141) ? X1 H ? 3.0 (265) 3.1 (274) 3.0 (265) 2.9 (256) ? ? AKI, acute kidney injury. presence of CKD. Furthermore, CKD and AKI may coexist. 1.2 mg/dl (106 mmol/l) (Table 9) and his initial stage on By using all available clinical data (laboratory, imaging, admission (day 1) would be assumed to be 2. However, once history, and physical exam) it should be possible to arrive at his SCr recovered to 1.0 mg/dl (88 mmol/l) on day 7, it would both an accurate diagnosis as well as an accurate estimate of be possible to restage him as having had Stage 3. Once he has baseline SCr. Importantly, excluding some cases of hemo- recovered, there may be no difference between Stage 2 or 3 in dilution secondary to massive fluid resuscitation (discussed terms of his care plan. On the other hand, accurately staging below), the lowest SCr obtained during a hospitalization the severity of AKI may be important for intensity of follow- is usually equal to or greater than the baseline. This SCr up and future risk. should be used to diagnose (and stage) AKI. For example, if Note that Cases G and H can only be staged if the no baseline SCr was available in Case A, diagnosis of AKI reference SCr can be inferred. Case G may be as mild as stage could be made using the MDRD estimated SCr (Table 9). If 1 if the baseline is equal to the nadir SCr on day 7. On the Case A were a 70-year-old white female with no evidence or other hand, if this case were a 70-year-old white female with history of CKD, the baseline SCr would be 0.8 mg/dl no known evidence or history of CKD, the reference SCr (71 mmol/l) and a diagnosis of AKI would be possible would be 0.8 mg/dl (71 mmol/l) based on an estimated even on day 1 (criterion 1, X50% increase from baseline). baseline (Table 9). In this case, the severity on day 1 would However, if the patient was a 20-year-old black male, his already be stage 2. baseline SCr would be estimated at 1.5 mg/dl (133 mmol/l). Since his admission SCr is lower, this is assumed to be the Urine output vs. SCr baseline SCr until day 7 when he returns to his true baseline, Both urine output and SCr are used as measures of an acute and this value can be taken as the baseline. These dynamic change in GFR. The theoretical advantage of urine output changes in interpretation are not seen in epidemiologic over SCr is the speed of the response. For example, if GFR studies, which are conducted when all the data are present, were to suddenly fall to zero, a rise in SCr would not be but are common in clinical medicine. Note that the only detectable for several hours. On the other hand, urine output way to diagnose AKI (by SCr criteria) in Case H is to use an would be affected immediately. Less is known about the use estimated SCr. of urine output for diagnosis and staging compared to SCr, since administrative databases usually do not capture urine Examples of application of AKI stages output (and frequently it is not even measured, especially Once a diagnosis of AKI has been made, the next step is to outside the ICU). However, studies using both SCr and urine stage it (Recommendation 2.1.2). Like diagnosis, staging output to diagnose AKI show increased incidence, suggesting requires reference to a baseline SCr when SCr criteria are that the use of SCr alone may miss many patients. The use used. This baseline becomes the reference SCr for staging of urine output criteria (criterion 3) will also reduce the purposes. Table 10 shows the maximum stage for each number of cases where criterion 1 and criterion 2 are Case described in Table 7. Staging for Case A was already discordant (cases B,C,D, and F in Table 7), as many of these mentioned. The maximum stage is 2 because reference SCr is cases will be picked up by urine output criteria. 1.0 mg/dl (88 mmol/l) and the maximum SCr is 2.0 mg/dl (177 mmol/l). Had the reference SCr been 0.6 mg/dl (53 mmol/ Timeframe for diagnosis and staging l), the maximum stage would have been 3. Case F was staged The purpose of setting a timeframe for diagnosis of AKI is to by using the lowest SCr (1.0 mg/dl [88 mmol/l]) as the clarify the meaning of the word ‘‘acute’’. A disease process reference. Of course, the actual baseline for this case might that results in a change in SCr over many weeks is not AKI have been lower but this would not affect the stage, since it is (though it may still be an important clinical entity: see already Stage 3. Note that if this patient was a 35-year-old Appendix B). For the purpose of this guideline, AKI is white male, his MDRD estimated baseline SCr would be defined in terms of a process that results in a 50% increase in 30 Kidney International Supplements (2012) 2, 19–36
chapter 2.4 SCr within 1 week or a 0.3 mg/dl (26.5 mmol/l) increase Clinical judgment within 48 hours (Recommendation 2.1.1). Importantly, there While the definitions and classification system discussed in is no stipulation as to when the 1-week or 48-hour time Chapter 2.1 provide a framework for the clinical diagnosis of periods can occur. It is stated unequivocally that it does not AKI, they should not be interpreted to replace or to exclude need to be the first week or 48 hours of a hospital or ICU stay. clinical judgment. While the vast majority of cases will Neither does the time window refer to duration of the fit both AKI diagnostic criteria as well as clinical judgment, inciting event. For example, a patient may have a 2-week AKI is still a clinical diagnosis—not all cases of AKI will fit course of sepsis but only develop AKI in the second week. within the proposed definition and not all cases fitting the Importantly, the 1-week or 48-hour timeframe is for definition should be diagnosed as AKI. However, exceptions diagnosis of AKI, not staging. A patient can be staged over should be very rare. the entire episode of AKI such that, if a patient develops a Pseudo-AKI. As with other clinical diagnoses defined by 50% increase in SCr in 5 days but ultimately has a three-fold laboratory results (e.g., hyponatremia), the clinician must be increase over 3 weeks, he or she would be diagnosed with AKI cautious to interpret laboratory data in the clinical context. and ultimately staged as Stage 3. The most obvious example is with laboratory errors or errors As with any clinical criteria, the timeframe for AKI is in reporting. Erroneous laboratory values should obviously somewhat arbitrary. For example, a disease process that not be used to diagnose disease and suspicious lab results results in a 50% increase in SCr over 2 weeks would not fulfill should always be repeated. Another example is when two SCr diagnostic criteria for AKI even if it ultimately resulted in measurements are obtained by different laboratories. While complete loss of kidney function. Similarly, a slow process the coefficient of variation for SCr is very small (o5%) by that resulted in a steady rise in SCr over 2 weeks, and then a various clinical testing methods, variation (bias) from one sudden increase of 0.3 mg/dl (26.5 mmol/l) in a 48-hour laboratory to the next may be considerably higher, although period, would be classified as AKI. Such are the inevitable it is unlikely to approach 50%. Given that the SCr definition vagaries of any disease classification. However, one scenario of AKI always uses at least two values, the variation and bias deserves specific mention, and that is the case of the patient between each measure is further magnified—the coefficient with an increased SCr at presentation. As already discussed, of variation for comparison of two lab tests is equal to the the diagnosis of AKI requires a second SCr value for square root of the sum of each coefficient squared. Although comparison. This SCr could be a second measured SCr the international standardization of SCr measurements will obtained within 48 hours, and if it is X0.3 mg/dl largely eliminate interlaboratory bias in the future, care is (X26.5 mmol/l) greater than the first SCr, AKI can be needed in interpreting lab values obtained from different diagnosed. Alternatively, the second SCr can be a baseline labs. Furthermore, daily variation in SCr due to differences in value that was obtained previously or estimated from the diet and activity may be as great as 10%. Finally, endogenous MDRD equation (see Table 9). However, this poses two chromogens (e.g., bilirubin, ascorbic acid, uric acid) and dilemmas. First, how far back can a baseline value be exogenous chromogens and drugs (e.g., cephalosporins, retrieved and still expected to be ‘‘valid’’; second, how can trimethoprim, cimetidine) may interfere with the creatinine we infer acuity when we are seeing the patient for the first assay. The cumulative effect of these various factors time? influencing precision, bias, and biological variation may Both of these problems will require an integrated approach the level at which it could impact the diagnosis of approach as well as clinical judgment. In general, it is AKI. A similar problem exists with urine output. Particularly reasonable in patients without CKD to assume that SCr outside the ICU, urine output is not often reported and urine will be stable over several months or even years, so that collections may be inaccurate, especially in noncatheterized a SCr obtained 6 months or even 1 year previously would patients. Finally, as discussed in Chapter 2.1, a weight-based reasonable reflect the patient’s premorbid baseline. However, criterion for urine output will mean that some very obese in a patient with CKD and a slow increasing SCr over several patients will fulfill the definition of AKI without any kidney months, it may be necessary to extrapolate the baseline SCr abnormality. Clinical judgment should always be exercised in based on prior data. In terms of inferring acuity it is most interpreting such data. reasonable to determine the course of the disease process Atypical AKI. A complementary problem to pseudo-AKI is thought to be causing the episode of AKI. For example, for a the situation where a case of AKI fails to meet the definition. patient with a 5-day history of fever and cough, and chest These cases should be distinguished from conditions in which radiograph showing an infiltrate, it would be reasonable to data are simply missing (discussed above) and refer to infer that the clinical condition is acute. If SCr is found to be situations in which existing data are unreliable. For example, X50% increased from baseline, this fits the definition of AKI. a patient might receive very large quantities of intravascular Conversely, a patient presenting with an increased SCr in the fluids such that SCr is falsely lowered.65 Similarly, massive absence of any acute disease or nephrotoxic exposure will blood transfusions will result in the SCr more closely require evidence of an acute process before a diagnosis can be reflecting the kidney function of the blood donors than the made. Evidence that the SCr is changing is helpful in patient. It is unusual for these cases not to result in oliguria establishing acuity. and, thus, most patients will be diagnosed with AKI even if Kidney International Supplements (2012) 2, 19–36 31
chapter 2.4 SCr is not increased. Nevertheless, the clinician should is decreased. Creatinine production may also be decreased in be cognizant of possibility that SCr may be falsely lowered sepsis66 possibly due to decreased muscle perfusion. by large-volume fluid resuscitation or transfusion; thus, a normal value may not rule out AKI. Changes in creatinine SUPPLEMENTARY MATERIAL production are also well known in conditions such as muscle Appendix B: Diagnostic Approach to Alterations in Kidney Function and Structure. breakdown where production increases and in muscle Supplementary material is linked to the online version of the paper at wasting (including advanced liver disease) where production http://www.kdigo.org/clinical_practice_guidelines/AKI.php 32 Kidney International Supplements (2012) 2, 19–36
http://www.kidney-international.org chapter 2.5 & 2012 KDIGO Chapter 2.5: Diagnostic approach to alterations in kidney function and structure Definitions of AKI, CKD and AKD GFR and SCr AKI and CKD were defined by separate Work Groups CKD, AKD, and AKI are defined by parameters expressing according to different criteria. The definition for each is the level of kidney function. Table 12 gives examples of each based on alterations in kidney function or structure. AKI and condition based on GFR and different magnitudes of increase CKD have many causes which may lead to alterations of in SCr. kidney function and structure that do not meet the criteria To illustrate the relationship of changes in SCr to changes for the definition of either AKI or CKD, yet patients with in eGFR, we simulated changes in eGFR that would result these diseases and disorders may need medical attention to from changes in SCr corresponding to the KDIGO definition restore kidney function and reverse damage to kidney of AKI in the Chronic Kidney Disease Epidemiology structure to avoid adverse outcomes. A uniform and Collaboration cohort.67,68 Figure 6 shows the relationship systematic nomenclature could enhance understanding and of these changes in eGFR to the definition and stages of AKI. communication about these diseases and disorders, and lead Not all patients with AKI would meet the eGFR criteria for to improved medical care, research, and public health. For the definition of AKD. these reasons, the Work Group proposed an operational definition for AKD to provide an integrated clinical approach GFR/SCr algorithm to patients with abnormalities of kidney function and Figure 7 provides a diagnostic algorithm based on a structure. sequential approach through three questions: i) Is GFR Table 11 compares the definitions for AKI, CKD, and decreased or is SCr increased (according to the criteria in AKD. We have also included an operational definition of ‘‘no Table 12)?; ii) Is SCr increasing or GFR decreasing (according known kidney disease’’ (NKD) for those who do not meet to the criteria in Table 12)?; and iii) Does the decrease in GFR these criteria, with the understanding that clinical judgment or increase in SCr resolve within 3 months? Based on a ‘‘yes’’ is required to determine the extent of the evaluation that is or ‘‘no’’ response to these three sequential questions, all necessary to assess kidney function and structure. In the combinations of AKI, AKD, and CKD can be identified. In following sections, we will elaborate on each component of this section, we review the algorithm and illustrate its use these definitions. for classification of patients with acute and chronic kidney disease in two previously reported cohorts. Table 11 | Definitions of AKI, CKD, and AKD Functional criteria Structural criteria Table 12 | Examples of AKI, CKD, and AKD based on GFR and AKI Increase in SCr by 50% within 7 days, OR No criteria increases in SCr Increase in SCr by 0.3 mg/dl (26.5 mmol/l) Baseline GFR Increase in GFR during within 2 days, OR (ml/min per SCr during next Oliguria 1.73 m2) 7 consecutive days 3 months Diagnosis CKD GFR o60 ml/min per 1.73 m2 for Kidney damage 43 months for 43 months 460 41.5 Â NA AKI AKD AKI, OR Kidney damage 460 o1.5 Â o60 AKD without AKI GFR o60 ml/min per 1.73 m2 for for o3 months 460 o1.5 Â 460 NKD o3 months, OR Decrease in GFR by X35% or increase Baseline GFR Change in SCr GFR during in SCr by 450% for o3 months (ml/min per during next next NKD GFR X60 ml/min per 1.73 m2 No damage 1.73 m2) 7 days 3 months Diagnosis Stable SCr o60 41.5 Â NA AKI + CKD GFR assessed from measured or estimated GFR. Estimated GFR does not reflect o60 o1.5 Â 435% decrease AKD without measured GFR in AKI as accurately as in CKD. Kidney damage assessed by pathology, AKI + CKD urine or blood markers, imaging, and—for CKD—presence of a kidney transplant. NKD o60 o1.5 Â o35% decrease CKD indicates no functional or structural criteria according to the definitions for AKI, AKD, or CKD. Clinical judgment is required for individual patient decision-making regarding GFR assessed from measured or estimated GFR. Estimated GFR does not reflect the extent of evaluation that is necessary to assess kidney function and structure. measured GFR in AKI as accurately as in CKD. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; SCr, serum creatinine. SCr, serum creatinine. Kidney International Supplements (2012) 2, 19–36 33
chapter 2.5 Figure 6 | Chronic Kidney Disease Epidemiology Collaboration cohort changes in eGFR and final eGFR corresponding to KDIGO definition and stages of AKI. Panels (a) and (b) show the final eGFR and the percent changes in eGFR, respectively, corresponding to the KDIGO definition and stages of AKI. The horizontal line in panel a and b indicates the threshold value for AKD (o60 ml/min per 1.73 m2 and 435% reduction in initial GFR, respectively). Points above the horizontal line indicate subjects who meet the SCr criteria for the definition of AKI but do not meet eGFR criteria for the definition of AKD. AKD, acute kidney disorder/disease; AKI, acute kidney injury; eGFR, estimated glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes; SCr, serum creatinine. (Lesley Inker, personal communication.) GFR/S cr 1 Is GFR decreased or is serum creatinine increased ? No Yes Yes <3 mo or >3 mo unknown NKD AKD CKD 2 Is Scr increasing or GFR decreasing ? No Yes-D Yes-I No Yes-D Yes-I No Yes-D Yes-I AKD AKD AKD CKD+ CKD +AKD NKD without AKI without without AKI CKD without AKI AKI AKI AKI AKI Yes-D, change in Scr meets AKD criteria but not AKI criteria CKD+ AKD CKD+ AKD without without AKI AKI AKI AKI Does the decrease in GFR or increase in Scr 3 resolve within 3 months? No Yes No Yes No Yes No Yes CKD CKD CKD CKD CKD CKD NKD NKD Worse Stable Worse Stable New New Figure 7 | GFR/SCr algorithm. See text for description. AKD, acute kidney disease/disorder; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; SCr, serum creatinine. The answer to Question 1 requires ascertainment of an patients into three categories: NKD, AKD, and CKD. index GFR/SCr as well during the prior 3 months. The index Question 2 requires repeat ascertainment of kidney function GFR/SCr can be assigned as any of the GFR/SCr measures after the index measure. ‘‘No’’ indicates that the increase in during the interval of observation. The answer classifies SCr or decrease in GFR after the index measure does not 34 Kidney International Supplements (2012) 2, 19–36
chapter 2.5 meet AKI or AKD criteria; ‘‘Yes-D’’ indicates that increase in Table 13 | Markers of kidney damage in AKD and CKD SCr and decrease in GFR meets the AKD criteria but not AKI Markers AKD CKD criteria; and ‘‘Yes-I’’ indicates that increase in SCr meets AKI Pathology X X criteria. Question 3 requires repeat ascertainment of GFR/ SCr 3 months after the index measure. ‘‘Yes’’ indicates GFR Urinary markers 460, indicating NKD. No indicates GFR o60, and based on RBC/casts X X prior level of GFR, may indicate stable, new, or worse CKD. WBC/casts X X RTE/casts X X Fine and coarse granular casts X X Oliguria as a measure of kidney function Proteinuria X X Although urine flow rate is a poor measure of kidney function, oliguria generally reflects a decreased GFR. If GFR Blood markers (tubular syndromes) X X is normal (approximately 125 ml/min, corresponding to Imaging approximately 107 ml/kg/h for a 70-kg adult), then reduction Large kidneys X X in urine volume to o0.5 ml/kg/h would reflect reabsorption Small kidneys — X of more than 99.5% of glomerular filtrate. Such profound Size discrepancy — X Hydronephrosis X X stimulation of tubular reabsorption usually accompanies Cysts X X circulatory disturbances associated with decreased GFR. Stones X X Oliguria is unusual in the presence of a normal GFR and is History of kidney transplantation — X usually associated with the non–steady state of solute balance Kidney damage is not required for diagnosis of AKI. In the presence of AKI, findings and rising SCr sufficient to achieve the criteria for AKI. As a of kidney damage do not indicate a separate diagnosis of AKD. corollary, if GFR and SCr are normal and stable over an AKD, acute kidney diseases and disorders; CKD, chronic kidney disease; RBC, red interval of 24 hours, it is generally not necessary to measure blood cells; RTE, renal tubular epithelial cells; WBC, white blood cells. urine flow rate in order to assess kidney function. In principle, oliguria (as defined by the criteria for AKI) Table 14 | Integrated approach to interpret measures of can occur without a decrease in GFR. For example, low kidney function and structure for diagnosis of AKI, AKD, and intake of fluid and solute could lead to urine volume of less CKD than 0.5 ml/kg/h for 6 hours or 0.3 ml/kg/h for 24 hours. On Measures the other hand, severe GFR reduction in CKD usually does Diagnosis GFR/SCr Oliguria Kidney damage Small kidneys not lead to oliguria until after the initiation of dialysis. AKI X X As described in Chapter 2.1, the thresholds for urine flow AKD X X for the definition of AKI have been derived empirically and CKD X X X X are less well substantiated than the thresholds for increase X indicates that the measures can contribute to the diagnosis indicated. in SCr. Urinary diagnostic indices, such as the urinary AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease. concentrations of sodium and creatinine and the fractional reabsorption of sodium and urea, remain helpful to distinguish among causes of AKI, but are not used in the definition (see Appendix D). the left side and 10.9 cm on the right side. Renal size decreased with age, almost entirely because of parenchymal Kidney damage reduction. The lowest 10th percentiles for length of the left Table 13 describes measures of kidney damage in AKD and and right kidney were approximately 10.5 and 10.0 cm, CKD. Kidney damage is most commonly ascertained by respectively, at age 30 years, and 9.5 and 9.0 cm, respectively, urinary markers and imaging studies. Most markers and at age 70 years. abnormal images can indicate AKD or CKD, based on the duration of abnormality. One notable exception is small Integrated approach to AKI, AKD, and CKD kidneys, either bilateral or unilateral, indicating CKD, which Clinical evaluation is necessary for all patients with are discussed separately below. Kidney damage is not a alterations in kidney function or structure. The expectation criterion for AKI; however, it may be present. Renal tubular of the Work Group is that the diagnostic approach will epithelial cells and coarse granular casts, often pigmented and usually begin with assessment of GFR and SCr. However, described as ‘‘muddy brown’’, remain helpful in distinguish- evaluation of kidney function and structure is not complete ing the cause of AKI, but are not part of the definition. unless markers of kidney damage—including urinalysis, examination of the urinary sediment, and imaging studies— Small kidneys as a marker of kidney damage have been performed. Table 14 shows a summary of the Loss of renal cortex is considered a feature of CKD, and is diagnostic approach using measures for kidney function often sought as a specific diagnostic sign of CKD. Kidney size and structure. Based on interpretation of each measure is most often evaluated by ultrasound. In a study of 665 separately, the clinical diagnosis indicated by an ‘‘X’’ can be normal volunteers,69 median renal lengths were 11.2 cm on reached. Kidney International Supplements (2012) 2, 19–36 35
chapter 2.5 SPONSORSHIP contributor, copyright holder, or advertiser concerned. KDIGO gratefully acknowledges the following sponsors that Accordingly, the publishers and the ISN, the editorial board make our initiatives possible: Abbott, Amgen, Belo Founda- and their respective employers, office and agents accept no tion, Coca-Cola Company, Dole Food Company, Genzyme, liability whatsoever for the consequences of any such Hoffmann-LaRoche, JC Penney, NATCO—The Organization inaccurate or misleading data, opinion or statement. While for Transplant Professionals, NKF—Board of Directors, every effort is made to ensure that drug doses and other Novartis, Robert and Jane Cizik Foundation, Shire, Trans- quantities are presented accurately, readers are advised that western Commercial Services, and Wyeth. KDIGO is new methods and techniques involving drug usage, and supported by a consortium of sponsors and no funding is described within this Journal, should only be followed in accepted for the development of specific guidelines. conjunction with the drug manufacturer’s own published literature. DISCLAIMER While every effort is made by the publishers, editorial board, and ISN to see that no inaccurate or misleading data, opinion SUPPLEMENTARY MATERIAL Appendix D: Evaluation and General Management Guidelines for or statement appears in this Journal, they wish to make Patients with AKI. it clear that the data and opinions appearing in the articles Supplementary material is linked to the online version of the paper at and advertisements herein are the responsibility of the http://www.kdigo.org/clinical_practice_guidelines/AKI.php 36 Kidney International Supplements (2012) 2, 19–36
http://www.kidney-international.org chapter 3.1 & 2012 KDIGO Section 3: Prevention and Treatment of AKI Kidney International Supplements (2012) 2, 37–68; doi:10.1038/kisup.2011.33 Chapter 3.1: Hemodynamic monitoring and support for prevention and management of AKI As discussed in Chapters 2.3 and Appendix D, patients with status and correction of any volume deficit will have a AKI and at increased risk for AKI require careful attention to salutary effect on kidney function, will help minimize further be paid to their hemodynamic status. This is first because extension of the kidney injury, and will potentially facilitate hypotension results in decreased renal perfusion and, if severe recovery from AKI with minimization of any residual func- or sustained, may result in kidney injury. Second, the injured tional impairment. AKI is characterized by a continuum kidney loses autoregulation of blood flow, a mechanism that of volume responsiveness through unresponsiveness maintains relatively constant flow despite changes in pressure (Figure 8),78,82 and large multicenter studies have shown above a certain point (roughly, a mean of 65 mm Hg). that a positive fluid balance is an important factor associated Management of blood pressure and cardiac output with increased 60-day mortality.78,83,84 require careful titration of fluids and vasoactive medication. The amount and selection of the type of fluid that should Vasopressors can further reduce blood flow to the tissues if be used in the resuscitation of critically ill patients is still there is insufficient circulating blood volume. Conversely, controversial. This guideline focuses on the selection of the patients with AKI are also at increased risk for fluid overload fluid (colloid vs. crystalloid fluid in the prevention and early (see Chapter 3.2) and continued fluid resuscitation despite management of AKI). The three main end-points of the increased intravascular volume can cause harm. Fluids and studies explored were the effects on mortality, need for RRT, vasoactive medications should be managed carefully and in and—if possible—the incidence of AKI. Although many concert with hemodynamic monitoring. Hemodynamic trials have been conducted to compare fluid types for evaluation and monitoring are discussed in Appendix D. resuscitation, studies without AKI outcomes were not In this chapter therapies aimed at correcting hemo- systematically reviewed for this Guideline. Suppl Table 1 dynamic instability will be discussed. Available therapies to summarizes the RCTs examining the effect of starch for the manage hypotension include fluids, vasopressors and proto- prevention of AKI. cols which integrate these therapies with hemodynamic goals. There is an extensive body of literature in this field and for a Albumin vs. Saline broader as well as more in depth review the reader is directed The role of albumin physiology in critically ill patients, and to the various reviews and textbooks devoted to critical care the pros and cons for administering albumin to hypoalbu- and nephrology.70–81 minemic patients, have recently been discussed.85 Results of the Saline vs. Albumin Fluid Evaluation (SAFE) study, a RCT FLUIDS comparing 4% human albumin in 0.9% saline with isotonic saline in ICU patients, seem to indicate that albumin is safe, 3.1.1: In the absence of hemorrhagic shock, we suggest albeit no more effective than isotonic saline (the standard of using isotonic crystalloids rather than colloids care choice of isotonic sodium chloride in most centers) for (albumin or starches) as initial management for fluid resuscitation. SAFE demonstrated further no difference expansion of intravascular volume in patients at in renal outcomes, at least based on the need for and risk for AKI or with AKI. (2B) duration of RRT.86 The SAFE study was a double-blind study and it was noted that patients in the albumin arm received 27% less study fluid compared to the saline arm (2247 vs. RATIONALE 3096 ml) and were approximately 1 l less positive in overall Despite the recognition of volume depletion as an important fluid balance.86 Furthermore, very few patients in the trial risk factor for AKI, there are no randomized controlled trials received large volume fluid resuscitation (45 l) and thus the (RCTs) that have directly evaluated the role of fluids vs. results may not be applicable to all patients. The Work Group placebo in the prevention of AKI, except in the field of noted that while isotonic crystalloids may be appropriate for contrast-induced acute kidney injury (CI-AKI) (see Chapter initial management of intravascular fluid deficits, colloids 4.4). It is accepted that optimization of the hemodynamic may still have a role in patients requiring additional fluid. Kidney International Supplements (2012) 2, 37–68 37
chapter 3.1 and during the perioperative period’’ (for a summary of this controversy, see de Saint-Aurin et al.90 and Vincent91). The first major randomized trial in patients with sepsis compared HES 200/0.60 to 0.66 with gelatin and showed a greater incidence of AKI in the HES group, but no effect on survival.92 Criticisms of this study include a higher baseline SCr level in the HES group, small sample size, and short follow-up duration of 34 days. In the Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis (VISEP) study,93 patients with severe sepsis were randomly assigned to Figure 8 | Conceptual model for development and clinical receive a hypertonic (10%) solution of low MW HES (HES course of AKI. The concept of AKI includes both volume- 200/0.5), or an isotonic modified Ringer’s lactate solution. responsive and volume-unresponsive conditions. These conditions are not mutually exclusive, and a given patient may Patients in the HES group received a median cumulative dose progress from one to the other. Time runs along the x-axis, and of 70.4 ml per kilogram of body weight. The mortality was the figure depicts a closing ‘‘therapeutic window’’ as injury not significantly different, although showing a trend toward evolves and kidney function worsens. Biomarkers of injury and function will begin to manifest as the condition worsens, but greater mortality at 90 days. However, the hypertonic HES traditional markers of function (e.g., urea nitrogen and creatinine) group had a significantly higher rate of AKI (34.9% vs. will lag behind hypothetical ‘‘sensitive’’ markers of kidney injury. 22.8%) and more days on which RRT was required (Suppl Mortality increases as kidney function declines. AKI, acute kidney Table 1). Also, this study has been criticized for: i) using a injury. Reproduced from Himmelfarb J, Joannidis M, Molitoris B, et al. Evaluation and initial management of acute kidney injury. hyperoncotic colloid solution with potentially harmful renal Clin J Am Soc Nephrol 2008; 3: 962–967 with permission from effects as shown in experimental research;94 ii) markedly American Society of Nephrology82 conveyed through Copyright exceeding the pharmaceutically recommended daily dose Clearance Center, Inc; accessed http://cjasn.asnjournals.org/ limit for 10% HES 200/0.5 by more than 10% in 438% of content/3/4/962.long patients; and iii) pre-existing renal dysfunction in 10% of study patients, which represents a contra-indication for infusion of 10% HES 200/0.5.95 Posthoc analyses of the Hydroxyethylstarch vs. Saline VISEP study showed the cumulative dose of HES to be a Hydroxyethylstarch (HES) is a widely used, relatively significant independent predictor for both mortality and inexpensive alternative to human albumin for correcting RRT at 90 days. The median cumulative dose of HES in the hypovolemia. Different HES preparations are available that VISEP Study was 70 ml/kg compared to 31 ml/kg in the study vary with regard to concentration, mean molecular weight by Schortgen et al.92 (MW), molar substitution, and substitution of hydroxyethyl A systematic review of RCTs on the use of HES for fluid for hydroxyl groups. The mean MW of the different HES management in patients with sepsis totaling 1062 patients, preparations ranges between 70 000 and 670 000 Da. The including 537 patients from the VISEP study, showed an colloid osmotic pressure effect is strongly dependent upon almost two-fold increased risk of AKI with HES compared to the concentration of colloid in the solution; e.g., 6% HES is crystalloids.96 Given these limitations, the results of these iso-oncotic, whereas 10% HES is hyperoncotic. The number studies should be interpreted with caution. Furthermore, a of hydroxyethyl groups per glucose molecule is specified by large, prospective observational study found that HES the molar substitution, ranging between 0.4 (tetrastarch) infusion of any type (median volume 555 ml/d; intraquartile and 0.7 (heptastarch). Accordingly, HES solutions with a range 500–1000) did not represent an independent risk factor molar substitution of 0.5 or 0.6 are referred to as for renal impairment.97; however, recently in a large cohort of ‘‘pentastarch’’ or ‘‘hexastarch’’, respectively. More recently, critically ill patients (approximately 8000 subjects), infusion tetrastarches (HES 130/0.4 and HES 130/0.42) have also been of 10% HES 200/0.5 instead of HES 130/0.4 appeared to be introduced.87 High molecular substitution starch may impair an independent risk factor for RRT.87 Finally, a recent coagulation by reducing the concentration of factor VIII: comprehensive Cochrane review98 concluded that there is no VIIIc and von Willebrand factor. Platelet activity may also be evidence from RCTs that resuscitation with colloids, instead affected by blockade of the platelet fibrinogen receptor of crystalloids, reduces the risk of death in patients with glycoprotein IIb/IIIa. Smaller starch molecules and those trauma, burns, or following surgery. with less molecular substitution produce negligible coagula- The mechanisms of colloid-induced renal injury are tion defects.88 incompletely understood, but may involve both direct Aside from these negative effects on coagulation, develop- molecular effects and effects of elevated oncotic pressure.99 ment of renal dysfunction has been a concern associated with These concerns have led to the widespread adoption of lower the use of mainly hypertonic HES. Hypertonic HES may MW starches as iso-oncotic solution, as resuscitation fluids. induce a pathological entity known as ‘‘osmotic nephrosis’’ Theoretically, such solutions may have lower nephrotoxicity; with potential impairment of renal function.89 It has even however, as yet, no appropriately powered prospective been recommended that ‘‘HES should be avoided in ICUs randomized studies have reported the clinical benefit and 38 Kidney International Supplements (2012) 2, 37–68
chapter 3.1 safety of such solutions in comparison with crystalloids. A VASOPRESSORS recent study by Magder et al. compared 10% 250/0.45 HES to isotonic saline in 262 patients who underwent cardiac 3.1.2: We recommend the use of vasopressors in conjunc- surgery.100 These investigators tested whether fewer patients tion with fluids in patients with vasomotor shock required catecholamines the morning after cardiac surgery with, or at risk for, AKI. (1C) (a chief determinant of ICU discharge) with HES compared to saline, and found indeed this was the case (10.9% vs. 28.8%; P ¼ 0.001). Importantly, the study found no evidence RATIONALE of nephrotoxicity: no difference in the daily creatinine, deve- Sepsis and septic shock are major contributing factors to lopment of AKI by RIFLE criteria during hospital stay (16% AKI7 and vasopressor requirement appears to be highly in both groups), or need for RRT (1% in each group). associated with AKI in this population. Despite the high Importantly, patients in the saline group received nearly 60% prevalence of AKI during critical illness in general, and severe more volume for fluid resuscitation in the ICU compared to sepsis specifically, success has been limited in improving the HES (887 vs. 1397 ml; Po0.0001). While overall volumes outcome of this complication.104 Septic shock is the proto- were small, advocates for colloid resuscitation will note that type of a high output–low resistance condition, although this is exactly the reason colloids are preferred for patients severe pancreatitis, anaphylaxis, burns, and liver failure requiring large-volume resuscitation. share similar physiologic alterations. Persistent hypotension, The tonicity of colloid preparations may also vary by despite ongoing aggressive fluid resuscitation or after agent. A recent meta-analysis101 described 11 randomized optimization of intravascular volume in patients with shock, trials with a total of 1220 patients: seven evaluating places patients at risk for development of AKI. In the setting hyperoncotic albumin and four evaluating hyperoncotic of vasomotor paralysis, preservation or improvement of starch. Hyperoncotic albumin decreased the odds of AKI by renal perfusion can only be achieved through use of 76% while hyperoncotic starch increased those odds by 92% systemic vasopressors once intravascular volume has been (odds ratio [OR] 1.92; CI 1.31–2.81; P ¼ 0.0008). Parallel restored.105 effects on mortality were observed. This meta-analysis con- It is not known which vasopressor agent is most effective cluded that the renal effects of hyperoncotic colloid solutions for prevention or treatment of patients with AKI and septic appear to be colloid-specific, with albumin displaying shock. Most studies have focused on norepinephrine, renoprotection and hyperoncotic starch showing nephro- dopamine, or vasopressin. Small open-label studies have toxicity. A 7000-patient study comparing 6% HES 130/0.4 in shown improvement in creatinine clearance (CrCl) following saline with saline alone was scheduled to begin in Australia a 6- to 8-hour infusion of norepinephrine106 or terlipres- and New Zealand in 2010. This study will provide further sin,107 while vasopressin reduced the need for norepinephrine high-quality data to help guide clinical practice.102 and increased urine output and CrCl.108 A large RCT109 Thus, the use of isotonic saline as the standard of care for comparing dopamine to norepinephrine as initial vasopres- intravascular volume expansion to prevent or treat AKI is sor in patients with shock showed no significant differences based upon the lack of clear evidence that colloids are between groups with regard to renal function or mortality. superior for this purpose, along with some evidence that However, there were more arrhythmic events among the specific colloids may cause AKI, in addition to higher costs. It patients treated with dopamine than among those treated is acknowledged that colloids may be chosen in some patients with norepinephrine, and a subgroup analysis showed that to aid in reaching resuscitation goals, or to avoid excessive dopamine was associated with an increased rate of death at fluid administration in patients requiring large volume 28 days among the patients with cardiogenic shock, but not resuscitation, or in specific patient subsets (e.g., a cirrhotic among the patients with septic shock or those with hypo- patient with spontaneous peritonitis, or in burns). Similarly, volemic shock. Thus, although there was no difference in although hypotonic or hypertonic crystalloids may be used in primary outcome with dopamine as the first-line vasopressor specific clinical scenarios, the choice of crystalloid with agent and those who were treated with norepinephrine, the altered tonicity is generally dictated by goals other than use of dopamine was associated with a greater number of intravascular volume expansion (e.g., hypernatremia or adverse events.109 hyponatremia). One of the concerns with isotonic saline is Vasopressin is gaining popularity in the treatment of that this solution contains 154 mmol/l chloride and that shock refractory to norepinephrine.110 Compared to nor- administration in large volumes will result in relative or epinephrine, it increases blood pressure and enhances absolute hyperchloremia (for a review, see Kaplan et al.103). dieresis, but has not as yet been proven to enhance survival Although direct proof of harm arising from saline-induced nor to reduce the need for RRT.111 A recent posthoc analysis hyperchloremia is lacking, buffered salt solutions approxi- of the above mentioned RCT used the RIFLE criteria for AKI mate physiological chloride concentrations and their admin- to compare the effects of vasopressin vs. norepinephrine.112 istration is less likely to cause acid-base disturbances. In patients in the RIFLE-R category, vasopressin as compared Whether use of buffered solutions results in better outcomes to norepinephrine was associated with a trend to a lower rate is, however, uncertain. of progression to F or L categories respectively, and a lower Kidney International Supplements (2012) 2, 37–68 39
chapter 3.1 rate of use of RRT. Mortality rates in the R category patients septic shock.93,113,114 In 2001, Rivers et al.115 published the treated with vasopressin compared to norepinephrine were results of a small (n ¼ 263), open-label, single-center study 30.8 vs. 54.7%, P ¼ 0.01, but this did not reach significance in that compared a treatment protocol that the authors referred a multiple logistic regression analysis. This study suggests to as EGDT in the emergency management of septic shock. thus that vasopressin may reduce progression to renal failure EGDT is predicated upon the premise that an early, and mortality in patients at risk of kidney injury who have protocolized resuscitation program with predefined physio- septic shock. The Work Group concluded that current logic end-points will prevent organ failure and improve the clinical data are insufficient to conclude that one vasoactive outcome of patients presenting with septic shock. agent is superior to another in preventing AKI, but Hypotensive patients with severe infection are rapidly emphasized that vasoactive agents should not be withheld assessed for evidence of tissue hypoperfusion and micro- from patients with vasomotor shock over concern for kidney circulatory dysfunction by mean arterial blood pressure perfusion. Indeed, appropriate use of vasoactive agents can measurement and plasma lactate levels.115 Blood lactate levels improve kidney perfusion in volume-resuscitated patients are neither sensitive nor specific but are readily available with vasomotor shock. measures of tissue hypoperfusion and do correlate with adverse outcomes in sepsis.116,117 Early recognition of septic PROTOCOLIZED HEMODYNAMIC MANAGEMENT shock then initiates a protocol of resuscitation with the goal of reestablishing tissue perfusion in patients within 6 hours of 3.1.3: We suggest using protocol-based management of diagnosis. The physiologic goals are: i) return of mean hemodynamic and oxygenation parameters to arterial blood pressure to X65 mm Hg; ii) central venous prevent development or worsening of AKI in pressure between 8–12 mm Hg; iii) improvement in blood high-risk patients in the perioperative setting (2C) lactate levels; iv) central venous oxygen saturation (ScvO2) or in patients with septic shock (2C). 470%; and v) a urine output of X0.5 ml/kg/h. In the study by Rivers et al. the protocol-driven process resulted in more rapid use of fluids, more blood transfusions, RATIONALE and in a small number of patients, earlier use of dobutamine A resuscitation strategy devised for patients with hypotension over the 6-hour time period than standard emergency care. from septic shock that is based upon achieving specific The in-hospital mortality rate in the control group was physiologic end-points within 6 hours of hospital admis- 46.5% vs. 30.5% in the EGDT group (Po0.01).115 Follow-up, sion has been termed Early Goal-Directed Therapy (EGDT). predominantly observational studies, have found less dra- This approach has been endorsed by the ‘‘Surviving matic but generally similar effects,118–122 though not without Sepsis Campaign’’113 and has gained considerable acceptance exception.123 despite only one, single-center, RCT evaluating its effective- The Rivers study did not specifically look at AKI out- ness. This protocolized strategy, consisting of fluids, vaso- comes, but multiple-organ function-scoring systems (i.e., active medication, and blood transfusions targeting physio- APACHE II and SAPS 2) both showed significant improve- logical parameters, is recommended by many experts for the ments with EGDT. In a subsequent study, prevention of prevention of organ injury in septic-shock patients. AKI was significantly improved in patients randomized to a Similarly, protocolized care strategies in surgical patients modified EGDT strategy (without measurement of ScvO2) at high risk for postoperative AKI have been extensively compared to a standard-care group.119 Criticisms of the studied in an effort to provide optimal oxygen delivery to Rivers study include: i) a complex, multistep protocol for tissues in the perioperative period. In these patients, goal- which individual interventions have not been validated; ii) directed therapy is defined as hemodynamic monitoring with the use of a treatment team in the active-therapy arm, thus defined target values and with a time limit to reach these risking a Hawthorn effect; iii) high mortality in the standard- stated goals. Together these protocols with bundled, hemo- care arm; and iv) the study was a small single-center study. dynamic, and tissue-support measures have the potential to Three large multicenter clinical trials in the USA, UK, and reduce the risk of AKI following major surgical procedures Australia are currently underway to definitively evaluate this in high-risk patients (e.g., age 460 years, emergent surgery, promising therapy. elevated American Society of Anesthesiologists score, preoperative comorbid illnesses). Goal-directed therapy for hemodynamic support during the perioperative period in high-risk surgical patients Protocolized hemodynamic management strategies Efforts to improve tissue oxygen delivery by optimizing in septic shock hemodynamic support in high-risk surgical patients to Early fluid resuscitation in the management of hypotensive prevent AKI and other adverse patient outcomes have been patients with septic shock has been a standard treatment investigated for many years.124–126 A recent meta-analysis of paradigm for decades.93,113,114 What has not been clear, these studies by Brienza et al.127 concluded that protocolized however, is how much fluid to give, for how long, or what therapies (regardless of the protocol) with specific physio- type of fluid therapy is optimal in the physiologic support of logical goals can significantly reduce postoperative AKI. 40 Kidney International Supplements (2012) 2, 37–68
chapter 3.1 A major problem in interpreting these studies is the lack of K Studies are needed that compare different types of standardized hemodynamic and tissue oxygenation targets vasopressors for prevention and treatment of AKI in and management strategies used to verify the efficacy of these hemodynamically unstable patients. Some evidence measures over standard perioperative care. A heterogeneous suggests that certain vasopressors may preserve renal collection of study populations, types of surgical procedures, function better than others (e.g., vasopressin analogues monitoring methods, and treatment strategies comprise this vs. catecholamines) and studies are needed to compare recent meta-analysis.127 The basic strategy of goal-directed them in this setting. therapy to prevent AKI in the perioperative period is based K The choice of a target mean arterial perfusion pressure on protocols that avoid hypotension, optimize oxygen range of 65–90 mm Hg as a component of resuscitation delivery, and include careful fluid management, vasopressors (perhaps in the context of age, chronic blood pressure, or when indicated, and inotropic agents and blood products if other comorbidities) also needs further study. needed.127 K The specific components of goal-directed therapy that The relative merits and risk:benefit ratio of each discrete accrue benefits for patients at risk for AKI need to be element of EGDT in the successful resuscitation of patients determined. Is it the timing of protocolized hemodynamic with septic shock requires further study. Given the limita- management that is beneficial: prophylactically in high- tions of the current studies and lack of comparative risk surgical patients, or early in the course of severe sepsis? effectiveness studies comparing individual protocols, we In contrast to the benefits of prophylactic or EGDT, can only conclude that protocols for resuscitation in the protocolized use of inotropes to normalize mixed venous setting of septic shock and high-risk surgery appear to be oxygen saturation or supranormalize oxygen delivery in superior to no protocol. ‘‘late’’ critical illness did not result in decreased AKI128 or improved outcomes.128,129 Alternatively, is it attention RESEARCH RECOMMENDATIONS to hemodynamic monitoring, the protocol itself that K Randomized trials of isotonic crystalloid vs. colloid standardizes supportive care to achieve the stated goals, or therapy for intravascular volume expansion to prevent a single or combination of the multiple possible interven- or treat AKI should be conducted in a variety of settings tions that improves outcome? Thus, further research is (critical illness, high-risk surgery, sepsis), including required to determine the specific components of goal- patient subsets. In particular, colloids may improve directed therapy that accrue benefits for patients at risk for efficiency of fluid resuscitation but some (starch) also AKI, if such benefits actually occur. carry some concerns regarding effects on the kidneys. If colloid results in less volume overload, it may lead to SUPPLEMENTARY MATERIAL improved outcomes. Supplementary Table 1: Summary table of RCTs examining the effect K Comparisons of specific solutions, with specific electrolyte of starch for the prevention of AKI. Appendix D: Evaluation and General Management Guidelines for composition or colloid type, for effectiveness in preventing Patients with AKI. AKI should be conducted. Specifically, there is a need to Supplementary material is linked to the online version of the paper at examine physiologic electrolyte solutions vs. saline. http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 37–68 41
http://www.kidney-international.org chapter 3.2 & 2012 KDIGO Chapter 3.2: General supportive management of patients with AKI, including management of complications Supportive management to prevent AKI was discussed in the complications that arise from AKI130–133; the reader is referred previous chapter and, for many patients, many of the supportive to these sources. Particular attention should be given to the therapies will continue even if AKI develops. Furthermore, assessment of the circulating volume and fluid administration, an important goal of early management of AKI is to prevent the prevention and/or treatment of hyperkalemia and metabolic further injury and to facilitate recovery of renal function. These acidosis, the knowledge of the changes in pharmacokinetics of goals can often best be achieved by strict attention to supportive many drugs with discontinuation of all potentially nephrotoxic therapy. However, as renal function deteriorates, complications drugs, and dose adaptation of drugs excreted by the kidneys to arise that require different management. Some of these issues the patient’s renal function. Finally, many of the other chapters have been discussed in Chapter 2.3 and several books have in this section of the guideline deal with supportive measures been devoted, in large part, to management of the many (e.g., diuretics for fluid management). 42 Kidney International Supplements (2012) 2, 37–68
http://www.kidney-international.org chapter 3.3 & 2012 KDIGO Chapter 3.3: Glycemic control and nutritional support GLYCEMIC CONTROL IN CRITICAL ILLNESS: RENAL EFFECTS patients), the primary end-point of in-hospital mortality AND OUTCOMES did not differ between groups (40% CIT group vs. 37.3% IIT group; P ¼ 0.33).141 As in the original surgical ICU study, a 3.3.1: In critically ill patients, we suggest insulin variety of secondary end-points were improved in this study, therapy targeting plasma glucose 110–149 mg/dl including a lower incidence of AKI and need for RRT. In the (6.1–8.3 mmol/l). (2C) original surgical ICU study, severe AKI (peak SCr 42.5 mg/dl [4221 mmol/l]) developed in 7.2% of the IIT group, compared to 11.2% of the CIT group (P ¼ 0.04); the RATIONALE incidence of RRT was also lower in the IIT group than the As outlined in a recent review,134 stress hyperglycemia is a CIT group (4.8% vs. 8.2%, respectively; P ¼ 0.007).138 In the distinctive clinical feature of critical illness. Stress mediators, medical ICU study, the IIT group similarly had a significantly and central and peripheral insulin resistance appears pivotal lower rate of AKI (doubling of SCr, 5.4%) than the CIT to the occurrence of stress hyperglycemia. Inflammatory group (8.9%, P ¼ 0.04), although RRT incidence was not mediators and counter-regulatory hormones have been decreased.141 In a recent analysis, Schetz et al.142 combined shown to impede crucial elements of the insulin-signaling the renal end-points of both of these trials and used a modi- pathway. Still, exogenous insulin administration normalizes fied version of the RIFLE classification of AKI to demonstrate blood glucose levels in this setting. Insulin treatment may that tight glycemic control reduced the incidence of severe counteract hepatic insulin resistance during acute critical AKI (peak SCr increments two- or three-fold increased from illness. Extensive observational data have shown a consistent, baseline) from 7.6% to 4.5% (P ¼ 0.0006) in a combined almost linear, relationship between blood glucose levels in patient population of 2707. The need for RRT was not patients hospitalized with MI and adverse clinical outcomes, decreased in the overall population or the medical ICU even in patients without established diabetes.135,136 population, but was significantly lower in the surgical ICU It has never been entirely clear, however, whether glycemia patients managed with IIT (4% vs. 7.4%, P ¼ 0.008). serves as a mediator of these outcomes or merely as a marker Several newer studies have provided additional insight of the sickest patients, who present with the well-known concerning the efficacy and safety of tight glycemic control in counter-regulatory stress response to illness.137 Interestingly, critically ill patients.93,95,143–146 Thomas et al.145 conducted a Kosiborod et al.135 recently showed, in a population with MI, systematic review of randomized trials of tight glycemic that while hypoglycemia was associated with increased control in 2864 critically ill patients, and found a 38% risk mortality, this risk was confined to patients who developed reduction of AKI with IIT, and a nonsignificant trend towards spontaneous hypoglycemia. In contrast, iatrogenic hypo- less acute dialysis requirement. However, IIT was also glycemia after insulin therapy was not associated with higher associated with a greater than four-fold increase in the risk mortality risk. of hypoglycemia. A body of literature demonstrating that Tight glycemic control is frequently used in patients at risk uncontrolled hyperglycemia was associated with increased of AKI, and in the management of those who develop AKI. It AKI following cardiac surgery led to the conduct of a 400- has been proposed that tight glycemic control can reduce the patient, single-center RCT of tight vs. conventional intra- incidence and severity of AKI. Since the landmark trial of Van operative glucose control.143,144 The investigators found that den Berghe et al.,138 additional studies provided initial this approach did not decrease perioperative morbidity or confirmation of the benefits (reduced morbidity and mortality (included in a composite end-point that included mortality), and some additional mechanistic insights of tight AKI within 30 days of surgery): the composite end-point glycemic control in critically ill patients.139 Further secondary occurred in 44% of the IIT group vs. 46% of the CIT group. analysis of the original trial, which was conducted in 1548 Although the incidence of hypoglycemia was similar in the mechanically ventilated surgical ICU patients, found that groups, there was a significantly higher incidence of stroke in intensive insulin therapy (IIT) target plasma glucose the IIT group (4.3%) compared to the CIT group (0.54%), as 80–110 mg/dl (4.44–6.11 mmol/l) was associated with sub- well as trends towards higher mortality and more post- stantial cost savings compared to conventional insulin operative heart block in the IIT group, raising concerns about therapy (CIT) target plasma glucose 180–200 mg/dl (9.99– the safety of this approach. 11.1 mmol/l).140 However, when Van den Berghe et al. Further prospective comparison of IIT vs. CIT in critically repeated their original study in a different population of ill septic patients was provided in the VISEP trial, which critically ill patients (medical rather than surgical ICU also incorporated a comparison on crystalloid vs. colloid Kidney International Supplements (2012) 2, 37–68 43
chapter 3.3 infusions in a 2 Â 2 factorial design.93 Patients with severe p180 mg/dl [p9.99 mmol/l]).148 The primary outcome was sepsis or septic shock in 18 ICUs were randomized to IIT mortality from any cause within 90 days after randomization. (target glycemia 80–110 mg/dl [4.44–6.11 mmol/l]; n ¼ 247) The two groups had similar characteristics at baseline. A total or CIT (target glycemia 180–200 mg/dl [9.99–11.1 mmol/l]; of 829 patients (27.5%) in the intensive-control group and n ¼ 290) (Suppl Tables 2 and 3). There were no significant 751 (24.9%) in the conventional-control group died (OR differences in 28-day or 90-day mortality, Sequential Organ for intensive control, 1.14; 95% CI 1.02–1.28; P ¼ 0.02). The Failure Assessment scores, or AKI rates between the groups. treatment effect did not differ significantly between surgical However, hypoglycemia (blood glucose level o40 mg/dl patients and medical patients. There was no significant [o2.22 mmol/l]) was more frequent in the IIT group (12% difference between the two treatment groups in incidence of vs. 2%; Po0.001) and led to early termination of the IIT new RRT (15.4% vs. 14.5%), respectively. Severe hypo- study arm. Following publication of this study, Thomas et al., glycemia (blood glucose level p40 mg/dl [p2.22 mmol/l]) updated the meta-analysis (discussed above) to include these was reported in 6.8% in the intensive-control group and in data, and reported that, with the addition of the VISEP data, 0.5% in the conventional-control group (Po0.001). In the analysis of a 3397-patient group found a 36% risk summary, the largest randomized trial of intensive vs. reduction of AKI with IIT, but this pooled estimate was no conventional insulin therapy found that intensive glucose longer statistically significant (relative risk [RR] 0.74; 95% CI control actually increased mortality among adults in the ICU: 0.47–1.17).95 In a detailed review of the VISEP trial, Thomas a blood glucose target of p180 mg/dl (p9.99 mmol/l) et al., also noted that another multicenter mixed ICU trial of resulted in lower mortality than did a target of 81–108 mg/ intensive insulin therapy (the GLUCOCONTROL Study: dl (4.50–5.99 mmol/l). Furthermore, this trial confirmed the Comparing the effects of two glucose control regimens by consistent finding of an increased incidence of hypoglycemia insulin in intensive care unit patients; available at: http:// associated with IIT, without any proven benefit in reducing www.clinicaltrials.gov/ct/show/NCT00107601) was stopped mortality, organ dysfunction, or bacteremia. after 1101 patients were enrolled because of greater rates of There were some methodological differences between the hypoglycemia with IIT.95 Such data have raised significant Leuven and NICE-SUGAR studies, possibly explaining the concerns regarding the effectiveness and safety of using IIT different outcomes.149 These comprised different target with tight glycemic control to prevent or ameliorate ranges for blood glucose in control and intervention groups, morbidity and mortality in patients at high risk of AKI and different routes for insulin administration and types of infu- other forms of organ injury. sion pumps, different sampling sites, and different accuracies The recent meta-analysis of IIT vs. CIT by Wiener et al.146 of glucometers, as well as different nutritional strategies and continued to find a greater incidence of hypoglycemia with varying levels of expertise. Finally, Griesdale et al.150 per- IIT, but the balance of evidence now suggests no improve- formed a meta-analysis of trials of intensive vs. conventional ment in survival with this approach. Twenty-nine RCTs glycemic control that included most of the studies in the totaling 8432 patients contributed data for this meta-analysis. Wiener meta-analysis, in addition to some newer studies, Twenty-seven studies reported no difference in hospital including data supplied by the NICE-SUGAR investigators. mortality (21.6% in IIT vs 23.3% in CIT) with a pooled RR All 26 trials that reported mortality found a pooled RR of of 0.93 (95% CI 0.85–1.03; P ¼ NS). Nine studies reported no death with IIT compared to CIT of 0.93 (95% CI 0.83–1.04). difference in incidence of new RRT. There was a significant Among the 14 trials reporting hypoglycemia, the pooled RR benefit of tight glycemic control in reducing the incidence of with IIT was 6.0 (95% CI 4.5–8.0). However, in subset septicemia but this was associated with a significantly analysis, patients in surgical ICUs appeared to benefit from increased risk of hypoglycemia (blood glucose o40 mg/dl IIT while patients in the other ICU settings (medical or [o2.22 mmol/l]) in patients randomized to IIT with a pooled mixed) did not. Although results from the early trials were RR of 5.13 (95% CI 4.09–6.43; Po0.05). better in studies that included surgical138 rather than purely In summary, pooled analysis of early multicenter studies medical ICU patients141, and this latest meta-analysis appears has failed to confirm the early observations of beneficial to confirm that trend, it should be noted that no such effects of IIT on renal function; the risk of hypoglycemia with phenomenon was noted in the NICE-SUGAR trial. Overall, this approach is significant, and even the survival benefits of the data do not support the use of IIT aiming to control IIT are in doubt. More recently, the international Normogly- plasma glucose below 110 mg/dl (6.11 mmol/l) in critically ill cemia in Intensive Care Evaluation and Survival Using patients, although subset analyses suggest that further trials Glucose Algorithm Regulation (NICE-SUGAR) study, with a may disclose benefits in perioperative patients, and perhaps targeted enrolment of 6100 patients, set out to definitively through the use of less-intensive glucose control targets. determine the risk-benefit comparison of tight glycemic Considering the balance between potential benefits and control in critically ill patients (Suppl Table 3).147,148 In this harm (see Suppl Table 2), the Work Group suggests using trial, adult patients were randomized within 24 hours after insulin for preventing severe hyperglycemia in critically ill admission to an ICU to receive either intensive glucose patients, but in view of the danger of potentially serious control (target blood glucose range of 81–108 mg/dl [4.50– hypoglycemia, we recommend that the average blood glucose 5.99 mmol/l]), or conventional glucose control (target of should not exceed 150 mg/dl (8.33 mmol/l), but that insulin 44 Kidney International Supplements (2012) 2, 37–68
chapter 3.3 therapy should not be used to lower blood glucose to less than 25–30 kcal/kg/d, equivalent to 100–130% of resting than 110 mg/dl (6.11 mmol/l). The Work Group recognizes energy expenditure. Energy provision should be composed of that these proposed thresholds have never directly been 3–5 (maximum 7) g per kilogram body weight carbohydrates examined in RCTs but are interpolated from the comparisons and 0.8–1.0 g per kilogram body weight fat. tested in the trials so far. 3.3.3: We suggest to avoid restriction of protein intake NUTRITIONAL ASPECTS IN THE PREVENTION AND with the aim of preventing or delaying initiation of TREATMENT OF CRITICALLY ILL PATIENTS WITH AKI RRT. (2D) Protein-calorie malnutrition is an important independent 3.3.4: We suggest administering 0.8–1.0 g/kg/d of protein predictor of in-hospital mortality in patients with AKI. In a in noncatabolic AKI patients without need for prospective study of 300 AKI patients, 42% presented with dialysis (2D), 1.0–1.5 g/kg/d in patients with AKI on signs of severe malnutrition on admission.151 RRT (2D), and up to a maximum of 1.7 g/kg/d in The nutritional management of AKI patients must patients on continuous renal replacement therapy consider the metabolic derangements and proinflammatory (CRRT) and in hypercatabolic patients. (2D) state associated with renal failure, the underlying disease process and comorbidities, as well as the derangements in nutrient balance caused by RRT. Very few systematic studies RATIONALE have assessed the impact of nutrition on clinical end-points Protein hypercatabolism driven by inflammation, stress, used in these guidelines (i.e., mortality, need for RRT, and acidosis is a common finding in critically ill and incidence of AKI). Recommendations are therefore patients.157,165,166 The optimal amount of protein supple- largely based on expert opinion. Several expert panels have mentation in AKI patients is unknown. Patients with AKI are developed clinical practice guidelines for the nutritional at high risk of malnutrition. Since malnutrition is associated management of patients with AKI, whether treated with or with increased mortality in critically ill patients, nutritional without RRT.152–156 A recent narrative review has also management should aim at supplying sufficient protein to provided updated information on this topic.157 maintain metabolic balance. Hence, nutritional protein administration should not be restricted as a means to 3.3.2: We suggest achieving a total energy intake of attenuate the rise in BUN associated with declining GFR. On 20–30 kcal/kg/d in patients with any stage of AKI. (2C) the other hand, there is little evidence that hypercatabolism can be overcome simply by increasing protein intake to supraphysiologic levels. While, in a crossover study of AKI RATIONALE patients, nitrogen balance was related to protein intake Carbohydrate metabolism in AKI is characterized by and was more likely to be positive with intakes larger than hyperglycemia due to peripheral insulin resistance158,159 2 g/kg/d,167 only 35% of patients achieved a positive nitrogen and accelerated hepatic gluconeogenesis, mainly from con- balance in a study applying a nutrient intake as high as version of amino acids released during protein catabolism 2.5 g/kg/d protein.168 No outcome data are currently that cannot be suppressed by exogenous glucose infusions.160 available concerning the clinical efficacy and the safety of In addition, hypertriglyceridemia commonly occurs due such high protein intakes, which may contribute to acidosis to inhibition of lipolysis. The clearance of exogenously and azotemia, and increase dialysis dose requirements. administered lipids can be reduced.161 The modifications of Due to their continuous nature and the high filtration energy metabolism are usually not caused by AKI per se but rates, CRRT techniques can better control azotemia and fluid related to acute comorbidities and complications.162 Energy overload associated with nutritional support but may also consumption is not increased by AKI. Even in multiple-organ result in additional losses of water-soluble, low-molecular- failure, the energy expenditure of critically ill patients weight substances, including nutrients.169 Normalized pro- amounts to not more than 130% of resting energy tein catabolic rates of 1.4 to 1.8 g/kg/d have been reported expenditure. The optimal energy-to-nitrogen ratio during in patients with AKI receiving CRRT.170–172 In a recent study AKI has not been clearly determined. In a retrospective study in critically ill cancer patients with AKI and treated with of AKI patients undergoing continuous venovenous hemofil- sustained low-efficiency dialysis (SLED), those with higher tration (CVVH), less negative or weakly positive nitrogen BUN and serum albumin levels, which were associated with balance was associated with an energy intake of approxi- infusion of higher amount of total parenteral nutrition, had a mately 25 kcal/kg/d.163 In a randomized trial in AKI patients lower mortality risk.173 comparing 30 and 40 kcal/kg/d energy provision, the higher In CRRT, about 0.2 g amino acids are lost per liter of energy prescription did not induce a more positive nitrogen filtrate, amounting to a total daily loss of 10–15 g amino balance but was associated with a higher incidence of acids. In addition, 5–10 g of protein are lost per day, hyperglycemia and hypertriglyceridemia and a more positive depending on the type of therapy and dialyzer membrane. fluid balance.164 These observations provide a rationale to Similar amounts of protein and amino acids are typically lost maintain a total energy intake of at least 20, but not more by peritoneal dialysis (PD). Nutritional support should Kidney International Supplements (2012) 2, 37–68 45
chapter 3.3 account for the losses related to CRRT, including PD, by nutritional requirements in children with critical illness and providing a maximum of 1.7 g amino acids/kg/d. AKI is limited to observational studies. With respect to calorie provision, it is generally agreed that critically ill children, 3.3.5: We suggest providing nutrition preferentially via like adults, should receive 100–130% of the basal energy the enteral route in patients with AKI. (2C) expenditure, which can be estimated with acceptable precision and accuracy by the Caldwell-Kennedy equation179: (resting RATIONALE energy expenditure [kcal/kg/d] ¼ 22 þ 31.05 Â weight [kg] þ Enteral feeding may be more difficult in patients with AKI 1.16 Â age [years]). because of impaired gastrointestinal motility and decreased In a recent survey of the nutritional management of 195 absorption of nutrients secondary to bowel edema.174 children with AKI on CRRT, the maximal calorie prescription Moreover, multiple factors negatively affect gastrointestinal in the course of treatment averaged 53, 31, and 21 kcal/kg/d, function in critically ill patients, e.g., medications (sedatives, and that for protein intake 2.4, 1.9, and 1.3 g/kg/d in children opiates, catecholamines, etc.), glucose and electrolyte dis- aged o1, 1–13, and 413 years, respectively.180 Although not orders, diabetes, or mechanical ventilation. However, the validated by outcome studies, these figures provide an provision of nutrients via the gut lumen helps maintain gut orientation for the macronutrient supply typically achieved integrity, decreases gut atrophy, and decreases bacterial and in and tolerated by children with AKI receiving CRRT. endotoxin translocation. Furthermore, AKI is a major risk factor for gastrointestinal hemorrhage.175 Enteral nutrition RESEARCH RECOMMENDATIONS should exert protective effects on the risk of stress ulcers or K The risk-benefit ratio of diets with low, medium, and bleeding. Clinical studies have suggested that enteral feeding high protein contents in different stages of AKI should be is associated with improved outcome/survival in ICU addressed in RCTs. patients.176,177 Hence, enteral nutrition is the recommended K Given gastrointestinal tract dysfunction in AKI, the form of nutritional support for patients with AKI. If oral possible benefit of enteral vs. parenteral feeding in AKI feeding is not possible, then enteral feeding (tube feeding) patients should be further evaluated in prospective RCTs. should be initiated within 24 hours, and has been shown to be safe and effective.178 SUPPLEMENTARY MATERIAL Supplementary Table 2: Evidence profile of RCTs examining insulin vs. Pediatric considerations conventional glucose therapy for the prevention of AKI. Supplementary Table 3: Summary table of RCTs examining the effect In children with AKI, physiological macronutrient require- of insulin for the prevention of AKI. ments are age-dependent, reflecting the developmental Supplementary material is linked to the online version of the paper at dynamics of growth and metabolism. Research exploring http://www.kdigo.org/clinical_practice_guidelines/AKI.php 46 Kidney International Supplements (2012) 2, 37–68
http://www.kidney-international.org chapter 3.4 & 2012 KDIGO Chapter 3.4: The use of diuretics in AKI Diuretics are frequently used in patients at risk of AKI, and in furosemide is beneficial for prevention or treatment of AKI. the management of those who develop AKI. Since fluid Specifically, prophylactic furosemide was found to be overload is one of the major symptoms of AKI, diuretics are ineffective or harmful when used to prevent AKI after cardiac often used for patients with AKI to facilitate fluid manage- surgery,189,190 and to increase the risk of AKI when given to ment. Recent observational studies showed that 59–70% of prevent CI-AKI.191 Epidemiologic data have suggested that patients with AKI were given diuretics at the time of the use of loop diuretics may increase mortality in patients nephrology consultation or before the start of RRT.181,182 with critical illness and AKI,181 along with conflicting data In addition, oliguric AKI has a worse prognosis than that suggest no harm in AKI.182 Finally, furosemide therapy nonoliguric AKI and physicians often prescribe diuretics to was also ineffective and possibly harmful when used to treat convert oliguric to nonoliguric AKI.183 Diuretics are also AKI.188,192 used to control fluid balance and permit administration of There is no evidence that the use of diuretics reduces the nutrition and medications. Furthermore, several diuretics incidence or severity of AKI. Ho et al.192,193 conducted two have potentially renoprotective effects that might prevent comprehensive systematic reviews on the use of the loop development of AKI and hasten its recovery. However, diuretic frusemide (furosemide) to prevent or treat AKI. diuretics can also be harmful, by reducing the circulating Furosemide had no significant effect on in-hospital mortality, volume excessively and adding a prerenal insult, worsening risk for requiring RRT, number of dialysis sessions, or even established AKI. Therefore, it is essential to evaluate the proportion of patients with persistent oliguria. Results usefulness of diuretics to improve outcome of patients with from the most recent review193 are shown in Figure 9 and AKI, not just for fluid management. Figure 10. The primary prevention studies included patients who underwent cardiac surgery,189 coronary angiography,191 3.4.1: We recommend not using diuretics to prevent and major general or vascular surgery.194 In two of these AKI. (1B) studies, all participants had mild pre-existing renal impair- 3.4.2: We suggest not using diuretics to treat AKI, except ment. Two of the three studies reported mortality in patients in the management of volume overload. (2C) randomized to furosemide (n ¼ 103) vs. placebo (n ¼ 99), with a pooled RR of 2.67 (95% CI 0.75–7.25; P ¼ 0.15). All three studies reported RRT incidence in patients randomized RATIONALE to furosemide (n ¼ 128) vs. placebo (n ¼ 127), with a pooled Loop diuretics have several effects that may protect against RR of 4.08 (95% CI 0.46–35.96; P ¼ 0.21). Thus, subanalysis AKI. They may decrease oxygen consumption in the loop of to separate primary and secondary prevention trials did not Henle by inhibiting sodium transport, thus potentially alter the conclusion that, within the sample size limitations lessening ischemic injury. Loop diuretics act at the luminal of this study, furosemide is not effective for the prevention surface of the thick ascending limb of the loop of Henle and of AKI. inhibit the Na-K-2Cl cotransporter,184,185 resulting in a loss The systematic review and meta-analysis by Ho and of the high medullary osmolality and decreased ability to Power193 also included six studies that used furosemide to reabsorb water. Inhibition of active sodium transport also treat AKI, with doses ranging from 600 to 3400 mg/d reduces renal tubular oxygen consumption, potentially (Figure 9 and Figure 10).192 No significant reduction was decreasing ischemic damage of the most vulnerable outer found for in-hospital mortality or for RRT requirement. The medullary tubular segments;183 therefore, furosemide might largest single study of furosemide for treating AKI was protect kidneys against ischemic injury.186 Furosemide also conducted by Cantarovich et al.,188 which included 338 might hasten recovery of AKI by washing out necrotic debris patients with AKI requiring dialysis. Patients were randomly blocking tubules, and by inhibiting prostaglandin dehydro- assigned to the administration of either furosemide (25 mg/ genase, which reduces renovascular resistance and increases kg/d i.v. or 35 mg/kg/d orally) or placebo. Although time to renal blood flow.186,187 Based on these properties, loop reach 2 l/d of diuresis was shorter with furosemide (5.7 days) diuretics might be expected to prevent or ameliorate AKI. than placebo (7.8 days, P ¼ 0.004), there was no difference in However, there are only minimal data to support this theory, survival and number of dialysis sessions. At present, the and there is some evidence of harm associated with loop current evidence does not suggest that furosemide can reduce diuretic use to prevent or treat AKI.188–191 Furosemide is the mortality in patients with AKI. most commonly prescribed diuretic in the acute-care Furosemide may, however, be useful in achieving fluid setting,183–185 and a number of RCTs have tested whether balance to facilitate mechanical ventilation according to the Kidney International Supplements (2012) 2, 37–68 47
chapter 3.4 Figure 9 | Effect of furosemide vs. control on all-cause mortality. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283–293 with permission from John Wiley and Sons193; accessed http://onlinelibrary.wiley.com/ doi/10.1111/j.1365-2044.2009.06228.x/full Figure 10 | Effect of furosemide vs. control on need for RRT. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283–293 with permission from John Wiley and Sons193; accessed http://onlinelibrary.wiley.com/doi/ 10.1111/j.1365-2044.2009.06228.x/full lung-protective ventilation strategy in hemodynamically conclude that there is no evidence that the use of loop stable patients with acute lung injury. On the other hand, diuretics reduces the severity of AKI, or improves outcomes the literature also suggests that high-dose furosemide in this syndrome. Although the use of loop diuretics in early (41 g/d) may cause ototoxicity. In the first meta-analysis or established AKI facilitates management of fluid balance, by Ho and Sheridan,192 high doses of furosemide (range hyperkalemia, and hypercalcemia, and is indicated for these 1–3.4 g/d) caused deafness or tinnitus more frequently than clinical purposes, any putative role in the prevention or the control (RR 3.97; 95% CI 1.00–15.78; P ¼ 0.05). When amelioration of AKI course is unproven. administered as continuous infusion a dose of 0.5 mg/kg/ Two recent studies have investigated whether the admin- hour was not associated with ototoxicity.195 Taken together istration of furosemide to patients treated with CVVH could with several small studies showing that the prophylactic use be associated with a more rapid discontinuation of the of diuretics to prevent AKI actually increased AKI incidence, dialysis therapy. van der Voort et al., observed, as expected, these data raise significant concerns regarding use of loop an increased urinary volume and sodium excretion, but this diuretics to prevent or treat AKI in any setting. We similarly intervention did not lead to a shorter duration of renal failure 48 Kidney International Supplements (2012) 2, 37–68
chapter 3.4 or more frequent renal recovery.195 The second study by renal dysfunction, but the results of these studies are not very Uchino et al.,196 analyzed data from the B.E.S.T. kidney and convincing.198 Two small randomized trials—one in patients found that, from a total of 529 critically ill patients who with pre-existing normal renal function,199 the second in survived during CRRT, 313 patients were removed success- patients with established renal dysfunction200—did not find fully from CRRT while 216 patients needed ‘‘repeat RRT’’ differences for any measured variable of renal function. after temporary discontinuation. Urine output (during the 24 More convincing are the results obtained with the preventive hours before stopping CRRT) was identified as a significant administration of mannitol, just before clamp release, during predictor of successful cessation, but the predictive ability of renal transplantation.201,202 The sparse controlled data urine output was negatively affected by the use of diuretics. available have shown that 250 ml of mannitol 20% given Thus, a beneficial role for loop diuretics in facilitating immediately before vessel clamp removal reduces the inci- discontinuation of RRT in AKI is not evident. dence of post-transplant AKI, as indicated by a lower require- ment of post-transplant dialysis. However, 3 months after Mannitol transplantation, no difference is found in kidney function Mannitol has been frequently used in the past for prevention compared to patients who did not receive mannitol.203 of AKI; however, most of the studies are retrospective, It has also been suggested that mannitol is beneficial in underpowered, and, overall, the studies did not meet the rhabdomyolysis by stimulating osmotic diuresis and by criteria of the Work Group to be included in formulation of lowering the intracompartmental pressure in the affected recommendations. Prophylactic mannitol has been promoted crushed limbs204–206; again, these studies were either not in patients undergoing surgery. While in most of these randomized or underpowered. A separate guideline on crush instances mannitol increases urine flow, it is highly probable injury associated with disasters, mainly earthquake victims, is that mannitol does not convey additional beneficial effects under preparation by the ISN Renal Disaster Relief Task beyond adequate hydration on the incidence of AKI. Force. In radiocontrast-induced nephropathy, loop diuretics In summary, despite experimental animal data and the and mannitol in one study have been shown to exacerbate anecdotal human evidence for the beneficial effects of ARF.191 Weisberg et al.,197 randomized patients under- mannitol, there are no adequately powered prospective RCTs going contrast-medium investigations to receive saline or comparing mannitol vs. other strategies. Based on these one of three renal vasodilator/diuretic drugs (dopamine considerations, the Work Group concludes that mannitol is [2 mg/kg/min], mannitol [15 g/dl in a one-half isotonic saline not scientifically justified in the prevention of AKI. solution given at 100 ml/h] or atrial natriuretic peptide). Dopamine, mannitol, and atrial natriuretic peptide were RESEARCH RECOMMENDATION associated with a much higher incidence of renal dysfunction K Given the potential to mitigate fluid overload but also to in diabetic subjects compared to patients receiving saline alone. worsen renal function and possibly cause kidney injury, Mannitol is often added to the priming fluid of the further study is required to clarify the safety of loop cardiopulmonary bypass system to reduce the incidence of diuretics in the management of patients with AKI. Kidney International Supplements (2012) 2, 37–68 49
http://www.kidney-international.org chapter 3.5 & 2012 KDIGO Chapter 3.5: Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides DOPAMINE FOR THE PREVENTION OR TREATMENT OF AKI analyzed 61 randomized or quasi-randomized controlled Dopamine was once commonly used for renal protection in trials of low-dose dopamine, and found no improvement of the critically ill. However, with multiple negative studies, survival (Figure 11), no decrease in dialysis requirement including a randomized, double-blind, placebo-controlled (Figure 12), no improvement in renal function, and trial of adequate size and power,207 its use has been improved urine output only on the first day of dopamine abandoned by most. Low-dose dopamine administration therapy.212 Similarly, although there were trends towards (1–3 mg/kg/min) to healthy individuals causes renal vasodila- transiently greater urine output, lower SCr, and higher GFR tion, natriuresis, and increased GFR; because of these effects, in dopamine-treated patients on day 1 of therapy (but not it has been given as prophylaxis for AKI associated with days 2 and 3), there was no evidence of a sustained beneficial radiocontrast administration, repair of aortic aneurysms, effect on renal function. In an earlier systematic review, orthotopic liver transplantation, unilateral nephrectomy, Kellum et al.,210 performed an analysis of studies that renal transplantation, and chemotherapy with interferon.208 reported incidence of AKI as an outcome, which developed in The majority of prevention trials with low-dose dopamine 15.3% in the dopamine arms and 19.5% in the control arms have been small, inadequately randomized, of limited (RR 0.79 [0.54–1.13]). Similar to the earlier analysis by statistical power, and with end-points of questionable clinical Kellum et al., restriction of the Work Group’s analysis to significance. Furthermore, recent data suggest that the renal prevention trials did not disclose any benefit of dopamine vs. vasodilatory effect of dopamine found in healthy populations placebo therapy. Similarly, analysis of adequate trials is not preserved in patients with AKI. Using Doppler restricted to patients treated for AKI does not suggest a ultrasound, Lauschke et al.209 found that dopamine signi- benefit of dopamine therapy. Specifically, a relatively large ficantly increased renal vascular resistance in AKI patients. randomized, placebo-controlled trial in 328 critically ill Kellum and Decker210 found no benefit of dopamine for patients with early AKI sufficiently powered to detect a small prevention or therapy of AKI in an adequately-powered benefit was reported.207 There was no effect of low-dose meta-analysis, and Marik211 found no benefit in a systematic dopamine on renal function, need for dialysis, ICU or review. hospital length of stay (LOS), or mortality (Suppl Table 4). There is also limited evidence that the use of dopamine to Taken together, these analyses found no evidence that prevent or treat AKI causes harm. Although the meta-analysis dopamine therapy is effective in the prevention or treatment by Friedrich et al.,212 found no significant increase in adverse of AKI. events or evidence of harm from low-dose dopamine, there is significant literature demonstrating adverse effects of dopa- FENOLDOPAM FOR THE PREVENTION OR TREATMENT OF AKI mine, even at low doses. It can trigger tachyarrhythmias Fenoldopam mesylate is a pure dopamine type-1 receptor and myocardial ischemia, decrease intestinal blood flow, agonist that has similar hemodynamic renal effects as cause hypopituitarism, and suppress T-cell function.208 Taken low-dose dopamine, without systemic a- or b-adrenergic together with the lack of positive trials to support the use of stimulation.213 dopamine for AKI prevention or therapy, the aforementioned potential deleterious effects of this drug provide additional 3.5.2: We suggest not using fenoldopam to prevent or arguments for abandoning its use entirely for the prevention treat AKI. (2C) and therapy of AKI. 3.5.1: We recommend not using low-dose dopamine to RATIONALE prevent or treat AKI. (1A) The results of animal experiments and small human studies measuring perioperative GFR in patients undergoing coro- nary artery bypass graft and aortic cross-clamp surgery RATIONALE suggested that fenoldopam might prevent or ameliorate the In their meta-analysis, Friedrich et al.,212 did not specifically course of AKI.139 Cogliati et al.,214 conducted a double-blind, separate prophylactic trials from trials where dopamine was randomized trial of fenoldopam infusion for renal protec- used therapeutically in patients with established AKI, because tion in 193 high-risk cardiac surgery patients, who were many of the original trials failed to do so.210 The authors randomized to receive a continuous infusion of fenoldopam, 50 Kidney International Supplements (2012) 2, 37–68
chapter 3.5 Figure 11 | Effect of low-dose dopamine on mortality. Reprinted from Friedrich JO, Adhikari N, Herridge MS et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510–524 with permission from American College of Physicians212; accessed http://www.annals.org/content/142/7/510.full 0.1 mg/kg/min (95 patients) or placebo (98 patients) for The fenoldopam group had a significantly lower rate of AKI 24 hours. AKI was defined as a postoperative SCr level of (29 vs. 51 patients, P ¼ 0.006; OR of 0.47, P ¼ 0.005), and X2 mg/dl (X177 mmol/l) with an increase in SCr level of shorter ICU stays, without any increase in complications. The X0.7 mg/dl (X61.9 mmol/l) from preoperative to maximum incidence of severe AKI, dialysis, and death were not different postoperative values. AKI developed in 12 of 95 (12.6%) between the groups. This study requires a larger confirmatory patients receiving fenoldopam and in 27 of 98 (27.6%) trial, which should be powered to test effectiveness in patients receiving placebo (P ¼ 0.02), and RRT was started in improving dialysis-free survival. 0 of 95 and 8 of 98 (8.2%) patients, respectively (P ¼ 0.004). Emerging data from experimental AKI models suggest These results suggested that a 24-hour infusion of that fenoldopam may have multiple protective effects in AKI, 0.1 mg/kg/min of fenoldopam prevented AKI in a high-risk including anti-inflammatory effects independent of any vaso- population undergoing cardiac surgery. A meta-analysis of dilatory action.217,218 Further large studies will be required 1059 patients in 13 studies that included this trial found that to determine if fenoldopam is an effective renoprotec- fenoldopam reduces the need for RRT and in-hospital death tive agent.213,219 As discussed elsewhere in this guideline in cardiovascular surgery patients.215 However, the pooled (Section 4), despite promising pilot study findings, fenoldo- studies included both prophylactic and early therapeutic pam was ultimately found to be ineffective for the prevention studies, as well as propensity-adjusted case-matched studies of CI-AKI,220 and as a potent antihypertensive (the only (rather than purely randomized trials). A 1000-patient RCT approved indication for the drug), fenoldapam carries a of fenoldopam to prevent the need for RRT after cardiac significant risk of hypotension. surgery is currently underway (ClinicalTrials.gov identifier: Fenoldopam mesylate has also been studied for early NCT00621790); meanwhile, this remains an unproven treatment of AKI. Tumlin et al.,221 conducted a randomized, indication for fenoldopam therapy. placebo-controlled pilot trial of low-dose fenoldopam Finally, Morelli et al.,216 in a prospective, double-blind mesylate in ICU patients with early AKI and found no trial, randomized 300 septic patients without renal dysfunc- benefit, though they did show a trend towards lower 21-day tion to receive infusions of fenoldopam (0.09 mg/kg/min) mortality and decreased need for dialysis in fenoldopam- and compared these individuals to a placebo group; the treated patients (11% difference in dialysis-free survival). treatment continued as long as the patient was in the ICU. In secondary analyses, fenoldopam tended to reduce the Kidney International Supplements (2012) 2, 37–68 51
chapter 3.5 Figure 12 | Effect of low-dose dopamine on need for RRT. Reprinted from Friedrich JO, Adhikari N, Herridge MS et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510–524 with permission from American College of Physicians212; accessed http://www.annals.org/content/142/7/510.full primary end-point in patients without diabetes and post- other positive trends in the literature, these results add to the operative cardiothoracic surgery patients with early ATN. discourse around fenoldopam’s use to treat early AKI in Brienza et al.,222 conducted a prospective, multicenter, critically ill patients. Similarly, Landoni et al.,223 in a recently RCT of fenoldopam therapy for early AKI in critically ill published meta-analysis found that fenoldopam decreased patients. The study included hemodynamically stable adults the risk of requiring acute RRT and resulted in a lower all- with renal dysfunction. This 100- subject study compared 4- cause, in-hospital mortality (15.1%) compared to controls day infusions of fenoldopam (0.1 mg/kg/min) or dopamine (18.9%; OR 0.64; 95% CI 0.4–0.91), along with a non- (2 mg/kg/min); there was no placebo arm. The primary end- significant trend towards more hypotension or pressor use in point of the study was a between-group comparison of the the fenoldopam group. maximum change of SCr over time during the 4-day study Our analysis revealed three suitable prophylactic studies of period. The peak SCr values and maximum increments adequate size and study design (Suppl Tables 5 and 6) that during the study did not differ between the fenoldopam and reported AKI incidence in patients randomized to fenoldo- dopamine groups; however, in the fenoldopam group at the pam (n ¼ 1790) vs. placebo (n ¼ 1839). The pooled RR and end of infusion, SCr had decreased by 0.29 ± 0.77 mg/dl 95% CI was 0.96 (0.76–1.2), P ¼ NS. Only one study reported (25.6 ± 68.1 mmol/l), a value significantly different from the mortality (8-day) in sepsis patients randomized to fenoldo- dopamine group (0.09 ± 0.94 mg/dl [7.96 ± 83.1 mmol/l]; pam (35%, n ¼ 150) vs. placebo (44%, n ¼ 150), with a RR of P ¼ 0.05). Also, the maximum decreases of SCr levels from 0.79 (95% CI 0.59–1.05; P ¼ 0.1). study entry were significantly larger in the fenoldopam In our analysis of the two suitable studies of fenoldopam group. There was no difference in heart rate, blood pressure, therapy for AKI, only one study221 reported (21-day) incidence of hypotension, or urinary output (apart from a mortality in critically ill patients with early AKI randomized transiently higher value within the first study day in the to fenoldopam (11/80; 13.8%) vs. placebo (n ¼ 19/75, 25.3%; dopamine group). The authors concluded that, for critically P ¼ 0.068) (Suppl Tables 7 and 8). The other study222 ill patients with impaired renal function, a continuous reported the change in renal function in AKI patients infusion of fenoldopam 0.1 mg/kg/min improves renal func- randomized to fenoldopam (n ¼ 50) vs. dopamine (n ¼ 50), tion when compared to renal-dose dopamine, without defined by the absolute SCr change between the beginning significant adverse effects. The study has, however, a number and end of the study drug infusion and maximum decrease of deficiencies, including the lack of a true control, from study entry, which were significantly larger in the unblinding of the investigators, and an unorthodox AKI fenoldopam group with a pooled RR of 0.96 (95% CI definition, among other limitations, but taken together with 0.76–1.2; P ¼ NS). These two studies reported new RRT 52 Kidney International Supplements (2012) 2, 37–68
chapter 3.5 incidence in patients with AKI randomized to fenoldopam ill patients with AKI was conducted.231 Patients received 24- (n ¼ 130) vs. placebo (n ¼ 125). In the study by Tumlin et al., hour i.v. infusion of either ANP (0.2 mg/kg/min) or placebo. no difference in requirement of RRT was found (with The primary outcome was dialysis-free survival for 21 days fenoldopam, 13 of 80 patients; 16.25%); with placebo (19 of after treatment. Despite the large size of the trial, ANP 75 patients; 25.3%; P ¼ 0.163). Requirement of RRT was very administration had no effect on 21-day dialysis-free survival, rare in the study of Brienza et al., and was prescribed in a mortality, or change in plasma creatinine concentration. Of total of only five patients; three in the dopamine group and note, the mean SCr at enrollment (anaritide group: 4.4 mg/dl two in fenoldopam group (P ¼ NS). Overall, no data from [389 mmol/l]; placebo group: 5.0 mg/dl [442 mmol/l]) in this adequately powered multicenter trials with clinically sig- study confirms that intervention in this trial was extremely nificant end-points and adequate safety are available to late in the course of AKI. In subgroup analysis, dialysis-free recommend fenoldopam to either prevent or treat AKI. The survival was higher in the treatment group for patients with guideline recommendation against using fenoldopam places a oliguria (o400 ml/d; ANP 27%, placebo 7%, P ¼ 0.008). A high value on avoiding potential hypotension and harm subsequent trial in 222 patients with oliguric renal failure, associated with the use of this vasodilator in high-risk however, failed to demonstrate any benefit of ANP.232 The perioperative and ICU patients, and a low value on potential dose and duration of ANP treatment and primary outcome benefit, which is currently only suggested by relatively low- were the same as the previous study. The dose of ANP might quality single-center trials. have been too high (0.2 mg/kg/min) in both studies: hypotension (systolic blood pressure o90 mm Hg) occurred RESEARCH RECOMMENDATION more frequently in the ANP groups of both trials (in the first K While randomized trials of fenoldopam to treat AKI in a study, 46% vs. 18%, Po0.001; and in the second study, 97% variety of settings (critical illness, high-risk surgery— vs. 58%, Po0.001), and this may have negated any potential particular cardiac, sepsis) may be considered, the benefit of renal vasodilation in these patients. In addition to pharmacologic strategy of renal vasodilatation has not an excessive dose, the failure of these large studies has also been successful to date and different approaches are likely been attributed in subsequent analyses to the late initiation of needed. the drug to patients with severe AKI and an inadequate duration of infusion (only 24 hours). A promising, but underpowered, study of ANP to treat NATRIURETIC PEPTIDES FOR THE PREVENTION OR AKI immediately following cardiac surgery showed a TREATMENT OF AKI decreased rate of postoperative RRT compared to placebo- Several natriuretic peptides are in clinical use or in treated patients.233 In this study, Sward et al. randomized 61 development for treatment of congestive heart failure patients with AKI following cardiac surgery (defined as a SCr (CHF) or renal dysfunction, and could potentially be useful to prevent or treat AKI. increase X50% from a baseline o1.8 mg/dl [o159 mmol/l]) to receive infusion of ANP or placebo until the SCr decreased Atrial natriuretic peptide (ANP) is a 28-amino-acid pep- below the baseline value at enrollment, the patient died, or tide with diuretic, natriuretic, and vasodilatory activity.224 one of four prespecified dialysis criteria was reached. Of note, ANP is mainly produced in atrial myocytes, and the rate of all patients received infusions of furosemide (20–40 mg/h) release from the atrium increases in response to atrial and oliguria, defined as a urine output p0.5 ml/kg/h for 3 stretch.225 Early animal studies showed that ANP decreases hours, was an exclusion criterion and an automatic dialysis preglomerular vascular resistance and increases postglomer- indication. The primary end-point was the rate of dialysis ular vascular resistance, leading to increased GFR.226 It also inhibits renal tubular sodium reabsorption. Increases in GFR within 21 days of enrollment. CrCl was significantly higher on the third study day in ANP-treated subjects (P ¼ 0.04). and diuresis have also been confirmed in clinical studies.227 It Using prespecified dialysis criteria, 21% of patients in the could thus be expected that ANP might be useful for ANP group and 47% in the placebo group were dialyzed treatment of AKI, and several RCTs have been conducted to within 21 days (hazard ratio [HR] 0.28; 95% CI 0.10–0.73; test this hypothesis. P ¼ 0.009). The combined secondary end-point of death-or- dialysis was similarly improved in the ANP group (28%) 3.5.3: We suggest not using atrial natriuretic peptide compared to placebo (57%; HR 0.35; 95% CI 0.14–0.82; (ANP) to prevent (2C) or treat (2B) AKI. P ¼ 0.017). The incidence of hypotension during the first 24 hours was 59% in the ANP group and 52% in controls RATIONALE (P ¼ NS). There have been several negative studies of prophylactic ANP It is intriguing to speculate on the potential reasons for the therapy; for example, ANP failed in two studies to prevent positive outcome of this trial, compared to larger prior primary renal transplant dysfunction228,229 and ANP pro- studies of ANP for AKI prevention and therapy. Apart from phylaxis also failed to prevent CI-AKI.230 Based on the the possibility that this is a false-positive, underpowered positive results of small clinical studies using ANP to treat study, possible explanations include the use of ANP earlier in AKI, a randomized placebo-controlled trial in 504 critically the course of AKI (the mean SCr in the prior ANP studies Kidney International Supplements (2012) 2, 37–68 53
chapter 3.5 was much higher), and at lower doses (50 ng/kg/min vs. whereas it was significantly higher in the ANP group in the 200 ng/kg/min) that avoided the significant rate of hypoten- high-dose ANP studies (OR 4.13; 95% CI 1.38–12.41). sion observed in prior trials. The use of prespecified dialysis Finally, a pooled analysis of studies that examined oliguric criteria was another strength of this trial. More recently, AKI did not show any significant benefit from ANP for RRT Sward et al.,234 compared the renal hemodynamic effects requirement (OR 0.46; 95% CI 0.19–1.12; P ¼ 0.09) or of ANP and furosemide in 19 mechanically ventilated mortality (OR 0.94; 95% CI 0.62–1.43; P ¼ 0.79). Only two post–cardiac surgery patients with normal renal function, of the treatment studies included in the Nigwekar analy- measuring renal blood flow, GFR, and renal oxygen sis231,232 were of adequate size and quality to meet the criteria extraction. ANP infusion (25–50 ng/kg/min) increased GFR, for our systematic review (Suppl Tables 12 and 13), which filtration fraction, fractional excretion of sodium, and urine found no significant inconsistencies in the findings of both output, accompanied by a 9% increase in tubular sodium trials that (combined) included 720 subjects (351 treated absorption and a 26% increase in renal oxygen consumption. with ANP) (Suppl Table 12). Thus, although subset analyses Furosemide infusion (0.5 mg/kg/h) increased urine output separating low-dose from high-dose ANP trials suggest 10-fold and fractional excretion of sodium 15-fold, while potential benefits, the preponderance of the literature decreasing tubular sodium absorption by 28% and lowering suggests no benefit of ANP therapy for AKI. Therefore, the renal oxygen consumption by 23%. Furosemide also lowered Work Group suggests that these agents not be used to prevent GFR by 12% and filtration fraction by 7%. Thus, although or treat AKI. This conclusion is based on placing a high value the balance of renal hemodynamic and tubular effects of the on avoiding potential hypotension and harm associated with two drugs appears to favor furosemide for improving renal the use of a vasodilator in high-risk perioperative and ICU oxygen delivery-consumption balance, ANP is more likely to patients, and a low value on potential benefit which is acutely improve GFR. One might speculate that the use of supported by relatively low-quality evidence from retro- furosemide infusion in all of the subjects in the successful spective subset analyses from negative multicenter trials. ANP trial may have provided an important protection Urodilatin is another natriuretic peptide that is produced against renal ischemia by reducing tubular sodium absorp- by renal tubular cells, and was found to have the same renal tion and associated oxygen consumption, despite an increase hemodynamic effect as ANP without systemic hypotensive in GFR in the ANP group. A larger prospective trial of ANP effects.236 Limited data suggest that urodilatin improves the to improve dialysis-free survival in this setting is required, course of established postoperative AKI.237 Fifty-one patients perhaps with and without furosemide infusion. who received orthotopic heart transplants received urodilatin Pooled analysis of 11 studies involving 818 participants in (6–20 ng/kg/min) up to 96 hours postoperatively. AKI the prevention cohort showed a trend toward reduction in occurred in 6% of these patients, compared to 20% in a the need for RRT in the ANP group (OR 0.45; 95% CI historical control group that did not receive urodilatin.237 0.21–0.99; P ¼ 0.05). Restricting the analysis to studies that However, in another small, placebo-controlled study of 24 used low-dose ANP preparations did not change the overall patients who underwent orthotopic heart transplants, the effect for this outcome. There was no significant difference incidence of AKI was unchanged,238 although duration of noted between the ANP and control groups for mortality in hemofiltration (HF) was significantly shorter and the the prevention category (OR 0.67; 95% CI 0.19–2.35; frequency of intermittent hemodialysis (IHD) less in those P ¼ 0.53), and this effect was unchanged by restricting the who received urodilatin. Taken together, these data suggest analysis to studies that used low-dose ANP preparations. that natriuretic peptides may have a role in the therapy of However, these studies were generally of poor quality, several early AKI following cardiac surgery, but further prospective without reported baseline SCr values or clear definitions of trials are needed to confirm this potential indication. AKI or RRT indications (Suppl Tables 10 and 11), and only Nesiritide (brain natriuretic peptide) is the latest natriuretic one was of adequate quality. peptide introduced for clinical use, and is approved by the Nigwekar et al., recently conducted a systematic review Food and Drug Administration (FDA) only for the therapy and meta-analysis of ANP for management of AKI.235 They of acute, decompensated CHF. Meta-analysis of outcome found 19 relevant studies, among which 11 studies were for data from these and some other nesiritide CHF trials prevention and eight were for treatment of AKI. Pooled has generated some controversy.239–241 Sackner-Bernstein analysis of the eight treatment studies, involving 1043 et al.,239 analyzed mortality data from 12 randomized trials; participants, did not show significant difference for RRT in three trials that provided 30-day mortality data, they requirement between the ANP and control groups (OR 0.59; found a trend towards an increased risk of death in nesiritide- 95% CI 0.32–1.08; P ¼ 0.12). There was also no significant treated subjects. In another meta-analysis of five randomized difference for mortality (OR 1.01; 95% CI 0.72–1.43; trials that included 1269 subjects,240 the same investi- P ¼ 0.89). However, low-dose ANP preparations were gators also found that there was a relationship between associated with significant reduction in RRT requirement nesiritide use and worsening renal function, defined as (OR 0.34; 95% CI 0.12–0.96; P ¼ 0.04). The incidence of a SCr increase 40.5 mg/dl (444.2 mmol/l). Nesiritide doses hypotension was not different between the ANP and control p0.03 mg/kg/min significantly increased the risk of renal groups for low-dose studies (OR 1.55; 95% CI 0.84–2.87), dysfunction compared to non–inotrope-based controls or 54 Kidney International Supplements (2012) 2, 37–68
chapter 3.5 compared to all control groups (including inotropes). Even Table 9). These trends were more pronounced in the small, at doses p0.015 mg/kg/min, nesiritide was associated with 62-patient subset with preoperative SCr values 41.2 mg/dl increased renal dysfunction compared to controls. There was (4106 mmol/l). Although SCr increased postoperatively in no difference in dialysis rates between the groups. Another both groups, it returned to baseline within 12 hours in the retrospective study determined independent risk factors for nesiritide group, and remained elevated throughout hospi- 60-day mortality by multivariate analysis in a cohort of 682 talization in the placebo group. Use of vasoactive drugs and elderly heart-failure patients treated with nesiritide vs. those hemodynamic parameters did not differ significantly between who were not.242 When patients were stratified according to the groups. Adverse events also were similar between the nesiritide usage, AKI emerged as an independent risk factor groups, as was 30-day and 180-day mortality (although for mortality only among patients who received the drug. capture of mortality data was incomplete). Thus, it appears Strikingly, among these heart-failure patients who developed that administration of nesiritide infusion during and after AKI, nesiritide usage emerged as the only independent cardiac surgery with cardiopulmonary bypass in patients predictor of mortality. with preoperative left ventricular dysfunction has favorable The manufacturers of nesiritide convened an expert panel, short-term effects on renal function, with short-term adverse which concluded that further trial data are needed to discern effects comparable to placebo infusion; however, as men- the effects of nesiritide therapy on renal function and survival tioned earlier, this is not an FDA-approved indication for this in patients with decompensated CHF. The panel also re- drug. It is interesting to speculate that, based upon these emphasized that the indication for nesiritide therapy is acute results, any renoprotective effect of this vasoactive drug decompensated CHF, not chronic intermittent therapy or during and after cardiopulmonary bypass is not mediated by other uses, and in particular noted that the drug should not effects on systemic perfusion (similar in both groups), but be used to improve renal function or in place of diuretic rather suggesting an effect on regional perfusion or a therapy in CHF patients, as there is no proof of the utility of pleiotropic phenomenon. Unfortunately, these promising the drug for these purposes. A 7000-patient multicenter RCT pilot study findings have not been followed up with a in acute decompensated heart failure is currently in progress confirmatory prospective clinical trial. to determine the clinical effectiveness of nesiritide therapy for A prospective, randomized clinical trial (the Nesiritide acute decompensated heart failure (the Acute Study of Study), found no benefit of nesiritide for 21-day dialysis and/ Clinical Effectiveness of Nesiritide in Decompensated Heart or death in patients undergoing high-risk cardiovascular Failure; Clinicaltrials.gov identifier NCT00475852). Mean- surgery.244 However, the study did demonstrate that the while, nesiritide is approved for treatment of symptomatic prophylactic use of nesiritide was associated with reduced acute decompensated heart failure. incidence of AKI, the latter defined by the AKIN Group, in Uncontrolled studies using nesiritide for cardiovascular the immediate postoperative period (nesiritide 6.6% vs. support of patients with CHF undergoing cardiac surgery placebo 28.5%, P ¼ 0.004). Recently, Lingegowda et al.245 have suggested beneficial effects on renal function. Mentzer investigated whether the observed renal benefits of nesiritide et al.,243 conducted a 303-patient, multicenter, randomized, had any long-term impact on cumulative patient survival and double-blind trial of a 24- to 96-hour infusion of 0.01 mg/kg/ renal outcomes. Data on all 94 patients from the Nesiritide min of nesiritide vs. placebo in patients with chronic left Study were obtained with a mean follow-up period of 20.8 ± ventricular dysfunction (ejection fraction p40%) under- 10.4 months. No differences in cumulative survival between going cardiac surgery using cardiopulmonary bypass. The the groups were noted, but patients with in-hospital Nesiritide Administered Peri-Anesthesia in Patients Under- incidence of AKI had a higher rate of mortality than those going Cardiac Surgery trial was an exploratory, safety- with no AKI (41.4% vs. 10.7%; P ¼ 0.002). It seemed, thus, oriented study with five primary end-points, including three that the possible renoprotection provided by nesiritide in the renal end-points and two hemodynamic end-points. There immediate postoperative period was not associated with were no significant differences between the groups in base- improved long-term survival in patients undergoing high- line patient characteristics; SCr values were B1.1 mg/dl risk cardiovascular surgery. (97.2 mmol/l), with eGFR B80 ml/min per 1.73 m2. The In summary, although evidence from a variety of small mean duration of study drug infusion was B40 hours in studies suggests the potential for therapy with natriuretic both groups. Perioperative renal function quantified by the peptides to be useful for the prevention or treatment of AKI three renal primary end-points was better in the nesiritide in a variety of settings, there are no definitive trials to support group (peak SCr increase of 0.15 mg/dl [13.3 mmol/l] vs. the use of ANP, BNP, or nesiritide for these purposes. Thus, placebo group 0.34 mg/dl [30.1 mmol/l]; Po0.001; eGFR the Work Group suggests that these agents not be used for decrease of À10.2 ml/min per 1.73 m2 vs. placebo À17.8 ml/ prevention or treatment of AKI. min per 1.73 m2, P ¼ 0.001; initial 24-hour urinary output 2.9 ± 1.2 l vs. placebo 2.3 ± 1 l; Po0.001). The RR of AKI in RESEARCH RECOMMENDATION the nesiritide group compared to placebo was 0.58 K We recommend further trials of ANP at doses below (0.27–1.21); the 180-day mortality was also reduced in the 0.1 mg/kg/min, for the prevention or treatment of AKI. nesiritide group (RR 0.48 [0.22–1.05]; P ¼ 0.046) (Suppl There is a possibility that ANP might be effective if it is Kidney International Supplements (2012) 2, 37–68 55
chapter 3.5 given at a lower dose (0.01–0.05 mg/kg/min) in patients Supplementary Table 8: Summary table of RCTs of examining the prophylactically or with early AKI, and during a longer effect of fenoldopam for the treatment of AKI. Supplementary Table 9: Summary table of RCTs of nesiritide vs. control period than in previous large studies. for the prevention of AKI. Supplementary Table 10: Evidence profile of RCTs examining anaritide SUPPLEMENTARY MATERIAL vs. control for the prevention of AKI. Supplementary Table 4: Summary table of RCTs examining the effect Supplementary Table 11: Summary table of RCTs examining the effect of dopamine vs. placebo for the treatment of AKI. of anaritide vs. control for the prevention of AKI. Supplementary Table 5: Evidence profile of RCTs examining fenoldo- Supplementary Table 12: Evidence profile of RCTs examining anaritide pam vs. control for the prevention of AKI. vs. placebo for the treatment of AKI. Supplementary Table 6: Summary table of RCTs examining the effect Supplementary Table 13: Summary table of RCTs examining the effect of fenoldopam for the prevention of AKI. of ANP vs. placebo for the treatment of AKI. Supplementary Table 7: Evidence profile of RCTs of fenoldopam vs. Supplementary material is linked to the online version of the paper at placebo for the treatment of AKI. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 56 Kidney International Supplements (2012) 2, 37–68
http://www.kidney-international.org chapter 3.6 & 2012 KDIGO Chapter 3.6: Growth factor intervention Recovery from AKI involves increased expression of various least equivocal, and considering that there is no benefit and growth factors acting via autocrine, paracrine, and endocrine the concern over potential harm and cost associated with this mechanisms. The advent of recombinant growth factors has drug, the Work Group recommends against its use in patients stimulated research exploring their therapeutic potential with AKI. in AKI. Experimental studies have yielded promising results with individual growth factors246 including insulin-like Erythropoietin growth factor-1 (IGF-1), hepatic growth factor, and, more A small pilot trial evaluated the effectiveness of erythro- recently, erythropoietin. The physiological basis for the use of poietin in the prevention of AKI after elective coronary erythropoietin in the prevention of AKI has recently been artery bypass graft.255 Patients received either 300 U/kg of described.247 erythropoietin or saline i.v. before surgery. AKI was defined as a 50% increase in SCr levels over baseline within the 3.6.1: We recommend not using recombinant human first five postoperative days. Of 71 patients, 13 developed (rh)IGF-1 to prevent or treat AKI. (1B) postoperative AKI: three of the 36 patients in the erythro- poietin group (8%) and 10 of the 35 patients in the placebo group (29%; P ¼ 0.035). The increase in postoperative SCr RATIONALE concentration and the decline in postoperative eGFR were IGF-1 is a peptide with renal vasodilatory, mitogenic and significantly lower in the erythropoietin group than in the anabolic properties. rhIGF-1 has been demonstrated to placebo group. accelerate the recovery of renal function in several animal More recently, Endre et al.,256 performed a pros- models of AKI.248–251 Three double-blind, placebo-controlled pective randomized trial with erythropoietin in the primary RCTs have addressed the usefulness of IGF-1 in adults prevention of AKI in ICU patients at risk for AKI (Suppl with imminent or established AKI.252–254 Franklin et al.,252 Table 14). As a guide for choosing the patients for treatment administered rhIGF-1 every 12 hours for 3 days post- the urinary levels of two biomarkers, the proximal tubular operatively to 54 patients undergoing abdominal aortic brush border enzymes c-glutamyl transpeptidase and alkaline surgery. While no patient developed ARF, a smaller propor- phosphatase were measured. Randomization to either tion of IGF-1–treated patients showed a decline in GFR as placebo or two doses of erythropoietin was triggered by an compared to the placebo group (22% vs. 33%). Hladunewich increase in the biomarker concentration product to levels et al.,254 administered rhIGF-1 or placebo in 43 patients above 46.3. The primary outcome was the relative average undergoing cadaveric renal transplantation at high risk of SCr increase from baseline over 4–7 days. The triggering delayed graft function. Treatment was started within 5 hours biomarker concentration product selected patients with of transplantation and continued for 6 days. On day 7, more severe illness and at greater risk of AKI, dialysis, neither inulin clearance, nor urine flow or fractional sodium or death; however, the urinary marker elevations were excretion differed between the treatment arms, nor did transient. The use of the biomarkers allowed randomization the nadir SCr after 6 weeks or the proportion of patients within an average of 3.5 hours of a positive sample. There require post-transplantation dialysis. Hirschberg et al.,253 was no difference in the incidence of erythropoietin-specific treated 72 patients suffering from AKI mainly due to sepsis or adverse events; however, there was also no difference hemodynamic shock with either rhIGF-1 or placebo for a in the primary outcome between the placebo and treatment mean of 10.6 days. No differences were observed with respect groups. to changes in GFR, urine output, need for RRT, and mortality. Hence, despite its therapeutic efficacy in various RESEARCH RECOMMENDATION animal models of ARF, rhIGF-1 largely failed to prevent K Recent animal studies suggest a potential clinical benefit or accelerate recovery from established AKI in humans. of erythropoietin in AKI. In various rodent models of In addition, the high cost of this treatment should be AKI, erythropoietin consistently improved functional mentioned. recovery. The renoprotective action of erythropoietin Based on an analysis of the three RCTs with rhIGF-1 that may be related to pleomorphic properties including are currently available and which were overall negative or at antiapoptotic and antioxidative effects, stimulation of cell Kidney International Supplements (2012) 2, 37–68 57
chapter 3.6 proliferation, and stem-cell mobilization.247 Although SUPPLEMENTARY MATERIAL Supplementary Table 14: Summary table of RCTs examining the effect one recent RCT in the prevention of human AKI was of erythropoietin vs. placebo for the prevention of AKI. negative, the usefulness of erythropoietin in human AKI Supplementary material is linked to the online version of the paper at should be further tested in RCTs. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 58 Kidney International Supplements (2012) 2, 37–68
http://www.kidney-international.org chapter 3.7 & 2012 KDIGO Chapter 3.7: Adenosine receptor antagonists The activation of tubuloglomerular feedback in response to is less evident in view of the complete long-term recovery of elevated luminal chloride concentrations in the distal renal renal function in the placebo-treated controls and the absence tubules is an early event in ischemic AKI. Adenosine released of an effect on patient survival. as part of the tubuloglomerular feedback loop binds to In recent years, the advent of selective adenosine A1 glomerular adenosine A1 receptor, causing vasoconstriction receptor antagonists has prompted the conduct of some of the afferent arteriole, decreased renal blood flow and GFR, interesting clinical trials, which to date have focused on the and sodium and water retention. This well-known role of prevention and treatment of cardiorenal syndrome. In a adenosine in this phenomenon has stimulated a body of double-blind placebo-controlled trial of 63 patients with research seeking to prevent or treat AKI with adenosine CHF, single doses of the adenosine A1 antagonist BG9719 receptor antagonists, primarily in three clinical syndromes had a marked stimulatory effect on diuresis and increased with increased risk of AKI: perinatal asphyxia, radiocontrast GFR.263 When coadministered with furosemide, BG9719 exposure, and cardiorenal syndrome. Theophylline is a showed a synergistic diuretic effect and prevented the nonselective adenosine receptor antagonist. decrease in GFR associated with the loop diuretic. Rolofylline, another adenosine A1 receptor antagonist, 3.7.1: We suggest that a single dose of theophylline may was tested in two double-blind placebo-controlled RCTs in be given in neonates with severe perinatal asphyxia, patients with acute decompensated heart failure. In the first who are at high risk of AKI. (2B) study, rolofylline or placebo was administered either concomitantly with furosemide for 3 days (146 patients), or as a single infusion in 35 diuretic resistant patients.264 In both RATIONALE substudies, rolofylline improved urine output and CrCl AKI occurs in 60% of neonates suffering from perinatal compared to placebo. The second trial involved 301 patients asphyxia.257 Experimental studies indicated an important role hospitalized for acute heart failure with renal impairment of adenosine-mediated vasoconstriction in neonatal kidneys who received either placebo or one of three doses of exposed to normocapnic hypoxemia.258 A potential renoprotec- rolofylline for 3 days.265 Rolofylline administration dose- tive effect of theophylline in perinatal asphyxia has been assessed dependently attenuated the rise in SCr observed in the in three randomized, placebo-controlled clinical trials,259–261 placebo group within 14 days, and tended to reduce 60-day including a total of 171 term neonates. Theophylline was mortality or readmission for cardiovascular or renal causes. uniformly administered in the first hour of life as a single i.v. Three pivotal phase III trials in a total of 2500 patients bolus at a dose of 5 mg/kg259,261 or 8 mg/kg.260 The three studies were recently completed, aiming to corroborate the reno- all observed significantly higher GFR, higher urine output with protective effects of rolofylline in patients with cardiorenal more negative fluid balance, and lower urinary b2-microglobu- syndrome, and to establish drug safety. The final results of the lin excretion, with theophylline as compared to placebo during PROTECT trial have recently been published.266 Rolofylline, the first 3–5 days of life. In each study, theophylline treatment as compared to placebo, did not provide a benefit with was associated with a significantly reduced risk of severe renal respect to the three primary end-points: survival, heart- dysfunction (17–25% vs. 55–60% in placebo group, RR failure status, and changes in renal function. Persistent renal 0.3–0.41). The beneficial effect was selective for kidney function, impairment developed in 15.0% of patients in the rolofylline whereas the incidence of central nervous system, cardiac, group and in 13.7% of patients in the placebo group pulmonary, and gastrointestinal complications was unaltered. (P ¼ 0.44). By 60 days, death or readmission for cardiovas- Patient survival was not affected by treatment. In line with these cular or renal causes had occurred in similar proportions of studies in mature neonates, a similar improvement of GFR and patients assigned to rolofylline and placebo (30.7% and urine output was observed during the first 2 days of life by 31.9%, respectively; P ¼ 0.86). Adverse-event rates were administration of 1 mg/kg theophylline vs. placebo in 50 very similar overall; however, only patients in the rolofylline preterm neonates with respiratory distress syndrome.262 The group had seizures, a known potential adverse effect of further evolution of renal function was followed throughout the A1-receptor antagonists. Thus, rolofylline does not appear to first year of life by Bhat et al.,260 who found equally normal be effective for treatment of cardiorenal AKI. glomerular and tubular function in both groups from 6 weeks of age onward. Hence, while theophylline clearly improves renal RESEARCH RECOMMENDATION function in the first week of life in postasphyctic neonates, the K It appears that if there are benefits of using adeno- overall benefit from this intervention in neonatal intensive care sine receptor antagonists to decrease tubuloglomerular Kidney International Supplements (2012) 2, 37–68 59
chapter 3.7 feedback-mediated vasoconstriction and increase renal distal salt delivery might harmfully increase tubular blood flow and GFR in AKI, they may be limited to very oxygen consumption in the presence of ATN), and specific populations (e. g., asphyctic neonates). These nonrenal (lower seizure threshold). Thus, further studies benefits must be balanced against potential adverse are still needed to clarify the role for theophylline in drug effects: both renal (increased renal blood flow and neonates. 60 Kidney International Supplements (2012) 2, 37–68
http://www.kidney-international.org chapter 3.8 & 2012 KDIGO Chapter 3.8: Prevention of aminoglycoside- and amphotericin-related AKI AMINOGLYCOSIDE NEPHROTOXICITY population studied)271–276,278 that they should no longer be Aminoglycoside antimicrobial agents are highly potent, used for standard empirical or directed treatment, unless no bactericidal antibiotics effective against multiple Gram- other suitable alternatives exist. The intrinsic risk of AKI with negative, and selected Gram-positive bacterial pathogens the administration of aminoglycosides has led some authors when administered with beta-lactams and other cell-wall to recommend the elimination of aminoglycosides as a active antimicrobial agents.267–269 Progressive antimicrobial clinical treatment option.277 Certainly their use should be resistance to other antimicrobial agents and lack of new restricted to treat severe infections where aminoglycosides are alternatives to aminoglycoside antibiotics have caused a the best, or only, therapeutic option. recent increase in their use. Aminoglycosides have many Aminoglycosides should be used for as short a period of favorable attributes, including their remarkable stability, time as possible. Repeated administration of aminoglycosides predictable pharmacokinetics, low incidence of immuno- over several days or weeks can result in accumulation of logically mediated side-effects, and lack of hematologic or aminoglycosides within the renal interstitium and within hepatic toxicity. Nephrotoxicity, and to a lesser degree the tubular epithelial cells.279 This can result in a higher ototoxicity and neuromuscular blockade, continue to be incidence of nephrotoxicity with repeated exposure to the major dose-limiting toxicities of the aminoglycosides. aminoglycosides over time. Older patients (465 years), Careful dosing and therapeutic drug monitoring of amino- patients with pre-existing renal dysfunction, and septic glycosides using pharmacokinetic and pharmacodynamic patients with intravascular volume depletion and rapid principles can mitigate the risk of AKI with these clinically alterations in fluid dynamics may be at greater risk for useful, yet nephrotoxic antibiotics.270 A number of meta- aminoglycoside nephrotoxicity. Other risk factors for ami- analyses and treatment guidelines have been published noglycoside-induced AKI are diabetes mellitus, concomitant recently indicating that the risk of AKI attributable to use of other nephrotoxic drugs, prolonged use, excessive aminoglycosides is sufficiently frequent that they should no blood levels, or repeated exposure to separate courses of longer be added to other standard antimicrobial agents for aminoglycoside therapy over a short time interval.267–279 the empirical or directed treatment of a number of severe Gram-positive or Gram-negative bacterial infections.271–276 3.8.2: We suggest that, in patients with normal kidney The intrinsic risk of AKI with the administration of function in steady state, aminoglycosides are aminoglycosides has led some authors to call for elimination administered as a single dose daily rather than of aminoglycosides as a therapeutic option in current clinical multiple-dose daily treatment regimens. (2B) management of infectious diseases.277 The anticipated demise of aminoglycosides from our therapeutic armamentarium has not occurred, however, in light of recent developments RATIONALE with progressive antimicrobial resistance to beta-lactams, Aminoglycoside demonstrates concentration-dependent bac- quinolones, and a number of other classes of antimicrobial tericidal activity, with a prolonged ‘‘postantibiotic effect’’, agents. thereby permitting extended interval dosing in an effort to optimize efficacy and minimize toxicity. This dosing strategy 3.8.1: We suggest not using aminoglycosides for the treat- and a number of other measures to limit aminoglycoside ment of infections unless no suitable, less nephro- uptake in renal tubular cells, prevent apoptosis, limit oxygen toxic, therapeutic alternatives are available. (2A) injury, and protect mitochondrial function have all been recommended to minimize the risk of AKI and preserve the therapeutic value of these important antimicrobial RATIONALE agents.280–296 Single-dose daily or extended-interval dosing Aminoglycosides exhibit a number of favorable pharmaco- of aminoglycosides offer a number of theoretical and kinetic and pharmacodynamic advantages, but a major dose- practical advantages to maintain antimicrobial activity while limiting toxicity of the aminoglycosides remains the risk limiting possible nephrotoxicity. This convenient and of drug-induced AKI.270 The risk of AKI attributable to inexpensive aminoglycoside dosing strategy has been widely aminoglycosides is sufficiently high (up to 25% in some adopted at many centers when using this potentially toxic, yet series, depending upon the definition of AKI used and the highly effective, class of antibiotics. Kidney International Supplements (2012) 2, 37–68 61
chapter 3.8 When feasible in patients with normal and stable kidney The use of single-daily dosing of aminoglycosides is function, once-daily (often referred to as extended-interval) generally well-tolerated but bolus infusions of aminoglyco- dosing of aminoglycosides should be used to limit amino- sides should be avoided. The high-dose, once-daily amino- glycoside nephrotoxicity. The pharmacokinetic and pharma- glycoside regimens should be administered over 60 minutes codynamic properties of aminoglycosides favor high dosing to avoid untoward events such as neuromuscular blockade. strategies with extended intervals between doses. The key This recommendation is particularly important when therapeutic parameter for efficacy is peak blood level divided patients are receiving other potential neuromuscular block- by minimum inhibitory concentration (MIC) of the infecting ing agents, or have underlying disorders affecting neuro- organism (Cmax/MIC) in an effort to obtain 410-fold muscular transmission (e.g., myasthenia gravis). Cmax/MIC. Aminoglycosides induce a prolonged postanti- biotic effect (inhibition of bacterial growth after blood levels 3.8.3: We recommend monitoring aminoglycoside drug have fallen below the MIC of the organism). The length of the levels when treatment with multiple daily dosing is postantibiotic effect is directly related to the peak blood used for more than 24 hours. (1A) levels. These pharmacokinetic/pharmacodynamic parameters make single-dose daily strategies an attractive option when RATIONALE using aminoglycosides. Therapeutic drug monitoring has been the standard of care The nephrotoxicity of aminoglycosides has been very well when administering aminoglycosides for many years. Amino- studied280–282,284–293,295,296 and is primarily related to uptake glycoside levels are variable among individuals, and subtle of aminoglycosides through a receptor known as megalin, changes in the volume distribution, renal blood flow, and expressed on epithelial cells along the proximal convoluted filtration rate can affect renal handling of aminoglycosides tubule.293 Aminoglycosides are concentrated in the proximal and alter the risk of nephrotoxicity. For these reasons, convoluted tubules, where they bind avidly to polyanionic, therapeutic drug monitoring, in combination with or phospholipid-containing membranes. Aminoglycosides in- independent from, single-dose daily treatment regimens is duce myeloid body formation, impair protein synthesis, recommended.318–321 When using therapeutic drug monitor- degrade mitochondrial function, and culminate in apoptosis ing in single-dose or extended-dose treatment strategies, the and eventual necrosis of renal tubular epithelial cells. Direct Cmax should be at least 10-fold greater than the MIC of the glomerular injury can occur288 but is usually a secondary infecting microorganism. This Cmin (trough level) should be consequence of aminoglycoside-induced tubular impairment. undetectable by 18–24 hours to limit accumulation of As the receptor uptake of aminoglycosides is saturable, high- aminoglycosides in renal tubular cells and to minimize the level intermittent doses of aminoglycosides actually reduced risk of AKI. The usual dosing strategy for once-daily the daily uptake and accumulation of aminoglycosides when aminoglycosides is 5 mg/kg/d for gentamicin and tobramycin compared to multiple-daily dosing strategies. This should (with normal renal function); 6 mg/kg/d for netilmicin; and limit the risk of nephrotoxicity, at least in principle. 15 mg/kg/d for amikacin. The multiple-dose daily regimen The potential efficacy of single-dose daily regimens (or for gentamicin and tobramycin is usually 1.7 mg/kg every other extended dosing treatment programs) of aminoglyco- 8 hours with peak blood levels at 8 ± 2 mg/ml (17±4 mmol/l) sides vs. multiple-daily dosing strategies has been extensively and trough of 1–2 mg/ml (2–4 mmol/l). Amikacin levels with studied in numerous controlled and uncontrolled clinical the multiple-dose daily dosing strategy should be a peak studies over many years297–308, and the subject has been the of 20±5 mg/ml (34±9 mmol/l) and a trough of 5–8 mg/ml focus of a number of formal meta-analyses.309–314 These (9–14 mmol/l). We recommend therapeutic drug monitoring investigations include pediatric populations, elderly popula- when using prolonged courses of aminoglycosides to limit tions, empirical therapy, targeted therapy, treatment directed the risk of nephrotoxicity when using multiple-daily dosing, towards Gram-negative bacterial pathogens and Gram- and suggest therapeutic drug monitoring when using single- positive bacterial pathogens. daily dosing strategies. The cumulative results of this evidence-based review and numerous meta-analyses indicate that once-daily dosing 3.8.4: We suggest monitoring aminoglycoside drug levels strategies generally tend to result in less AKI when compared when treatment with single-daily dosing is used for to multiple-dose dosing strategies, although the benefit more than 48 hours. (2C) accrued by the single-daily dose strategy is modest and inconsistent across a number of these studies. For this reason, a level 2 recommendation is suggested in support of the RATIONALE use of single-daily dose strategies over multiple-dose daily The timing of measurement of peak doses of aminoglycosides strategies. It should be noted that multiple-daily dosing with single-daily dosing strategies is not standardized and strategies continue to be the standard of care for enterococcal remains somewhat controversial. Some investigators do not endocarditis; no detailed, randomized trials have been measure therapeutic drug levels at all in patients receiving reported comparing single-daily vs. multiple-daily regimens this dosing strategy. Others recommend at least a single peak for enterococcal endocarditis.272,315–317 measurement to ensure that the blood levels are 10-fold 62 Kidney International Supplements (2012) 2, 37–68
chapter 3.8 greater than the MIC of the infecting organism. Many and method of therapeutic drug monitoring with single- investigators recommend at least one or at least a weekly daily dosing regimens, would be of great assistance.319 Cmin level obtained at either 12, 18, or 24 hours after the K It is generally recommended that patients receiving aminoglycoside dose.267–270 The Cmin level should be below extended-dosing interval aminoglycosides should have the limits of detection of the assay (o1 mg/ml) at these time aminoglycosides administered at even greater dosing intervals. intervals if mild or moderate degrees of underlying renal Measuring aminoglycoside levels with multiple-daily impairment exist. Optimal therapeutic monitoring in dosing strategies have been standardized for Cmax to be the setting of infrequent dosing intervals for patients obtained 30 minutes after a 30-minute infusion, and Cmin with underlying CKD needs to be standardized and right before the next dose for trough levels. The aminoglyco- uniform recommendations need to be provided by sides should be administered in patients who are volume- careful pharmacokinetic/pharmacodynamic observa- replete; volume depletion increases the risk of nephrotoxicity tional studies. in experimental studies and is suggested in clinical studies. K The impact of IHD and high-flux CRRT upon the efficacy Additionally, potassium repletion has been shown experi- and toxicity of extended-duration dosing of aminoglyco- mentally and clinically to diminish the risk of AKI related to sides needs further study. As membranes with greater aminoglycoside administration. sieving coefficients come into greater use, the impact on Single-dose daily regimens are difficult to apply in patients aminoglycoside elimination needs to be carefully con- with pre-existing kidney disease, and patients with vacillating sidered. This could be investigated by RCTs using eGFR and hemodynamics, such as critically ill patients in the standard dosing intervals vs. individualized dosing regi- ICU setting. The changing pharmacokinetics and pharma- mens, with frequent drug-level monitoring and the use codynamics of antibiotics in general and aminoglycosides in of efficacy measures and kidney injury markers as particular, in the critically ill patient, are such that the outcomes. avoidance of single-daily dosing and application of frequent K The interaction between aminoglycosides and other anti- therapeutic drug monitoring is indicated.322 microbial agents, and other therapeutic agents with nephrotoxic potential needs to be more carefully 3.8.5: We suggest using topical or local applications of quantified. The degree of aminoglycoside-induced aminoglycosides (e.g., respiratory aerosols, instilled nephrotoxicity alone vs. combination effects with such antibiotic beads), rather than i.v. application, when drugs as vancomycin, amphotericin B, cephalosporins, feasible and suitable. (2B) extended-spectrum penicillins, colistin, loop diuretics, clindamycin, cisplatin, and nonsteroidal anti-inflamma- tory agents needs to be more carefully examined in RATIONALE observational studies. Local instillation of aminoglycosides for a variety of indications is gaining more widespread use in a selected set AMPHOTERICIN B NEPHROTOXICITY of clinical situations where aminoglycoside levels can be Amphotericin B has been the standard of treatment for life- concentrated at specific tissue sites. The use of aminoglyco- threatening systemic mycoses for over 50 years. This polyene side-loaded beads for the prevention and treatment of bone antifungal agent is insoluble in water and needs to be and joint infections have become commonplace as a strategy solubilized with deoxycholate and given i.v. in the absence of to limit nephrotoxicity, while providing antimicrobial electrolyte solutions to maintain solubility. Despite its activity of aminoglycosides at the tissue level.323 Local broad-spectrum fungicidal activity against a large number concentrations of aminoglycoside are achieved for prolonged of invasive systemic mycoses, drug-induced nephrotoxicity is periods when administered by this route. Aminoglycoside common and remains the principal dose-limiting toxicity of aerosol delivery systems are now in use to provide high amphotericin B.328–330 Amphotericin B has numerous other intrapulmonary antibiotic levels with minimal systemic and significant toxicities, including thrombophlebitis, electrolyte kidney concentrations of the antibiotic. This strategy has disturbances, hypoplastic anemia, and systemic toxicity been used successfully in cystic fibrosis patients for the associated with fever, chills, hypotension, and cytokine management of difficult-to-treat Gram-negative bacillary release.331,332 AKI related to amphotericin B is clinically pneumonia.324,325 However, significant nephrotoxicity with significant and is associated with higher mortality rates, the use of inhaled tobramycin has been described in at least increased LOS, and increased total costs of health care when two cases.326,327 managing patients with systemic fungal infection.328,330 Over the past two decades, three major advances in RESEARCH RECOMMENDATIONS antifungal therapy have become clinically available: i) the K No standard method exists for therapeutic drug moni- lipid formulations of amphotericin B; ii) the introduction of toring of aminoglycosides by single daily dosing. Uniform the echinocandin class of antifungal agents; and iii) an guidance, based upon carefully performed pharmaco- expanding number of azoles with extended activity against kinetic/pharmacodynamic studies on the optimal timing a variety of fungal pathogens. Therapeutic alternatives to Kidney International Supplements (2012) 2, 37–68 63
chapter 3.8 amphotericin B have been a welcome addition in the of volume repletion and potassium supplementation during management of systemic mycoses and selected, protozoan, amphotericin B therapy supports their routine use, despite parasitic infections, but their incremental costs and tradeoffs the relative lack of compelling clinical evidence to recom- in spectrum of activity against fungal pathogens need to be mend these maneuvers. considered, in addition to their favorable toxicity profiles and Various dosing strategies have also been instituted in an reduced potential for nephrotoxicity. A number of therapeu- attempt to limit amphotericin B–induced nephrotoxicity. tic options are now available to the clinician when deciding One strategy is to give amphotericin B as a continuous upon the choice for empiric or directed antifungal therapy. infusion rather than a 2- to 4-hour infusion to limit Avoidance of risk of nephrotoxicity is one of the major, but nephrotoxicity.329,334 While there is some suggestion that a not the only, determinants when selecting antifungal therapy continuous infusion may limit nephrotoxicity, enthusiasm at present. for this strategy is tempered by the potential loss of some antifungal activity. Amphotericin B exhibits concentration- 3.8.6: We suggest using lipid formulations of ampho- dependent antifungal activity, and continuous infusion of tericin B rather than conventional formulations of low-doses of amphotericin B could result in suboptimal amphotericin B. (2A) protection for some patients with invasive fungal infec- tions.334 Another common strategy is the administration of RATIONALE alternate-day doses of amphotericin B, rather than daily The broad-spectrum, polyene, antifungal agent amphotericin doses.335,336 This strategy is better tolerated and might reduce B deoxycholate has been the mainstay of treatment for nephrotoxicity without sacrificing efficacy in stable patients. systemic mycoses for decades. Despite its well-known toxicity However, clear evidence that this strategy reduces nephro- profile, the potent antifungal activity of amphotericin B, in toxicity is not supported by large, adequately controlled addition to its activity against certain protozoan parasites clinical trials as yet. (Plasmodium spp., Leishmania spp., Naegleria spp.), indicates One of the major innovations in amphotericin B therapy that this therapy will remain a standard agent in clinical over the last 15 years has been the introduction of lipid medicine for the foreseeable future. formulations of amphotericin to limit the problem of Amphotericin B–induced nephrotoxicity is related to nephrotoxicity associated with conventional amphotericin B multiple mechanisms, including ischemic injury and direct deoxycholate. Three lipid formulations are available includ- tubular- and glomerular-cell membrane toxicity. Amphoter- ing: amphotericin B colloidal dispersion, amphotericin B icin causes vasoconstriction of the afferent renal arteriole lipid complex, and liposomal amphotericin B. Amphotericin along with a systemic inflammatory response that may B colloidal dispersion is formulated by amphotericin B reduce renal blood flow. Amphotericin B also directly inserts complexed with cholesteryl sulfate. Amphotericin B lipid into human cellular membranes, where it disrupts membrane complex is composed of amphotericin B complexed with permeability and physiology.331,332 Tubular epithelial cells dimyristoyl phosphatidylcholine and dimyristoyl phospha- residing in the deep medullary regions of the kidney are tidylglycerol. Liposomal amphotericin consists of amphoter- particularly susceptible to injury where considerable osmotic icin B complexed with hydrogenated soy phosphatidyl- stress exists across cell membranes even under physio- choline, distearoylphosphatidylcholine, and cholesterol.337–340 logic conditions. The end result is enzymuria, loss of Other formulations that might further reduce the risk of AKI renal tubular concentrating ability, renal tubular acidosis, from amphotericin B include nanoparticle packaging in increasing urinary losses of potassium and magnesium, and micelles with polyaspartic acid.340 decreased glomerular function, resulting in azotemia and The safety and efficacy (in incidence of nephrotoxicity) of decreased synthesis of erythropoietin. Amphotericin B– lipid formulations of amphotericin have been studied in induced nephrotoxicity is often accompanied by concomitant numerous experimental and clinical trials with conventional administration of other potentially nephrotoxic agents amphotericin B deoxycholate as the comparator.337–339,341–350 such as cyclosporine A, aminoglycosides, chemotherapeutic A detailed analysis of these various trials, and a number of agents, and a number of other potentially nephrotoxic meta-analyses that have analyzed this clinical question, agents.328,329,333 concluded that the lipid formulations are less nephrotoxic Considerable efforts have been undertaken to try to limit than amphotericin B deoxycholate.344,346 When feasible, we nephrotoxicity and permit the continued use of amphotericin recommend that lipid formulations supplant the use of B deoxycholate for the management of systemic mycoses. conventional amphotericin B deoxycholate to reduce the risk Simple maneuvers, such as salt repletion and provision of of nephrotoxicity. adequate amounts of potassium, are beneficial in animal The incremental costs associated with the lipid formula- models in the prevention of amphotericin B nephrotoxicity. tions and their relative efficacy for systemic mycoses remains These measures have a mixed record in clinical practice, and the subject of considerable debate. The existing evidence their capacity to prevent AKI when treating severe fungal would suggest that the overall risk-benefit ratio and cost- infections remain unclear. The relative ease and simple logic effectiveness with these lipid formulations is essentially 64 Kidney International Supplements (2012) 2, 37–68
chapter 3.8 cost-neutral with amphotericin B deoxycholate.337,339 There is currently insufficient evidence as to whether the Attempts to increase the doses of lipid formulations of echinocandins, the azoles, or the lipid formulations of amphotericin further to improve efficacy have resulted in amphotericin B differ significantly from each other with mixed results and are not recommended at present.342,343 respect to the risk of nephrotoxicity. No adequately Lipid formulations of amphotericin are less nephrotoxic but controlled, large, randomized studies have been reported to require different dosing strategies (three- to five-fold higher date comparing the relative risk of nephrotoxicity amphoter- doses than deoxycholate formulations of amphotericin B). icin B lipid formulations with either azole or echinocandin Some of these agents continue to induce general systemic antifungal agents. Such studies face the difficulty of recruiting toxicity reactions similar to those observed with the deoxy- sufficient numbers of patients with similar baseline risk for cholate formulation (e.g., amphotericin B colloidal dispersion). drug-induced AKI, and with a balance of exposure to other potentially nephrotoxic agents. Until such time as these 3.8.7: In the treatment of systemic mycoses or parasitic studies are completed, no evidence-based recommendations infections, we recommend using azole antifungal can be given about the relative risk of AKI attributable agents and/or the echinocandins rather than directly to these antifungal agents. conventional amphotericin B, if equal therapeutic efficacy can be assumed. (1A) RESEARCH RECOMMENDATIONS K Some studies indicate that the liposomal form of amphotericin B is less nephrotoxic than amphotericin B RATIONALE lipid complex or amphotericin B colloidal dispersion. Another approach to prevent amphotericin B nephrotoxicity RCTs in patients with systemic mycosis, with the rate of is to avoid polyene antifungal agents entirely and use alte- AKI as a primary or secondary end-point, should be rnative agents, such as the azoles and echinocandins.351–355 conducted to answer this question. Azole antifungal agents inhibit sterol synthesis in fungal cell K Innovative strategies to formulate amphotericin B in membranes by blocking the activity of the 14-demethylase microvesicles, nanoparticles, or micelles should be under- enzyme essential for ergosterol synthesis. Nephrotoxicity taken to limit nephrotoxicity in treating fungal infections. is an unusual event following the use of azole compounds. Clinical trials should compare existing formulations to The echinocandins are beta-glucan inhibitors that inter- these novel formulations, and could generate cost-effective, fere with cell-wall synthesis of fungal elements, and have an yet non-nephrotoxic derivatives of amphotericin B. entirely different mechanism of action from that of K Carefully selected combinations of antifungal therapies to amphotericin B. Both the azole compounds (voriconazole, enhance efficacy and shorten duration of therapy may fluconazole, itraconazole, and posaconazole) and the echi- limit toxicity and reduce costs in the treatment of fungal nocandins (caspofungin, anidulafungin, and micafungin) infections. Investigations need to be carried out in the compare favorably to amphotericin B with respect to their laboratory and in clinical studies to improve the care of efficacy against a variety of the systemic mycoses. Both patients with severe fungal infections. The costs and classes of antifungal agents have the advantage of lacking complication rates of AKI, and other toxicities of short- the intrinsic nephrotoxicity associated with amphotericin B course combination treatment, should be compared to deoxycholate. Both the azole compounds and echinocandins standard dosing regimens of antifungal therapy. have proven to be less nephrotoxic than conventional K Markers of early nephrotoxicity and mechanisms to avoid amphotericin B deoxycholate in observational studies, nephrotoxicity with amphotericin B formulations need historical control studies, and in small comparative trials.355 to be studied further in clinical investigations. These An important consideration in using these antifungal antifungal agents are given for prolonged periods, and agents is their relative efficacy with respect to the likely should allow ample opportunity to test the validity of pathogen that is targeted for treatment. Candida krusei is novel biomarkers of drug-induced nephrotoxicity. A intrinsically resistant to the azoles and Candida parapsilosis is group monitored with novel AKI biomarkers should be frequently resistant to the echinocandins. Amphotericin compared to conventional monitoring of AKI, to B-resistant strains of selected Aspergillus spp. and Pseudal- determine if one or more early biomarkers of kidney lescheria boydii are well described and require alternative injury add to standard clinical care in the prevention of therapies. drug-induced AKI. Kidney International Supplements (2012) 2, 37–68 65
http://www.kidney-international.org chapter 3.9 & 2012 KDIGO Chapter 3.9: Other methods of prevention of AKI in the critically ill ON-PUMP VS. OFF-PUMP CORONARY ARTERY BYPASS [4133 mmol/l]) (Suppl Table 16). There was no significant SURGERY difference between off-pump and on-pump coronary artery The type of cardiac surgery is important in the discussion on bypass graft in the rate of the 30-day composite outcome. risk for kidney problems associated with this surgery. The rate of the 1-year composite outcome was higher for Valvular procedures or aorta surgery are associated with a off-pump than for on-pump coronary artery bypass graft. higher risk. One of the most controversial risk factors is Follow-up angiograms in the majority of the patients on-pump vs. off-pump coronary artery bypass surgery. revealed that the overall rate of graft patency was lower in Off-pump coronary artery bypass obviously removes the the off-pump group than in the on-pump group (82.6% vs. bypass circuit but can be associated with greater hemo- 87.8%, Po0.01). dynamic instability secondary to ventricular compression as A comprehensive meta-analysis including RCTs, and the heart is manipulated to access the coronary arteries.356 abstracts from the proceedings of scientific meetings through It is possible, with standard operative techniques, to perform February 2010, was recently published.358 AKI was defined coronary artery bypass surgery (but not valve surgery) by a mixture of criteria, including biochemical parameter, without using cardiopulmonary bypass. This technique is urine output, and dialysis requirement. Mortality was known as ‘‘off-pump’’ coronary artery bypass surgery. evaluated among the studies that reported kidney-related It has been hypothesized that preservation of physiologic outcomes. This analysis compared off-pump with the more renal perfusion by avoidance of cardiopulmonary bypass traditional on-pump technique. Off-pump coronary artery would partially nullify the risk of AKI in patients receiving bypass graft was associated with a statistically significant coronary artery bypass surgery. Potential benefits that have 40% lower odds of postoperative AKI and a nonsignificant been posited for off-pump coronary artery bypass (compared 33% lower odds for dialysis requirement. Within the to on-pump procedures) are reduced mortality, reduction of selected trials, off-pump coronary artery bypass graft surgery AKI risk (and in particular, acute dialysis, which is associated was not associated with a significant decrease in mortality. with a perioperative mortality of 42% in the Society of It is apparent from this meta-analysis that the trials Thoracic Surgeons database), reduced risk of cerebral were clinically heterogeneous, particularly in regards to dysfunction (due to stroke and neurocognitive dysfunction, their definitions of kidney outcomes, and mostly were of the latter sometimes referred to as ‘‘pump head’’), reduction poor to fair quality (based on the Jadad score). The very in ICU stay and days in hospital, and reduction in atrial low event rates (often 0–1 patients) make the estimates fibrillation. As in other areas covered by these guidelines only suspect and highly imprecise. There is also a question of mortality, risk for RRT, and AKI risk are addressed as end- publication bias. There are several large trials in progress point measures. It must, however, be remembered that the that are likely to generate more definitive data. In chronic potential benefits of off-pump coronary artery bypass might dialysis patients, there are observational US Renal Data be predominantly outside these areas of focus. Systems data to weakly support the use of off-pump technique (slightly lower mortality). However, with any 3.9.1: We suggest that off-pump coronary artery bypass technical advance that is introduced in certain centers, graft surgery not be selected solely for the purpose institutional familiarity with the technique, operator experi- of reducing perioperative AKI or need for RRT. (2C) ence, and characteristics of the population referred to the center are likely to be important modulators of out- comes. In conclusion, based on the analysis of the RCTs RATIONALE and the recent meta-analysis, the Work Group found As detailed in Suppl Tables 15 and 16, which summarize that there was not enough evidence to recommend off- RCTs, the balance of the potential benefit and harms is pump coronary artery bypass for reducing AKI or the need uncertain and the quality of the evidence is weak, that off- for RRT. pump surgery is associated with better outcomes of the three end-points used in these guidelines: incidence of AKI, need RESEARCH RECOMMENDATION for RRT, or mortality. K Further studies are needed to clarify the role of off-pump A recent good-quality RCT357 was performed in 2203 coronary artery bypass in patients with increased risk patients (only B8% of patients with SCr 41.5 mg/dl for AKI. 66 Kidney International Supplements (2012) 2, 37–68
chapter 3.9 N-ACETYLCYSTEINE (NAC) tested the potentially confounding effect of NAC in a CKD population (Stages 3–5) following doses of NAC currently 3.9.2: We suggest not using NAC to prevent AKI in recommended for prophylaxis of AKI. There was no effect of critically ill patients with hypotension. (2D) NAC on either SCr or cystatin C levels. It is thus safe to conclude that NAC, in doses currently recommended for prophylaxis of AKI, has—by itself—no RATIONALE effect on SCr or cystatin C levels. In addition, NAC is NAC has been most frequently applied in the prevention inexpensive and appears to be safe, although it may have of CI-AKI, and this topic is discussed in more detail in some detrimental effects on myocardial and coagulation Chapter 4.4. function.371–373 The ‘‘safety’’ of NAC should further be NAC is a modified form of L-cysteine, an amino acid that amended, particularly when high i.v. doses are used, as in is a precursor to reduced glutathione that can regenerate some of the RCTs in CI-AKI. When prospectively studied in glutathione stores. It is known to be a potent antioxidant that acetaminophen poisoning, i.v. NAC produced anaphylactoid scavenges oxygen-free radicals in the body. It also has reactions in up to 48% of participants.374 Although most of vasodilatory properties derived from enhanced nitric oxide these reactions were mild, at least one death has been availability.359 NAC has been shown to attenuate ischemic reported in a patient with asthma.375 It should also be noted and nephrotoxic ARF in a number of animal studies,360–363 that the doses of acetaminophen used are still much higher and the pharmacological characteristics of NAC that could than in the ‘‘high doses’’ used, particularly in AKI trials. play a role in the prevention of AKI have recently been Besides the prevention of CI-AKI, NAC has also been tested summarized.364 NAC undergoes extensive first-pass metabo- in the setting of cardiothoracic surgery and liver transplanta- lization in the gastric mucosa and liver. This results in a very tion, and in hypotensive critically ill patients. low oral bioavailability, with substantial intrapatient varia- bility (3–20%), as well as inconsistency between available NAC IN CRITICALLY ILL PATIENTS oral products. The plasma half-life of acetylcysteine after i.v. injection is approximately 6–40 minutes, and there is 3.9.3: We recommend not using oral or i.v. NAC for extensive binding to plasma and tissue proteins through prevention of postsurgical AKI. (1A) the sulfhydryl group. Virtually no acetylcysteine can be detected in the systemic circulation after i.v. or oral administration, suggesting that any potential therapeutic RATIONALE benefit must be due to secondary effects such as the The above recommendation is based on an evaluation of induction of glutathione synthesis, rather than due to direct the available literature on prevention studies with NAC in effects. As these secondary effects are not directly measurable, cardiovascular and abdominal vascular surgery, and liver the determination of the optimal dosage schedule has been transplantation. necessarily empirical.365 The tables summarize the RCTs where either oral or i.v. A particularly important problem with NAC is whether it NAC was compared to placebo; only studies containing a can alter SCr independent of a change in GFR. NAC has been minimum of 50 patients in each study arm have been reported to decrease SCr levels in subjects with normal included. In addition, a recent meta-analysis is available,376 kidney function. This reduction in SCr was not accompanied containing 10 studies involving a total of 1193 adult patients by a change in serum cystatin C levels. This suggests an effect undergoing major surgery. Seven studies (1003 patients) independent of a change in GFR, such as an increase in evaluated the effects of NAC in patients undergoing cardiac tubular secretion of creatinine or a decrease in creatinine surgery, and three of these (508 patients) exclusively studied production.366 By contrast, in vitro analysis on the effect of patients with pre-existing renal impairment. Two studies NAC on SCr367 showed no analytical interference with the (111 patients) evaluated the effects of NAC on patients measurement of SCr by any of the commonly used analytical undergoing abdominal aneurysm repair surgery and one methods. Haase et al.,368 studied 30 patients with normal study (79 patients) was of patients undergoing major kidney function who received i.v. NAC for 24 hours in abdominal cancer surgery. End-points in most of the studies association with cardiac surgery. No change in the ratio of were mortality, need for RRT, or varying increases in SCr to cystatin C, compared to baseline values, was observed postoperative SCr concentrations compared to preoperative at the end of the 24-hour infusion or 48 hours after the SCr values. cessation of the infusion. In addition, there was no effect on Suppl Tables 17 and 18 summarize the five studies where urinary creatinine excretion during the infusion. However, in NAC was compared to placebo in patients undergoing clinical practice, NAC is generally recommended for patients cardiac surgery and who were not exposed to radiocontrast with CKD, with an eGFR o60 ml/min per 1.73 m2. Mainra media.377–381 All five studies analyzed the effects of NAC in et al.,369 observed no change in SCr or cystatin C at 4, 24, or patients with moderate, pre-existing renal functional impair- 48 hours after administration of a single 600-mg dose of NAC ment. Surgery included elective or emergency coronary artery to 30 patients with CKD Stage 3. Finally, Rehman et al.,370 bypass graft operations or heart valve surgery. NAC was given Kidney International Supplements (2012) 2, 37–68 67
chapter 3.9 i.v. in most of the studies; mortality was evaluated at different SPONSORSHIP follow-up times; either in-hospital or at 30 or 90 days. Only KDIGO gratefully acknowledges the following sponsors that one study found a significantly lower mortality at 30 days.377 make our initiatives possible: Abbott, Amgen, Belo Founda- None of the studies found either a difference in need for RRT, tion, Coca-Cola Company, Dole Food Company, Genzyme, or in AKI defined as variable changes in SCr after surgery. All Hoffmann-LaRoche, JC Penney, NATCO—The Organization studies were of A-level quality. Two relatively small studies for Transplant Professionals, NKF—Board of Directors, evaluated the effects of NAC on patients undergoing Novartis, Robert and Jane Cizik Foundation, Shire, Trans- abdominal aneurysm repair surgery382,383 and did not find western Commercial Services, and Wyeth. KDIGO is any protective effect on renal function. supported by a consortium of sponsors and no funding is Further, one meta-analysis376 did not find evidence that accepted for the development of specific guidelines. NAC used perioperatively can alter mortality or renal outcomes after major cardiovascular or abdominal cancer DISCLAIMER surgery when radiocontrast agents are not used. In none of While every effort is made by the publishers, editorial board, the studies were significant treatment-related adverse effects and ISN to see that no inaccurate or misleading data, opinion of NAC reported. These reports suggest that NAC, in the or statement appears in this Journal, they wish to make it clear context of cardiovascular surgery, is not associated with that the data and opinions appearing in the articles and increased risk of mortality, surgical re-exploration, or advertisements herein are the responsibility of the contributor, allogeneic transfusion. copyright holder, or advertiser concerned. Accordingly, the Only one single study has compared NAC to placebo in publishers and the ISN, the editorial board and their respective critically ill patients (Suppl Table 18).384 One hundred and employers, office and agents accept no liability whatsoever for forty-two ICU patients with new-onset (within 12 hours) of the consequences of any such inaccurate or misleading data, at least X30 consecutive minutes of hypotension and/or opinion or statement. While every effort is made to ensure that vasopressor requirement were randomized to receive either drug doses and other quantities are presented accurately, oral NAC or placebo for 7 days, in addition to standard readers are advised that new methods and techniques supportive therapy. AKI was defined as X0.5 mg/dl involving drug usage, and described within this Journal, (X44 mmol/l) increase in SCr. Patients who received NAC should only be followed in conjunction with the drug had an incidence of AKI of 15.5%, compared to 16.9% in manufacturer’s own published literature. those receiving placebo (NS). There were no significant differences between treatment arms in any of the secondary SUPPLEMENTARY MATERIAL Supplementary Table 15: Evidence profile of RCT examining on vs. off outcomes examined, including incidence of a 50% increase in pump cardiothoracic surgery. SCr, maximal rise in creatinine, recovery of renal function, Supplementary Table 16: Summary table of RCTs examining the effect length of ICU and hospital stay, and requirement for RRT. of on vs. off pump CABG for the prevention of AKI. Mortality in both arms was 10%. Based on this single study, Supplementary Table 17: Evidence profile of RCTs examining NAC vs. which is underpowered but did not show any beneficial effect placebo in the prevention of AKI. Supplementary Table 18: Summary table of RCTs examining the effect on incidence of AKI, need for RRT, or patient mortality, we of NAC vs. placebo in the prevention of AKI. suggest not using NAC to prevent AKI in critically ill patients Supplementary material is linked to the online version of the paper at with hypotension. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 68 Kidney International Supplements (2012) 2, 37–68
http://www.kidney-international.org chapter 4.1 & 2012 KDIGO Section 4: Contrast-induced AKI Kidney International Supplements (2012) 2, 69–88; doi:10.1038/kisup.2011.34 Chapter 4.1: Contrast-induced AKI: definition, epidemiology, and prognosis BACKGROUND adverse cardiovascular events after percutaneous coronary Contrast-related acute kidney problems are frequent and intervention.385 The Society of Urogenital Radiology used the occur in both ambulatory and hospitalized patients. Since same definition, but the creatinine changes were said to occur there is accumulating evidence that many risk factors, within 3 days after intravascular administration of contrast preventive measures, and the immediate and long-term media without an alternative etiology.386 It should be prognosis of these problems are common to the other causes recognized that, in a minority of cases, the peak increase of of AKI, the Work Group believes that there is a need for a SCr may occur up until 5 days after contrast exposure. unifying definition for all forms of AKI and therefore However, a recent prospective study387 showed that the proposes that the term contrast-induced acute kidney injury percentage change of SCr 12 h after contrast vs. the basal (CI-AKI) be used for patients developing AKI secondary to value was the best predictor of CI-AKI (Po0.001). A 5% intravascular radiocontrast media exposure. increase of its value yielded 75% sensitivity and 72% The literature on CI-AKI is predominantly related to AKI specificity, with an area under the curve (AUC) of 0.80 and following iodinated contrast-media administration. As will an OR of 7.37 (95% CI 3.34–16.23) for early detection. be discussed in Appendix E, non–iodine contrast media— Furthermore, this 12-hour basal value strongly correlated notably Gd-containing contrast media—may also occasion- with the development of renal impairment at 30 days ally induce AKI. (P ¼ 0.002; sensitivity 87%, specificity 70%; AUC 0.85; OR 13.29; 95% CI 2.91–60.64). 4.1: Define and stage AKI after administration of intra- It has been shown that substantial variation in SCr may vascular contrast media as per Recommendations occur from day to day in hospitalized patients who do not 2.1.1–2.1.2. (Not Graded) receive contrast-media injections.388 Depending on the 4.1.1: In individuals who develop changes in threshold criterion for CI-AKI chosen, this variation can kidney function after administration of intra- lead to rates of 6–35% of inpatients, not exposed to contrast vascular contrast media, evaluate for CI-AKI media, who would be labeled as having CI-AKI had they as well as for other possible causes of AKI. received contrast media. The exact cause of this ‘‘hospital- (Not Graded) induced nephropathy’’389 is not known, but other studies have shown that AKI (various etiologies) is common in hospitalized patients. RATIONALE The magnitude of the impact of the ‘‘background Pending the validation of future biomarkers which would fluctuation of kidney function’’ in patients receiving iodinated allow a more straightforward comparison and integration of contrast has not been prospectively studied, but a recent retro- CI-AKI in the overall framework of AKI, we suggest that the spective study compared the incidence of AKI among patients same criteria, using the changes in SCr concentrations and undergoing enhanced computed tomography (CT) with i.v. urine output be used as for the other forms of AKI. The Work low-osmolar (iohexol) or iso-osmolar (iodixanol) contrast Group is not aware of any pathophysiological or epidemio- media to the AKI incidence among patients undergoing CT logical reason why the definition and staging of CI-AKI without contrast-media administration.390 The incidence of should be different from the RIFLE/AKIN criteria. It should, AKI (defined as an increase of SCr of 0.5 mg/dl [44 mmol/l] or however, be stressed that for the development of this a X25% decrease in eGFR within 3 days after CT) was similar guideline, the term contrast-induced nephropathy is widely in all three groups (two receiving contrast agents and one not) used in the literature and usually defined as a rise in SCr up to a baseline SCr level of 1.8 mg/dl (159 mmol/l). A high of X0.5 mg/dl (X44 mmol/l) or a 25% increase from base- incidence of ‘‘AKI’’ among control subjects undergoing line value, assessed at 48 hours after a radiological proce- noncontrast CT was thus identified. Given the results of this dure. This definition also consistently predicted major retrospective study, it is clear that AKI after i.v. administration Kidney International Supplements (2012) 2, 69–88 69
chapter 4.1 of iodine contrast media cannot be automatically attributed increased risk of CI-AKI but, as recently summarized,396 to the contrast agent, but may, in fact, reflect AKI from other the published evidence to support this premise is rather causes, such as worsening underlying disease or drug toxicity. scarce.397 Therefore, the Work Group strongly recommends that individuals showing increases of SCr compatible with the Prognosis of CI-AKI definition of AKI after administration of intravascular contrast Many studies have now shown that patients who develop media be also evaluated for other possible causes of AKI. CI-AKI have a greater risk for death or prolonged hospitali- In a study using cystatin C as an early marker for AKI, zation, as well as for other adverse outcomes, including early a cut-off cystatin C increase concentration of X10% at 24 or late cardiovascular events. The latter are more common hours after contrast-media exposure was detected in 87 after, for example, percutaneous coronary interventions (for patients (21.2%), and was the best cut-off value for the early review, see McCullough398). In a retrospective analysis identification of patients at risk for CI-AKI with a negative including 27 608 patients who underwent coronary angio- predictive value of 100% and a positive predictive value of graphy at the University of Pittsburgh Medical Center during 39%. As in other cases of AKI, it appears that, in patients a 12-year period, discrete proportional odds models were with CKD, cystatin C may be a useful marker for the early used to examine the association between increases in SCr and diagnosis of CI-AKI. 30-day in-hospital mortality and LOS, respectively. It appea- red that small absolute (0.25–0.5 mg/dl [22–44 mmol/l]) and Epidemiology of CI-AKI relative (25–50%) increases in SCr were associated with Keeping the above-mentioned problems of definition in risk-adjusted OR for in-hospital mortality of 1.83 and 1.39, mind, it is not surprising that the reported incidence of respectively; larger increases in SCr generally were associated CI-AKI varies widely across the literature, depending on the with greater risks for these clinical outcomes.399 Moreover, definitions used, the patient population, and the baseline risk when patients with CI-AKI require dialysis, the mortality is factors. higher compared to those not requiring dialysis. For example, The. impact of different definitions on the incidence of in the study by McCullough et al.,400 the hospital mortality CI-AKI can be illustrated by the recent results of the Oxilan was 7.1% in CI-AKI and 35.7% in patients who required Registry.391 In this registry, CI-AKI was defined as either a dialysis. By 2 years, the mortality rate in patients who SCr increase 40.5 mg/dl (444 mmol/l), or a SCr increase required dialysis was 81.2%. 425%, or a decrease 425% of eGFR, or the composite of The more recent Cardiac Angiography in Renally all three definitions. The baseline SCr was 1.12 ± 0.3 mg/dl Impaired Patients study401—a large, multicenter, prospective, (99 ± 26.5 mmol/l) and 24% had an eGFR o60 ml/min. double-blind RCT of patients who had moderate to severe CI-AKI rates were 3.3% (SCr increase 40.5 mg/dl CKD and were undergoing cardiac angiography—also [444 mmol/l]), 10.2% (SCr increase 425%), 7.6% (eGFR showed that the adjusted incidence rate ratio for adverse decrease 425%), and 10.5% (composite), respectively. events was twice as high in those with CI-AKI. However, It is accepted that, in patients with normal renal function— these data demonstrating a temporal association between CI- even in the presence of diabetes—the risk for CI-AKI is low AKI and short or long-term prognosis do not establish a (1–2%).392 However, the incidence may be as high as 25% in causal relationship, since most of the patients in these patients with pre-existing renal impairment or in presence of observational studies have underlying risk factors that, in certain risk factors, such as the combination of CKD and addition to increasing the patient’s risk of CI-AKI, can diabetes, CHF, advanced age, and concurrent administration directly increase their overall risk for the complications of nephrotoxic drugs.393 CI-AKI was described as the third studied. Finally, many of the retrospective studies may also most common cause of new AKI in hospitalized patients have introduced selection bias for patients who presumably (after decreased renal perfusion and nephrotoxic medications) had a clinical reason for having their SCr concentration and was responsible for 11% of cases.394 followed. The epidemiology of de novo CI-AKI in critically ill Data on the association between risk of ESRD and CI-AKI patients is not known. In a group of 75 ICU patients with a are scarce. In contemporary studies, CI-AKI requiring normal baseline SCr who were exposed to CT scans with an dialysis developed in almost 4% of patients with underlying i.v. low-osmolar contrast medium, an increase in SCr 425% renal impairment and 3% of patients undergoing primary was recorded in 18% of the patients. There was no change of percutaneous coronary interventions for acute coronary the SCr in a control group of patients undergoing CT scans syndrome. However, only a small proportion of patients but not receiving contrast media.395 This rather small study continued on chronic dialysis.402,403 Although CI-AKI shows that in critically ill patients, even with an apparently requiring dialysis is relatively rare, the impact on patient ‘‘normal’’ renal function, i.v. administration of iodinated prognosis is considerable, with high hospital and 1-year contrast media is associated with a significant incidence of mortality rates (for a review, see McCullough398). Only one CI-AKI. study404 reported the incidence of new CKD Stage 4–5 It could be expected that radiological procedures (eGFRo30 ml/min) following percutaneous coronary inter- performed in an emergency would be associated with an ventions and found that this occurred in 0.3% of patients 70 Kidney International Supplements (2012) 2, 69–88
chapter 4.1 with an eGFR 430 ml/min at baseline and newly diagnosed RESEARCH RECOMMENDATION kidney disease within 6 months after the procedure, and in K Large prospective RCTs examining the epidemiology of 0.9% of patients with an eGFR460 ml/min at baseline. These CI-AKI are needed, especially on long-term outcomes, percentages are higher than the estimated annual incidence of with attention to controlling for confounders. CKD at 0.17% that was found in a British general population cohort over a 5.5-year period of follow-up.405 Thus, careful SUPPLEMENTARY MATERIAL Appendix E: Risks with Gadolinium-Based Contrast Agents. long-term follow-up of SCr following contrast exposure is Supplementary material is linked to the online version of the paper at warranted. http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 69–88 71
http://www.kidney-international.org chapter 4.2 & 2012 KDIGO Chapter 4.2: Assessment of the population at risk for CI-AKI At present, millions of doses of intravascular contrast be requested, but an emergent imaging/intervention, where media are being administered worldwide.406,407 Most of the benefit of very early imaging outweighs the risk of these radiological examinations are performed in ambu- waiting, should not be delayed. latory populations who do not need special preventive For its relative simplicity, only SCr is used at many measures. However, contrast media are also increasingly used hospitals to determine whether a patient is a candidate in an elderly population, many of whom have CKD and for intravascular contrast-media administration, but the diabetes—the principal risk factors for CI-AKI. It is, thus, thresholds used and the acceptable time between the of utmost importance to screen the population at risk for determined SCr value and administration of contrast media CI-AKI. to perform the radiology examination differs among radiology departments. 4.2.1: Assess the risk for CI-AKI and, in particular, screen for pre-existing impairment of kidney Risk-factor questionnaire function in all patients who are considered for a For outpatient radiological studies where renal function data procedure that requires intravascular (i.v. or i.a.) are unavailable, a simple survey or questionnaire may be administration of iodinated contrast medium. used to identify outpatients at higher risk for AKI in whom (Not Graded) appropriate precautions should be taken. Choyke et al.411 (Figure 13) used a questionnaire and could identify a high proportion of patients with normal SCr RATIONALE concentrations, and reduced by 67% the number of patients Screening for pre-existing impairment of kidney function in whom SCr measurement was necessary before imaging Pre-existing renal functional impairment is the most studies. important risk factor above all other risk factors for The European Society of Urogenital Radiology386 recom- developing CI-AKI408 and screening for both acute and mends a risk-factor analysis based on the Choyke ques- chronic kidney disease is highly recommended. There is no tionnaire to identify patients with a higher risk of abnormal sharp GFR threshold below which the risk for CI-AKI is clearly increasing. Both the KDOQI guideline and KDIGO renal function. The CI-AKI Consensus Working Panel410 considered that a survey or questionnaire may be a useful recommend that, in stable patients, an eGFR should be guide for identifying patients at higher risk for CI-AKI used.409 compared to the general population. A CI-AKI Consensus Working Panel410 agreed that the risk of CI-AKI becomes clinically important when the baseline SCr concentration is X1.3 mg/dl (X115 mmol/l) in men and Urinary protein screening X1.0 mg/dl (X88.4 mmol/l) in women, equivalent to an The CI-AKI Consensus Working Panel also supported the eGFR o60 ml/min per 1.73 m2. However, Bruce et al.390 use of dipstick testing for urine protein as a rapid screen to showed that the incidence of ‘‘true’’ AKI became significant identify patients who can undergo studies requiring contrast only between controls and contrast-media administered media without SCr measurement.410 Of 310 patients with a patients from a baseline SCr concentration of 41.8 mg/dl negative urine protein test and no history of diseases poten- (4159 mmol/l) onward. The CI-AKI Consensus Working tially associated with renal impairment, none had a SCr Panel410 recommended that precautions to reduce the risk level 42.0 mg/dl (4177 mmol/l), and only 1% had a level should be implemented in patients with a baseline 41.7 mg/dl (4150 mmol/l). eGFRo60 ml/min per 1.73 m2. In light of more recent Thus, the Work Group recommends that, when a recent information, this threshold could probably be lowered to SCr is not available, a simple questionnaire or a dipstick 45 ml/min per 1.73 m2. testing for urine protein may be useful for identifying In many institutions, point-of-care SCr testing is present, pre-existing kidney disease. Risk stratification hinges on age, and the results can be available quite fast. In places without baseline kidney function, other comorbidities, and other risk point-of-care laboratories, the appropriate blood tests should factors. 72 Kidney International Supplements (2012) 2, 69–88
chapter 4.2 In the past 3 months have you been told there may have been a change in your kidney function? Y/N In the past 3 months have you been on any medications? Please list: Have you used any over-the-counter pain relievers within the last 10 days? Y/N Please list: In the past 3 months have you had any surgery? Y/N Describe: Do you feel dry or thirsty? Y/N Circle one *Have you ever been told you have kidney disease of any type? Y N Please describe: *Have you had kidney surgery? Y N *Do you have diabetes? Y N Do you use insulin? Y N Do you use metformin or glucophage? Y N *Do you have hypertension, heart disease, or vascular disease? Y N *Do you have gout? Y N Do you have multiple myleoma? Y N Have you ever had x-ray contrast media (dye) for CT, angiography, or IVP? Y N Have you had contrast media within the last 3 days? Y N Do you have any allergies to x-ray contrast media (dye)? Y N Please describe: Have you received pretreatment with medication for this study? Y N Do you have any allergies or asthma? Please describe: Y N Figure 13 | Sample questionnaire. Asterisks denote questions with the highest association with abnormal renal function. Adapted from Choyke PL, Cady J, DePollar SL et al. Determination of serum creatinine prior to iodinated contrast media: is it necessary in all patients? Tech Urol 1998; 4: 65–69 with permission.411 Other risk factors of CI-AKI Table 15 | CI-AKI risk-scoring model for percutaneous Besides pre-existing kidney disease with renal function coronary intervention impairment, other risk factors for developing CI-AKI Risk factors Integer score (calculate) include diabetes, hypertension, CHF, advanced age, volume Hypotension 5 depletion, hemodynamic instability, use of concurrent IABP 5 nephrotoxic medications, and large volume or high osmol- CHF 5 ality of the contrast agent.408,412 Although there is doubt that Age 475 years 4 Anemia 3 diabetes by itself is an independent risk factor, in a patient Diabetes 3 with CKD it acts as a risk multiplier.398 Metabolic syndrome, Contrast-media volume 1 per 100 ml prediabetes, and hyperuricemia have been identified as SCr 41.5 mg/dl (4132.6 mmol/l) 4 new risk factors for CI-AKI, while the use of ACE-I and or eGFR o60 ml/min per 1.73 m2 2 for 40–60 angiotensin-receptor blockers (ARB), renal transplantation, 4 for 20–39 diabetes mellitus with normal renal function, low-osmolar 6 for o20 contrast media, multiple myeloma, female gender, and Note: Low risk: cumulative score o5; high risk: cumulative score 416. cirrhosis have been classified as conflicting risk factors for CHF, congestive heart failure; eGFR, estimated glomerular filtration rate; IABP, intra- aortic balloon pump; SCr, serum creatinine. Reprinted from Mehran R, Aymong ED, CI-AKI.413 There are conflicting data on the impact of ACE-I Nikolsky E et al. A simple risk score for prediction of contrast-induced nephropathy or ARB but, overall, there is currently insufficient evidence to after percutaneous coronary intervention: development and initial validation. J Am recommend discontinuation of these medications prior to Coll Cardiol 2004; 44: 1393–1399 et al.,418 copyright 2004, with permission from American College of Cardiology Foundation; accessed http://content.onlinejacc.org/ contrast-media administration. cgi/content/full/44/7/1393 When possible, the administration of contrast media should be delayed in patients with circulatory collapse or CHF until their hemodynamic status is corrected. Repeated exposure should be delayed for 48 hours in patients doses of loop diuretics, and antiviral drugs like acyclovir without risk factors for CI-AKI, and for 72 hours in those and foscarnet—should preferably be stopped. A recent with diabetes mellitus or pre-existing chronic renal dysfunc- study using a so-called forced euvolemic diuresis protocol tion. If acute renal dysfunction develops after contrast-media including mannitol and furosemide led to a signi- administration, repeated exposure should preferably be ficantly increased risk of CI-AKI.415 It can be advised that delayed until the SCr level has returned to baseline levels.414 such strategy should be abandoned, and that furose- Concurrent nephrotoxic medication—including, in mide therapy should preferably be stopped before angio- particular, NSAIDs, aminoglycosides, amphotericin B, high graphy. Kidney International Supplements (2012) 2, 69–88 73
chapter 4.2 Risk models of CI-AKI Nephrogenic systemic fibrosis (NSF) Most risk factors for CI-AKI can be detected by The risk of developing NSF with Gd, particularly in patients history-taking and physical examination, and the risk rises with severe AKI and CKD, is reviewed in detail in Appendix E. exponentially with the number of risk factors present.416 It should be noted here that the European Medicines Validated risk-prediction models using patient and proce- Agency stated a contraindication for use of gadodiamide in dural risk factors to assess for CI-AKI have been developed patients with a GFR o30 ml/min per 1.73 m2, and issued a for patients undergoing percutaneous coronary inter- warning for its use in patients who have a GFR between 30 vention.417,418 For example, the Mehran risk model418 is and 60 ml/min per 1.73 m2 (EMEA Public assessment report. given in Table 15. The overall occurrence of CI-AKI in the http://www.esur.org/fileadmin/NSF/Public_Assessment_Report_ development set of the score was 13.1% (range 7.5% to NSF_Gadolinium_26_June_2007.pdf; last accessed January 5, 57.3% for a low [p5] and high [X16] risk score, 2012). The US FDA requested that vendors add warnings respectively); the rate of CI-AKI increased exponentially about the risk for developing NSF to the full prescri- with increasing risk score. In the validation dataset, the bing information on the packaging for all Gd-containing increasing risk score was again strongly associated with contrast agents (gadopentetate dimeglumine, gadodiamide, CI-AKI (range 8.4% to 55.9% for the low and high risk score, gadoversetamide, gadoteridol, gadobenate dimeglumine).427 respectively). These models can help in counseling about the New labeling describes the risk for NSF following expo- risks of the procedure, selecting prophylactic interventions, sure to Gd in patients with a GFR o30 ml/min per and can also be used to characterize patients in studies of 1.73 m2 and in patients with AKI of any severity due to CI-AKI. hepato-renal syndrome or in the perioperative liver trans- plantation period. Additional recommendations were 4.2.2: Consider alternative imaging methods in patients recently proposed by Perazella420 and were endorsed by the at increased risk for CI-AKI. (Not Graded) Work Group: (a) Use of a macrocyclic chelate (gadoteridol in the USA), is preferred over linear chelates. The risk associated RATIONALE with the various Gd-containing agents is likely The selection and advantages and disadvantages of non- different. Gadodiamide, the linear nonionic chelate–- iodinated contrast media are beyond the scope of these based formulation, maintains the highest risk on the guidelines. Detailed discussions of all these techniques can basis of epidemiologic data and animal studies. be found in radiology textbooks and the radiology litera- Gadopentetate, the linear ionic chelate–based product ture. The Work Group suggests that, in patients at increased probably has a medium risk, less than the linear risk for CI-AKI, the risks and benefits of iodinated nonionic chelates but more than the macrocyclic contrast-media administration should be discussed with the chelates. Gadoteridol, the only FDA-approved macro- radiologist. cyclic chelate, maintains less risk. Clearly, high dosages Because of the great relevance for the nephrologist, and large cumulative dosages of all these agents will radiologist, and cardiologist of the side-effects of Gd chelates increase risk for NSF. used in magnetic resonance imaging (MRI), a short overview (b) Demonstration of significant quantities of insoluble of their nephrotoxicity is given here. Gd in the skin of NSF patients, months after expo- sure to Gd-based contrast material and after exten- Nephrotoxicity of Gd chelates sive tissue processing, suggests that Gd might have Gd chelates are widely used as MRI contrast agents, and undergone transmetallation in vivo. Supporting the are considered to have a good overall safety profile. Early importance of transmetallation, all NSF cases reported on, phase III trials and small studies in low-risk patients before 2009 have been associated with linear MRI suggested a benign renal profile; however, more recent contrast agents (for a review, see Kay428) that have studies raised the possibility of nephrotoxicity, although inferior thermodynamic stability and a kinetic or it is not clear whether it approaches the incidence of conditional stability that favors transmetallation. How- AKI associated with iodine-containing contrast media. ever, a recent case of NSF in a dialysis patient after Gd-related AKI appears to be a risk in patients with advanced exposure to a macrocyclic chelate has been described,429 kidney disease, especially those with diabetic nephro- and at least two additional cases are known.430 pathy.419,420 Perazella et al.420 have summarized studies (c) Use the lowest dosage of the agent possible to achieve showing Gd-induced nephrotoxic AKI compared to the image. CI-AKI.421–425 Studies in patients with underlying kidney (d) Avoid repeat exposures with Gd. disease demonstrate the importance of renal clearance in (e) Consider performing IHD after the exposure (and determining the pharmacokinetic profile of Gd chelates.426 the next 2 days) in patients who are already main- More details on the pharmacokinetics of Gd chelates and tained on IHD, recognizing that there are no data their dialyzability are provided in Appendix E. that support prevention of NSF with this modality. 74 Kidney International Supplements (2012) 2, 69–88
chapter 4.2 This recommendation is based on the pharmaco- SUPPLEMENTARY MATERIAL Appendix E: Risks with Gadolinium-Based Contrast Agents. kinetics of Gd and the theoretical benefit of removing Supplementary material is linked to the online version of the paper at it with IHD (495% plasma clearance). PD clears these http://www.kdigo.org/clinical_practice_guidelines/AKI.php agents rather poorly. Kidney International Supplements (2012) 2, 69–88 75
http://www.kidney-international.org chapter 4.3 & 2012 KDIGO Chapter 4.3: Nonpharmacological prevention strategies of CI-AKI There have been a large number of strategies/agents evaluated the experimentally measured AUC for the contrast agent to prevent CI-AKI. Sterling et al.431 have recently summa- iodixanol. The experimentally determined AUC data correlated rized most of these strategies and classified them as having highly with the dose:CrCl ratio. This ratio could thus be a rapid either definitive, possible, or doubtful value. From the many and accurate way to estimate AUC for an iodinated contrast strategies, these authors only retain parenteral volume medium, without the need for multiple blood samples. expansion, minimizing contrast-media volume, use of low- A recent study by Nyman et al.436 in patients undergoing osmolar and iso-osmolar contrast media, and administration coronary angioplasty calculated the probability of CI-AKI of non-iodinated contrast media as strategies with definitive (SCr rise 40.5 mg/dl [444.2 mmol/l] or oliguria/anuria) at value. A recent comprehensive meta-analysis by Kelly various eGFR levels based on g-I (grams iodine)/eGFR ratios et al.432—including RCTs that administered NAC, theophyl- of 1:2, 1:1, 2:1, and 3:1. At a ratio o1, the risk of CI-AKI line, fenoldopam, dopamine, iloprost, statins, furosemide, was 3%, while it was 25% at a ratio X1. This, and other or mannitol, and covering studies up to November 2006— preliminary studies, indicate that a g-I/GFR ratio o1 may be provides an excellent overview. relatively safe in a patient without multiple risk factors.436–438 Finally, the association between absolute and body weight- DOSE/VOLUME OF CONTRAST-MEDIA ADMINISTRATION and SCr-adjusted contrast-media volume, CI-AKI incidence (X25% SCr increase), and clinical outcome was prospec- 4.3.1: Use the lowest possible dose of contrast medium in tively investigated in patients with acute MI.439 For each patients at risk for CI-AKI. (Not Graded) patient, the maximum contrast-medium dose was calculated according to the formula (5 Â body weight [kg]) C SCr, and the contrast-medium ratio—defined as the ratio between the RATIONALE contrast-medium volume administered and the maximum The correlation between the volume of contrast media dose calculated—was assessed. Development of CI-AKI was administered and the risk of CI-AKI has been recognized. 433 associated with both contrast-medium volume and ratio. In the vast majority of papers dealing with CI-AKI after Additional radiological measures to reduce CI-AKI can be coronary procedures, contrast-media doses are only ex- found in Table 16. pressed in volumes. The Work Group feels that such expression can be misleading, since commercially available Route of administration of contrast media contrast-media concentrations range from 140 to 400 The risk of CI-AKI appears to be greater after arterial milligrams of iodine per milliliter, a difference with almost compared to venous administration of contrast media. a factor of 3. The Work Group recommends, therefore, that Indeed, in the rare studies where an appropriate control the dose of contrast medium should be better expressed in group without contrast media was included, no significant relation to both volume and concentration, e.g., grams difference was observed in the rate of CI-AKI between the iodine, which also directly relates to the diagnostic capacity, patients who received i.v. iodinated contrast media and the the primary purpose of the contrast medium. Such ‘‘double’’ control subjects who did not.440–442 Thus, the risk of CI-AKI expression would also facilitate the comparison between with i.v. contrast medium is probably very low. CI-AKI different studies on epidemiology and prognosis of CI-AKI. reportedly occurs after i.v. contrast-medium injection for CT It is well known that, when measuring the plasma in only 4% of patients with CKD.443 Katzberg and Lamba444 clearance of a GFR marker (e.g., with the contrast medium summarized the six studies on CI-AKI after i.v. contrast- iohexol), the AUC is directly related to the dose of iohexol medium administration in patients at risk and all suffering and inversely related to the GFR. Thus, by mathematically from moderate CKD. The overall incidence of CI-AKI in estimating the AUC and knowing the injected iodine these studies, using the current generation of low-osmolar dose, the GFR can be calculated by dose C AUC. Thus, contrast media, was about 5%. AUC ¼ dose C GFR, and AUC is directly related to the Given the logistic challenges in the outpatient setting, the systemic exposure of a drug, including the contrast medium, use of specific prophylactic measures prior to administration which, in turn, is mostly correlated with its efficacy and of i.v. contrast media could be limited to those subjects toxicity.434 An interesting experimental study435 investigated who are at higher levels of baseline risk than they would be the correlation between the calculated dose to CrCl ratio and when an i.a. procedure was planned.445 This conclusion, may 76 Kidney International Supplements (2012) 2, 69–88
chapter 4.3 Table 16 | Additional radiological measures to reduce CI-AKI Some CT strategies in patients at risk of CI-AKI K Perform CT, when possible, without contrast media; scrutinize the examination and discuss with the referral physician-surgeon before deciding on the need for contrast media. K Dosing per kilogram body weight to reduce the amount of contrast media is needed in thin patients. K Adapt injection duration to scan duration when performing CT-angiography, so that the injection is not still running when the scan is finished. K Use a saline chaser to decrease the amount of contrast media, by using the contrast medium that otherwise would remain in the dead space of the arm veins; this may save 10–20 ml of contrast media. K Use 80 kVp; contrast-medium dose may be reduced by a factor of 1.5–1.7 compared to the dose used at 120 kVp since iodine attenuation increases, and combine with increased tube loading (mAs) to maintain signal-to-noise ratio. K Further reduction of contrast media may be instituted in patients with known decreased cardiac output (not unusual in patients with renal impairment) undergoing CT-angiographic studies. Some angiographic strategies in patients at risk of CI-AKI K Use biplane when appropriate. K Avoid test injections; the same amount may be enough for a diagnostic digital-subtraction angiography run. K Scrutinize each series before performing the next; avoid unnecessary projections. K Decrease kilovoltage in a thin patient; a lower iodine concentration may be used. K Assess the physiologic significance of a stenosis by measurement of translesional pressure gradient and fractional flow reserve, a technique well accepted and validated for the coronary circulation. For different arterial beds, perform manometry of a questionable stenosis instead of multiple projections. K Avoid ventriculography: echocardiography (and ‘‘echo contrast’’) is always a reasonable alternative. K Use plasma isotonic contrast-media concentrations for renal artery injections. K When renal artery stenosis is suspected, map the origin of major renal arteries with noninvasive procedures (e.g., CT without contrast media) for proper initial renal angiographic projections to avoid unnecessary runs, or perform primary manometry. K CO2 may be used as contrast medium in venous examinations and below the diaphragm for arterial examinations or alternatively use iodinated contrast media with the same contrast effect, i.e., about 40 mg iodine per milliliter. K Since the contrast effect of 0.5 M Gd-contrast media has been regarded as diagnostic by many investigators (coronary, renal, aortofemoral arteriography, etc.), iodinated contrast media may be diluted to the same density, i.e., about 75 mg iodine per milliliter. K Use selective or superselective catheterizations when appropriate, e.g., ‘‘single leg run-off’’. K Reduce aortic flow and amount of contrast medium by temporal occlusion of femoral arteries with tourniquets when performing aortography. Gd, gadolinium; kVp, peak kilovoltage. however, be too optimistic when applied to critically ill High-osmolar vs. iso-osmolar or low-osmolar contrast media patients undergoing emergency CT scans.395 The recommendation to avoid high-osmolar contrast media The majority of the literature covering CI-AKI and its is based on older literature, since recent RCTs comparing prevention involves i.a. iodinated contrast-medium admin- high- vs. low- and iso-osmolar iodine-based contrast media istration.445,446 The higher risk of CI-AKI after i.a. admin- are not available. In addition, high-osmolar contrast media istration is probably due to the more direct exposure of the have virtually been abandoned in modern radiological units. kidneys to contrast media,447 or to the fact that, in general, Both the review of Goldfarb et al.,448 and the meta-analysis of i.a. contrast-media examinations are performed in patients Barrett and Carlisle combining 24 randomized studies449 who carry a higher risk. suggest that the risk of CI-AKI is similarly low with high- osmolar and low-osmolar agents among otherwise stable RESEARCH RECOMMENDATIONS patients with normal renal function, but that in contrast to K Randomized trials should explore whether there is need high-osmolar contrast media, low-osmolar contrast media for discontinuation of ACE-I and/or ARBs in patients at are less nephrotoxic in patients with pre-existing kidney risk for CI-AKI. function impairment. K Additional studies are needed to better determine the exact relationship between the dose of contrast media and Low-osmolar vs. iso-osmolar contrast media the risk for CI-AKI. The present hotly debated question is whether iso-osmolar contrast media are safer than low-osmolar contrast media in SELECTION OF A CONTRAST AGENT high-risk patients. This question has been the subject of a 4.3.2: We recommend using either iso-osmolar or low- number of randomized trials as well as systematic reviews osmolar iodinated contrast media, rather than and meta-analyses (Suppl Tables 19–21). high-osmolar iodinated contrast media in patients We separated studies meeting our inclusion criteria (see at increased risk of CI-AKI. (1B) Chapter 1.2) into those administering i.a. or i.v. contrast media. We used the general definitions of CI-AKI provided in RATIONALE the studies (an increase in SCr by 425% or 0.5 mg/dl This recommendation is supported by the summary tables of [44.2 mmol/l]) occurring within 72 hours after contrast- the different RCTs and on the evidence profile tables (Suppl medium administration, in the absence of an alternative Tables 19–21). etiology for the decrease in kidney function. Kidney International Supplements (2012) 2, 69–88 77
chapter 4.3 Figure 14 | Risk for contrast-induced nephropathy. (a) Iodixanol vs. iohexol and risk for contrast-induced nephropathy; (b) iodixanol vs. nonionic low-osmolar contrast media other than iohexol and risk for contrast-induced nephropathy. Reprinted from Heinrich MC, Haberle L, Muller V et al. Nephrotoxicity of iso-osmolar iodixanol compared with nonionic low osmolar contrast media: meta-analysis of randomized controlled trials. Radiology 2009; 250: 68–86 with permission, copyright 2009, from Radiological Society of North America457; accessed http://radiology.rsna.org/content/250/1/68.long In total, 14 RCTs fulfilling the search criteria were found. iodixanol was compared to other low-osmolar contrast Ten RCTs were found with i.a. and four RCTs with i.v. agents (RR 0.95; 95% CI 0.50–1.78; P ¼ 0.86). Iodixanol is injection, respectively (Suppl Tables 19–21). There is only thus not associated with a significantly reduced risk of CI- moderate quality of evidence and overall, no benefit—or, at AKI compared to the low-osmolar contrast media pooled least, no consistent benefit—was found of nonionic iso- together. However, in patients with decreased kidney osmolar (iodixanol) contrast media compared to low- function, iodixanol is associated with a reduced risk of CI- osmolar ionic or nonionic contrast media. In eight studies AKI compared to iohexol. comparing contrast media given i.a.401,450–456 some showed The clinical heterogeneity between all these studies, as far superiority of iso-osmolar contrast media (iodixanol), as basal kidney function and prevalence of diabetes mellitus compared to iohexol450 and iopromide.455 There was no are concerned, hampers the ability to compare the results difference when iodixanol was compared to iopamidol,401,452 across studies, but can widen the applicability of consistent iopromide,451,453 and ioversal.456 findings across different risk groups provided the mechan- The most recent prospective, multicenter, randomized, isms of contrast-induced nephrotoxicity are the same. One double-blind study compared the renal effects of iodixanol to should note, also, that in all these studies different definitions the nonionic, low-osmolar agent iopamidol, in 526 subjects of CI-AKI have been used and that the timing of SCr with CKD and diabetes mellitus undergoing diagnostic measurements after contrast-media injection was not uni- and/or therapeutic coronary angiography.454 The overall form. It has been shown that different time-points for the CI-AKI incidence was 10.5% (11.2% % in the iodixanol measurement of CI-AKI can give different results.458 One arm and 9.8% in the iopamidol arm, NS). The volume of may expect that those studies with a standardized and contrast medium, volume of saline administered, frequency simultaneous measurement of renal function between the of coronary interventional procedures, and severity of two arms are probably the most conclusive. Finally, different baseline kidney disease and of diabetes mellitus were similar types and amounts of volume expansion and different between treatments. pharmacological preventive strategies have been used Finally, a recent meta-analysis457 (Figure 14) analyzed throughout the studies, making conclusive comparisons studies comparing iodixanol with low-osmolar contrast virtually impossible. media. The pooled RR was 0.68 (95% CI 0.46–1.01; P ¼ 0.06). In studies that included patients with normal i.a. Iodixanol vs. ioxaglate renal function after i.a. contrast-media administration, the Two studies fulfilled our inclusion criteria; one study459 RR was 0.82 (95% CI 0.45–1.51; P ¼ 0.53). In the studies that showed a superiority of iodixanol vs. ioxaglate, but this was included only patients with decreased kidney function after not confirmed in the study by Mehran et al.,460 who found no i.a. contrast-media administration, the RR was 0.59 (95% CI difference between these two contrast agents. Although 0.33–1.07; P ¼ 0.08). However, in all three studies in which overall the number of patients is substantial, there is iohexol was the low-osmolar contrast medium used, the risk heterogeneity among the comparators with which iodixanol of CI-AKI was significantly lower with iodixanol (RR 0.38; has been compared. In addition, the cost of iodixanol is 95% CI 0.21–0.68; Po0.01). In contrast, the risk of CI-AKI probably higher than the cost of most of the low-osmolar did not significantly differ in the two studies in which contrast agents. No studies comparing a possible difference 78 Kidney International Supplements (2012) 2, 69–88
chapter 4.3 among low-osmolar contrast media have been performed. iopromide, but not to iopamidol and iomeprol. It is, Based on evidence profiles (Suppl Tables 19 and 20) and however, difficult to determine whether this is simply due the most recent meta-analysis457 (Figure 14) of the studies to spurious findings in a smaller number of comparisons, or comparing i.a. administration of iso- vs. low-osmolar due to true differences between low-osmolar agents. Until contrast media, the Work Group found no evidence to better head-to-head comparative studies among the different recommend a preference for either type of agent. contrast media agents are available, the Work Group is unable to draw definite conclusions on the selection of i.v. Administration iso-osmolar vs. low-osmolar contrast media. There are four studies following i.v. injections fulfilling our inclusion criteria: Barrett et al.,443 Kuhn et al.,461 Thomsen RESEARCH RECOMMENDATION et al.,462 and Nguyen et al.463 The overall conclusion, based K Additional studies with head-to-head comparisons on the evidence profile summarized in Suppl Table 20 among the different contrast media should be performed comparing i.v. iso- vs. low-osmolar contrast media, is that in order to draw definite conclusions on the selection there is no benefit for the nonionic iso-osmolar agent of iso-osmolar vs. low-osmolar contrast media. A more (iodixanol); the overall quality of the evidence is moderate. uniform definition of CI-AKI, as suggested in this This conclusion is supported by the above-mentioned recent guideline, should be used as the end-point. meta-analysis457 which, in seven studies comparing i.v. contrast-media administration with iodixanol vs. low-osmolar SUPPLEMENTARY MATERIAL Supplementary Table 19: Evidence profile of RCTs examining the effect contrast media, showed no statistically significant difference of intrarterial isosmolar vs. low osmolar contrast agent on the for CI-AKI (RR 1.08; 95% CI 0.62–1.89; P ¼ 0.79). Subgroup prevention of CI-AKI. analysis did not show superiority of any agent in studies of Supplementary Table 20: Evidence profile of RCTs examining the effect individuals with normal kidney function (RR 1.12; 95% CI of intravenous isosmolar vs. low osmolar contrast agent on the 0.35–3.65; P ¼ 0.85) or in studies of individuals with reduced prevention of CI-AKI. Supplementary Table 21: Summary table of RCTs examining the effect of kidney function (RR 1.07; 95% CI 0.56–2.02; P ¼ 0.84). isosmolar vs. low osmolar contrast agent on the prevention of CI-AKI. In head-to-head comparisons with different low-osmolar Supplementary material is linked to the online version of the paper at agents, iodixanol has been shown to be superior to http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 69–88 79
http://www.kidney-international.org chapter 4.4 & 2012 KDIGO Chapter 4.4: Pharmacological prevention strategies of CI-AKI FLUID ADMINISTRATION incidence of CI-AKI was lowest following CT (range, Extracellular volume expansion at the time of radiocontrast- 0.0–10.9%) and was highest following noncoronary angio- media administration may serve to counteract both the graphy (range, 1.9–34.0%). intrarenal hemodynamic alterations and the direct tubulo- The fluids that have been tested in the prevention of toxic effects that play a role in the pathophysiology of CI- CI-AKI are hypotonic saline (0.45%), isotonic saline (0.9%) AKI. Neurohumoral effects of volume expansion that may and isotonic sodium bicarbonate. The interpretation of all attenuate radiocontrast-induced medullary hypoxia include these studies is hampered by the fact that not all other risk suppression of vasopressin as well as inhibition of the renin- factors (susceptibilities) for CI-AKI were excluded or angiotensin axis; but an increased synthesis of vasodilatory considered in every study (i.e., age of the patient, presence renal prostaglandins may also play a role.464 of CKD and/or diabetes prior to contrast-media administra- Volume expansion may also directly reduce cellular tion, type and dose of contrast agent, associated therapy with damage by dilution of the contrast medium, particularly in NAC, and other risk factors [see Chapter 2.2]). the medullary tubular segments. Likewise, an effect of There is no clear evidence from the literature to guide the radiocontrast media to increase tubular fluid viscosity may choice of the optimal rate and duration of fluid infusion in be diminished by intravascular volume expansion.465 It is CI-AKI prevention, but most studies suggest that the fluids important to note that these potentially attenuating effects of should be started at least 1 h before and continued for 3–6 volume expansion are speculative, and the precise mechan- hours after contrast-media administration. A ‘‘good’’ urine isms by which volume expansion protects against CI-AKI output (4150 ml/h) in the 6 hours after the radiological remain unknown. procedure has been associated with reduced rates of AKI in one study.468 Since not all of i.v. administered isotonic 4.4.1: We recommend i.v. volume expansion with either crystalloid remains in the vascular space, in order to achieve isotonic sodium chloride or sodium bicarbonate a urine flow rate of at least 150 ml/h, X1.0–1.5 ml/kg/h of solutions, rather than no i.v. volume expansion, in i.v. fluid has to be administered for 3–12 hours before and patients at increased risk for CI-AKI. (1A) 6–12 hours after contrast-media exposure. Mueller et al.469 found that i.v. 0.9% saline solution, compared to 0.45% saline solution in dextrose, in 1620 RATIONALE patients undergoing coronary angiography significantly Despite the recognition of volume depletion as an important reduced CI-AKI. The sustained administration of isotonic risk factor for AKI, there are no RCTs that have directly saline before and after radiocontrast injection seems, thus, evaluated the role of fluids vs. placebo in the prevention of to be more protective than equivalent volumes of hypotonic AKI. However, RCTs have compared different fluids and have saline.464 Although the mechanism by which sodium combined fluids with other interventions.191 Furthermore, bicarbonate, beyond its volume-expanding effects, might comparisons between outcomes seen in these trials191 and further reduce CI-AKI remains poorly defined, it has been historical untreated control subjects466 suggest a large benefit postulated that sodium bicarbonate infusion may decrease from fluids. In particular, volume expansion and treatment of generation of free radicals mediated by the Haber-Weiss dehydration are well-established interventions in the preven- reaction by increasing tubular pH. The Haber-Weiss reaction tion of CI-AKI. A recent propensity analysis, however, noted is most active at lower pH levels.470 Sodium bicarbonate that strategies to prevent CI-AKI are implemented rather infusion may also scavenge the potent oxidant peroxynitrate, nonuniformly.467 Pre– and post–contrast-media administra- produced via a nitric oxide–mediated pathway.471 Reactive tion i.v. fluids were given to only 264 of 660 study patients oxygen species activate cytokine-induced inflammatory (40.0%), more commonly with coronary angiography than mediators, resulting in damage to proximal tubular cells,472 with CT (91.2% vs. 16.6%). Other preventive measures, such and it is likely that the activation of these mediators is as administration of NAC or discontinuation of NSAIDs, influenced by tissue hypoxia and intracellular medullary were equally rarely applied. Only 39.2% of patients received acidosis.473 NAC, while only 6.8% of patients were instructed to It is worth noting that, compared to i.v. bicarbonate, the discontinue NSAIDs. In a propensity analysis, the use of combination of oral azetazolamide inducing an alkaline i.v. fluids was associated with a reduced rate of CI-AKI. The urine, plus i.v. saline, was more effective for the prevention of 80 Kidney International Supplements (2012) 2, 69–88
chapter 4.4 Figure 15 | Bicarbonate vs. saline and risk of CI-AKI. Reprinted from Zoungas S, Ninomiya T, Huxley R et al. Systematic review: sodium bicarbonate treatment regimens for the prevention of contrast-induced nephropathy. Ann Intern Med 2009; 151: 631–638 with permission from American College of Physicians481; accessed http://www.annals.org/content/151/9/631.full CI-AKI than saline alone, in a relatively small study in studies. Some heterogeneity was due to the difference in the children with stable chronic renal failure (CRF).474 It could estimates between published and unpublished studies: RR also be hypothesized that sodium bicarbonate has a stronger 0.43 (95% CI 0.25–0.75) vs. 0.78 (95% CI 0.52–1.17), impact in lowering the intratubular viscosity caused by the respectively. Meta-regression showed that small, poor-quality contrast medium, compared to isotonic saline, because it studies that assessed outcomes soon after contrast-media causes less tubular sodium reabsorption than saline. administration were more likely to suggest the benefit of Sodium bicarbonate solutions have been tested in the bicarbonate (Po0.05 for all). No clear effects of treatment on prevention of CI-AKI in comparison with isotonic saline, the risk for dialysis, heart failure, and total mortality were either with or without NAC. A number of systematic reviews identified. on the role of sodium bicarbonate compared to isotonic Suppl Tables 22 and 23 summarize the evidence from saline in the prevention of CI-AKI are available.475–481 RCTs where isotonic bicarbonate was compared to isotonic The most recent and probably the most complete saline alone, without concomitant other ‘‘preventive’’ inter- systematic review481 analyzed MEDLINE, PubMed, EMBASE, ventions. In all studies, a minimum of 50 patients in both and the Cochrane Central Register of Controlled Trials from arms and publication as full paper were required for 1950 to December 2008; conference proceedings; and inclusion in the tables. Only three studies directly compared ClinicalTrials.gov, without language restriction (Figure 15). isotonic bicarbonate to isotonic saline.470,482,483 In a fourth This systematic review included RCTs of i.v. sodium study by Brar et al.,484 NAC was included in 47% and 46% of bicarbonate that prespecified the outcome of CI-AKI as a the patients in both arms of the study (bicarbonate vs. 25% increase in baseline SCr concentration or an absolute saline), respectively. The first study was a small single-center increase of 0.5 mg/dl (44.2 mmol/l) after contrast-media RCT470 enrolling 119 patients with stable SCr of at least administration. Twenty-three published and unpublished 1.1 mg/dl (97.2 mmol/l), randomized to either infusion of trials with information on 3563 patients and 396 CI-AKI isotonic saline or isotonic sodium bicarbonate before and events were included. The pooled RR was 0.62 (95% CI after contrast-media administration. CI-AKI (defined as an 0.45–0.86), with evidence of significant heterogeneity across increase of 25% in SCr from baseline within 48 hours) Kidney International Supplements (2012) 2, 69–88 81
chapter 4.4 developed in 1.7% in the bicarbonate group, compared to prophylactic administration of 0.9% saline infusion plus 13.6% in the saline solution group. NAC (n ¼ 111), sodium bicarbonate infusion plus NAC Ozcan et al.483 included three prophylactic regimens: (n ¼ 108), and 0.9% saline plus ascorbic acid plus NAC infusion of sodium bicarbonate, sodium chloride, and sodium (n ¼ 107). CI-AKI was defined as an increase of X25% in the chloride plus oral NAC (600 mg b.i.d.). The incidence of SCr concentration 48 hours after the procedure. CI-AKI CI-AKI, defined as an increase in SCr level 425% or 0.5 mg/dl occurred in 9.9% of the saline plus NAC group, in 1.9% of (44.2 mmol/l) after 48 hours was significantly lower in the the bicarbonate/NAC group (P ¼ 0.019 vs. saline plus NAC sodium bicarbonate group (4.5%) compared to sodium group), and in 10.3% of the saline plus ascorbic acid plus chloride alone (13.6%, P ¼ 0.036). After adjusting for the NAC group (P ¼ 1.00 vs. saline plus NAC group). There was Mehran nephropathy risk score, the risk of CI-AKI signifi- no difference in mortality nor in need for RRT among the cantly reduced with sodium bicarbonate compared to sodium different groups. While these two studies suggest that chloride alone (adjusted risk ratio 0.29; P ¼ 0.043). isotonic bicarbonate may provide greater benefit than By contrast, Adolph et al.482 did not find differences in CI- isotonic saline, either in association with NAC or not, neither AKI between the two fluid regimens on day 1 after study can be considered conclusive. angiography; even on day 2, most parameters were similar Maioli et al.487 prospectively compared the efficacy of in both groups. In none of the above-mentioned studies was sodium bicarbonate vs. isotonic saline in addition to NAC in there need for RRT. a larger population of 502 patients with an estimated CrCl Finally, a recent but retrospective study485 defined CI-AKI o60 ml/min, and undergoing coronary angiography or as an increase in SCr X25% within 48 hours of receiving intervention. CI-AKI was defined as an absolute increase of contrast media, and compared sodium bicarbonate to SCr X0.5 mg/dl (X44.2 mmol/l) measured within 5 days. CI- normal saline in patients exposed to cardiac angiography. AKI occurred in 10.8%; 10% were treated with sodium One group of patients (n ¼ 89) received prophylactic bicarbonate and 11.5% with saline. In patients with CI-AKI, bicarbonate; a second group, normal saline (n ¼ 98). The the mean increase in creatinine was not significantly different patients in the bicarbonate group had more severe renal in the two study groups. Based on this last prospective study, disease with higher baseline SCr (1.58 ± 0.5 mg/dl; 140 ± bicarbonate does not seem to be more efficient than saline. 44.2 mmol/l) vs. (1.28 ± 0.3 mg/dl; 113 ± 26.5 mmol/l), Furthermore, a retrospective cohort study at the Mayo Clinic P ¼ 0.001 and a lower eGFR, compared to the normal saline assessed the risk of CI-AKI associated with the use of sodium group. After contrast-media exposure, there was significant bicarbonate, NAC, or the combination. Surprisingly, i.v. drop in eGFR (6.4%) and increase in SCr (11.3%) in the sodium bicarbonate was associated with an increased normal saline group and no significant change in the incidence of CI-AKI.489 bicarbonate group. Three patients (3.4%) in the bicarbonate While one might take the position that, if in doubt, one group, as opposed to 14 patients (14.3%) in the normal saline should choose the regimen that is potentially superior, the group, developed CI-AKI (P ¼ 0.011). Two patients in the Work Group also considered the potential harm. In addition, normal saline group and none in the bicarbonate group isotonic bicarbonate solutions are usually composed by needed dialysis. This study suggests that the use of i.v. adding 154 ml of 8.4% sodium bicarbonate (i.e., 1 mmol/ sodium bicarbonate is more effective than normal saline in ml) to 846 ml of 5% glucose solution, resulting in a final preventing CI-AKI. sodium and bicarbonate concentration of 154 mmol/l each. Three studies compared bicarbonate and saline solutions Since this mixing of the solution is often done at the bedside associated with the administration of NAC in both study or in the hospital pharmacy, there is the possibility for errors arms.486–488 Recio-Mayoral et al.488 conducted a prospective leading to the infusion of a hypertonic bicarbonate solution. single-center RCT in 111 consecutive patients with acute The potential for harm from dosing errors, and the added coronary syndrome undergoing emergency angioplasty. One burden from preparation of the bicarbonate solution, has to group of patients received an infusion of sodium bicarbonate be taken into account in clinical practice when making a plus NAC started just before contrast-media injection and choice between using bicarbonate rather than standard continued for 12 hours after angioplasty. The second isotonic saline solutions. Taken together, the Work Group (control) group received the standard fluid protocol consist- concluded that there is a possible but inconsistent benefit of ing of i.v. isotonic saline for 12 hours after angioplasty. In bicarbonate solutions based on overall moderate-quality both groups, two doses of oral NAC were administered the evidence (Suppl Table 22). As discussed above, the potential next day. A SCr concentration 40.5 mg/dl (444.2 mmol/l) of harm and the additional burden for preparing the from baseline after emergency angioplasty was observed in bicarbonate solutions led the Work Group not to express a 1.8% in the bicarbonate group and in 21.8% of the saline preference for or against one solution (isotonic saline or group. Mortality and need for RRT were not significantly isotonic bicarbonate). Thus, either can be used for the different between both groups. Briguori et al.486 randomized prevention of CI-AKI. 326 CKD patients (SCr X2 mg/dl [X177 mmol/l] and/or eGFR o40 ml/min per 1.73 m2), and referred for coronary 4.4.2: We recommend not using oral fluids alone in and/or peripheral procedures to three different protocols: patients at increased risk of CI-AKI. (1C) 82 Kidney International Supplements (2012) 2, 69–88
chapter 4.4 RATIONALE intoxication. A meta-analysis497 of studies using high doses Oral volume expansion may have some benefit, but there is of NAC defined the latter as a daily dose greater than 1200 mg not enough evidence to show that it is as effective as i.v. or a single periprocedural dose greater than 600 mg volume expansion.490 One small RCT of 53 patients491 who (periprocedural being described as immediately or within 4 underwent nonemergent cardiac catheterization found that hours of the planned contrast exposure). It should also be i.v. volume expansion with saline was more effective than remembered that no FDA label is available for NAC as a unrestricted oral fluid intake. A more recent trial492 examined preventive drug of AKI. the effects of oral volume intake on renal function in 180 Suppl Tables 24 and 25 summarize the quite numerous patients with preserved renal function referred for coronary RCTs where NAC has been compared to placebo on the CT angiography. The patients were divided into two groups: impact of patient mortality, need for RRT, or prevention of 106 subjects with an increase in SCr after coronary CT CI-AKI. In most of the studies, i.v. fluids, either with isotonic angiography; and 74 without. Significant correlations were saline or with isotonic bicarbonate, was used in both arms. observed between the amount of oral fluid intake and the Moreover, the impact of NAC on important ‘‘hard’’ patient percentage changes in SCr as well as the absolute changes in outcomes, such as all-cause mortality, need for RRT, or eGFR. In multiple regression analysis, the amount of oral doubling of SCr level has only rarely been studied. At present, fluid intake was the only independent predictor for an there is no current evidence that either oral or i.v. NAC can increase in SCr. However, a recent study compared oral fluids alter mortality or need for RRT after contrast-media (water with or without bicarbonate) to i.v. fluids (isotonic administration to patients at risk for CI-AKI. The only study saline or bicarbonate) and did not find differences in showing a significant decrease in hospital mortality is the incidence of CI-AKI patients with mild CKD. If confirmed three-arm study of Marenzi et al.498 in patients undergoing in larger studies, this regimen could offer an equivalent and primary angioplasty. Overall in-hospital mortality was higher more practical approach in preventing a decline in renal in patients with CI-AKI, defined as a 25% increase in SCr, function after contrast exposure, without accruing additional than in those without CI-AKI (26 % vs. 1 %; Po0.001). delay in hospital days or in-hospital mortality.493 Thirteen patients (11%) in the control group died, as did five (4%) in the standard-dose NAC and three (3%) in the high- ROLE OF NAC IN THE PREVENTION OF CI-AKI dose NAC group (P ¼ 0.02). All other studies did not show a beneficial effect on mortality (Suppl Table 25). Overall, this 4.4.3: We suggest using oral NAC, together with i.v. iso- evidence was deemed to be of moderate quality and the tonic crystalloids, in patients at increased risk of possible positive effect on mortality dubious. CI-AKI. (2D) The effect of NAC on the incidence of CI-AKI is quite variable. As is shown in the evidence profile (Suppl Table 24), the evidence that NAC reduces CI-AKI, as defined in the RATIONALE different trials, comes from studies with rather heterogeneous NAC—in many, but not all, studies—has been shown to have results; most of the studies were of either high or modest a protective effect on CI-AKI when administered before the quality. In one study, a protective—even dose-dependent— onset of renal insult; for a review, see McCullough.494 In effect was observed.498 In that study, the risk for CI-AKI was addition, NAC is inexpensive and appears to be safe, reduced by 54.5% in the standard-dose NAC group and by although it may have some detrimental effects on myocardial 75.8% in the high-dose NAC group. These findings are in and coagulation function.371–373 The ‘‘safety’’ of NAC should sharp contrast to many other studies showing no effect and, further be amended, particularly when high i.v. doses are in particular, with the large study of Webb et al.,499 which was used, as in some of the RCTs in CI-AKI. When prospectively terminated early after enrollment of 487 patients because studied in acetaminophen poisoning, i.v. NAC produced of a determination of futility by the Data Safety Monitoring anaphylactoid reactions in up to 48% of participants.374 Committee. As mentioned earlier, combination studies of Although most of these reactions were mild, at least one NAC with bicarbonate administration486 have found a death has been reported in a patient with asthma.375 It should moderate benefit for this combination, compared to the be noted that the doses used in acetaminophen intoxication combination of NAC-saline. are still much higher than in the ‘‘high doses’’ used in CI-AKI As recently remarked by Fishbane,364 most of the studies prevention trials. In a recent review,495 doses of NAC 300 mg/ published on NAC for the prevention of CI-AKI are quite kg i.v. over 21 hours, 980 mg/kg i.v. over 48 hours, and small in size, and meta-analyses have been performed to 1330 mg/kg p.o. over 72 hours were mentioned to have been increase the probability of explaining the full spectrum of all comparably effective at preventing hepatotoxicity in most utility for NAC. To date, seven out of the 11 meta-analyses uncomplicated early-presenting acute acetaminophen over- that have been published on this subject found a net benefit doses. Although a variety of doses of NAC has been for NAC in the prevention of CI-AKI.364 However, as pointed administered in the prevention of CI-AKI, the i.v. ‘‘high out before, marked heterogeneity in the studies, and doses’’ used in one study496 are mostly 2 Â 1200 mg NAC per publication bias must lead to the conclusion that ‘‘pooling day for 2–3 days, far below the doses used in acetaminophen of data to arrive at a summary estimate for treatment efficacy Kidney International Supplements (2012) 2, 69–88 83
chapter 4.4 should generally be avoided in situations where the trials NAC alone; one study compared combination therapy to exhibit significant statistical and/or clinical hetero- NAC with normal saline, and a separate arm with NAC and geneity’’.500,501 A recent prospective RCT502 was performed in ascorbic acid. Collectively, combination treatment of NAC patients with decreased kidney function (CrCl p60 ml/min with i.v. sodium bicarbonate reduced CI-AKI by 35% and/or SCr level of X1.1 mg/dl [X97.2 mmol/l]), comparing a compared to the other above-mentioned combinations (RR high oral dose of NAC with high doses of vitamin C. All 0.65; 95% CI 0.40–1.05). However, the combination of NAC patients underwent a coronary angiography. The primary end- plus sodium bicarbonate did not significantly reduce renal point was the maximum increase of SCr level, and the failure requiring dialysis (RR 0.47; 95% CI 0.16–1.41). It was secondary end-point was the incidence of CI-AKI, defined as a concluded that combination prophylaxis with NAC and relative increase in baseline SCr level of X25% and/or an sodium bicarbonate substantially reduced the occurrence absolute increase of X0.5 mg/dl (X44.2 mmol/l) within 48 of CI-AKI overall, but not dialysis-dependent renal failure. hours after contrast-media administration. The maximum This paper suggests that combination prophylaxis should increase of SCr level was significantly lower in the NAC group be incorporated for all high-risk patients (emergent cases than in the ascorbic acid group (À0.03±0.18 mg/dl [À2.65± or patients with pre-existing CKD). Most of the studies 15.9 mmol/l] vs. 0.04 ± 0.20 mg/dl [3.54±17.7 mmol/l]), administered NAC orally; some studies used the i.v. route or respectively (P ¼ 0.026). The incidence of CI-AKI tended to even a combination of oral and i.v. There was also a substantial be in favor of NAC rather than ascorbic acid, 1.2% vs. 4.4%, variation in doses and timing of NAC administration. respectively, although this difference was not significant One additional study was recently published and was thus (P ¼ 0.370). It was concluded that an oral high dose of NAC not included in the meta-analysis discussed above. Koc seemed to be more beneficial than ascorbic acid in preventing et al.,504 investigated the efficacy of prophylactic i.v. NAC and CI-AKI, particularly in diabetic patients with pre-existing CKD. fluids for the prevention of CI-AKI in patients with mild to Finally, a randomized, single-blind, controlled trial was moderate renal dysfunction (SCr X1.1 mg/dl [X97.2 mmol/l] recently published to assess NAC effects on CI-AKI and or a CrCl p60 ml/min) who were undergoing coronary reperfusion injury in ST-segment elevation myocardial angiography. A group of patients was assigned to i.v. NAC infarction (MI) patients undergoing primary angioplasty (bolus of 600 mg twice daily before and on the day of the with moderate contrast-media volumes (between 120–230 ml procedure) plus high-dose normal saline, a second group to of an iso-osmolar contrast medium).496 The patients under- only high-dose saline, and a third (control) group received going primary angioplasty were randomized to either high- standard saline. Patients in the NAC plus high-dose saline dose NAC (two times 1200 mg/d for 48 hours; or placebo group received an i.v. bolus of 600 mg of NAC twice daily plus fluids). CI-AKI occurred in 14% of the NAC group and before and on the day of the coronary procedure (total 2.4 g) in 20% of the placebo group (P ¼ 0.28). The myocardial plus i.v. 0.9% saline 1 ml/kg/h before, on, and after the day of salvage index was also not different between both treatment the coronary procedure. Patients in the high-dose arm groups. Activated oxygen protein products and oxidized low- received the same amount of isotonic saline, while patients density lipoprotein as markers for oxidative stress were in the control group received an i.v. dose of 0.9% saline reduced by as much as 20% in the NAC group, whereas no 1 ml/kg/h for 12 hours before and 12 hours after the coronary change was evident in the placebo group. procedure. The rate of CI-AKI in the NAC plus high-dose Thus, despite high-dose i.v. NAC reducing oxidative stress, saline group was lower than in the high-dose saline group it does not provide an additional clinical benefit, compared without NAC. No significant differences in the primary and to placebo, with respect to CI-AKI and myocardial reper- secondary end-points were found between the high-dose fusion injury in nonselected patients undergoing angioplasty. saline and control groups. A recent meta-analysis of all prospective trials of individuals In conclusion, based on the evidence tables and even randomized to either orally or i.v. administered high doses of taking the last recent study into account, the overall benefit of NAC, defined as a daily dose greater than 1200 mg or a single NAC is not consistent or overwhelming. On the other hand, periprocedural dose (within 4 hours of contrast-media oral NAC has a low risk of adverse events and usually a low exposure) 4600 mg, was published by Trivedi et al.497 The cost. overall effect size, assuming a common OR, was 0.46 (95% CI 0.33–0.63) for the occurrence of CI-AKI with the use of high- THEOPHYLLINE AND FENOLDOPAM IN PREVENTION OF CI-AKI dose NAC. The results of the more conservative random- Theophylline effects approach were similar (OR 0.52; 95% CI 0.34–0.78). Another recently published meta-analysis of RCTs inclu- 4.4.4: We suggest not using theophylline to prevent ded published trials and conference abstracts (Figure 16).503 CI-AKI. (2C) The primary and secondary outcomes of interest were CI-AKI, and renal failure requiring dialysis, respectively. Ten RCTs met the inclusion criteria. Nine studies compared RATIONALE combination treatment (bicarbonate and NAC) to NAC and A rationale for the prophylactic use of adenosine antago- normal saline; one study compared combination therapy to nists in patients undergoing radiocontrast procedures was 84 Kidney International Supplements (2012) 2, 69–88
chapter 4.4 Figure 16 | NAC and bicarbonate vs. NAC for risk of CI-AKI. Reprinted from Brown, JR, Block CA, Malenka DJ et al. Sodium bicarbonate plus N-acetylcysteine prophylaxis: a meta-analysis. JACC Cardiovasc Interv 2009; 2: 1116–1124,503 copyright 2009, with permission from American College of Cardiology Foundation; accessed http://interventions.onlinejacc.org/cgi/content/full/2/11/1116 suggested by results showing increased serum levels and Neither meta-analysis included a RCT published in 2006 urinary excretion of adenosine occurring after intravascular in 150 contrast-media examinations in 91 patients, in which administration of contrast media.505 The efficacy of theo- the renoprotective effects of theophylline, NAC, and the phylline in preventing CI-AKI has been addressed by a combination of both were directly compared.507 All patients systematic review and meta-analysis in 2005 (nine RCTs, 585 had at least one risk factor for developing CI-AKI, and patients),506 and another meta-analysis in 2008 (six RCTs, received more than 100 ml of low-osmolar radiocontrast 629 patients).432 Both meta-analyses indicated a nonsigni- agent. The incidence of CI-AKI was significantly lower with ficant trend toward a renoprotective effect of theophylline theophylline as compared to NAC pretreatment (2% vs. 12%; prophylaxis. The incidence of CI-AKI tended to be P ¼ 0.045), and did not differ between theophylline mono- lower (Bagshaw: OR 0.4, CI 0.14–1.16, P ¼ 0.09; Kelly: OR therapy and the combination treatment. The renoprotective 0.49, CI 0.23–1.06, P ¼ 0.14), SCr concentrations 48 hours superiority of theophylline, which was given as a single i.v. after intervention were significantly lower (À0.17 mg/dl; 200 mg dose 30 minutes prior to the procedure, was even 95% CI À0.2 to À0.06 mg/dl [À15.0 mmol/l, CI À17.7 to more significant in patients with pre-existing renal damage as À5.30 mmol/l]; P ¼ 0.002) with theophylline compared to indicated by an SCr 41.5 mg/dl (4133 mmol/l) (P ¼ 0.008). control therapies. However, the overall benefit was small and Moreover, a recent study508 randomized 217 patients with findings were inconsistent across studies. The benefit eGFR between 30 and 60 ml/min who were undergoing attributable to the use of theophylline tended to be less coronary angiography to one of three prophylactic treat- marked in patients receiving iso-osmolar, nonionic contrast ments: i.v. isotonic saline (1 ml/kg/h for 12 hours before and media, and in patients undergoing a predefined saline after contrast media (group 1, n ¼ 72); isotonic saline as in protocol. group 1 together with NAC (600 mg p.o. twice daily the Kidney International Supplements (2012) 2, 69–88 85
chapter 4.4 preceding day and the day of angiography (group 2, n ¼ 73); were randomized to saline alone or with fenoldopam or isotonic saline and NAC as in group 2 together with (0.1 mg/kg per minute for 4 hours before and after the 200 mg theophylline orally twice daily for the preceding day procedure); a third arm was treated with NAC. The incidence and the day of angiography (group 3, n ¼ 72). The incidence of CI-AKI was similar in the fenoldopam (15.7%) and of CI-AKI (0.5 mg/dl or 44.2 mmol/l SCr increase within 48 control (15.3%) groups, and there was no benefit over hours of intravascular contrast-media injection) was 6.9% in saline alone. A second, larger trial220 also confirmed the group 1, 9.6% in group 2, and 0% in group 3 (Po0.03), lack of benefit with fenoldopam. In this double-blind trial suggesting a beneficial effect of adding theophylline to a of 315 patients, all with saline 0.45%, were randomized to standard regimen in the prevention of CI-AKI. Notably, at fenoldopam (0.05 mg/kg per minute titrated to 0.1 mg/kg least in this study, NAC administration had no additive per minute) or placebo starting 1 h before the procedure and protective effect compared to isotonic saline alone. continuing for 12 hours afterward. There was no significant A very recent study509 randomly assigned patients to difference in the incidence of CI-AKI within 96 hours in prophylactic administration of saline with sodium bicarbo- the two groups (fenoldopam, 33.6%; placebo, 30.1%) or in nate plus theophylline (either orally or i.v.) or sodium the rates of dialysis, rehospitalization, or death at 30 days. bicarbonate only. Theophylline plus bicarbonate prophylaxis significantly reduced the incidence of CI-AKI (1.6% vs. 7.9%; Statins in the prevention of CI-AKI P ¼ 0.015) compared to bicarbonate alone. Theophylline was Two recent studies examined the use of statins in the administered either orally (200 mg b.i.d. starting the day prevention of CI-AKI patients with CKD. In the first study,514 before the contrast administration and continuing for 24 31 patients were prospectively randomized to receive atorvas- hours thereafter) or i.v. 200 mg in a short infusion before tatin 80 mg/d or placebo for 48 hours before and 48 hours contrast administration and continuing orally at 200 mg after contrast-medium administration. All patients received i.v. b.i.d. for 48 hours. Theophylline prophylaxis significantly saline and oral NAC. CI-AKI occurred in 16 patients (11%) in reduced the incidence of CI-AKI in moderate and high-risk the placebo group and 15 patients (10%) in the atorvastatin patients (0% vs. 8.8%; P ¼ 0.022 and 9.1% vs. 42.1%; group. Persistent kidney injury, defined as 1-month increase P ¼ 0.014, respectively). This study did not mention side- from baseline creatinine value 425%, was observed in 30% effects of theophylline. in the placebo group and in 31% in the atorvastatin group. Although these data suggest that preinterventional theo- The second study515 followed 431 patients, 194 of whom were phylline administration might be helpful in patients at receiving pravastatin treatment for hypercholesterolemia. SCr increased risk for CI-AKI, the possibility of cardiovascular levels were measured at baseline (preprocedure) and within 48 side-effects and the interactions with numerous drugs hours after contrast-medium exposure (peak postprocedure). associated with theophylline510,511 should be recognized Logistic regression analysis revealed that pravastatin treatment, (Suppl Tables 26 and 27). As can be noted from the evidence preprocedure SCr, and contrast volume were independently profile tables, the evidence is low and the balance of benefits related to the decreased risk of CI-AKI. However, such studies vs. harm is uncertain. In view of the low evidence and the are susceptible to the so-called ‘‘healthy user effect’’ where uncertain balance of benefits vs. harm, the Work Group certain groups may have reduced risk, not because of the does not support the use of theophylline for prevention of drug but because of healthier lifestyles, for which use of the CI-AKI. medication is a marker. For example, patients taking statins may also be more compliant with other medical-care regimens Fenoldopam that may reduce adverse events. 4.4.5: We recommend not using fenoldopam to prevent SUPPLEMENTARY MATERIAL CI-AKI. (1B) Supplementary Table 22: Evidence profile of RCTs examining effect of i.v. sodium bicarbonate vs. control for the prevention of CI-AKI. Supplementary Table 23: Summary table of RCTs examining the effect RATIONALE of i.v. sodium bicarbonate on the prevention of CI-AKI. Supplementary Table 24: Evidence profile of RCTs examining the effect Fenoldopam is a selective dopamine A1 receptor agonist of NAC vs. placebo on the prevention of CI-AKI. that might theoretically increase blood flow, especially to the Supplementary Table 25: Summary table of RCTs examining the effect renal medulla. Several uncontrolled studies (historical of NAC vs. placebo on the prevention of CI-AKI. controls, retrospective review) suggested that it is effective Supplementary Table 26: Evidence profile of RCTs examining the effect in reducing the risk for contrast-induced nephropathy, and of theophylline vs. placebo on the prevention of CI-AKI. Supplementary Table 27: Summary table of RCTs examining the effect the results of a pilot trial were promising (for review, see of theophylline vs. placebo on the prevention of CI-AKI. Stacul et al.512). However, two prospective randomized trials Supplementary material is linked to the online version of the paper at showed negative results.220,513 In the first trial,513 patients http://www.kdigo.org/clinical_practice_guidelines/AKI.php 86 Kidney International Supplements (2012) 2, 69–88
http://www.kidney-international.org chapter 4.5 & 2012 KDIGO Chapter 4.5: Effects of hemodialysis or hemofiltration 4.5.1: We suggest not using prophylactic intermittent By contrast, Lee et al.521 presented a prospective RCT hemodialysis (IHD) or hemofiltration (HF) for indicating that prophylactic IHD might be useful in patients contrast-media removal in patients at increased scheduled for coronary angiography or coronary intervention risk for CI-AKI. (2C) with severely impaired renal function (baseline CrCl of 13 ml/ min per 1.73 m2). Patients were treated with normal saline at 1 ml/kg/h for 6 hours before and 12 hours after contrast- RATIONALE media administration and randomized to receive IHD for Contrast media are excreted mainly by glomerular filtration 4 hours as soon as possible after angiography or control and there is a significant correlation between both total body treatment. Four days after angiography, SCr concentrations and renal clearances of contrast media and GFR; the renal were lower in the IHD group compared to the control group. excretion of contrast media will thus be delayed in patients Out of 42 patients, one patient (2%) in the IHD group but 14 with renal failure (for review, see Deray).516 Contrast media (35%) out of 40 patients in the control group required can be efficiently removed from blood by IHD and a single temporary IHD after coronary angiography. Furthermore, session effectively removes 60–90% of contrast media.516,517 none of the 42 patients in the IHD group, but five (13%) out On the basis of these observations, several studies have of 40 patients in the control group, required maintenance explored the prophylactic value of IHD in patients at high IHD after discharge from the hospital (Po0.05). risk, but most of these studies have not demonstrated a A recent meta-analysis of studies using periprocedural reduced incidence of CI-AKI.516,518 For example, Vogt extracorporeal blood purification techniques517 concluded et al.518 recorded renal function and other parameters, IHD that such treatments did not decrease the incidence of requirements, and relevant clinical events before and during 6 CI-AKI. It could theoretically be anticipated that high-flux days after administration of contrast media in 113 patients membranes used in HF or hemodiafiltration (HDF) moda- with a baseline SCr 42.3 mg/dl (4203 mmol/l). Eight out of lities should be able to remove contrast media more 55 patients in the prophylactic IHD group and three in the efficiently than low-flux membranes used in routine IHD. non-IHD group (P ¼ 0.12), required IHD after contrast- However, recent publications on this topic have added to the media examination. Reinecke et al.519 performed a prospec- controversy about the role of IHD or HF to prevent CI-AKI tive single-center trial in 424 consecutive patients with (Suppl Tables 28 and 29). Marenzi et al.522 studied 114 SCr concentrations between 1.3–3.5 mg/dl (115–309 mmol/l) consecutive patients with CRF (SCr concentration 42 mg/dl who underwent elective coronary angiography. Patients were or 4177 mmol/l) who were undergoing coronary interven- randomized to one of three treatment strategies with all tions. Fifty-eight patients were assigned to either HF starting patients receiving pre- and postprocedural fluids: one group before the contrast-medium administration and continuing received no additional therapy, patients in the second group for up to 24 hours after, while 56 patients were treated with were hemodialyzed once, and the third group received oral isotonic saline at a rate of 1 ml per kilogram of body weight NAC. The frequency of CI-AKI (defined as an increase in SCr per hour, given in a step-down unit over the same time X0.5 mg/dl or X44.2 mmol/l) from 48 to 72 hours after interval. In-hospital mortality was 2% in the HF group and catheterization was 6.1% in the fluids-only group, 15.9% with 14% in the control group (P ¼ 0.02), and the cumulative IHD treatment, and 5.3% in the NAC group (intention- 1-year mortality was 10% and 30%, respectively (P ¼ 0.01). to-treat analysis; P ¼ 0.008). There were no differences Temporary RRT was required in 25% of the control group between the treatment groups with regard to increased SCr and in only 3% of the patients in the HF group. An increase X0.5 mg/dl (X44.2 mmol/l) after 30–60 days (4.8%, 5.1%, and in the SCr concentration of 425% from the baseline value 3.1%, respectively; P ¼ 0.700). Analyses of long-term follow- after the coronary intervention occurred less frequently up (range 63–1316 days) by Cox regressions models of the among patients in the HF group than among the control study groups found quite similar survival rates (P ¼ 0.500). patients (5% vs. 50%, Po0.001). The effective removal of This large study concluded that IHD, in addition to fluids, for creatinine during HF or IHD makes it difficult to be certain the prevention of CI-AKI provided no evidence for any that an observed lower incidence of CI-AKI is not related to outcome benefit but showed evidence for probable harm. the transport removal of creatinine during the procedure. A retrospective but important cohort study of 391 patients In a subsequent study, the same authors523 randomized (age 69 ± 8 years, with chronic renal insufficiency [SCr 92 patients with CKD (CrCl p30 ml/min) to three different X1.3 mg/dl; X115 mmol/l]) who underwent cardiac cathe- prophylactic treatments: i.v. isotonic saline (control group); terization, also did not find any beneficial preventive effect.520 i.v. saline for 12 hours before contrast-media exposure, Kidney International Supplements (2012) 2, 69–88 87
chapter 4.5 followed by HF for 18–24 hours after contrast-media Novartis, Robert and Jane Cizik Foundation, Shire, exposure; and a third group where HF was performed for 6 Transwestern Commercial Services, and Wyeth. KDIGO is hours before and for 18–24 hours after contrast-media supported by a consortium of sponsors and no funding is exposure. The incidence of CI-AKI (425% increase in accepted for the development of specific guidelines. SCr) and the in-hospital clinical course were compared in the three groups. In-hospital mortality was 20%, 10%, and 0%, DISCLAIMER respectively, in the three groups; IHD was required in nine While every effort is made by the publishers, editorial (30%), 3 (10%), and zero (0%) patients, respectively board, and ISN to see that no inaccurate or misleading data, (P ¼ 0.002). According to these results, pre-HF is required opinion or statement appears in this Journal, they wish to obtain the full clinical benefit, suggesting that among to make it clear that the data and opinions appearing in different mechanisms possibly involved, high-volume con- the articles and advertisements herein are the responsibility trolled volume expansion before contrast-media exposure of the contributor, copyright holder, or advertiser concerned. plays a major role in prevention. This study further suggests Accordingly, the publishers and the ISN, the editorial board that bicarbonate exposure with HF may ultimately have been and their respective employers, office and agents accept the mechanism for the lower CI-AKI incidence (Suppl Table no liability whatsoever for the consequences of any such 29). In summary, the evidence profile for IHD vs. HF showed inaccurate or misleading data, opinion or statement. While low-quality evidence and an uncertain benefit vs. harm every effort is made to ensure that drug doses and other balance of HF/IHD in preventing CI-AKI in patients with quantities are presented accurately, readers are advised that severe CKD. Given the costs and logistical difficulties, the use new methods and techniques involving drug usage, and of HF modalities for CI-AKI prevention can only be described within this Journal, should only be followed in advocated if future studies will convincingly show clear conjunction with the drug manufacturer’s own published benefit. literature. SPONSORSHIP SUPPLEMENTARY MATERIAL KDIGO gratefully acknowledges the following sponsors that Supplementary Table 28: Evidence profile of RCTs examining the effect make our initiatives possible: Abbott, Amgen, Belo Founda- of hemodialysis or hemofiltration on the prevention of CI-AKI. Supplementary Table 29: Summary table of RCTs examining the effect tion, Coca-Cola Company, Dole Food Company, Genzyme, of hemodialysis or hemofiltration on the prevention of CI-AKI. Hoffmann-LaRoche, JC Penney, NATCO—The Organization Supplementary material is linked to the online version of the paper at for Transplant Professionals, NKF—Board of Directors, http://www.kdigo.org/clinical_practice_guidelines/AKI.php 88 Kidney International Supplements (2012) 2, 69–88
http://www.kidney-international.org chapter 5.1 & 2012 KDIGO Section 5: Dialysis Interventions for Treatment of AKI Kidney International Supplements (2012) 2, 89–115; doi:10.1038/kisup.2011.35 Chapter 5.1: Timing of renal replacement therapy in AKI Whether or not to provide RRT, and when to start, are two of infusion, and beta-2 agonists) are exhausted, an excess of the fundamental questions facing nephrologists and inten- potassium can only be eliminated with RRT. On the other sive-care practitioners in most cases of severe AKI. In recent hand, when intermittent dialysis is used after these publications, the timing of initiation of RRT was listed as one therapeutic interventions, the extracorporeal removal of of the top priorities in research on AKI.524 However, this potassium will be reduced and the post-treatment rebound dimension has not been included as a factor in any of the of serum potassium will be more pronounced.526 large RCTs in this area. The optimal timing of dialysis for Metabolic acidosis is a frequent clinical problem in AKI is not defined. In current practice, the decision to start patients with severe AKI. Although the discussion as to RRT is based most often on clinical features of volume when metabolic acidosis in critically ill patients should be overload and biochemical features of solute imbalance corrected is outside the scope of this guideline, metabolic (azotemia, hyperkalemia, severe acidosis). However, in the acidosis associated with AKI can usually be corrected with absence of these factors there is generally a tendency to avoid bicarbonate and should rarely require urgent dialysis if not dialysis as long as possible, a thought process that reflects the accompanied by volume overload or uremia.527 As the pH decisions made for patients with CKD Stage 5. and bicarbonate values to initiate dialysis for metabolic Clinicians tend to delay RRT when they suspect that acidosis are not supported by evidence, no standard criteria patients may recover on their own, and because of concern for initiating dialysis for acidosis exist. A variety of poisons, for the well-known risks associated with the RRT procedure, drug overdoses, and toxic compounds (e.g., salicylates, including hypotension, arrhythmia, membrane bioincom- ethylene glycol, methanol, metformin) can contribute to patibility, and complications of vascular access and anti- acid-base problems and also lead to AKI. In these circum- coagulant administration. There is also some concern that stances, RRT may also facilitate removal of the offending RRT may compromise recovery of renal function, and drug.528–530 increase the progression of CKD.525 Whether these risks Only one RCT has evaluated the effect of timing of outweigh the potential benefits of earlier initiation of RRT is initiation of RRT on outcome. Bouman et al.531 randomized still unclear. 106 critically ill patients with AKI to early vs. late initiation of RRT. The early initiation group started RRT within 5.1.1: Initiate RRT emergently when life-threatening 12 hours of oliguria (o30 ml/h for 6 hours, not respond- changes in fluid, electrolyte, and acid-base balance ing to diuretics or hemodynamic optimization), or CrCl exist. (Not Graded) o20 ml/min. The late-initiation group started RRT when 5.1.2: Consider the broader clinical context, the presence classic indications were met. The study did not find of conditions that can be modified with RRT, and differences in ICU or hospital mortality, or in renal recovery trends of laboratory tests—rather than single BUN among survivors, but was clearly too small to allow for and creatinine thresholds alone—when making the definitive conclusions (Suppl Table 30). decision to start RRT. (Not Graded) The remaining data come from observational studies. The association of early initiation of dialysis with survival benefit was first suggested by case series with historical controls RATIONALE conducted in the 1960 s and 1970 s.532–535 In these studies, While no RCTs exist for dialysis for life-threatening levels of blood urea or BUN were used to distinguish early vs. indications, it is widely accepted that patients with severe late start of dialysis. However, these studies mostly combined hyperkalemia, severe acidosis, pulmonary edema, and uremic early start with more-intensive dialysis and late start with complications should be dialyzed emergently. In the absence less-intensive dialysis. More recent studies have continued the of kidney function, and when therapeutic measures that trend focusing on BUN as a biomarker for starting RRT. promote the intracellular shift of potassium (such as Single-center observational studies that were restricted to correction of acidosis with bicarbonate, glucose and insulin AKI after trauma536 and coronary artery bypass surgery537,538 Kidney International Supplements (2012) 2, 89–115 89
chapter 5.1 suggested a benefit to RRT initiation at lower BUN concen- a causal relationship remains to be proven, although a trations. A prospective multicenter observational cohort randomized trial in hemodynamically stable patients with study performed by the Program to Improve Care in Acute acute respiratory distress syndrome seems to suggest that Renal Disease (PICARD) analyzed dialysis initiation—as it is.549 Randomizing patients according to RRT initiation on inferred by BUN concentration—in 243 patients from five the basis of fluid status would allow this question to be geographically and ethnically diverse clinical sites. Adjusting answered. A secondary analysis of a randomized trial for age, hepatic failure, sepsis, thrombocytopenia, and SCr, comparing IHD to CRRT showed that patients receiving and stratified by site and initial dialysis modality, initiation of RRT predominantly for solute control experienced better RRT at higher BUN (476 mg/dl [blood urea427.1 mmol/l]) outcomes than those predominantly treated for volume was associated with an increased risk of death (RR 1.85; 95% overload. Patients dialyzed for control of both azotemia and CI 1.16–2.96).539 In a prospective multicenter observational volume overload experienced the worst outcome.550 Analysis study conducted at 54 ICUs in 23 countries, timing of RRT of a multicenter observational cohort showed that mean was stratified into ‘‘early’’ or ‘‘late’’ by median urea at the daily fluid balance in AKI patients was significantly more time RRT started (24.2 mmol/l [BUN 67.8 mg/dl]), and also positive among nonsurvivors than survivors.84 Data from categorized temporally from ICU admission into early (less the PICARD group examining 396 ICU patients with AKI than 2 days), delayed (between 2–5 days), or late (more than requiring RRT further supports these findings. Survivors had 5 days). Timing by serum urea showed no significant lower fluid accumulation at dialysis initiation compared to difference in mortality. However, when timing was analyzed nonsurvivors (8.8% vs. 14.2% of baseline body weight; in relation to ICU admission, late RRT was associated with P ¼ 0.01 adjusted for dialysis modality and severity score). greater crude mortality (72.8% late vs. 62.3% delayed vs. 59% The adjusted OR for death associated with fluid overload at early, P ¼ 0.001) and covariate-adjusted mortality (OR 1.95; dialysis initiation was 2.07 (95% CI 1.27–3.37).83 These data 95% CI 1.30–2.92; P ¼ 0.001). Overall, late RRT was asso- suggest that fluid overload should be further evaluated as ciated with a longer duration of RRT and stay in hospital, and parameter to guide the initiation of RRT (see also Pediatric greater dialysis dependence.540 It is, however, not clear Considerations). whether AKI occurring later in the course of ICU stay has the Other factors that might influence the decision of when to same pathophysiology and prognosis than AKI present on or start RRT are the severity of the underlying disease (affecting early after admission. The most recent study on this subject is the likelihood of recovery of kidney function), the degree of the analysis of surgical ICU patients with AKI, showing that dysfunction in other organs (affecting the tolerance to e.g., late initiation of RRT (defined as RIFLE-I or -F) was an inde- fluid overload), the prevalent or expected solute burden (e.g., pendent predictor of mortality (HR 1.846; CI 1.07–3.18).541 in tumor lysis syndrome), and the need for fluid input related Traditional indications for RRT, developed for patients to nutrition or drug therapy (Table 17). Early detection and with advanced CKD, are not necessarily valid in the context accurate prediction of patients that ultimately will require of AKI. For instance, massive volume overload resulting from RRT may allow earlier initiation in those who need it and, at volume resuscitation may be an indication for RRT even in the same time, prevent harm in those who do not. Recent the absence of significant elevations in BUN or SCr. In this evidence suggests a potential role for biomarkers in this field. instance, it may be more appropriate to consider dialytic Plasma neutrophil gelatinase-associated lipocalin was shown intervention in the ICU patient as a form of renal support to have an area under the receiver operating characteristic rather than renal replacement. Indeed, some of the curve of 0.82 for the prediction of RRT requirement.551 traditional indications for dialysis (e.g., uremic pericarditis, pleuritis, encephalopathy, coagulopathy) would be consid- Pediatric considerations ered ‘‘complications’’ of AKI rather than indications for RRT. Provision of acute RRT to children requires special consi- Additionally, the decision to start RRT should recognize the derations. Pediatric and adolescent patients range in age from goals of therapy, keeping in mind the therapeutic potential of the premature neonate to 25 years of age, with a size range of dialysis in general, and each dialysis modality in particular. 1.5–200 kg. In addition, the epidemiology of the pediatric The treatment of AKI with RRT has the following goals: i) to AKI has changed from primary kidney disease in the 1980 s to maintain fluid and electrolyte, acid-base, and solute homeo- injury resulting from another systemic illness or its treatment stasis; ii) to prevent further insults to the kidney; iii) to (e.g., sepsis and nephrotoxic medications).552,553 Newborns permit renal recovery; and iv) to allow other supportive with inborn errors of metabolism who do not respond to measures (e.g., antibiotics, nutrition support) to proceed dietary and pharmacologic management require expeditious without limitation or complication. Ideally, therapeutic inter- dialytic removal of ammonia to decrease the risk of death and ventions should be designed to achieve the above goals and a long-term neurologic dysfunction,554 and infants who receive systematic assessment of all these factors is key to determi- surgical correction of congenital heart disease, often receive ning the optimal timing for initiating dialysis (Table 17). PD early after cardiopulmonary bypass to prevent fluid There is increasing evidence that fluid overload in critical overload and/or minimize the proinflammatory response. illness and AKI is associated with adverse outcomes, Finally, children develop multiorgan dysfunction very rapidly especially in the pediatric setting.83,84,542–549 Whether this is in their ICU course, with the maximal organ dysfunction 90 Kidney International Supplements (2012) 2, 89–115
chapter 5.1 Table 17 | Potential applications for RRT Applications Comments Renal replacement This is the traditional, prevailing approach based on utilization of RRT when there is little or no residual kidney function. Life-threatening indications No trials to validate these criteria. Hyperkalemia Dialysis for hyperkalemia is effective in removing potassium; however, it requires frequent monitoring of potassium levels and adjustment of concurrent medical management to prevent relapses. Acidemia Metabolic acidosis due to AKI is often aggravated by the underlying condition. Correction of metabolic acidosis with RRT in these conditions depends on the underlying disease process. Pulmonary edema RRT is often utilized to prevent the need for ventilatory support; however, it is equally important to manage pulmonary edema in ventilated patients. Uremic complications In contemporary practice it is rare to wait to initiate RRT in AKI patients until there are uremic complications. (pericarditis, bleeding, etc.) Nonemergent indications Solute control BUN reflects factors not directly associated with kidney function, such as catabolic rate and volume status. SCr is influenced by age, race, muscle mass, and catabolic rate, and by changes in its volume of distribution due to fluid administration or withdrawal. Fluid removal Fluid overload is an important determinant of the timing of RRT initiation. Correction of acid-base No standard criteria for initiating dialysis exist. abnormalities Renal support This approach is based on the utilization of RRT techniques as an adjunct to enhance kidney function, modify fluid balance, and control solute levels. Volume control Fluid overload is emerging as an important factor associated with, and possibly contributing to, adverse outcomes in AKI. Recent studies have shown potential benefits from extracorporeal fluid removal in CHF. Intraoperative fluid removal using modified ultrafiltration has been shown to improve outcomes in pediatric cardiac surgery patients. Nutrition Restricting volume administration in the setting of oliguric AKI may result in limited nutritional support and RRT allows better nutritional supplementation. Drug delivery RRT support can enhances the ability to administer drugs without concerns about concurrent fluid accumulation. Regulation of acid-base Permissive hypercapnic acidosis in patients with lung injury can be corrected with RRT, without inducing fluid overload and electrolyte status and hypernatremia. Solute modulation Changes in solute burden should be anticipated (e.g., tumor lysis syndrome). Although current evidence is unclear, studies are ongoing to assess the efficacy of RRT for cytokine manipulation in sepsis. AKI, acute kidney injury; BUN, blood urea nitrogen; CHF, congestive heart failure; SCr, serum creatinine; RRT, renal replacement therapy. Table 18 | Fluid overload and outcome in critically ill children with AKI Author Cohort (N) Outcome P 545 Goldstein 2001 Single-center (22) Survivors 16% FO Nonsurvivors 34% FO 0.03 Gillespie 2004544 Single-center (77) % FO 410% with OR death 3.02 0.002 Foland 2004543 Single-center (113) 3 organ MODS patients 0.01 Survivors 9% FO Nonsurvivors 16% FO 1.78 OR death for each 10% FO increase Goldstein 2005546 Multicenter (116) 2+ organ MODS patients 0.002 Survivors 14% FO Nonsurvivors 25% FO o20% FO: 58% survival 420% FO: 40% survival Hayes 2009547 Single-center (76) Survivors 7% FO Nonsurvivors 22% FO 0.001 OR death 6.1 for 420% FO Sutherland 2010548 Multicenter (297) o10% FO: 70% survival 0.001 10–20% FO: 57% survival 420% FO: 34% survival OR 1.03 (1.01–1.05) per % FO AKI, acute kidney injury; FO, fluid overload; MODS, multiple-organ dysfunction syndrome; OR, odds ratio. Reprinted from Goldstein SL. Advances in pediatric renal replacement therapy for acute kidney injury. Semin Dial 2011; 24: 187–191 with permission from John Wiley and Sons560; accessed http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2011.00834.x/full occurring with 72 hours and mortality occurring within 7 Both recommendations in this section of the guideline are days of ICU admission, respectively.555,556 Thus, the issue of applicable to pediatric patients. A detailed discussion of the timing of dialysis initiation is critically important in children. specific pediatric clinical situations is beyond the scope of Kidney International Supplements (2012) 2, 89–115 91
chapter 5.1 this guideline, and the reader is referred to in-depth in 297 children treated with RRT: 29.6% mortality with less reviews.557,558 than 10% fluid overload, 43.1% with 10–20% fluid overload, Importantly, fluid overload has emerged as a significant and 65.6% with 420% fluid overload.548 However, strong factor associated with mortality in children with AKI evidence to suggest that preventing this fluid overload with requiring CRRT (Table 18), although the physiological link earlier RRT will improve outcome remains absent. between increasing percent volume overload and mortality is not completely clear.543–548,559 The largest trial to assess this RESEARCH RECOMMENDATIONS relationship in children is a multicenter prospective study K Determine reproducible criteria (e.g., fluid overload, showing that the percentage fluid accumulation at CRRT biomarker level, severity score) to inform the decision to initiation is significantly lower in survivors vs. non-survivors start RRT in adult and pediatric AKI patients. Such (14.2 ± 15.9% vs. 25.4 ± 32.9%; Po0.03) even after criteria may also permit the identification of patients who adjustment for severity of illness. This study also found a will ultimately require RRT and hence limit uncertainty significantly higher mortality in patient with 420% fluid around whether to begin therapy. overload (58%) vs. o20% fluid overload (40%) at CRRT K Determine whether early vs. late start of RRT, based on initiation.546 One retrospective study, in pediatric patients the above-mentioned criteria, results in improved clinical who received stem-cell transplantation and developed AKI, outcomes (e.g., mortality, evolution to CKD Stage 5) of suggested that survival may be improved by an aggressive use AKI patients. of diuretics and early initiation of RRT. All survivors (n ¼ 11) maintained or remained with percentage fluid accumulation o10%, with diuretics and RRT. Among the 15 nonsurvivors, SUPPLEMENTARY MATERIAL Supplementary Table 30: Summary table of RCTs examining the effect only 6 (40%) had percentage fluid accumulation o10% at of early vs. late CVVH in the treatment of AKI. the time of death.559 The latest analysis on this issue Supplementary material is linked to the online version of the paper at confirmed increased mortality with increasing fluid overload http://www.kdigo.org/clinical_practice_guidelines/AKI.php 92 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.2 & 2012 KDIGO Chapter 5.2: Criteria for stopping renal replacement therapy in AKI Although many patients with AKI recover kidney function solute levels prevent achieving a steady state and thus exclude sufficiently to be independent of RRT, discontinuation of the use of clearance measurements. Native kidney function RRT in AKI has received little attention in the literature. The can only be assessed during the interdialytic period by decision whether or when to stop RRT in a patient with AKI evaluating urine volume, urinary excretion of creatinine, and needs to consider an improvement in kidney function changes in SCr and/or BUN values. However, one must adequate to meet demand, an improvement in the disorder realize that intermittent treatment will be associated with that prompted kidney support or futility. It is evident post-treatment rebound in solute levels, and that changes that each of these events is influenced by the initial in BUN and creatinine levels can also be modified by indication for starting RRT and is subject to individual nonrenal factors, such as volume status and catabolic rate. variation. The strategy for stopping RRT requires considera- In CRRT, continuous solute clearance of 25–35 ml/min will tion of additional factors and often involves a modality stabilize serum markers after 48 hours. This allows more transition. reliable measurements of CrCl by the native kidneys during CRRT. 5.2.1: Discontinue RRT when it is no longer required, Very few investigators have looked at urine CrCl values as either because intrinsic kidney function has recov- a guide for CRRT withdrawal. One small retrospective study ered to the point that it is adequate to meet patient (published as abstract) demonstrated that a CrCl (measured needs, or because RRT is no longer consistent with over 24 hours) 415 ml/min was associated with successful the goals of care. (Not Graded) termination of CRRT, defined as the absence of CRRT requirement for at least 14 days following cessation.567 Further prospective trials will be needed to support these RATIONALE findings. A large prospective observational study showed Many, but not all, patients requiring RRT will recover that, in 529 patients who survived the initial period of CRRT, enough function not to require long-term RRT. 21,394,561 313 were successfully removed from RRT, whereas 216 The mean duration of RRT in two recent large RCTs patients needed ‘‘repeat CRRT’’ within 7 days of discontinua- was 12–13 days.562,563 Thus, daily assessment of both tion. Multivariate logistic regression identified urine output intrinsic kidney function and the ongoing appropriate- as the most significant predictor of successful termination ness of RRT consistent with the goals of therapy for the (OR 1.078 per 100 ml/d). Not surprisingly, the predictive patient are required. More than 50% of patients with severe ability of urine output was negatively affected by the use AKI will not improve, despite appropriate therapy. The of diuretics.196 Another retrospective observational analysis incidence of withdrawal of life-support treatments in showed that, of a total of 304 patients with postoperative critically ill patients with multiorgan failure has increased AKI requiring RRT (IHD), 31% could be weaned for more over the last decade.564 In addition to vasoactive medication, than 5 days and 21% were successfully weaned for at least mechanical ventilation, and artificial nutrition, RRT is one of 30 days. Independent predictors for restarting RRT within the therapies most likely to be discontinued during with- 30 days were longer duration of RRT, a higher Sequential drawal of life support. In general, decisions to withdraw Organ Failure Assessment score, oliguria, and age 465 therapy occur in 10% of all patients from general ICUs, and years.568 In other words, urine output seems to be a very are responsible for roughly 40% of all deaths. Analysis of a important predictor of successful discontinuation of RRT. database of 383 AKI patients shows withdrawal of life Whether too-early discontinuation of RRT, requiring support in 72% of deaths.565 In another single-center reinstitution, is by itself harmful has not been properly retrospective study involving 179 AKI patients requiring investigated. The above-mentioned observational studies RRT, therapy was withheld or withdrawn in 21.2%.566 A found a higher mortality in patients who needed to be posthoc analysis of the BEST KIDNEY database showed that retreated with RRT (42.7% vs. 28.5%196 and 79.7% vs. CRRT was withdrawn in 13% of the patients, representing 40%568). It is, however, not clear whether failure to wean is 29% of those who died while on CRRT and 21% of all simply a marker of illness severity or contributed by itself to nonsurvivors.196 the adverse outcome. Assessment of kidney function during RRT is not easy and The process of stopping RRT may consist of simple will depend on the modality used. In IHD, the fluctuations of discontinuation of RRT, or may include a change in the Kidney International Supplements (2012) 2, 89–115 93
chapter 5.2 modality, frequency, or duration of RRT. For example, Pediatric considerations switching from CRRT to IHD, or decreasing the frequency of The medical indications guiding discontinuation of RRT in IHD from daily to every other day, represents different children do not differ from adults, except in those instances methods of testing the ability of the patient’s own kidney to where RRT is initiated for pediatric-specific disease, such as take over. No specific guidance can be provided for how to inborn errors of metabolism to treat hyperammonemia557 or manage the transition of RRT from continuous to inter- immediately after surgical correction of congenital heart mittent. Evidence from large observational studies suggests disease to maintain euvolemia, and/or possibly mitigate the that large variation in practice exists.196 postbypass proinflammatory response.558 Prognosis in children who survive an AKI episode is 5.2.2: We suggest not using diuretics to enhance kidney significantly better than in adults, and many children may have function recovery, or to reduce the duration or several decades of life expectancy. Askenazi demonstrated nearly frequency of RRT. (2B) 80% 3- to 5-year survival for children discharged after an AKI episode from a tertiary center,569 yet two-thirds of deaths occur- red in the first 2 years after discharge, suggesting a high prob- RATIONALE ability of greater life expectancy after that period. In addition, no The role of diuretics in the prevention and treatment of AKI data exist to define a maximal RRT duration; even data from the has already been discussed in Chapter 3.4. Only one RCT has Prospective Pediatric CRRT Registry show 35% survival in evaluated the potential role of diuretics in resolving AKI in children receiving CRRT for 428 days.570 Finally, since pediatric patients receiving RRT. After the end of the CVVH session, AKI now results more often as a secondary phenomenon from the urine of the first 4 hours was collected for measuring another systemic illness or its treatment,552,553 determination of CrCl. Seventy one patients were subsequently randomized to the overall goals of therapy for children, as in for adults, must receive furosemide (0.5 mg/kg/h) or placebo by continuous take into consideration local standards, patient and family infusion, continued until CrCl reached 30 ml/min. Urinary wishes, as well as the probability of recovery of the underlying fluid losses were compensated by i.v. infusion. The primary illness leading to AKI and the need for RRT. end-point was renal recovery (CrCl 430 ml/min or stable SCr without RRT) in the ICU and in the hospital. CVVH RESEARCH RECOMMENDATIONS was restarted based on predefined criteria. Patients treated K Determine clinical parameters (e.g., parameters of kidney with furosemide (n ¼ 36) had a significantly increased function, fluid overload, hypercatabolism) that predict urinary volume and greater sodium excretion compared to successful discontinuation of RRT in AKI patients. placebo-treated patients (n ¼ 35). However, there were no K Determine biomarkers that may indicate renal recovery, differences in need for repeated CVVH, or renal recovery and whether their levels can be used to guide disconti- during ICU or hospital stay.195 An observational study of nuation of RRT. discontinuation of RRT also found no difference in diuretic K Determine more reliable predictors of long-term out- use between patents with successful or unsuccessful dis- comes (e.g., mortality, quality of life) in AKI patients continuation of IHD.568 In summary, diuretics may improve (including clinical severity scores, biomarkers, machine urine volume after RRT, but do not appear to have any learning techniques, or combinations of these), that— significant benefit in reducing the need for RRT or promoting after validation in large cohorts—could be helpful renal recovery from AKI. adjuncts in the decision to withdraw treatment. 94 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.3 & 2012 KDIGO Chapter 5.3: Anticoagulation In patients with AKI requiring RRT, the contact of blood with flow rates, diffusive treatment, the reduction of blood-air the foreign surface of the extracorporeal circuit results in contact in the bubble trap, and assuring prompt reaction to activation of both the intrinsic and the extrinsic pathway of alarms.577,578 plasmatic coagulation and activation of platelets.571 Preven- Many patients with AKI require systemic anticoagulation tion of dialyzer/hemofilter clotting often requires some for their underlying diseases (e.g., artificial heart valve, acute form of anticoagulation, which may represent a particular coronary syndrome, atrial fibrillation). It is evident that, in challenge in patients with AKI. The need for continuous most instances, these patients will not require additional anticoagulation represents a potential drawback of CRRT. anticoagulation for RRT; however, this should be assessed on a case-by-case basis. 5.3.1: In a patient with AKI requiring RRT, base the 5.3.2: For patients without an increased bleeding decision to use anticoagulation for RRT on assess- risk or impaired coagulation and not already ment of the patient’s potential risks and benefits receiving effective systemic anticoagulation, we from anticoagulation (see Figure 17). (Not Graded) suggest the following: 5.3.1.1: We recommend using anticoagulation 5.3.2.1: For anticoagulation in intermittent RRT, during RRT in AKI if a patient does we recommend using either unfractio- not have an increased bleeding risk or nated or low-molecular-weight heparin, impaired coagulation and is not already rather than other anticoagulants. (1C) receiving systemic anticoagulation. (1B) 5.3.2.2: For anticoagulation in CRRT, we sug- gest using regional citrate anticoagula- tion rather than heparin in patients RATIONALE who do not have contraindications for The goal of anticoagulation with RRT is to prevent clotting of citrate. (2B) the filter and/or reduction in membrane permeability, and 5.3.2.3: For anticoagulation during CRRT in thus to achieve adequate RRT and to prevent blood loss in patients who have contraindications for the clotted filter. These benefits have to be weighed against citrate, we suggest using either unfractio- the risk of bleeding, and economic issues, such as workload nated or low-molecular-weight heparin, and costs. rather than other anticoagulants. (2C) Patients with impaired coagulation (e.g., thrombocytopenia, or prolonged prothrombin time or activated partial thrombo- plastin time [aPTT]), due to underlying diseases such as liver RATIONALE failure or dilution coagulopathy, may not benefit from Worldwide, unfractionated heparin is still the most widely additional anticoagulation for RRT. In two recent large trials used anticoagulant. Many European centers, however, have 50–60% of AKI patients requiring RRT were treated without switched from unfractionated to low-molecular-weight anticoagulant.562,563 While filter performance was not assessed, heparin for routine anticoagulation during IHD.579 Advan- adequate CRRT filter survival without anticoagulation has tages and disadvantages of each type of heparin are mostly been described in patients with coagulopathies.572–575 summarized in Table 19. However, no specific cut-off points have been determined for A recent meta-analysis of 11 RCTs comparing unfractio- platelet count, aPTT, International Normalized Ratio, fibrino- nated to low-molecular-weight heparin in chronic IHD gen, or other coagulation factors that would indicate the concluded that both are equally safe in terms of bleed- possibility to perform RRT without anticoagulation. On the ing complications (RR 0.96; CI 0.27–3.43) and as effective other hand, prolonged clotting times can also point to a con- in preventing extracorporeal thrombosis (RR 1.15; CI sumptive coagulopathy based on the presence of an activated 0.7–1.91).586 Mainly because of the convenience of using a coagulation. In these patients, frequent filter clotting will occur single bolus injection at the start of IHD, the reduced risk of and necessitate a switch to some form of anticoagulation.576 heparin-induced thrombocytopenia (HIT), and of long-term In patients that are treated without anticoagulation, side-effects such as abnormal serum lipids, osteoporosis, and special attention is required to non-anticoagulant strategies hypoaldosteronism, the European practice guideline for to prolong filter survival. These include a good functioning prevention of dialyzer clotting suggests using low-molecu- vascular access, the reduction of blood viscosity and lar-weight rather than unfractionated heparin in chronic hemoconcentration by saline flushes, predilution, high blood dialysis patients.587 Many European centers have extrapolated Kidney International Supplements (2012) 2, 89–115 95
chapter 5.3 Impaired Yes Proceed without coagulation? anticoagulation Rec No 5.3.1.1 Underlying Yes Use anticoagulation condition requires adapted to this systemic anticoagulation? condition No Choose RRT CRRT Intermittent RRT Modality Recs No 5.3.2.2 Contraindication Regional Citrate & to Citrate? Anticoagulation 5.3.3.1 Yes No Rec Increased Heparin 5.3.2.3 Bleeding Risk? Yes Rec Proceed without 5.3.3.2 anticoagulation No Increased Heparin Bleeding Risk? Rec 5.3.2.1 Yes Proceed without anticoagulation Figure 17 | Flow-chart summary of recommendations. Heparin includes low-molecular-weight or unfractionated heparin. CRRT, continuous renal replacement therapy; RRT, renal replacement therapy. this to IHD for AKI, although studies in this setting are on the degree of kidney injury, and the dose and type of lacking. In patients with AKI, the dose of heparin for IHD low-molecular-weight heparin.590 The American College of and the target aPTT should be individualized according to Chest Physicians (ACCP) guidelines for antithrombotic and the presence or absence of coagulation abnormalities and/or thrombolytic therapy therefore suggest using unfractionated risk of bleeding.588,589 Monitoring should also include instead of low-molecular-weight heparin in patients with platelet count, allowing timely detection of HIT.581 Since severe renal insufficiency (CrCl o30 ml/min) who require low-molecular-weight heparins rely on the kidney as primary therapeutic anticoagulation, or to reduce the dose of low- route of elimination, patients with kidney injury are at risk molecular-weight heparin by 50%.580 The doses of low- of accumulation and bleeding complications, depending molecular-weight heparin that are required for IHD are 96 Kidney International Supplements (2012) 2, 89–115
chapter 5.3 Table 19 | Overview of the advantages and disadvantages of different anticoagulants in AKI patients Anticoagulant Advantage Disadvantage References Heparin (unfractionated) Wide availability Narrow therapeutic index – risk of bleeding Large experience Unpredictable kinetics – monitoring required Short half-life HIT Antagonist available Heparin resistance 580,581 Monitoring with routine tests (aPTT or ACT) Low costs Low-molecular-weight More predictable kinetics Risk of accumulation in kidney failure heparin – Weight-based dosing possible More reliable anticoagulant response Monitoring requires nonroutine test (anti–Factor Xa) 580,582–584 – No monitoring required Single predialysis dose may be Different drugs not interchangeable sufficient in IHD Reduced risk of HIT Incomplete reversal by protamine In most countries more expensive than unfractionated heparin Citrate Strict regional anticoagulation Risk of accidental overdose with potentially fatal consequences – reduced bleeding risk Insufficient citrate metabolism in patients with reduced liver function and shock states resulting in accumulation with metabolic acidosis and hypocalcemia 585 Other metabolic complication (acidosis, alkalosis, hypernatremia, hypocalcemia, hypercalcemia) Increased complexity Requires strict protocol aPTT, activated partial thromboplastin time; ACT, activated clotting time; HIT, heparin-induced thrombocytopenia; IHD, intermittent hemodialysis lower than those required for therapeutic anticoagulation. The anticoagulant effect of sodium citrate relies on The doses of low-molecular-weight heparin, as provided by forming a complex with ionized calcium, thus removing an the manufacturers, should be adapted to the bleeding risk of essential component of the coagulation cascade. Part of the the individual patient. Dose reduction may also be required citrate is removed in the extracorporeal circuit. Citrate in patients receiving daily dialysis, which increases the risk reaching the systemic circulation is rapidly metabolized in of accumulation. Since many patients with AKI require the liver, muscle, and kidney, liberating the calcium and prophylaxis for deep-vein thrombosis, scheduling this producing bicarbonate. The buffering effect of sodium citrate prophylactic (or a slightly higher) dose at the beginning of is proportional to the sodium ions it contains: a mole of the dialysis session may serve the two purposes. Periodic trisodium citrate produces the same buffering effect as measurement of anti–Factor Xa levels may be useful with 3 moles of sodium bicarbonate; whereas preparations of prolonged use. citrate, including hydrogen citrate, have proportionally less Alternative anticoagulants for IHD include protease buffering effect. Extracorporeal losses of calcium have to be inhibitors such as nafamostate and platelet inhibitors such compensated by an exogenous infusion. Additional compli- as prostacyclin or its analogues. Randomized trials compar- cations of citrate are summarized in Table 19. Regional citrate ing these anticoagulants/antiaggregants with heparin in the anticoagulation requires a strict protocol, adapted to the local setting of IHD for AKI are not available, and their use in treatment modality and flow settings. The protocol should clinical practice is limited. Nafamostat is a protease inhibitor include instructions for the infusion of citrate and calcium, that is mainly used in Japan and not available in the USA or for the composition of the dialysate/replacement fluid, and Europe. Small observational trials in chronic dialysis patients for intensive metabolic monitoring, including acid-base with increased bleeding risk suggest a reduced bleeding status, sodium, and total and ionized calcium levels. incidence.591–593 Concerns with nafamostat include the Five randomized trials have compared citrate to heparins absence of an antidote, and side-effects such as anaphylaxis, during CRRT (Suppl Tables 31 and 32). For ethical reasons, hyperkalemia, and bone marrow suppression.594–596 Cross- these trials were performed in patients without increased over comparisons of prostacyclin with low-molecular-weight bleeding risk. The first trial by Monchi et al. used a crossover heparin in chronic dialysis patients show reduced effi- design to compare anticoagulation with unfractionated ciency.597 A small trial showed reduced bleeding complica- heparin or citrate in 20 patients treated with postdilution tions compared to low-dose heparin; however, at the expense CVVH. Patients with high bleeding risk, liver cirrhosis, and of slightly more premature terminations.598 Additional sensitivity to heparin were excluded. Forty-nine filters were drawbacks are systemic hypotension and the high costs. evaluated. Citrate was titrated to achieve a postfilter ionized Therefore, the routine use of alternative anticoagulants can calcium level below 1.20 mg/dl (0.3 mmol/l). The dosing not be recommended in patients with AKI. regimen of heparin consisted of a bolus of 2000 to 5000 U, Kidney International Supplements (2012) 2, 89–115 97
chapter 5.3 followed by a continuous infusion of 500–2000 U/h, aiming the low-molecular-weight heparin, nadroparin. Again, patients at an aPTT of 60–80 seconds. Despite this rather high heparin with bleeding risk or liver cirrhosis were excluded. Nadroparin dose, the citrate group had a longer filter lifetime and less was started with a bolus of 2850 U followed by 380 U/h without spontaneous filter failure. Fewer patients in the citrate group further monitoring. Citrate (500 mmol/l) was administered at a required transfusion, and the number of transfused units was dose of 3 mmol per liter blood flow, without monitoring of also lower. One patient in the heparin group experienced postfilter ionized calcium. The primary outcomes were safety, bleeding and one patient in the citrate group had metabolic defined as the absence of adverse events necessitating disconti- alkalosis.599 nuation of the study anticoagulant, and efficacy, defined as circuit The second trial randomized 30 patients with AKI survival. Safety was significantly better in the citrate group with undergoing predilution continuous venovenous hemodiafil- only two patients requiring a change in anticoagulation regimen tration (CVVHDF) to anticoagulation with citrate or vs. 20 patients in the nadroparin group (P40.001). Adverse unfractionated heparin. Patients with contra-indications to events were citrate accumulation (n ¼ 1) and early clotting due to one of the two anticoagulants (mainly high bleeding risk/ protocol violation (n ¼ 1) in the citrate group, and bleeding severe coagulopathy or metabolic problems that might be (n ¼ 16) or severe thrombocytopenia (n ¼ 4) in the nadroparin aggravated by citrate) or who required systemic antic- group. Circuit survival did not significantly differ. A computer- oagulation for medical reasons were excluded. Heparin was driven combination of buffered and nonbuffered replacement titrated to achieve an aPTT of 45–65 seconds. Citrate was fluids was used in the citrate group, explaining why metabolic titrated to a postfilter ionized calcium between 1.0–1.40 mg/dl alkalosis occurred more frequently in the nadroparin group. (0.25–0.35 mmol/l). Two patients in each group crossed over Rather surprisingly, the authors also found an improved renal to the other anticoagulant and these filters were not included recovery and an improved hospital survival in the citrate group. in the analysis. The trial was stopped early after 79 filters This could not be attributed to differences in severity of illness, because of an advantage using citrate, which resulted in a nor in bleeding or transfusion requirement, and requires further significantly improved filter survival (124.5 hours vs. 38.3 investigation.603 hours; Po0.001). In addition, significantly less citrate- Metabolic complications were infrequent in these rando- anticoagulated filters were terminated for clotting (16.7% mized trials. In observational trials, the most frequent vs. 53.5%). The incidence of bleeding also tended to be lower metabolic complication is metabolic alkalosis, occurring in with citrate (RR 0.17; CI 0.03–1.04; P ¼ 0.06), but transfusion up to 50% of the patients.604–606 In recently published surveys requirement was not significantly different. Three patients in or large clinical trials, the use of regional citrate antic- the citrate group had metabolic alkalosis and two had oagulation is still limited to 0–20% of the patients/ hypocalcemia.600 treatments.562,563,607 The third trial randomized 48 patients with AKI, treated A major contra-indication for the use of citrate antic- with CVVH, to citrate or unfractionated heparin. Patients oagulation is severely impaired liver function or shock with requiring systemic anticoagulation for medical reasons and muscle hypoperfusion, both representing a risk of citrate patients with high bleeding risk, severe coagulopathy, circulatory accumulation. Markedly reduced citrate clearances and lower failure, liver failure, or hypocalcemia were excluded (n ¼ 12). ionized calcium levels have been found in patients with acute A total of 142 circuits was analyzed. Heparin was administered liver failure or with severe liver cirrhosis.608–610 These patients as a bolus of 3000–5000 U followed by a continuous infusion of were excluded in all the randomized trials. In patients at risk, 1500 U/h adjusted to achieve an aPTT of 50–70 seconds. Citrate intensified monitoring is recommendable. The ratio of total (500 mmol/l) was titrated to a postfilter ionized calcium to ionized calcium appears to be the best parameter to detect between 1.0–1.20 mg/dl (0.25–0.30 mmol/l). Neither circuit citrate accumulation611,612 with an optimal cutoff at 2.1.613 survival nor the reasons for disconnecting the CVVH circuit Another important drawback of citrate anticoagulation, that differed significantly between the two groups. However, the might influence the decision to implement it in routine number of major bleedings and the need for transfusion was clinical practice, is the increased complexity of the procedure, significantly greater in the heparin group. Two cases of with risk of metabolic complications and the need for a strict metabolic alkalosis were noted in the heparin group and two protocol adapted to the local RRT modality. We, therefore, episodes of hypocalcemia in the citrate group.601 Findings from only recommend the use of citrate for anticoagulation during two studies published after the cut-off date for our literature CRRT in patients that do not have shock or severe liver review are consistent with recommendation 5.3.2.2.601a,601b failure, and in centers that have an established protocol for A small randomized crossover study compared citrate citrate anticoagulation. anticoagulation to regional heparinization in 10 CVVH Unfractionated heparin still remains the most widely used patients. Both treatment arms had a relatively short filter life anticoagulant during CRRT,562,563,607 mostly administered as (13 hours for regional heparinization and 17 hours for a prefilter infusion, with large variability in the administered citrate) that did not differ significantly. No bleeding occurred doses. When choosing a dose of heparin, the clinician should in either group.602 realize that the relationship among heparin dose, aPTT, filter In the largest and most recent randomized trial, 200 patients survival, and bleeding complications is not straightfor- treated with postdilution CVVH were randomized to citrate or ward,574,614–619 but it is common practice to measure aPTT 98 Kidney International Supplements (2012) 2, 89–115
chapter 5.3 for safety reasons and to adapt the target to the bleeding risk 5.3.3: For patients with increased bleeding risk who are of the patient. not receiving anticoagulation, we suggest the Only two small prospective RCTs have compared un- following for anticoagulation during RRT: fractionated to low-molecular-weight heparin for anti- 5.3.3.1: We suggest using regional citrate anti- coagulation during CRRT in patients with AKI and, thus, coagulation, rather than no anticoagula- no firm recommendations can be made. The first trial tion, during CRRT in a patient without randomized 47 patients with AKI or systemic inflammatory contraindications for citrate. (2C) response syndrome undergoing CVVHDF to heparin, start- 5.3.3.2: We suggest avoiding regional heparini- ing with a bolus of 2000–5000 U followed by an infusion of zation during CRRT in a patient with 10 U/kg/h titrated to an aPTT of 70–80 seconds, or to increased risk of bleeding. (2C) dalteparin administered as bolus of 20 U/kg followed by an infusion of 10 U/kg/h. The mean aPTT in the heparin group was 79 seconds. The mean anti–Factor Xa level, determined in RATIONALE six patients in the dalteparin group, was 0.49 U/ml. Only 37 The risk of bleeding is considered high in patients with recent of the 82 tested filters were stopped for coagulation. There (within 7 days) or active bleeding, with recent trauma or was no difference in filter survival (with electively discon- surgery (especially in head trauma and neurosurgery), recent tinued filters being censored). The mean time to filter failure stroke, intracranial arteriovenous malformation or aneurysm, was 46.8 hours in the dalteparin group and 51.7 hours in the retinal hemorrhage, uncontrolled hypertension, or presence heparin group (NS). Three patients in each group had of an epidural catheter. In these patients, the benefit of bleeding, with no difference in transfusion requirement anticoagulation may not outweigh the risk of bleeding, between the two groups. Daily costs, including the coagula- and they should (at least initially) be treated without tion assays, were 10% higher with dalteparin.620 anticoagulation, or with CRRT with regional citrate anti- The second trial used a crossover design in 40 patients coagulation. with normal coagulation parameters undergoing predilution We suggest performing RRT without anticoagulation in CVVH. Patients treated with unfractionated heparin received patients with increased bleeding risk. A possible exception a bolus of 30 U/kg followed by a continuous infusion of can be made for patients who do not have contraindications 7 U/kg/h titrated to achieve an aPTT of 40–45 seconds. for citrate. Randomized trials comparing citrate with Enoxaparin was given as an initial bolus of 0.15 mg/kg heparins have been performed in patients without increased followed by a continuous infusion of 0.05 mg/kg/h, adjusted bleeding risk. However, since citrate results in strictly regional to an anti–Factor Xa level of 0.25–0.30 U/ml. In the 37 anticoagulation, it seems reasonable to also suggest its use patients that completed both treatment arms, mean filter life during CRRT in AKI patients with increased bleeding risk. was 21.7 hours with heparin and 30.6 hours with enoxaparin Another approach to achieve regional anticoagulation is (P ¼ 0.017). A similar difference was found in the per- regional heparinization combining a prefilter dose of heparin, protocol analysis. The incidence of bleeding was low and not aiming at a prolongation of the extracorporeal aPTT, with different between the two anticoagulants. Filter life did not postfilter neutralization with protamine, aiming at normali- correlate with aPTT or anti–Factor Xa level. Costs were zing the systemic aPTT. This procedure has been described in similar in the two groups.616 Interestingly, these clinical chronic dialysis and CRRT,572,573,624,627,628 but has not been studies did not find a correlation between anti–Factor Xa studied with much scrutiny. It is cumbersome and difficult to levels and filter life, questioning the value of anti–Factor Xa titrate because heparin has a much longer half-life than monitoring with regard to efficacy.616,621 However, if used for protamine, inducing a risk of rebound. In addition, it exposes more than a few days, monitoring might be useful to detect the patient to the side-effects of both heparin (mainly the risk accumulation. of HIT) and protamine (mainly anaphylaxis, platelet dysfunc- Alternative anticoagulants for use during CRRT include tion, hypotension, and pulmonary vasoconstriction with right the protease inhibitor nafamostate and the platelet inhibitors, ventricular failure)629 and is therefore not recommended. prostacyclin and analogues. Both have a short half-life and a low MW, with the theoretical advantage of extracorporeal elimination and reduced systemic anticoagulation. Nafamo- 5.3.4: In a patient with heparin-induced thrombocytopenia stat is not available in the USA and Europe; there is no (HIT), all heparin must be stopped and we antidote and several side-effects (agranulocytosis, hyperkale- recommend using direct thrombin inhibitors (such mia, anaphylactoid reactions) have been described.594–596 A as argatroban) or Factor Xa inhibitors (such as few small trials showed improved filter survival during CRRT danaparoid or fondaparinux) rather than other or when adding prostaglandins to heparin compared to heparin no anticoagulation during RRT. (1A) alone.622–624 However, prostaglandins appear to have a 5.3.4.1: In a patient with HIT who does not have limited efficacy when used alone, induce systemic hypoten- severe liver failure, we suggest using sion,625,626 and are expensive. Their use during CRRT can argatroban rather than other thrombin therefore not be recommended. or Factor Xa inhibitors during RRT. (2C) Kidney International Supplements (2012) 2, 89–115 99
chapter 5.3 RATIONALE frequently studied pediatric citrate protocol636–638 uses Immune-mediated HIT results from antibodies directed Anticoagulant Dextrose solution A (ACD-A, Baxter Health- against the complex of heparin and platelet factor 4, and care, USA), prescribed based on the blood flow rate: occurs in 1–3% of heparin-exposed patients. Its main clinical complication is the development of thrombocytopenia with ACD rate ðml=hÞ ¼ blood pump rate ðml= min  min =hÞÂ1:5 or without thrombosis.581 In patients with AKI undergoing CRRT, the diagnosis should therefore also be suspected in ACD-A is infused via a stopcock at the catheter-CRRT patients with repeated premature filter clotting.630 The circuit connection leading to the CRRT machine. Since our likelihood of having HIT can be predicted by the so-called prescribed blood pump flow is 200 ml/min, the resulting 4 T score, that includes the degree of thrombocytopenia, the ACD-A rate would be 300 ml/h. The second aspect of the timing of onset of the fall in platelet count, the presence citrate protocol provides prevention of citrate-induced of thrombosis or acute systemic symptoms, and the presence systemic hypocalcemia by providing a calcium chloride of other etiologies of thrombocytopenia.631 If HIT is likely, all continuous infusion (8 g calcium chloride per liter normal heparins have to be stopped, including any ‘‘heparin lock’’ saline) to the patient via a central line. The calcium chloride solutions for dialysis or other catheters. rate is also based on the blood pump rate: With regard to the diagnosis and management of HIT, we refer to the recent guideline of the ACCP581 and the Calcium chloride ðml=hÞ ¼ blood pump rate ðml= min  min =hÞÂ0:6 European best practice guideline on chronic dialysis.587 These guidelines recommend the use of therapeutic doses of an The goals of regional citrate anticoagulation are to alternative nonheparin anticoagulant in patients with strong maintain the circuit ionized calcium between 0.8 and suspicion of HIT. Candidates are the direct thrombin 1.6 mg/dl (0.2 and 0.4 mmol/l), and the patient’s systemic inhibitors lepirudin, argatroban, or bivaluridin, or the anti- ionized calcium in the normal physiologic range 4.4–5.2 mg/ thrombin-dependent Factor Xa inhibitors, danaparoid or dl (1.1–1.3 mmol/l). The circuit ionized calcium concentra- fondaparinix. Pharmacokinetic data and dosing guidelines tion is managed by adjustment of the citrate rate, while the for these alternative anticoagulants have been published for patient’s systemic ionized calcium concentration is managed IHD588,632 and CRRT.633 by adjustment of the calcium chloride rate. Argatroban is a direct thrombin inhibitor, is eliminated by the liver, has a short half-life, and can be monitored RESEARCH RECOMMENDATIONS with aPTT.634 A recent observational study on the use of K Randomized trials should compare unfractionated to argatroban for anticoagulation during continuous dialysis in low-molecular-weight heparin during IHD in patients 30 patients with AKI and HIT derived a dosing equation, with AKI. based on illness severity scores or by use of indocyanine green K Randomized trials should compare unfractionated to plasma clearance.635 Regional citrate anticoagulation has low-molecular-weight heparin during CRRT in patients been used along with reduced doses of argatroban or other with AKI. nonheparin anticoagulants in cases where bleeding occurs. K Randomized trials should compare citrate to unfractio- However, there are no published reports on this practice. nated to low-molecular-weight heparin during CRRT in patients with AKI. Pediatric considerations K Future trials should compare a strategy without anti- Standardized protocols have been well established for both coagulation against one of anticoagulation during CRRT. heparin and regional citrate anticoagulation in children K Outcomes of interest for trials testing different anti- receiving dialysis. The ppCRRT Registry Group has shown coagulation strategies with RRT in AKI are clinical that heparin- and citrate-based anticoagulation protocols end-points, including bleeding, renal recovery, mortality, have been shown to confer equitable filter survival in incidence of HIT, and surrogates such as circuit survival pediatric CRRT, and the use of either is clearly supported and efficiency of dialysis, metabolic complications, and over the use of no anticoagulation schemes.636 The main effects on the coagulation system. advantage of citrate anticoagulation was the prevention of systemic pharmacological anticoagulation of the patient, SUPPLEMENTARY MATERIAL which can be an issue in patients with multiorgan failure and Supplementary Table 31: Evidence profile of RCTs examining the effect sepsis. Calcium is a requisite cofactor in both the intrinsic of citrate vs. heparin/nadroparin in CRRT for AKI. Supplementary Table 32: Summary table of RCTs examining the effect and extrinsic coagulation cascades. Citrate functions by of citrate vs. heparin/nadroparin in CRRT for AKI. binding free calcium, thereby inhibiting coagulation in both Supplementary material is linked to the online version of the paper at the intrinsic and extrinsic coagulation pathways. The most http://www.kdigo.org/clinical_practice_guidelines/AKI.php 100 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.4 & 2012 KDIGO Chapter 5.4: Vascular access for renal replacement therapy in AKI Functional vascular access is essential for adequate RRT. Basic duration of RRT for AKI was 12–13 days.562,563 This probably requirements are to ensure adequate and regular flow with does not justify the burden of an initial tunneled catheter in all low morbidity. Most studies on indwelling tunneled dialysis patients with AKI receiving RRT. Rather, selected use of tunneled catheters have been performed in chronic dialysis patients. catheters in patients who require prolonged RRT is warranted. For individuals requiring acute dialysis, the evidence on No recommendation can be given regarding the optimal dialysis catheters is more limited, but there is a body of timing to change the nontunneled-uncuffed catheter to a more literature on nondialysis central venous catheters (CVC) in permanent access. It seems reasonable to create a more intensive-care patients. Many of the recommendations for permanent access when recovery of kidney function is unlikely. patients requiring acute dialysis are, therefore, based on The optimal timing should take into account the increased risk extrapolation of evidence from tunneled dialysis catheters or of infection with untunneled catheters, but also the practical from nondialysis nontunneled CVC. issues related to the insertion of a tunneled catheter. Several configurations of dialysis catheter lumen and tip 5.4.1: We suggest initiating RRT in patients with AKI via have emerged over the years with no proven advantage of one an uncuffed nontunneled dialysis catheter, rather design over another. The outer diameter varies between 11 than a tunneled catheter. (2D) and 14 French and it is self-evident that larger sizes decrease the risk of inadequate blood flow. In order to provide an adequate blood flow and reduce the risk of recirculation, RATIONALE the tip of the catheter should be in a large vein (see Since most early catheter-related infections have a cutaneous Recommendation 5.4.2). This means that the optimal length origin, tunneling the catheter under the skin together with a is 12–15 cm for the right internal jugular vein, 15–20 cm for subcutaneous anchoring system, may reduce the risk of the left internal jugular vein, and 19–24 cm for the femoral infection. Tunneling also increases mechanical stability of vein.642–644 the catheter. On the other hand, the insertion of a tunneled In PD, the Tenckhoff catheter, a soft, silicone rubber cuffed catheter (TCC) is a cumbersome procedure that catheter with a polyester cuff, reduced early complications such requires expertise (mostly performed by surgeons or inter- as bowel perforation, massive bleeding, or leakage, and has ventional radiologists), time, and effort (mostly performed in become the standard for PD. Further modifications, including the operating room or radiology department), thus poten- the use of swan-neck catheters, T-fluted catheters, curled tially delaying initiation of RRT. The removal of TCCs is also intraperitoneal portions, dual cuffs, and insertion through the technically more difficult. rectus muscle instead of the midline, have been made to reduce A randomized trial compared the initial use of tunneled remaining complications such as peritonitis, exit/tunnel vs. nontunneled femoral catheters in 34 patients with AKI. infection, cuff extrusion, obstruction, and dialysate leaks.645,646 Failure to insert the TCC occurred in four patients (12%) Blind placement has been largely replaced by surgical that were excluded from the final analysis. In the remaining placement or placement guided by ultrasound/fluoroscopy, 30 patients, those with tunneled catheters had an increased laparoscopy, or peritoneoscopy.647–649 Continuous-flow PD insertion time and more femoral hematomas, but also less dictates the need for an efficient dual-lumen catheter or two dysfunction, fewer infectious and thrombotic complications, separate catheters with ports separated maximally.646 Outside and a significantly better catheter survival.639 The small size the pediatric setting, no investigations have specifically looked of this study and the absence of an intention-to-treat analysis at peritoneal catheters in the setting of AKI. preclude firm conclusions (Suppl Table 33). In addition, the use of tunneled catheters for starting acute dialysis is not 5.4.2: When choosing a vein for insertion of a dialysis widespread practice. catheter in patients with AKI, consider these Both the Centers for Disease Control (CDC) guidelines for preferences (Not Graded): prevention of catheter-related infections and the KDOQI K First choice: right jugular vein; guideline for vascular access in chronic dialysis patients K Second choice: femoral vein; recommend using a cuffed catheter for dialysis if a prolonged K Third choice: left jugular vein; (e.g., 41–3 weeks) period of temporary access is antici- K Last choice: subclavian vein with preference for pated.640,641 In two recent large randomized trials, the mean the dominant side. Kidney International Supplements (2012) 2, 89–115 101
chapter 5.4 RATIONALE for femoral) but the study was not powered for this end- Although generally associated with the lowest rate of point. This was also the case for thrombotic complications infectious complications, the CDC guideline as well as the (Suppl Table 34).658 KDOQI guideline recommend avoiding the subclavian vein Malfunction is another issue that needs to be considered for RRT access,640,641 because this may lead to central vein when choosing between a jugular and femoral vascular stenosis and jeopardize subsequent permanent access. This access. Observational trials show more malfunctioning and a recommendation is mainly derived from observational data shorter actuarial survival for femoral than for jugular dialysis in ESRD patients showing a higher incidence of central vein catheters],659–661 and more malfunction with left-sided stenosis with subclavian than with jugular dialysis cathe- jugular catheters compared to right-sided.662 Recirculation ters.650,651 On the other hand, central vein stenosis has also has been shown to be more frequent in femoral than been described after jugular catheterization.652,653 Contact of subclavian or jugular dialysis catheters, especially with the catheter with the vessel wall is considered a primary shorter femoral catheters.642,643 A secondary analysis of the initiating event for catheter-related thrombosis and stenosis. French multicenter trial did not find a difference in catheter Catheters in the right internal jugular vein have a straight dysfunction between jugular and femoral catheters in the course into the right brachiocephalic vein and superior vena intention-to-treat analysis. However, a separate analysis of cava, and, therefore, the least contact with the vessel wall. A the right and left jugular catheters showed a trend toward catheter inserted through the subclavian or the left jugular more dysfunction with femoral than with right jugular vein has one or more angulations. explaining the higher risk catheters, but significantly more dysfunction with left jugular of vessel contact and thrombosis/stenosis with subclavian compared to femoral catheters.663 compared to jugular catheters,650,651 and with left-sided Another point to consider is that any patient who has the compared to right-sided jugular catheters.654–656 The sub- option of undergoing a kidney transplantation should not clavian vein should, therefore, be considered the last choice have a femoral catheter placed to avoid stenosis of the iliac for insertion of a dialysis catheter in patients with AKI, vein, to which the transplanted kidney’s vein is anato- especially when the risk of nonrecovery of kidney function is mized.640 The presence of a femoral catheter also reduces the substantial. Whether this recommendation should be ex- patient’s mobilization, especially when the RRT is contin- tended to the left jugular vein remains unclear. In patients uous. where the subclavian vein remains the only available option, In summary, the right jugular vein appears to be the best preference should be given to the dominant side in order to option for insertion of a dialysis catheter. Femoral catheters spare the nondominant side for eventual future permanent are preferred over left jugular catheters because of reduced access. malfunction, and the subclavian vein should only be Because the subclavian vein should be avoided, the considered a rescue option. It is evident that individual remaining options are the jugular and femoral veins. The patient characteristics may require deviations from this order use of femoral catheters is thought to be associated with the of preferences. Catheter insertion should be performed with highest risk of infection, and avoidance of femoral lines is strict adherence to infection-control policies, including part of many ‘‘central line bundles’’ that intend to reduce the maximal sterile barrier precautions (mask, sterile gown, incidence of catheter-related bloodstream infection.657 sterile gloves, large sterile drapes) and chlorhexidine 2% skin This dogma was questioned in a concealed, randomized, antisepsis.641,664,665 multicenter, evaluator-blinded, parallel-group trial of 750 AKI patients, comparing the femoral with the jugular site for 5.4.3: We recommend using ultrasound guidance for first catheter insertion for RRT. Ultrasound was seldom used, dialysis catheter insertion. (1A) probably explaining the somewhat higher rate of failure on one side and crossover in the jugular group. The rate of hematoma formation was also higher in the jugular group. RATIONALE In both groups, 20% of the catheters were antiseptic- For several decades, techniques involving the use of anatomic impregnated. Mean duration of catheterization was 6.2 days landmarks have been the traditional mainstay of accessing the for the femoral and 6.9 days for the jugular group. The major central venous system. Using the ‘‘blind’’ landmark technique reasons for catheter removal were death or ‘‘no longer is not without significant morbidity and mortality. Compli- required’’. The incidence of catheter colonization at removal cations of central venous catheterization include arterial (the primary end-point) was not significantly different puncture (0.5–6%), hematoma (0.1–4.4%), hemothorax between the femoral and jugular group. When stratified (0.4–0.6%), pneumothorax (0.1–3.1%), and up to 10–20% according to body mass index (BMI), those within the lowest of insertion attempts are not successful.666,667 In view of their BMI tertile had a higher incidence of colonization with the large size, the risk of complications of dialysis catheters is jugular site, whereas those within the highest BMI tertile had expected to be even higher. Two meta-analyses have the highest colonization rate with femoral catheters. Blood- addressed the role of real-time two-dimensional ultrasound stream infection did not differ between the groups (2.3 per for central vein cannulation, and concluded that, compared 1000 catheter-days for jugular and 1.5 per 1000 catheter-days to the landmark method, ultrasound-guided venous access 102 Kidney International Supplements (2012) 2, 89–115
chapter 5.4 increases the probability of successful catheter placement and instructions on catheter care, the reader is referred to pub- reduces the risk of complications, the need for multiple lished guidelines.640,641,664,665 These guidelines also recom- catheter placement attempts, and the time required for the mend not using dialysis catheters for applications other than procedure. The advantage appears most pronounced for the RRT, except under emergency circumstances.641 jugular vein, whereas the evidence is scarce for the subclavian A recent meta-analysis of five RCTs confirmed that topical and femoral vein.668,669 Subsequent large randomized trials antibiotics (mainly mupirocin) reduce the risk of bacteremia, have confirmed the superiority of ultrasound guidance.670,671 exit-site infection, need for catheter removal, and hospitali- Trials evaluating the placement of dialysis catheters in ESRD zation for infection in ESRD patients.682 The majority of the patients, mostly with observational design, yield a similar catheters in the included studies were tunneled. However, the conclusion.672–678 The KDOQI guideline for vascular access CDC, National Health Service, and Infectious Diseases also recommends using ultrasound-assisted insertion.640 Society of America guidelines strongly recommend against topical antibiotic ointment for the care of CVC, because of 5.4.4: We recommend obtaining a chest radiograph their potential to promote fungal infections and antimicro- promptly after placement and before first use of an bial resistance.641,664,665 For patients with AKI that are treated internal jugular or subclavian dialysis catheter. (1B) in an ICU, it seems reasonable to follow this last recommen- dation. No recommendations can be given for AKI patients that are treated outside an ICU. RATIONALE Uncuffed, nontunneled dialysis catheters are semirigid. Their 5.4.6: We suggest not using antibiotic locks for preven- tip should not be in the heart, because of the risk of atrial tion of catheter-related infections of nontunneled perforation and pericardial tamponade. On the other hand, a dialysis catheters in AKI requiring RRT. (2C) position too high in the brachiocephalic vein, especially with subclavian and left-sided catheters, should also be avoided, because it allows a narrow contact between the catheter tip RATIONALE and the vessel wall, which may result in improper catheter Four meta-analyses have evaluated the efficacy of various function and vessel thrombosis.655,679,680 The correct position antibiotic lock solutions in chronic dialysis patients, and of the tip of a semirigid dialysis catheter is at the junction of conclude that they significantly reduce catheter-related the superior vena cava and the right atrium, allowing the bloodstream infection. Drawbacks are the overall moderate catheter to run in parallel with the long axis of the superior trial quality and the short follow-up that does not allow vena cava.679 Tunneled catheters are usually softer and can be excluding the development of resistance.682–685 However, the positioned into the right atrium, thus allowing a higher CDC, National Health Service, and Infectious Diseases blood flow.680 Society of America guidelines strongly recommend against To confirm the correct position and to assess for potential routinely using antibiotic lock solutions in CVC, because of complications, a postprocedural chest radiograph is conven- their potential to promote fungal infections, antimicrobial tionally performed. Although this procedure has been debated resistance, and systemic toxicity.641,664,665 Mentioned excep- after uneventful placement of a CVC, the high blood flows tions are long-term cuffed and tunneled catheters with used during RRT and the administration of anticoagulants history of multiple catheter-related bloodstream infections necessitate confirming the correct position before initiating despite maximal adherence to aseptic technique,641,665 dialysis therapy.640 It should, however, be remembered that patients with limited venous access and history of recurrent none of the radiographic landmarks (carina, right tracheo- catheter-related bloodstream infection, or patients with bronchial angle, etc) that are used to exclude intra-atrial tip heightened risk of severe sequelae from a catheter-related position are 100% reliable.679,680 Echocardiography might be bloodstream infection.664 another tool to confirm the correct position of the catheter.681 Pediatric considerations 5.4.5: We suggest not using topical antibiotics over the Most of the guidelines for adults are applicable to children. skin insertion site of a nontunneled dialysis cathe- Functional CRRT circuit survival in children is favored by ter in ICU patients with AKI requiring RRT. (2C) larger catheter size686 that should be adapted to patient size (Table 20).687 Recent data from the Prospective Pediatric CRRT Registry group shows that internal jugular catheters RATIONALE may be associated with longer functional CRRT circuit The incidence of catheter-related bloodstream infection can survival, compared to femoral and subclavian access.686 In be reduced by implementing education-based programs and addition, the Prospective Pediatric CRRT Registry group so-called central-line bundles, that emphasize the importance showed extremely poor circuit survival with two single- of hand hygiene, maximal barrier precautions upon inser- lumen 5 F catheters; these catheters should therefore be tion, chlorhexidine skin antisepsis, optimal catheter site avoided. Future permanent access in the form of an arterio- selection, and daily review of line necessity.657 For detailed venous graft or fistula for patients who develop CKD may be Kidney International Supplements (2012) 2, 89–115 103
chapter 5.4 Table 20 | Catheter and patient sizes catheters.689 A more recent retrospective analysis with Patient size Catheter size Site of insertion historical controls reports that, compared to the surgically placed Tenckhoff catheter, using a more flexible catheter for Neonate Double-lumen 7F Femoral artery or vein percutaneous insertion may achieve a comparable catheter 3–6 kg Double- or triple-lumen 7F Jugular, subclavian, survival and complication rate.690 or femoral 6–30 kg Double-lumen 8F Jugular, subclavian, RESEARCH RECOMMENDATIONS or femoral 415 kg Double-lumen 9F Jugular, subclavian, K Determine whether the initial use of a tunneled vs. or femoral nontunneled catheter for RRT in AKI patients results in a 430 kg Double-lumen 10F or Jugular, subclavian, beneficial effect on catheter function and catheter-related triple-lumen 12F or femoral complications, including infections and number of Reprinted from Bunchman TE, Brophy PD, Goldstein SL. Technical considerations for additional access procedures. renal replacement therapy in children. Semin Nephrol 2008; 28: 488–492 687, copyright 2008, with permission from Elsevier; accessed http://www.seminarsinnephrology.org/ K Develop better means of predicting the need for long- article/S0270-9295(08)00117-4/fulltext term access and better methods to select access site in individual patients by balancing various risks and benefits. compromised if acute access is placed in a subclavian vein. Clinicians must therefore consider the potential long-term SUPPLEMENTARY MATERIAL vascular needs of patients who may be expected to develop Supplementary Table 33: Summary table of RCTs examining the effect CKD, especially children who have demonstrated excellent of access placement with tunneled versus non-tunneled catheters on long-term survival with CKD and ESRD.688 AKI. Supplementary Table 34: Summary table of RCTs examining the effect Analysis of a pediatric database (1989–1999) showed of jugular vs. femoral access placement on AKI. that surgically placed Tenckhoff catheters for PD induce Supplementary material is linked to the online version of the paper at less complications than more stiff percutaneously placed http://www.kdigo.org/clinical_practice_guidelines/AKI.php 104 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.5 & 2012 KDIGO Chapter 5.5: Dialyzer membranes for renal replacement therapy in AKI Semipermeable hollow-fiber dialyzers are used as standard the synthetic membranes to cuprophane, there was a trend of care for both solute clearance and ultrafiltration in towards reduced mortality with the synthetic membranes. IHD and CRRT circuits. Membrane composition and This meta-analysis also did not assess the side-effects of clearance characteristics vary among the commercially different membrane compositions on more proximal, available dialyzers. While no RCTs exist to provide definitive temporal associations, such as acute hypotension or fever. recommendations for a particular dialyzer type, the charac- As a result, we agree with the authors’ conclusion that the use teristics and potential side-effects of each dialyzer type of either a biocompatible or modified cellulose acetate require consideration. membrane appears to be appropriate. Recent observations reveal specific potential side-effects 5.5.1: We suggest to use dialyzers with a biocompatible when using certain dialyzer membranes. Bradykinin release membrane for IHD and CRRT in patients with syndrome has been observed at the start of CRRT with AKI. (2C) uncoated AN-69 membranes.703 Bradykinin release syn- drome is characterized by acute hypotension and pulmonary vascular congestion. The syndrome is usually self-limited and RATIONALE is pH-dependent, and therefore more pronounced in patients Semipermeable hollow-fiber dialyzers currently represent the with severe acidosis. Also, priming of the circuit with banked standard of care for IHD or CRRT for patients with AKI. All blood (that is acidotic and contains a large amount of citrate, dialyzer membranes induce some degree of activation of inducing hypocalcemia) may evoke bradykinin release blood components, a phenomenon called bioincompati- syndrome. Numerous measures have been published to bility.691 Earlier-generation dialyzer membranes composed of prevent or mitigate this syndrome, including zero-balance cuprophane or unmodified cellulose were more bioincom- HF to normalize the banked blood pH and calcium,704 or a patible and had the potential to cause a ‘‘dialyzer membrane bypass maneuver in which the blood prime is given to the reaction’’, mediated by complement activation, release of patient instead of the circuit, while the patient is bled on to proinflammatory markers, and oxidative stress, and mani- the circuit with the saline prime discarded.705 Finally, a form fested clinically by acute hypotension, vasodilatation, leuco- of bradykinin release syndrome has been reported in patients penia, hypoxia and fever.692–697 More recently, modified receiving ACE-I and IHD with AN-69 membranes,706–708 cellulosic membranes (with substitution of the hydroxyl since ACE-I prevent the conversion of bradykinin and groups) and synthetic membranes composed of polyacyl- thereby prolong the hypotensive response when acidic blood nitrile, polysulfone, or poly(methyl methacrylate) have been comes in contact with the AN-69 membrane. However, developed. These ‘‘biocompatible membranes’’ (or less others have disputed this interaction.704,705 Nevertheless, bioincompatible membranes) produce less complement and clinicians should be aware of the potential for bradykinin cytokine activation, and decrease oxidative stress.697,698 release syndrome if an uncoated AN-69 membrane is Recent studies suggest that platelet activation might also employed for RRT, especially in acidotic patients or in those be involved in the bioincompatibility phenomenon.698–701 receiving ACE-I. Neutralizing the electronegativity of the Another membrane characteristic that might have clinical AN-69 membrane by coating with polyethyleneimine sig- importance is the flux property, with membranes generally nificantly reduces bradykinin generation.709 being divided in low-flux and high-flux, the latter having Whether conventional dialysis membranes are able to larger pores and thus the potential to clear larger solutes. affect clinical outcomes in sepsis by removal of inflammatory The question of whether membrane bioincompatibility or mediators remains highly controversial. Until further evi- flux has clinical relevance in the setting of AKI has been the dence becomes available, the use of RRT to treat sepsis should subject of many clinical trials. A recent meta-analysis of 10 be considered experimental. randomized or quasi-randomized controlled trials in 1100 patients could not establish any advantage for biocompatible or high-flux membranes.702 Of note, the authors chose to RESEARCH RECOMMENDATIONS include modified cellulose membranes in the bioincompa- K Future research should assess the impact of middle- tible group, although other investigators consider modified molecule clearance by high-flux membranes and/or cellulosic membranes to be biocompatible. When comparing membrane adsorption on patient outcome in sepsis. Kidney International Supplements (2012) 2, 89–115 105
chapter 5.5 The comparator group should be patients with sepsis that remains unsettled, due to the relatively small size of trials. do not receive extracorporeal treatment (if no AKI) or It would be useful to conduct larger trials comparing conventional RRT (if AKI). different membranes and examining patient-centered K The potential impact of dialyzer membrane composition outcomes include survival, renal recovery, and resource (material, flux, etc.) on outcomes in patients with AKI utilization. 106 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.6 & 2012 KDIGO Chapter 5.6: Modality of renal replacement therapy for patients with AKI Controversy exists as to which is the optimal RRT modality of toxins and the restricted treatment period, allowing for patients with AKI. In current clinical practice, the down-time for diagnostic and therapeutic interventions. choice of the initial modality for RRT is primarily based IHD may, therefore, be the preferred treatment in patients on the availability of, and experience with, a specific where immediate removal of small solutes is required, such as treatment and on the patient’s hemodynamic status. Transi- severe hyperkalemia, some cases of poisoning, and tumor tions between CRRT and IHD are also frequent, mostly lysis syndrome. Hybrid treatments, such as SLED, may share determined by the hemodynamic status of the patient or some of the advantages of both IHD and CRRT without coagulation problems. Experience with PD in AKI is limited, having their disadvantages (Table 22). except in the pediatric setting and in regions with limited Several RCTs have compared CRRT to IHD in AKI resources. patients. The most inclusive meta-analysis was performed by the Cochrane Collaboration, analyzing 15 RCTs in 1550 AKI 5.6.1: Use continuous and intermittent RRT as comple- patients. This analysis concluded that outcomes were similar mentary therapies in AKI patients. (Not Graded) in critically ill AKI patients treated with CRRT and IHD for hospital mortality (RR 1.01; 95% CI 0.92–1.12; n ¼ 1245), ICU mortality (RR 1.06; 95% CI 0.90–1.26; n ¼ 515), length RATIONALE of hospitalization (mean deviation À6.1; 95% CI À26.45 Current modalities of RRT for AKI include IHD, CRRT, and to À14.25; n ¼ 25), and renal recovery (free of dialysis on PD. An overview of the different modalities of RRT and their discharge) in survivors (RR 0.99; 95% CI 0.92–1.07; commonly used settings is given in Table 21. n ¼ 161).713 Comparable results have been reported by other Since the introduction of CRRT into clinical practice in meta-analyses.714,715 Individual studies used different defini- the early 1980 s, its use in critically ill patients with AKI has tions of AKI and were underpowered. Most of the trials increased steadily.710–712 The theoretical advantages of CRRT excluded patients with hypotension or maximized efforts to over IHD are the slower fluid removal, resulting in more improve the hemodynamic tolerance of IHD. The high rate of hemodynamic stability and better control of fluid balance, crossover between the treatment modalities also complicates the slower control of solute concentration, avoiding large the interpretation of the results. In addition, in some of the fluctuations and fluid shifts (including a reduced risk trials, IHD patients were treated with bioincompatible [worsening] of cerebral edema), the great flexibility (allowing membranes and studies were not standardized for treatment adaptation of the treatment to the patient’s need at any time), dose. A subsequent RCT not included in the Cochrane meta- and the ability to perform the treatment with relatively analyses reported similar outcomes.716 Two recent studies, simple and user-friendly machines (allowing ICU nurses to confined to single geographic regions, showed reduced costs monitor the treatment). Disadvantages include the need for with IHD compared to CRRT.717,718 However, an analysis of immobilization, the use of continuous anticoagulation, the cost ranges from a multicenter, multinational observational risk of hypothermia and, in some settings, higher costs. study found considerable heterogeneity in costs related to Major advantages of IHD over CRRT are the fast removal IHD and CRRT, and concluded that either therapy might be Table 21 | Typical setting of different RRT modalities for AKI (for 70-kg patient) SCUF CVVH CVVHD CVVHDF PD SLED IHD Blood flow (ml/min) 100–200 150–250 150–250 150–250 N/A 100–300 200–300 Predominant solute transport convection convection diffusion diffusion þ convection diffusion diffusion diffusion principle Ultrafiltrate (ml/h) 100–300 1500–2000 variable 1000–1500 variable variable variable Dialysate flow (ml/h) 0 0 1500–2000 1000–1500 1–2 l per exchange 100–300 ml/min 300–500 ml/min Effluent volume (l/d) 2–8 36–48 36–48 36–72 24–48 N/A N/A Replacement fluid for zero 0 1500–2000 0 1000–1500 0 0 0 balance (ml/h) Urea clearance (ml/min) 1–5 25–33 25–33 25–33 variable 80–90 variable CVVH, continuous venovenous hemofiltration; CVVHD, continuous venovenous hemodialysis, CVVHDF, continuous venovenous hemodialfiltration; IHD, intermittent hemodialysis; N/A, not applicable; PD, peritoneal dialysis; SCUF, slow continuous ultrafiltration; SLED, slow low-efficiency dialysis. Kidney International Supplements (2012) 2, 89–115 107
chapter 5.6 Table 22 | Theoretical advantages and disadvantages of CRRT, IHD, SLED, and PD Modality Potential setting in AKI Advantages Disadvantages IHD Hemodynamically stable Rapid removal of toxins and low-molecular-weight Hypotension with rapid fluid removal substances Dialysis disequilibrium with risk of cerebral Allows for ‘‘down time’’ for diagnostic and edema therapeutic procedures Technically more complex and demanding Reduced exposure to anticoagulation Lower costs than CRRT CRRT Hemodynamically unstable Continuous removal of toxins Slower clearance of toxins Patients at risk of increased Hemodynamic stability Need for prolonged anticoagulation intracranial pressure Easy control of fluid balance Patient immobilization No treatment-induced increase of intracranial Hypothermia pressure Increased costs User-friendly machines SLED Hemodynamically unstable Slower volume and solute removal Slower clearance of toxins Hemodynamic stability Technically more complex and demanding Allows for ‘‘down time’’ for diagnostic and therapeutic procedures Reduced exposure to anticoagulation PD Hemodynamically unstable Technically simple Poor clearance in hypercatabolic patients Coagulopathy Hemodynamic stability Protein loss Difficult access No anticoagulation No control of rate of fluid removal Patients at risk of increased No need for vascular access Risk of peritonitis intracranial pressure Lower cost Hyperglycemia Under-resourced region Gradual removal of toxins Requires intact peritoneal cavity Impairs diaphragmatic movement, potential for respiratory problems CRRT, continuous renal replacement therapy; IHD, intermittent hemodialysis; PD, peritoneal dialysis; SLED, sustained low-efficiency dialysis. more or less costly depending on local practices, especially 95% CI 0.72–1.16; n ¼ 514). On the other hand, the mean staffing.719 arterial pressure at the end of the treatment was significantly Some large observational studies, including all patients higher with CRRT than with IHD (mean deviation 5.35; 95% receiving RRT, suggest that CRRT is an independent predic- CI 1.41–9.29; n ¼ 112) and the number of patients requiring tor of renal recovery among survivors.720–722 This evidence, escalation of vasopressor therapy was significantly lower however, is insufficient to fully elucidate the impact of choice with CRRT compared to IHD (RR 0.49; 95% CI 0.27–0.87; of therapy on this outcome. Appropriately planned prospec- n ¼ 149).713 In general, the number of patients included in tive trials will be required to address this issue. these analyses of the hemodynamic tolerance of RRT remains In conclusion, no RRT is ideal for all patients with AKI. limited, and none of the RCTs has specifically looked at the Clinicians should be aware of the pros and cons of different effect of different modalities of RRT in patients with shock. RRTs, and tailor RRT on the basis of the individual and SLED has been proposed as an alternative to other forms potentially changing needs of their patients. Besides the of RRT and is used in many centers worldwide for logistical individual patient’s characteristics, the available expertise and reasons. A recent review723 summarizes the results obtained resources may also be an important determinant of the with SLED in several studies and discusses in detail the ultimate choice. technical aspects of this dialysis method. However, rando- mized trials comparing IHD with SLED have not been 5.6.2: We suggest using CRRT, rather than standard performed. Also, clinical experience is far more limited with intermittent RRT, for hemodynamically unstable SLED compared to CRRT, and very few randomized studies patients. (2B) have compared SLED to CRRT. A first small trial in 39 AKI patients did not find any difference in hemodynamics, and less need for anticoagulation with SLED compared to RATIONALE CRRT.724 An (even smaller) Australian study showed similar Many clinicians prefer CRRT in critically ill AKI patients with control of urea, creatinine, and electrolytes, but a better severe hemodynamic instability, because of better hemo- control of acidosis and less hypotension during the first dynamic tolerance due to the slower fluid removal and hours of the treatment with CRRT.725,726 A recent retro- the absence of fluid shifts induced by rapid solute removal. spective analysis examined the mortality data from three The Cochrane meta-analysis could not establish a difference general ICUs in different countries that have switched their in the number of patients with (however poorly defined) predominant therapeutic dialysis approach from CRRT to hemodynamic instability (RR 0.48; 95% CI 0.10–2.28; SLED. This change was not associated with a change in n ¼ 205) nor with (variably defined) hypotension (RR 0.92; mortality.727 In addition, Fieghen et al.728 examined the 108 Kidney International Supplements (2012) 2, 89–115
chapter 5.6 relative hemodynamic tolerability of SLED and CRRT in protocols: fixed dialysate sodium (140 mEq) and fixed ultra- critically ill patients with AKI. This study also compared the filtration rate vs. variable dialysate sodium (160 to 140 mEq) feasibility of SLED administration with that of CRRT and and variable ultrafiltration rate (50% in first third of the IHD. Relatively small cohorts of critically ill AKI patients in treatment and 50% in the last two-thirds of the treatment). four critical-care units included 30 patients treated with The variable sodium and ultrafiltration rate protocol CRRT, 13 patients with SLED, and 34 patients with IHD. achieved better hemodynamic stability, needed fewer inter- Hemodynamic instability occurred during 22 (56.4%) SLED ventions, and induced lesser relative blood volume changes, and 43 (50.0%) CRRT sessions (P ¼ 0.51). In a multivariable despite higher ultrafiltration rates. analysis that accounted for clustering of multiple sessions Schortgen et al.734 evaluated the effects of implementing within the same patient, the OR for hemodynamic instability specific guidelines aiming to improve IHD hemodynamic with SLED was 1.20 (95% CI 0.58–2.47) compared to CRRT. tolerance. The clinical practice algorithm included priming Significant session interruptions occurred in 16 (16.3%), the dialysis circuit with isotonic saline, setting dialysate 30 (34.9%), and 11 (28.2%) of IHD, CRRT, and SLED sodium concentration at 145 mEq/l, discontinuing vasodi- therapies, respectively. This study concluded that, in critically lator therapy, and setting dialysate temperature to below ill patients with AKI, the administration of SLED is feasible 37 1C. A total of 289 RRT sessions were performed in 76 and provides hemodynamic control comparable to CRRT. patients and compared to a historical series of 248 sessions in In conclusion, in the presence of hemodynamic instability 45 patients. Hemodynamic tolerance was better in the in patients with AKI, CRRT is preferable to standard IHD. guideline patients. They developed less systolic drop at and SLED may also be tolerated in hemodynamically unstable during RRT. They also had less hypotensive episodes and the patients with AKI in settings where other forms of CRRT are need for therapeutic interventions was less frequent. The not available, but data on comparative efficacy and harm are adoption of guidelines did not influence ICU mortality, but limited. Once hemodynamic stability is achieved, treatment death rate was significantly lower than predicted from illness may be switched to standard IHD. severity in the guideline patients, but not in the historical series subjects. Length of ICU stay was also reduced for 5.6.3: We suggest using CRRT, rather than intermittent survivors in the protocol-oriented group, as compared to the RRT, for AKI patients with acute brain injury or historical series of patients. other causes of increased intracranial pressure or generalized brain edema. (2B) Peritoneal dialysis In the developing world, the development of CRRT techniques has resulted in a substantial decline in the RATIONALE expertise with, and use of, PD for treatment of AKI. The In a patient with acute brain injury, IHD may worsen use of PD in AKI is mainly confined to pediatrics and in neurological status by compromising cerebral perfusion regions with limited resources, because of its ease of use, low pressure. This may be the result of a decrease of mean cost, and minimal requirements on infrastructure. Other arterial pressure (dialysis-induced hypotension) or an advantages include the lack of a need for vascular access and increase of cerebral edema and intracranial pressure (dialysis anticoagulation, the absence of a disequilibrium syndrome disequilibrium), and may jeopardize the potential for and the relatively good hemodynamic tolerance compared to neurologic recovery. Dialysis disequilibrium results from IHD. Disadvantages are the overall lower effectiveness the rapid removal of solutes, resulting in intracellular fluid (especially in patients with splanchnic hypoperfusion or shifts. Both hypotension and disequilibrium can be avoided who are on vasopressors), the risk of protein loss, the by the slow progressive removal of fluids and solutes that unpredictability of solute and fluid removal, the need for an occurs during CRRT.729 Small observational trials and case intact peritoneal cavity, risk of peritonitis, diaphragmatic reports in patients with intracranial pressure monitoring splinting leading to ventilatory compromise and fluctuating indeed reported increases in intracranial pressure with blood glucose levels. Recent developments in the technique of IHD.730,731 Using CT scans to measure brain density, Ronco PD (use of flexible and cuffed catheters, automatic cycling, et al.732 showed an increase of brain water content after IHD, and continuous flow PD) have increased its potential to whereas no such changes were observed after CRRT. become an acceptable alternative to other forms of RRT in AKI,735–737 but direct comparative effectiveness trials are Protocols for decreasing hemodynamic instability with extremely limited. Earlier reports on PD in AKI are mainly intermittent RRT uncontrolled observations. Only two relatively recent rando- Intradialytic hypotension is a major problem during RRT in mized trials have compared PD to other modalities of RRT in AKI patients, limiting its efficacy and causing morbidity. AKI. Phu randomized 70 patients with septic AKI to PD or Surprisingly, there are only a few studies assessing this highly continuous venovenous hemofiltration (CVVH) and found relevant clinical problem. Paganini et al.733 performed a a better survival with CVVH. However, the PD treat- small-sample (10 subjects) randomized crossover controlled ment appeared not to be ‘‘up to date’’ with use of a rigid trial in AKI patients. They evaluated two different RRT catheter, manual exchanges with open drainage and acetate Kidney International Supplements (2012) 2, 89–115 109
chapter 5.6 buffering.738 The second trial compared daily IHD to high- use of adaptive CRRT equipment to production of high-flow volume PD (with Tenckhoff catheter and automated cycler) machines with volumetric control allowing for accurate and showed no difference in survival or recovery of kidney ultrafiltration flows has likewise lead to a change in pediatric function. The duration of RRT was significantly shorter in the RRT modality prevalence patterns in the USA. Accurate PD group (Suppl Table 35).739 However, this trial has not ultrafiltration and blood flow rates are crucial for pediatric been published in a peer-reviewed journal and the randomi- RRT, since the extracorporeal circuit volume can comprise zation process is unclear. Currently indications for PD in more than 15% of a small pediatric patient’s total blood patients with AKI may include bleeding diathesis, hemo- volume, and small ultrafiltration inaccuracies may represent a dynamic instability and difficulty in obtaining a vascular large percentage of a small pediatric patient’s total body access. Extremely high catabolism, severe respiratory failure, water. Polls of USA pediatric nephrologists demonstrate severe ileus, intra-abdominal hypertension, recent abdominal increased CRRT use over PD as the preferred modality for surgery and diaphragmatic peritoneum-pleura connections treating pediatric ARF. In 1995, 45% of pediatric centers are contraindications to PD. ranked PD and 18% ranked CRRT as the most common modality used for initial ARF treatment. In 1999, 31% of Pediatric considerations centers chose PD vs. 36% of centers reported CRRT as their RRT modality choice for children with AKI is guided by many primary initial modality for ARF treatment.745 of the same principles used for adult patients. However, since In the 1990 s, survival rates stratified by RRT modality were severe AKI is relatively rare in children compared to adults, better for children receiving IHD (73–89%) than those receiving occurring in less than 1% of hospitalized children740 and only PD (49–64%) or CRRT (34–42%).545,746 However, this analysis 4.5% of children admitted to an intensive care unit,741 the did not correct for illness severity. More recent data demon- impact of local expertise and resource restrictions may be strate much improved survival in children receiving greater for pediatric acute RRT modality decisions. As noted CRRT,543,544,546,570 with survival rates ranging from 50–70% below, each modality of acute RRT can be successfully for children with multiple-organ dysfunction who receive provided to pediatric patients of all sizes. Thus, with rare CRRT. While no RCT exists to assess the impact of CRRT exception driven by medical indication or contraindication, modality on survival, convective modalities were associated with no form of acute RRT can be recommended above another at increased survival in children with stem-cell transplants in a the present time. Each program should evaluate which prospective cohort study (59% vs. 27%, Po0.05).747 modality is provided most optimally and feasibly in its particular setting. RESEARCH RECOMMENDATIONS Provision of RRT as IHD, PD, or CRRT is now a mainstay K Large RCTs should compare SLED against other forms of of treatment for the child with severe AKI. The widely RRT in patients with AKI. These trials should be varying size range of pediatric patients imparts technical standardized for treatment dose, buffer, membrane, considerations in selection of a modality. Given their small anticoagulant, and timing of treatment. size and associated low blood volume, PD may provide the K The effects of different modalities of RRT on the long- least technically challenging option for infants and small term need for chronic dialysis, along with mortality, children. However, technological advances aimed at provid- should be evaluated in prospective randomized trials. ing accurate ultrafiltration with volumetric control incorpo- rated into IHD and CRRT equipment, and disposable lines, SUPPLEMENTARY MATERIAL Supplementary Table 35: Summary table of RCTs examining the effect circuits, and dialyzers sized for the entire pediatric weight of dialysis modality (continuous vs. intermittent RRT) in AKI. spectrum have made IHD and CRRT safer and feasible for Supplementary material is linked to the online version of the paper at children of all ages and sizes.570,742–744 Transition from the http://www.kdigo.org/clinical_practice_guidelines/AKI.php 110 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.7 & 2012 KDIGO Chapter 5.7: Buffer solutions for renal replacement therapy in patients with AKI One goal of CRRT is to maintain normal or near-normal that lactate may not be rapidly metabolized in the setting of acid-base balance, thus preventing detrimental effects of multiple-organ failure.749 Since lactate is a strong anion, acidosis on cardiovascular performance and hormonal insufficient lactate conversion will result in worsening response. Options for correction of metabolic acidosis acidosis, especially since bicarbonate losses are ongoing in include the use of acetate-, lactate-, and bicarbonate- the extracorporeal circuit. Hyperlactatemia has also been containing replacement solutions or dialysate. Some centers linked to impaired cellular function and catabolism due to use citrate anticoagulation, and the citrate load provides an lowering of the cellular redox state and phosphorylation adequate supply of anionic base to control metabolic potential.750 In addition, iatrogenic increases in lactate levels acidosis. Dialysate solutions for IHD are produced on-line may lead to misinterpretation of the clinical situation. The by the dialysis machine, by mixing specially treated risk of ‘‘lactate intolerance’’ is highest in patients with liver municipal water with electrolytes. Dialysate or replacement failure (impaired lactate clearance) or circulatory shock solutions for CRRT are produced commercially or locally in (increased endogenous lactate production). hospital pharmacies. Few adequately designed trials have compared different buffers during RRT in AKI patients, and most of them have 5.7.1: We suggest using bicarbonate, rather than lactate, been performed during CRRT. Barenbrock et al.751 rando- as a buffer in dialysate and replacement fluid for mized 117 AKI patients to CVVH with lactate or bicarbonate RRT in patients with AKI. (2C) replacement fluid. The use of bicarbonate resulted in better 5.7.2: We recommend using bicarbonate, rather than correction of acidosis and lower lactate levels. Also, the lactate, as a buffer in dialysate and replacement incidence of hypotension and other cardiovascular events was fluid for RRT in patients with AKI and circulatory lower with bicarbonate. In the subgroup of patients with shock. (1B) cardiac failure, mortality tended to be lower with bicarbo- 5.7.3: We suggest using bicarbonate, rather than lactate, nate, whereas in the subgroup of septic patents no difference as a buffer in dialysate and replacement fluid for in outcome was found (Suppl Table 36). A nonrandomized RRT in patients with AKI and liver failure and/or crossover study in 54 patients with multiple-organ dysfunc- lactic acidemia. (2B) tion undergoing CVVHDF confirmed the superior control of acidosis and better hemodynamic tolerance with bicarbo- nate.752 However, another RCT in 40 patients treated with RATIONALE CVVH could not find a difference in hemodynamic Options for correction of metabolic acidosis in patients with tolerance, despite the higher lactate levels in the lactate- AKI include acetate, lactate, bicarbonate, and citrate. The use buffered group.753 Differences in the case-mix may explain of acetate has been largely abandoned in view of the these different results. associated hemodynamic instability and weight loss, probably Two small prospective randomized crossover comparisons related to excessive nitric oxide production and cytokine of bicarbonate- and lactate-buffered solutions in AKI patients synthesis.748 Citrate, used for regional anticoagulation of the treated with CVVH or CVVHDF found elevated serum extracorporeal circuit, is alkalinizing, and most patients lactate levels with lactate, an effect that was more pronounced receiving citrate anticoagulation do not need an additional in patients with hepatic insufficiency.754,755 An observational buffer in the dialysate or replacement fluid. trial in 27 patients found a compromised lactate tolerance in Original HF solutions contained lactate as a buffer. Under patients with coincidental liver disease, those on inotropic normal circumstances, this lactate is metabolized, resulting in support, and in patients with initial blood lactate measure- adequate correction of acidosis in most patients. A survey in ments of 490.1 mg/dl (410 mmol/l) and large base 34 Australian ICUs concluded that 55% of the ICU patients deficits.756 with AKI were treated with lactate-based solutions710 that, in In conclusion, the use of bicarbonate as a buffer in the most countries, are less expensive than bicarbonate solutions. dialysate or replacement fluid of AKI patients results in better In addition, bicarbonate solutions have a higher risk of correction of acidosis, lower lactate levels, and improved bacterial contamination and the solution is unstable in the hemodynamic tolerance. This effect is most pronounced in presence of calcium and magnesium. However, in recent patients with circulatory problems and in those with liver years, bicarbonate has gained popularity because of concerns dysfunction. Kidney International Supplements (2012) 2, 89–115 111
chapter 5.7 Table 23 | Microbiological quality standards of different regulatory agencies ANSI/AAMI/ISO763–765 ERA-EDTA guidelines765a Water for dialysis Bacteria (CFU/ml) o100 (action level at 50) o100 Endotoxin (EU/ml) o0.5 o0.25 Dialysate Bacteria (CFU/ml) o100 (action level at 50) o100 Endotoxin (EU/ml) o0.5 o0.25 Ultrapure dialysate Bacteria (CFU/ml) o0.1 o0.1 Endotoxin (EU/ml) o0.03 o0.03 Substitution fluid for infusion Bacteria (CFU/ml) Sterile o10À6 Endotoxin (EU/ml) Undetectable o0.03 AAMI, Association for the Advancement of Medical Instrumentation; ANSI, American National Standards Institute; CFU, colony-forming units; ERA-EDTA, European Renal Association—European Dialysis and Transplant Asssociation; EU, endotoxin units; ISO, International Organization for Standardization. 5.7.4: We recommend that dialysis fluids and replacement commercial) fluids and circuitry during CRRT.760,761 Dialysate fluids in patients with AKI, at a minimum, comply for CRRT should preferably be ultrapure, and should at least with American Association of Medical Instrumen- comply with quality standards for dialysis water and dialysis tation (AAMI) standards regarding contamination fluids that may differ worldwide (Table 23).762 with bacteria and endotoxins. (1B) Finally, an international quality standard for dialysis fluid is in preparation by the International Society for Standardi- zation. Until international standards are in place, we RATIONALE recommend that dialysis fluids and replacement fluids in Replacement fluids for HF or HDF are infused directly into patients with AKI, at a minimum, comply with AAMI the patient’s circulation and should be sterile. A potential standards for bacteria and endotoxins. When local standards major step forward in acute RRT, reducing the costs and the exceed AAMI standards, local standards should be followed need for storage of fluids, is the on-line production of (Table 23). replacement fluids, which is achieved by passing water and/or dialysate through two or three ultrafilters before being RESEARCH RECOMMENDATION infused.757,758 On-line production of replacement fluids has K Further studies are required to explore the impact of on- not yet been approved by the FDA or by some regulatory line preparation of replacement fluid for HDF on clinical authorities in Europe. outcomes (incidence of sepsis, renal recovery, mortality) Conventional IHD uses nonsterile dialysate, as there is no in AKI patients requiring RRT. direct contact between blood and dialysate. However, with the use of high-permeability membranes, the lower blood side SUPPLEMENTARY MATERIAL pressures at the end of the dialyzer filter may allow back- Supplementary Table 36: Summary table of RCTs examining the effect of bicarbonate vs. lactate as buffer for CVVH replacement fluid on filtration of dialysate to the blood,759 raising the possibility of acidosis in AKI. endotoxin or other contaminant exposure. Two studies Supplementary material is linked to the online version of the paper at confirmed microbial contamination of (locally prepared and http://www.kdigo.org/clinical_practice_guidelines/AKI.php 112 Kidney International Supplements (2012) 2, 89–115
http://www.kidney-international.org chapter 5.8 & 2012 KDIGO Chapter 5.8: Dose of renal replacement therapy in AKI The first report of RRT in AKI was published in 1965.766 nutrition, presence of liver disease, sepsis, muscle injury, Despite more than six decades of clinical experience and drugs, etc. research, controversy remains about the best way to measure Several clinical investigations have shown that the actual and what constitutes optimal dose of RRT for patients with delivered dose of RRT in AKI patients is frequently smaller AKI. Indeed, three of the top five questions considered most than the prescribed dose, and even smaller than the relevant by an international expert’s panel on RRT delivery in recommended minimum for CKD patients.771,773,776–778 AKI were about dose.767 Impediments to adequate dose delivery were hemodynamic The methods used for RRT dose quantification in AKI instability, patient size, access problems, technical problems, have several limitations, and have not been fully validated in need for patient transportation, and early filter clotting. this specific population. Earlier single-center trials assessing Trials studying dose in CRRT have used the amount the effects of RRT dose in AKI provided conflicting of effluent volume normalized by the patient’s weight results.531,768–772 Considering the complexity of AKI patients, and procedure time as a parameter for dose evaluation. RRT dose, by itself, may have less impact on mortality both However, the actual effluent flow will be influenced by in patients with very high or very low chance of surviving, interruptions of CRRT, and effluent flow will exceed actual but may be most important in patients with intermediate dose with use of predilution or with reductions in mem- scores of disease severity.773 In addition, it is possible that brane permeability during the treatment. In summary, it is dose and timing are closely linked factors, i.e., a high RRT essential to check very carefully if the prescribed RRT dose dose may not work adequately if provided late, or an early is really being delivered to AKI patients. Increasing filter RRT starting may not be able to change outcomes if the dose size, dialysis time, blood flow rate, dialysate flow rate, and/or is not optimized. Currently, only one small RCT considered effluent flow rate should be considered in case of dose both variables at the same time.531 inadequacy. In determining a prescription of RRT it is mandatory to 5.8.1: The dose of RRT to be delivered should be consider parameters other than small-solute clearance, such prescribed before starting each session of RRT. as patients’ fluid balance, acid-base and electrolyte home- (Not Graded) We recommend frequent assessment ostasis, and nutrition, among others, as possible components of the actual delivered dose in order to adjust the of an optimal RRT dose. In fact, positive fluid balance prescription. (1B) appears to be an independent risk factor for mortality in AKI 5.8.2: Provide RRT to achieve the goals of electrolyte, patients.83 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) RATIONALE 5.8.4: We recommend delivering an effluent volume of The judgment and awareness of how much of a particular 20–25 ml/kg/h for CRRT in AKI (1A). This will therapeutic procedure should be, and actually it is, delivered usually require a higher prescription of effluent is essential for a good medical practice. However, recent volume. (Not Graded) surveys have shown a disappointingly low number of physicians that report being aware of, or calculating, RRT dose in AKI.774 RATIONALE Although widely used for evaluation of RRT in CKD, Kt/V Three RCTs evaluated the dose of IHD in AKI (Suppl Tables urea has important limitations as a tool for RRT dosing in 37 and 38). Schiffl et al.771 compared daily to alternate-day AKI. AKI patients are metabolically unstable, with variations IHD in 146 ICU patients with AKI. RRT was started with in urea generation. In addition, their urea volume of rather high values of SCr (over 4.5 mg/dl [398 mmol/l]) and distribution appears to exceed the patient’s total body-water BUN (around 90 mg/dl [32.1 mmol/l urea]). The daily arm volume.775 Different ways to measure Kt/V obtained received a weekly Kt/V approximately two times higher than significantly different results in AKI patients.776 In the same the alternate-day arm (5.8 ± 0.6 vs. 3 ± 0.6, respectively). way, the selection of a target serum urea level as an indicator Daily IHD resulted in lower mortality (28% vs. 46%, of dialysis dose is highly arbitrary, as serum urea is influenced P ¼ 0.01) and faster recovery of kidney function (9 ± 2 vs. by several extrarenal factors, such as ethnicity, age, gender, 16 ± 6 days, P ¼ 0.001). Major limitations of this study were Kidney International Supplements (2012) 2, 89–115 113
chapter 5.8 inadequate randomization, a ‘‘very low dose’’ in the control compared to 1.16.781 If we assume that AKI patients should group (actually less than that recommended for CKD). Also receive at least the same dose as CKD patients, it seems overall mortality in the study (34%) was lower than in other reasonable to recommend a thrice-weekly Kt/V of 1.3 or a studies in this population, suggesting that the results may not weekly Kt/V of 3.9 (assuming at least thrice-weekly generalize. Moreover, alternate-day IHD was associated with treatment), which also represents the lowest dose in the significant differences in fluid removal and dialysis-associated largest randomized trial in AKI (ARFTN study). Whether hypotension, suggesting that aspects other than solute specific subgroups of AKI patients, such as those with control might modify patient outcomes. hypercatabolism, may benefit from higher doses will require The Veterans Affairs/National Institutes of Health Acute further investigation. Renal Failure Trial Network (ARFTN) study563 was a RCT In conclusion, there are only two adequately designed and assessing the effects of intensive compared to less-intensive executed RCTs testing intermittent or extended RRT dose in RRT in 1124 ICU patients with AKI in 27 Veterans Affairs– AKI. Neither study showed improvement in mortality or renal and university-affiliated North-American centers. Within recovery when the dialysis dose was increased, either by each randomization arm patients were switched between increasing Kt/V above 3.9 weekly or by achieving a plasma urea IHD and CRRT or SLED, based on their hemodynamic target below 90 mg/dl (15 mmol/l) in AKI patients. However, status, reflecting average clinical practice in the USA. consistent with the data on dose of IHD in CKD, and consistent Intermittent treatments were prescribed at a Kt/V of 1.4, with the lower-dose arm in the ARFTN study, we recommend with a delivered Kt/V averaging 1.3, and were performed thrice-weekly Kt/V of 1.3 or a weekly Kt/V of 3.9 for IHD in AKI. three (less-intensive arm) or six (more-intensive arm) times Seven RCTs have investigated the role of CRRT dose in per week. Consequently, the weekly Kt/V was approximately AKI (Suppl Tables 37 and 38).531,562,563,768–770,772 While 6.5 in the intensive and 3.9 in the less-intensive arm. earlier single-center trials showed mixed results, two large Mortality at 60 days was similar in both groups (53.6% and multicenter trials have reached remarkably consistent con- 51.5%) as was the percentage of patients recovering kidney clusions concerning the dose of CRRT that should be function (15.4% and 18.4%). Limitations of this study provided to critically ill patients with AKI. include the predominance of males, and the nonstandardized The ARFTN study563 compared standard-intensity timing for initiating RRT. In addition, a significantly higher predilution CVVHDF with a prescribed effluent flow of frequency of hypotension and electrolyte disturbances were 20 ml/kg/h to high-intensity CVVHDF at 35 ml/kg/h. As dis- seen in the more-intensive arm. Similar to what has been cussed in Recommendation 5.8.3 rationale, there were no reported in chronic dialysis, acute IHD results in under- differences in outcomes between the two study arms. dosing when Kt/V is not measured. In the ARFTN study, the Importantly, more than 95% of the prescribed dose of CRRT first session of IHD had an average delivery of 1.1 Kt/V, while was delivered in the less-intensive group. This represents a the prescribed dose was 1.4. considerably greater intensity of delivered dose than is The Hannover Dialysis Outcome Study768 randomized typically seen in clinical practice. As in chronic dialysis, 148 ICU patients with AKI to two different doses of SLED: a studies in CRRT have shown that delivery usually falls standard-dialysis arm dosed to maintain plasma urea levels substantially short of the prescribed dose.782 Thus, it will between 120–150 mg/dl (20–25 mmol/l), or an intensified- usually be necessary to prescribe a high dose of CRRT in dialysis arm dosed to maintain plasma urea levels o90 mg/dl order to achieve a specific target. For example, in order to (o15 mmol/l). Patients were included with SCr around achieve a delivered dose of 20–25 ml/kg/h, it is likely that the 3 mg/dl (265 mmol/l) and plasma urea around 60 mg/dl prescription will need to be in the range of 25–30 ml/kg/h. (10 mmol/l). The mean plasma urea was kept at 68 ± The Randomized Evaluation of Normal vs. Augmented Level 24 mg/dl (11.3 ± 4 mmol/l) in the intensified and 114 ± of RRT study was conducted in 35 centers in Australia and 36 mg/dl (19 ± 6 mmol/l) in the standard group. Mortality New Zealand.562 It compared the effects of postdilution at 28 days was not statistically different between groups CVVHDF at doses of 25 and 40 ml/kg/h on 28- and 90-day (38.7% and 44.4%) and the frequency of survivors recovering mortality rates in 1464 AKI patients. The delivered dose was kidney function at day 28 was very similar (63% and 60%). 88% and 84% of prescribed in the low- and high-dose In CKD, the analysis by Gotch and Sargent779 of the groups, respectively. As in the ARFTN study, there was no National Cooperative Dialysis Study showed that survival difference in 28- or 90-day mortality between the two groups. could be increased by increasing Kt/V to 1.0–1.2. Analysis of a Apart from a higher incidence of hypophosphatemia in the large database of 2311 Medicare IHD patients also showed a high-dose group, the complication rate was similar.562 strong association between the delivered IHD dose and In conclusion, there are now consistent data from two mortality, with a decreased mortality risk of 7% for each 0.1 large multicenter trials showing no benefits of increa- higher level of delivered Kt/V in CKD patients. However, sing CRRT doses in AKI patients above effluent flows of above a Kt/V of 1.3, no further decrease in mortality was 20–25 ml/kg/h. In clinical practice, in order to achieve a noted.780 The HEMO study, a large RCT comparing two delivered dose of 20–25 ml/kg/h, it is generally necessary to different dialysis doses in CKD, also could not demonstrate a prescribe in the range of 25–30 ml/kg/h, and to minimize further reduction of mortality with equilibrated Kt/V of 1.43 interruptions in CRRT. 114 Kidney International Supplements (2012) 2, 89–115
chapter 5.8 Additional considerations necessarily mean efficiency), assessing control of BUN, In patients who do not achieve the target dose of RRT, creatinine, fluid balance, and acid-base and electrolyte despite optimization of the initial modality, a switch to status. The comparators might be different efficiency another modality or the combination of different modalities targets. The suggested outcomes are 60- to 90-day morta- should be considered. lity, need for vasopressor drugs, time on mechanical Although there are insufficient data supporting a ventilation, ICU and hospital stay, and renal recovery. recommendation for elevated RRT doses in patients with AKI and septic shock, limited data suggest that a higher SPONSORSHIP dose might be beneficial in some patients. A small single- KDIGO gratefully acknowledges the following sponsors that center RCT was conducted in 20 patients with septic shock make our initiatives possible: Abbott, Amgen, Belo Founda- and AKI. Patients were randomized to either high- tion, Coca-Cola Company, Dole Food Company, Genzyme, volume (effluent flow of 65 ml/kg/h) or low-volume CVVH Hoffmann-LaRoche, JC Penney, NATCO—The Organization (effluent flow of 35 ml/kg/h). The primary end-point was for Transplant Professionals, NKF—Board of Directors, vasopressor dose required to maintain mean arterial pressure Novartis, Robert and Jane Cizik Foundation, Shire, at 65 mm Hg. Mean norepinephrine dose decreased more Transwestern Commercial Services, and Wyeth. KDIGO is rapidly after 24 hours of high-volume as compared to supported by a consortium of sponsors and no funding is low-volume CVVH treatment. Survival on day 28 was not accepted for the development of specific guidelines. affected.783 DISCLAIMER RESEARCH RECOMMENDATIONS While every effort is made by the publishers, editorial board, K Determine the optimal dose parameter that should be and ISN to see that no inaccurate or misleading data, opinion used in future trials comparing different intensities of or statement appears in this Journal, they wish to make it dialysis in AKI patients. Some possible methods to clear that the data and opinions appearing in the articles and explore are on-line Kt/V urea, urea reduction ratios, or advertisements herein are the responsibility of the contri- application of the concept of corrected equivalent renal butor, copyright holder, or advertiser concerned. Accord- urea clearance for solute removal measurement and ingly, the publishers and the ISN, the editorial board and ultrafiltration effluent volume, or substitution fluid their respective employers, office and agents accept no volume normalized by body weight and time for CRRT. liability whatsoever for the consequences of any such Other aspects of intensity should also be studied, e.g., inaccurate or misleading data, opinion or statement. While fluid control and acid-base and electrolyte balance. The every effort is made to ensure that drug doses and other comparators might be the standard ways to measure dose quantities are presented accurately, readers are advised that as Kt/V or prescribed effluent volume. Suggested outcome new methods and techniques involving drug usage, and parameters are 60- to 90-day mortality, ICU and hospital described within this Journal, should only be followed in LOS, and recovery of kidney function. conjunction with the drug manufacturer’s own published K Determine the optimal dose of RRT in AKI in homo- literature. geneous subpopulations, such as cardiac surgery or sepsis patients, and separately in ICU and non-ICU patients. SUPPLEMENTARY MATERIAL Future RCTs should be controlled for timing of RRT Supplementary Table 37: Evidence profile of RCTs examining the effect initiation and, perhaps, for general care of patients of dose of continuous and intermittent RRT on AKI. Supplementary Table 38: Summary table of RCTs examining the effect (antibiotics, nutrition, kind and indication for vasoactive of dose of continuous and intermittent RRT on AKI. drugs, mode of mechanical ventilation). Studies should Supplementary material is linked to the online version of the paper at also assess the efficiency of RRT (since dose does not http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 89–115 115
biographic and disclosure information http://www.kidney-international.org & 2012 KDIGO Biographic and Disclosure Information Kidney International Supplements (2012) 2, 116–121; doi:10.1038/kisup.2011.36 John A Kellum, MD, FCCM, FACP (Work Group Co-Chair), contributions to improving and implementing KDOQI is Professor of Critical Care Medicine, Medicine, Bio- Guidelines. He also served as the KDIGO Co-Chair from engineering and Clinical and Translational Science, and Vice 2004 to 2007. Chair for Research within the Department of Critical Care Dr Lameire reported no relevant financial relationships. Medicine at the University of Pittsburgh. In addition, he is the Director of the Program on Bioengineering and Organ Peter Aspelin, MD, PhD, received his basic training in Support for the CRISMA (Clinical Research Investigation ¨ radiology at Malmo University Hospital (Lund University) and Systems Modeling of Acute Illness) Center at the and was Associate Professor there for 13 years. In 1989 he University of Pittsburgh. became Professor and Chairman of the Department of Dr Kellum is actively involved in education, research, and Radiology at Karolinska Institutet, Huddinge University administration. His research interests span various aspects Hospital. Professor Aspelin was Vice Dean of the Medical of critical-care medicine, but center in critical-care nephro- School at Karolinska Institutet from 1993 to 1995 and served logy, sepsis, multiorgan failure, and clinical epidemiology, as Vice President at the institution from 1995 to 2001. He was including consensus development and research methodology. also Head of Research & Development at Huddinge He has authored more than 300 publications and served as University Hospital in 2002 and Vice Chairman of Research editor and contributor to recent texts including Continuous & Development at the Karolinska University Hospital. Other Renal Replacement Therapy, Critical Care Nephrology, and notable accomplishments also include his roles as President Management of Acute Kidney Problems. Dr Kellum has won for the Scientific Board of the Swedish Council of Technology several awards for teaching and has given more than 400 Assessment in Health Care (1999–2005); Chairman of the seminars and invited lectures worldwide related to his Swedish Society of Medical Radiology (2003–2005); and past research. Vice Chairman and current Chairman of the Swedish Advisor/Consultant: Abbott; Alere; Astute Medical; Baxter; Medical Association. CytoSorbents; EBI; Eli Lilly; Fresenius; Gambro; Siemens; Professor Aspelin has conducted research on contrast Spectral Diagnostics media since 1972 when he studied under the tutelage of Speaker: Baxter; Fresenius; Gambro ´ Professor Torsten Almen. He has written more than 170 Grant/Research Support: Astute Medical; Baxter; CytoSorbents; scientific publications to date and his primary research Gambro centers on the development of nonionic contrast media and the examination of their effects on medical imaging and Norbert Lameire, MD, PhD (Work Group Co-Chair), is patient safety. Professor of Internal Medicine and former Chief of Renal Speaker: GE Healthcare Division at the University of Ghent where he also received his Expert witness: GE Healthcare medical degree and PhD. Dr Lameire’s interests include basic research topics such as renal circulation in experimental ARF Rashad S Barsoum, MD, FRCP, FRCPE, is Emeritus and peritoneal circulation, as well as clinical topics spanning Professor of Medicine at Cairo University and current clinical ARF, PD, and organizational and economic aspects Chairman of Cairo Kidney Center and Medical Sector of chronic RRT and transplantation. He currently oversees Committee for Supreme Council for Egyptian Universities. the worldwide continuing medical education programs of He received his medical degree from Cairo University, where COMGAN of the International Society of Nephrology, and he also completed his fellowship in nephrology in 1967. serves as current Editor-in-Chief for Acta Clinica Belgica Dr Barsoum has been a primary investigator in clinical trials and is emeritus Editor-in-Chief for Nephrology Dialysis involving the study of immunosuppression agents in kidney Transplantation. For his activities in the Renal Sister Program transplantation and treatment of HCV infection in dialysis of the International Society of Nephrology and his leadership patients. He has also authored more than 200 journal articles of the Renal Disaster Relief Task Force, he was awarded and book chapters and currently serves as Associate Editor Doctor Honoris Causa at the Kaunas Medical Academy in for Nephron Clinical Practice and editorial board member for Lithuania and an honorary membership of the International American Journal of Kidney Diseases. Dr Barsoum is also Society of Nephrology (ISN). Dr Lameire also received the active in numerous medical societies, having served as Past Garabed Eknoyan Award from the NKF (USA) in 2007 for his President for the Arab Society of Nephrology and Renal continuing work to improve dialysis therapy and PD, and his Transplantation and Egyptian Society of Nephrology. Among 116 Kidney International Supplements (2012) 2, 116–121
biographic and disclosure information his noted achievements include the International Award from Charles A Herzog, MD, is Director of the Cardiovascular the NKF (USA), the Roscoe Robinson Award from the Special Studies Center, United States Renal Data System International Society of Nephrology, and the Distinguished (USRDS). An investigator at the USRDS since 1999, Researcher Award from Cairo University. Dr Herzog has been a cardiologist at Hennepin County Advisor/Consultant: Wyeth Medical Center (HCMC) in Minneapolis and a member of the Speaker: Amgen; B. Braun; Fresenius; Janssen Cilag; University of Minnesota faculty for 27 years. He has been Novartis; Roche; Wyeth a professor of medicine at the University of Minnesota since 2004 and the cardiology consultant to the ESRD program Emmanuel A Burdmann, MD, PhD, is Head of Intensive Care (dialysis and renal transplant) at HCMC since 1985. He Unit and Associate Professor, Division of Nephrology at founded the program in interventional cardiology and served ˜ University of Sao Paulo Medical School. He received his as the director of the cardiac catheterization laboratory at ˜ medical degree from the University of Sao Paulo, where he also HCMC from 1985 to 1991. Since 1997, Dr Herzog has been completed his fellowship. He was the Past President of the the director of the cardiac ultrasound laboratory at HCMC. Latin American Society of Nephrology and Hypertension and He participated in the development of the National Kidney current President of Brazilian Society of Nephrology. Dr Foundation’s K/DOQI Clinical Practice Guidelines for Cardio- Burdmann has authored over 150 journal articles and book vascular Disease in Dialysis Patients, and co-chaired the 2010 chapters and is currently on the editorial boards of Clinical KDIGO Controversies Conference, ‘‘Cardiovascular Disease in Journal of the American Society of Nephrology, Clinical CKD: What is it and What Can We Do About It?’’ The author Nephrology, Kidney International, Nephrology Dialysis Trans- or co-author of more than 100 published papers and reviews, plantation, and Nephron Clinical Practice. He is also a member Dr Herzog has served on the Editorial Board for the American of numerous professional societies and has served on the Heart Journal since 2005 and as liaison editor (cardiology) for Council of the International Society of Nephrology and Nephrology Dialysis Transplantation since 2007. His areas of KDIGO Board. In addition to his research interest in AKI, research and special interests include cardiac disease and Dr Burdmann is also a coinvestigator in the TREAT study. chronic kidney disease, and echocardiography. Dr Burdmann reported no relevant financial relationships. Advisor/Consultant: Abbott; Affymax; Amgen; CorMedix; FibroGen; Fresenius Stuart L Goldstein, MD, is Professor of Pediatrics and Director, Board of Trustees: Roche Foundation for Anemia Research Center for Acute Care Nephrology at Cincinnati Children’s Honorarium: UpToDate Hospital Medical Center. He received his medical degree from Grant/Research Support: Johnson & Johnson; National Institutes Columbia University and completed both clinical and research of Health fellowships in pediatric nephrology at the Children’s Hospital Equity Interest: Boston Scientific; Cambridge Heart; Johnson in Boston, Massachusetts. Dr Goldstein is a member of the & Johnson; Merck American Academy of Pediatrics, the American Society of Nephrology, the International Pediatric Nephrology Asso- Michael Joannidis, MD, is Associate Professor in Medicine ciation, the American Society of Pediatric Nephrology, the and serves as Director of the Medical Intensive Care Unit, International Society of Nephrology, and the Society for Dept. Internal Medicine I at Medical University Innsbruck in Pediatric Research. In addition, he is Chairman of the Medical Austria. He is a certified specialist in critical-care medicine, Advisory Committee to the FORUM of ESRD Networks and a nephrology, and cardiology, and his research interests cover member of the Medical Review Board for the ESRD Networks several aspects of critical-care medicine with a major focus on 9 and 10, is the Pediatric Nephrologist Representative for the AKI, renal tubular epithelial pathophysiology, RRT, and sepsis. International Society of Nephrology Commission of Acute Dr Joannidis currently serves as chair of the section Acute Renal Failure, and has been elected to the Council of the Kidney Injury of the European Society of Intensive Care American Society of Pediatric Nephrology. Dr Goldstein has Medicine (ESICM), President of the Austrian Society of developed and validated the pediatric modified RIFLE Medical and General Intensive Care Medicine (OEGIAIM) (pRIFLE) AKI criteria, is Founder and Principal Investigator and associate editor of Intensive Care Medicine. for the Prospective Pediatric Continuous Renal Replacement Speaker: Baxter; Fresenius; Gambro Therapy (ppCRRT) Registry Group, and has evaluated novel urinary AKI biomarkers in the pediatric critical care setting. He Andreas Kribben, MD, is Professor of Medicine and Head of has written over 110 journal articles and contributed book the Department of Nephrology at the University Hospital chapters to numerous texts including, Critical Care Nephrology, Essen at the University of Duisburg-Essen. He received his Evidence-Based Nephrology, Handbook of Dialysis Therapy, medical degree at the Johann-Wolfgang Goethe University Management of Acute Kidney Problems, Pediatric Critical Care, Frankfurt, Germany in 1983. Dr Kribben was trained in Pediatric Nephrology, and Pediatric Nephrology in the ICU. Internal Medicine and Nephrology at the Department of Advisor/Consultant: Baxter; Gambro Nephrology of the University Hospital Klinikum Steglitz, Speaker: Gambro Free University of Berlin, Germany and at the University Grant/Research Support: Amgen; Baxter; Gambro Hospital Essen, University Duisburg-Essen, Germany. From Kidney International Supplements (2012) 2, 116–121 117
biographic and disclosure information 1990 to 1993, he was a research fellow at the Renal Division systematic literature reviews and she is a member of the of the University of Colorado Health Sciences Centre in Editorial Board of the Cochrane Review Group. Dr MacLeod Denver, Colorado, USA. His major scientific interests include is a current committee member of the European Renal all aspects of AKI, CRF, as well as transplantation and Registry Executive Committee, Anemia Management in hypertension. Chronic Kidney Disease–National Institute for Health and Dr Kribben is member of numerous professional organi- Clinical Excellence, Scientific Committee, and European zations, including the International Society of Nephrology, Renal Association Congress. In addition, she is Chairman the American Society of Nephrology, the European Dialysis of the Scottish Intercollegiate Guidelines Network, Diagnosis and Transplantation Association, and he is a member of the and Management of Chronic Renal Failure and was a Board of Directors of the German Society of Nephrology. member of the Executive Committee of KDIGO. He is an editorial member of Clinical Nephrology and served Dr MacLeod reported no relevant financial relationships. as subject editor of Nephrology Dialysis Transplantation. Dr Kribben is also a member of the World Health Ravindra L Mehta, MD, FACP, FASN, FRCP, is Professor Organization Work Group for the 11th revision of ICD. of Medicine in the Division of Nephrology and Associate Advisor/Consultant: Roche; Shire; Teva Chair for Clinical Research in the Department of Medicine Speaker: Amgen; Apherese ForschungsInstitut; Baxter; at the University of California, San Diego (UCSD) where Bayer-Schering; Berlin-Chemie; Fresenius; GE Healthcare; he directs the Acute Dialysis Program and the UCSD Genzyme; Roche; Shire CREST and Masters in Clinical Research Program. He Grant/Research Support: B. Braun; Biosite; Fresenius; received the M.B.B.S. degree (1976) from the Government Koehler; Roche; Teva Medical School in Amritsar, India, and the M.D. (1979) and D.M. (1981) degrees from the Post-Graduate Institute Andrew S Levey, MD, is Dr Gerald J. and Dorothy R. of Medical Education and Research in Chandigarh, India. Friedman Professor of Medicine at Tufts University School He subsequently completed a nephrology fellowship at of Medicine, Chief of the William B. Schwartz, MD Division the University of Rochester in Rochester, New York and of Nephrology at Tufts Medical Center, Senior Scientist at obtained his boards in internal medicine (1986) and the US Department of Agriculture Human Nutrition Nephrology (1988). He has been on the faculty at UCSD Research Center on Aging at Tufts University, and Professor, since 1988. Clinical Research at the Sackler School of Graduate Dr Mehta is an internationally recognized expert in the Biomedical Sciences at Tufts University. His research is field of ARF and has directed several clinical studies in the mainly in the areas of epidemiology of CKD and cardio- management of patients with kidney disease including vascular disease in CKD, controlled trials to slow the comparing different dialytic modalities in the treatment of progression of CKD, clinical assessment of kidney function, AKI, conducting large multicenter observational studies of assessment and improvement of outcomes in dialysis and AKI with the PICARD group, evaluating different predictive transplantation, and clinical practice guideline develop- models for outcomes in AKI, investigating the role of ment and implementation. Dr Levey is currently Program cytokine removal by dialysis membranes in sepsis and AKI, Director for an NIDDK-funded clinical research training and evaluating techniques for determining the amount of program, ‘‘Clinical Trials, Epidemiology and Outcomes excess fluid in dialysis patients. In addition to his clinical and Research in Nephrology’’. He is also the Director of the research activities, he has worked with the American Society Tufts Center for Guideline Development and Implementation of Nephrology, NKF, Society of Critical Care Medicine, and and Editor of the American Journal of Kidney Disease. the International Society of Nephrology in developing Dr Levey is past Chair of the NKF’s Task Force on courses for fellows and practicing physicians in clinical Cardiovascular Disease in Chronic Renal Disease, KDOQI nephrology and dialysis techniques. Dr Mehta chairs the Work Group on Chronic Kidney Disease: Evaluation, annual International Conference on CRRT that is now in its Classification and Stratification, and KDOQI Work Group 15th year and he is also the Chair of the International Society on Hypertension and Antihypertensive Agents in Chronic of Nephrology Committee on AKI, founding member of the Kidney Disease. ADQI and AKIN. He has authored over 150 scientific articles, Grant/Research Support: Amgen; National Institutes of papers and book chapters, and has been actively involved in Health; National Kidney Foundation resident and scholar teaching. He won the house staff teaching award on four occasions and was awarded School of Alison M MacLeod, MBChB, MD, FRCP London and Medicine Faculty teaching award in 2003. He has been Edinburgh, is Professor in the Department of Medicine recognized as one of the Best Doctors in San Diego and the and Therapeutics at the University of Aberdeen Medical USA. In 2008, he was recognized by the American School, UK. She completed her fellowship at the Royal Nephrologists of Indian Origin for his achievements in Colleges of Physicians of London and Edinburgh, and has nephrology. In March 2009, he was elected as a Fellow of the interests in epidemiology of CKD, AKI, and evidence based Royal College of Physicians in the UK. Over the course of his medicine in nephrology. Her research group also conducts academic career, he has trained over 50 postdoctoral fellows 118 Kidney International Supplements (2012) 2, 116–121
biographic and disclosure information in nephrology, of whom 15 have carried out their research Medal of NKF of the USA in 2005 and was awarded the projects with him. prestigious Roscoe Robinson award for nephrology education Advisor/Consultant: Astute Medical; Eli Lilly; Takeda by the ISN at its World Congress in Milan in May 2009. She Speaker: Baxter; Gambro has hosted the nephrology training of ISN Fellows from Grant/Research Support: Eli Lilly Ethiopia, Nigeria, Botswana, Tanzania, Rwanda, Kenya and Zambia as well as ISPD trainees from Nigeria and Tanzania. Patrick T Murray, MD, FASN, FRCPI, FJFICMI, is a During her period as Chair of the Africa Committee of ISN nephrologist and clinical pharmacologist at the Mater COMGAN from 2000 to 2007, she made site visits and Misericordiae University Hospital and University College participated in continuing medical education programs in Dublin, Ireland. Dr Murray received his medical education at many African countries. Her research interests include areas University College Dublin, Ireland and following his intern- related to HIV and kidney disease, prevention of CKD, CVD ship at the Mater Misericordiae University Hospital in in renal disease, and medical education. Dublin, he completed his residency in internal medicine Advisor/Consultant: Amgen; Novartis; Roche at Hennepin County Medical Center in Minneapolis, Minnesota, USA and fellowship training programs in nephrology, critical Steven M Opal, MD, is Professor of Medicine at The Warren care medicine, and clinical pharmacology at the University of Alpert Medical School of Brown University and Chief of the Chicago Hospitals in Chicago, Illinois, USA. Infectious Disease Division, Memorial Hospital of Rhode Dr Murray is board-certified in internal medicine, Island. He received his medical degree from Albany Medical nephrology, critical care medicine, and clinical pharmacology School, Albany, New York and completed his fellowship and practiced as an intensivist, nephrologist, and clinical training in infectious diseases at Walter Reed Army Medical pharmacologist at the University of Chicago Hospitals from Center in Washington, DC. Dr Opal is a member of 1996 to 2008, serving as the fellowship training program numerous national and international committees including, director in nephrology and also directing the Acute Dialysis International Steering Committee for Sepsis Clinical Trials; Service. Since 2008, he has been the Professor of Clinical Steering Committee FDA Meta-analysis Committee on Pharmacology at University College Dublin, and a Con- Sepsis; International Endotoxin Society; and International sultant in Nephrology & Clinical Pharmacology at the Mater Sepsis Forum. He has written extensively with over 300 Misericordiae University Hospital. Dr Murray has published publications and has given more than 100 invited presenta- extensively with contributions in numerous books inclu- tions. Dr Opal currently serves on the editorial boards of ding, Critical Care Nephrology, Evidence-Based Nephrology, Advances in Sepsis, Critical Care Forum, Current Opinion in Evidence-Based Practice of Critical Care, and Intensive Care in Critical Care, and Shock. In recognition for his work, he was Nephrology. He has a long-standing interest in research and awarded the Brown Medical School Infectious Disease education to improve the prevention, diagnosis, and therapy Fellowship Teacher of the Year Award in 2008 and was of AKI. acknowledged in Best Doctors in America from 2003 to 2009. Advisor/Consultant: Abbott; Alere; AM Pharma; Argutus Dr Opal reported no relevant financial relationships. Medical; FAST Diagnostics; Reata; Sanofi-Aventis Grant/Research Support: Abbott; Alere; Argutus Medical Franz Schaefer, MD, is Professor of Pediatrics and Chief of the Pediatric Nephrology Division at Heidelberg University Saraladevi Naicker, MBChB, MRCP, FRCP, FCP (SA), PhD, Hospital. Dr Schaefer received his M.D. at Wurzburg ¨ is currently Academic Head of the Department of University Medical School and performed research scholar- Internal Medicine and Professor of Renal Medicine and head ships at the Institute of Child Health, London, University of of the Division of Nephrology at the University of the Virginia, and Stanford University. His research interests Witwatersrand in Johannesburg. She completed her under- include topics on physiopathology of growth failure, graduate and postgraduate medical training primarily at the cardiovascular and endocrine disorders in CKD and the role University of Natal in Durban, South Africa and spent short of genetic abnormalities in congenital kidney disorders. In periods training in nephrology at the Universities of the clinical research, he conducted numerous collaborative Witwatersrand, Johannesburg and Newcastle on Tyne in the clinical trials and established several international consortia UK. She currently chairs the Postgraduate (Higher Degrees) such as the the European Study Group on Progressive CKD Committee of the Faculty of Health Sciences at the University in Children, the International Pediatric Peritoneal Dialysis of the Witwatersrand and is a member of the Council of the Network, and the PodoNet Registry for Steroid Resistant College of Physicians of the Colleges of Medicine of South Nephrotic Syndrome. Dr Schaefer has published over 280 Africa. She is also a Council member of the International articles and book chapters, and co-edited the standard Society of Nephrology (ISN) and chairs its Education textbooks Comprehensive Pediatric Nephrology and Pediatric Committee. Dialysis. He received several prestigious awards for innovative Dr Naicker was the recipient of the Philip Tobias/Convo- research including the Recklinghausen Prize and the IBM cation Distinguished Teachers Award at the University of the Faculty Award. Dr Schaefer is a current council member of Witwatersrand in 2006, the International Distinguished the International Pediatric Nephrology Association and the Kidney International Supplements (2012) 2, 116–121 119
biographic and disclosure information International Society of Peritoneal Dialysis. He is a member Disorders. Dr Eckardt is a member of the executive committee of several editorial boards and serves as Section Editor for of KDIGO. Nephrology Dialysis Transplantation and Pediatric Nephrology. Advisor/Consultant: Affymax; Amgen; Hexal Sandoz; Dr Schaefer reported no relevant financial relationships. Johnson & Johnson; Roche Speaker: Amgen; Janssen Cilag; Johnson & Johnson; Roche Miet Schetz, MD, PhD, graduated from the faculty Grant/Research Support: Roche of Medicine of the Catholic University of Leuven, Belgium, after which she specialized in anesthesiology and later in Bertram L Kasiske, MD, is Professor of Medicine at the intensive care medicine. Since 1981 she is staff member of University of Minnesota, USA. He received his medical the department of Intensive Care Medicine at the University degree from the University of Iowa and completed his Hospital Leuven (Chair: Greet Van den Berghe) and has Internal Medicine residency and fellowship training in been Associate Professor at the Catholic University Leuven Nephrology at Hennepin County Medical Center where he since 2000. Dr Schetz completed her PhD thesis on the is currently Director of Nephrology. subject, ‘‘The Hemostatic System and Continuous Renal Dr Kasiske is former Deputy Director of the United States Replacement Therapy: Mutual Effects’’. Her main field of Renal Data System and former Editor-in-Chief of The interest is AKI and its treatment, on which she published American Journal of Kidney Diseases. He has served as several articles. Secretary/Treasurer and on the Board of Directors of the Grant/Research Support: Gambro American Society of Transplantation, and on the Organ Procurement and Transplantation Network/United Network Shigehiko Uchino, MD, PhD, is Associate Professor and Staff of Organ Sharing Board of Directors, and the Scientific Intensivist in the Department of Anesthesiology at Jikei Advisory Board of the National Kidney Foundation. He is University School of Medicine in Tokyo, Japan. He received currently serving on the Board of Councilors of the his medical degree from Tokyo Medical and Dental International Society of Nephrology. He is the Principal University and his PhD from Jikei University School of Investigator for a National Institutes of Health-sponsored, Medicine. Dr Uchino is a member of the Japanese Society of multi-center study of long term outcomes after kidney Intensive Care Medicine, Japanese Association for Acute donation. He is the Director of the Scientific Registry of Medicine, Society of Critical Care Medicine, and the Transplant Recipients. He has over 160 scientific publications European Society of Intensive Care Medicine. In addition in major peer reviewed journals, and 230 review articles, to serving as a reviewer for numerous journals, he has written editorials and textbook chapters. Dr Kasiske is also a recipient book chapters in recent texts such as Critical Care Nephrology, of the NKF’s Garabed Eknoyan Award in 2003. Evidence-Based Practice of Critical Care, and Intensive Care Advisor/Consultant: Litholink in Nephrology. Dr Uchino is also a coinvestigator in the Grant/Research Support: Bristol-Myers Squibb; Merck-Schering BEST Kidney study. Plough Dr Uchino reported no relevant financial relationships. EVIDENCE REVIEW TEAM KDIGO CHAIRS Katrin Uhlig, MD, MS, is the Director, Guideline Develop- Kai-Uwe Eckardt, MD, is Professor of Medicine and Chief ment at the Tufts Center for Kidney Disease Guideline of Nephrology and Hypertension at the University of Development and Implementation, Boston, MA, Associate Erlangen—Nuremberg, Germany. He received his MD from Professor of Medicine at Tufts University School of Medicine, ¨ ¨ ¨ the Westfalische Wilhelms-Universitat Munster, Germany. In and a staff nephrologist at Tufts Medical Center. Dr Uhlig 1993, following postgraduate training in internal medicine, completed her training in internal medicine, nephrology, and pathology and physiology, he was appointed Assistant rheumatology in Germany (Aachen University Hospital and Professor of Physiology at the University of Regensburg, Munich University Hospital) and the USA (Georgetown Germany. Subsequently, he continued his training in internal University Medical Center and Tufts Medical Center). Since ´ medicine and nephrology at the Charite, Humboldt Uni- 2001, she has been participating in or directing the evidence versity in Berlin, where he was appointed Associate Professor review for KDOQI and KDIGO guidelines. In 2005, she of Nephrology in 2000. His major scientific interests are in co-chaired the KDIGO Evidence Rating Group to develop the molecular mechanisms and physiological/pathophysio- a consensus on grading of KDIGO guidelines. From 2006 logical relevance of oxygen sensing and the management of to 2007, she served as Co-Editor of the American Journal anemia. As such, he has contributed to the development of of Kidney Diseases. Her focus in teaching and research is in the European Best Practice Guidelines for Anemia Manage- evidence-based medicine, systematic review, clinical practice ment and participated in the CREATE and TREAT studies. guideline development, and critical literature appraisal. Professor Eckardt is subject editor of Nephrology Dialysis Dr Uhlig reported no relevant financial relationships. Transplantation and serves on the editorial board of several other journals. He has also authored book chapters and most Jose Calvo-Broce, MD, MS, served as a research fellow at the recently served as a Co-Editor of the text, Studies on Renal Tufts Center for Kidney Disease Guideline Development and 120 Kidney International Supplements (2012) 2, 116–121
biographic and disclosure information Implementation in Boston, MA and participated in the conduct of systematic reviews and critical literature appraisals conduct of systematic reviews and critical literature apprai- for this guideline. Dr Deo was awarded a Master of Science sals for this guideline. Dr Calvo-Broce was recently awarded in Clinical Research for her thesis on ‘‘Loss to Analysis in a Master of Science in Clinical Research for his thesis Randomized Controlled Trials of Chronic Kidney Disease’’. on ‘‘Hospital-Acquired AKI: An Analysis of Nadir-to-Peak Dr Deo reported no relevant financial relationships. Serum Creatinine Increments Stratified by Baseline Estimated GFR’’. Amy Earley, BS, is a project coordinator at the Tufts Center Dr Calvo-Broce reported no relevant financial relationships. for Kidney Disease Guideline Development and Implementa- tion in Boston, MA. She assists in the development of clinical Aneet Deo, MD, MS, served as a research fellow at the practice guidelines and conducts systematic reviews and Tufts Center for Kidney Disease Guideline Development critical literature appraisals. and Implementation in Boston, MA. She participated in the Ms Earley reported no relevant financial relationships. Kidney International Supplements (2012) 2, 116–121 121
acknowledgments http://www.kidney-international.org & 2012 KDIGO Acknowledgments Kidney International Supplements (2012) 2, 122–123; doi:10.1038/kisup.2011.37 A special debt of gratitude is owed to the current KDIGO Hemmelgarn (Canadian Society of Nephrology), Hallvard Co-Chairs Kai-Uwe Eckardt and Bertram Kasiske and the Holdaas (National Hospital - Norway), Lai Seong Hooi KDIGO Board for their invaluable guidance throughout (Hospital Sultanah Aminah), Atsuko Ikemori (St. Marianna the development of this guideline. In particular, we thank the University School of Medicine), Enyu Imai (Nagoya Uni- ERT members: Katrin Uhlig, Jose Calvo-Broce, Aneet Deo, versity School of Medicine), Lesley Inker (Tufts-New England and Amy Earley, for their substantial contribution to the Medical Center), Sarwar Iqbal (BIRDEM Hospital), Kuni- rigorous assessment of the available evidence. We are also toshi Iseki (Ryukyn University), Simon Jenkins, Svend especially grateful to the Work Group members for their Lorentz Jorgensen (Pharmacosmos A/S), Takei Kake (Chugai expertise throughout the entire process of literature review, Pharmaceutical), Nada Kanaan (Cliniques Universitaires data extraction, meeting participation, the critical writing Saint Luc), Markus Ketteler (Klinikum Coburg GGmbH), and editing of the statements and rationale, which made the Mahmoud El-Khatib (University of Cincinnati), Pradeep publication of this guideline possible. The generous gift of Kumar Rai (Opal Hospital, Varanasi, India), Hanife Kurtal their time and dedication is greatly appreciated. Finally, and ´ ¨ (Charite-Universitatsmedizin, Berlin), Craig B Langman on behalf of the Work Group, we gratefully acknowledge (Children’s Memorial Hospital, Chicago), Ingrid Ledebo the careful assessment of the draft guideline by external (Gambro AB), Edgar Lerma (University of Illinois at Chicago reviewers. The Work Group considered all of the valuable College of Medicine), Nathan W Levin (Renal Research comments made and where appropriate, suggested changes Institute), Andrew Lewington (The Renal Association, UK), were incorporated into the final publication. The following Visnja Lezaic (Clinical Centre of Serbia), Zhi-Hong Liu individuals and organizations provided review of the draft (Nanjing University School of Medicine), Raul Lombardi guideline: (Latin American Society of Nephrology & Hypertension), Omar Abboud, Mona Al–Rukhaimi (Dubai Hospital), ´ ´ ´ Gerard London (ERA/EDTA), Jose Antonio Lopes (Hospital Mustafa Arici (Hacettepe University Faculty of Medicine), de Santa Maria), Robert Mactier (The Renal Association, Mariano Arriola (Clinica de Nefrologia, Urologia y UK), Constantine Manthous (American Thoracic Society), Enfermedades Cardiovasculares, Argentina), Adanze Asinobi Omar Maoujoud (Mohammed V Military Hospital), Pablo U (University of Ibadan, Nigeria), Alper Azak (Ankara Educa- Massari, John McIlwaine (American College of Chest tion and Research Hospital), Gavin Becker (Royal Melbourne Physicians), Cecilia Mengarelli (Fresenuis Mansilla), Gong Hospital), Rudy Bilous (The James Cook University Hospi- Mengchun (Peking Union Medical College Hospital), Walid tal), Yousef Boobes (Tawam Hospital, UAE), Catherine Mohamed (Alexandria University Hospital), Rafique Moosa Bouman (Dutch Society of Intensive Care Medicine), Carlo (University of Stellenbosch), Jose M Morales (Hospital 12 de Briguori (Clinica Mediterranea), Eric S Cantor (GE Health- Octubre, Spain; European Society for Organ Transplanta- care), Maria Ines Carvallo, William R Clark (Gambro), tion), Sameh K Morcos (Northern General Hospital), Adrian Covic (Hospital CI Parhon, Romania), Daniel Coyne Toshiki Moriyama (Osaka University Health Care Center), (Washington University School of Medicine), Joe Dasta Abdou Niang (Cheikh Anta Diop University), Eisei Noiri (Society of Critical Care Medicine), Jane S Davis (University (Japanese Society of Nephrology), Fernando Nolasco of Alabama at Birmingham), Angel de Francisco (Spanish (Portuguese Society of Nephrology), Maurizio Nordio Society of Nephrology), Jean-Yves De Vos (AZ Werken (Dirigente Medico), Michał Nowicki (Medical University of Glorieux Dialysis Unit), Pierre Delanaye (University of Lodz), Ercan Ok (Turkish Society of Nephrology), Suzanne ` Liege), Sarah Faubel (American Society of Nephrology), Oparil (University of Alabama at Birmingham), Heleen ˜ Ana Elizabeth Figueiredo (Hospital Sao Lucas), Thorsten Oudemans (Danish Society of Intensive Care), Erling Feldkamp ¨ (Universitatsklinikum Essen, ¨ Universitat Pedersen (Holstebro Hospital and University of Aarhus), Duisburg-Essen), Kevin Finkel (Society of Critical Care Momir Polenakovic (Balkan Cities Association of Nephro- Medicine), Lui G Forni (European Society of Intensive Care logy, Dialysis, Transplantation and Artificial Organs), Manuel Medicine), Heidi Frankel (Society of Critical Care Medicine), Praga (Hospital 12 de Octubre, Spain), Wajeh Qunibi Gerard Fulda (Society of Critical Care Medicine), (University of Texas Health Science Center), Enrique Andres´ Mohammed Benghanem Gharbi (University Hospital Ibn ´ Ribes (Fundacio Puigvert), Eduardo Rocha (Rio de Janeiro Rochd), Richard J Glassock (UCLA), Robert S Gold (DCBA), Federal University Medical School), Cibele Rodrigues Basu Gopal (Christian Medical College), Jeff Harder ˜ (Catholic University of Sao Paulo), Guillermo Rosa-Diez (University of Washington Medical Center), Brenda (Hospital Italiano de Buenos Aires - Argentina), Brad Rovin 122 Kidney International Supplements (2012) 2, 122–123
acknowledgments (Ohio State University), Nestor Schor (Universidade Federal Raymond Vanholder (University Hospital Ghent), Rowan de Sao Paulo-UNIFESP), Mehmet Sukru Sever (European Walker (Royal Melbourne Hospital), Michael Walsh Renal Best Practice), Amma Sewaah-Bonsu (Nephrology (McMaster University), HaiYan Wang (Beijing University), Associates of Central Florida), Deepak Sharma (Mil Hospital Jiandong Wei (SUNY Downstate Medical Center), Colin Jalandhar, India), Justin Silver (Hadassah University Hospi- White (University of British Columbia), Hitoshi Yokoyama tal), Richard Solomon (Fletcher Allen Health Care), Peter (Kanazawa Medical University), Luis Yu (University of Spiro (American College of Chest Physicians), Takeshi ˜ Sao Paulo), Elena Zakharova (Moscow City Hospital), Sugaya (St. Marianna University School of Medicine), Cem Carmine Zoccali (CNR-IBIM Clin Research Unit Ospedali Sungur (Anadolu Medical Center), Charles Swanepoel Riuniti, Italy), Kim Zuber (Metropolitan Nephrology (University of Cape Town), Seng Hoe Tan (Gleneagles Associates). Medical Centre, Singapore), Samuel A Tisherman (Society Participation in the review does not necessarily constitute of Critical Care Medicine), Charles Tomson (Southmead endorsement of the content of this report by above indivi- ´ ˆ Hospital), Stephan Troyanov (Hopital du Sacre-Coeur,´ duals or the organization or institution they represent. Montreal), Hung-Bin Tsai (Buddhist Dalin Tzu Chi General Hospital), Hirokazu Tsukahara (Okayama University John A Kellum, MD, FCCM, FACP, Work Group Co-Chair Hospital), Wim Van Biesen (University Hospital Ghent), Norbert Lameire, MD, PhD, Work Group Co-Chair Kidney International Supplements (2012) 2, 122–123 123
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Kdigo aki guideline

  • 1. OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF NEPHROLOGY KDIGO Clinical Practice Guideline for Acute Kidney Injury VOLUME 2 | ISSUE 1 | MARCH 2012 http://www.kidney-international.org KI_SuppCover_2.1.indd 1 2/7/12 12:32 PM
  • 2. http://www.kidney-international.org contents & 2012 KDIGO VOL 2 | SUPPLEMENT 1 | MARCH 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury iv Tables and Figures 1 Notice 2 Work Group Membership 3 KDIGO Board Members 4 Reference Keys 5 Abbreviations and Acronyms 6 Abstract 7 Foreword 8 Summary of Recommendation Statements 13 Section 1: Introduction and Methodology 13 Chapter 1.1: Introduction 17 Chapter 1.2: Methodology 19 Section 2: AKI Definition 19 Chapter 2.1: Definition and classification of AKI 23 Chapter 2.2: Risk assessment 25 Chapter 2.3: Evaluation and general management of patients with and at risk for AKI 28 Chapter 2.4: Clinical applications 33 Chapter 2.5: Diagnostic approach to alterations in kidney function and structure 37 Section 3: Prevention and Treatment of AKI 37 Chapter 3.1: Hemodynamic monitoring and support for prevention and management of AKI 42 Chapter 3.2: General supportive management of patients with AKI, including management of complications 43 Chapter 3.3: Glycemic control and nutritional support 47 Chapter 3.4: The use of diuretics in AKI 50 Chapter 3.5: Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides 57 Chapter 3.6: Growth factor intervention 59 Chapter 3.7: Adenosine receptor antagonists 61 Chapter 3.8: Prevention of aminoglycoside- and amphotericin-related AKI 66 Chapter 3.9: Other methods of prevention of AKI in the critically ill 69 Section 4: Contrast-induced AKI 69 Chapter 4.1: Contrast-induced AKI: definition, epidemiology, and prognosis 72 Chapter 4.2: Assessment of the population at risk for CI-AKI 76 Chapter 4.3: Nonpharmacological prevention strategies of CI-AKI 80 Chapter 4.4: Pharmacological prevention strategies of CI-AKI 87 Chapter 4.5: Effects of hemodialysis or hemofiltration 89 Section 5: Dialysis Interventions for Treatment of AKI 89 Chapter 5.1: Timing of renal replacement therapy in AKI 93 Chapter 5.2: Criteria for stopping renal replacement therapy in AKI 95 Chapter 5.3: Anticoagulation 101 Chapter 5.4: Vascular access for renal replacement therapy in AKI 105 Chapter 5.5: Dialyzer membranes for renal replacement therapy in AKI 107 Chapter 5.6: Modality of renal replacement therapy for patients with AKI 111 Chapter 5.7: Buffer solutions for renal replacement therapy in patients with AKI 113 Chapter 5.8: Dose of renal replacement therapy in AKI 116 Biographic and Disclosure Information 122 Acknowledgments 124 References
  • 3. contents http://www.kidney-international.org & 2012 KDIGO TABLES 18 Table 1. Implications of the strength of a recommendation 19 Table 2. Staging of AKI 21 Table 3. Comparison of RIFLE and AKIN criteria for diagnosis and classification of AKI 21 Table 4. Cross-tabulation of patients classified by RIFLE vs. AKIN 22 Table 5. Causes of AKI and diagnostic tests 23 Table 6. Causes of AKI: exposures and susceptibilities for non-specific AKI 28 Table 7. AKI diagnosis 29 Table 8. Overview of the approaches to determine baseline SCr in the application of RIFLE classification in previous studies 29 Table 9. Estimated baseline SCr 30 Table 10. AKI staging 33 Table 11. Definitions of AKI, CKD, and AKD 33 Table 12. Examples of AKI, CKD, and AKD based on GFR and increases in SCr 35 Table 13. Markers of kidney damage in AKD and CKD 35 Table 14. Integrated approach to interpret measures of kidney function and structure for diagnosis of AKI, AKD, and CKD 73 Table 15. CI-AKI risk-scoring model for percutaneous coronary intervention 77 Table 16. Additional radiological measures to reduce CI-AKI 91 Table 17. Potential applications for RRT 91 Table 18. Fluid overload and outcome in critically ill children with AKI 97 Table 19. Overview of the advantages and disadvantages of different anticoagulants in AKI patients 104 Table 20. Catheter and patient sizes 107 Table 21. Typical setting of different RRT modalities for AKI (for 70-kg patient) 108 Table 22. Theoretical advantages and disadvantages of CRRT, IHD, SLED, and PD 112 Table 23. Microbiological quality standards of different regulatory agencies FIGURES 14 Figure 1. The RIFLE criteria for AKI 20 Figure 2. Overview of AKI, CKD, and AKD 20 Figure 3. Conceptual model for AKI 25 Figure 4. Stage-based management of AKI 26 Figure 5. Evaluation of AKI according to the stage and cause 34 Figure 6. Chronic Kidney Disease Epidemiology Collaboration cohort changes in eGFR and final eGFR corresponding to KDIGO definition and stages of AKI 34 Figure 7. GFR/SCr algorithm 38 Figure 8. Conceptual model for development and clinical course of AKI 48 Figure 9. Effect of furosemide vs. control on all-cause mortality 48 Figure 10. Effect of furosemide vs. control on need for RRT 51 Figure 11. Effect of low-dose dopamine on mortality 52 Figure 12. Effect of low-dose dopamine on need for RRT 73 Figure 13. Sample questionnaire 78 Figure 14. Risk for contrast-induced nephropathy 81 Figure 15. Bicarbonate vs. saline and risk of CI-AKI 85 Figure 16. NAC and bicarbonate vs. NAC for risk of CI-AKI 96 Figure 17. Flow-chart summary of recommendations Additional information in the form of supplementary materials can be found online at http://www.kdigo.org/clinical_practice_guidelines/AKI.php iv Kidney International Supplements (2012) 2, iv
  • 4. http://www.kidney-international.org & 2012 KDIGO Notice Kidney International Supplements (2012) 2, 1; doi:10.1038/kisup.2012.1 SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE This Clinical Practice Guideline document is based upon the best information available as of February 2011. It is designed to provide information and assist decision-making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The recommendations for research contained within this document are general and do not imply a specific protocol. SECTION II: DISCLOSURE Kidney Disease: Improving Global Outcomes (KDIGO) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived or actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information is published in its entirety at the end of this document in the Work Group members’ Biographical and Disclosure Information section, and is kept on file at the National Kidney Foundation (NKF), Managing Agent for KDIGO. Kidney International Supplements (2012) 2, 1 1
  • 5. http://www.kidney-international.org & 2012 KDIGO Work Group Membership Kidney International Supplements (2012) 2, 2; doi:10.1038/kisup.2012.2 WORK GROUP CO-CHAIRS John A Kellum, MD, FCCM, FACP Norbert Lameire, MD, PhD University of Pittsburgh School of Medicine Ghent University Hospital Pittsburgh, PA Ghent, Belgium WORK GROUP Peter Aspelin, MD, PhD Alison M MacLeod, MBChB, MD, FRCP Karolinska University Hospital University of Aberdeen Stockholm, Sweden Aberdeen, United Kingdom Rashad S Barsoum, MD, FRCP, FRCPE Ravindra L Mehta, MD, FACP, FASN, FRCP Cairo University UCSD Medical Center Cairo, Egypt San Diego, CA Emmanuel A Burdmann, MD, PhD Patrick T Murray, MD, FASN, FRCPI, FJFICMI ˜ University of Sao Paulo Medical School UCD School of Medicine and Medical Science ˜ Sao Paulo, Brazil Dublin, Ireland Saraladevi Naicker, MBChB, MRCP, FRCP, Stuart L Goldstein, MD FCP(SA), PhD Cincinnati Children’s Hospital & Medical Center University of the Witwatersrand Cincinnati, OH Johannesburg, South Africa Charles A Herzog, MD Steven M Opal, MD Hennepin County Medical Center Alpert Medical School of Brown University Minneapolis, MN Pawtucket, RI Michael Joannidis, MD Franz Schaefer, MD Medical University of Innsbruck Heidelberg University Hospital Innsbruck, Austria Heidelberg, Germany Andreas Kribben, MD Miet Schetz, MD, PhD University Duisburg-Essen University of Leuven Essen, Germany Leuven, Belgium Andrew S Levey, MD Shigehiko Uchino, MD, PhD Tufts Medical Center Jikei University School of Medicine Boston, MA Tokyo, Japan EVIDENCE REVIEW TEAM Tufts Center for Kidney Disease Guideline Development and Implementation, Tufts Medical Center, Boston, MA, USA: 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 In addition, support and supervision were provided by: Ethan M Balk, MD, MPH, Program Director, Evidence Based Medicine 2 Kidney International Supplements (2012) 2, 2
  • 6. http://www.kidney-international.org & 2012 KDIGO KDIGO Board Members Kidney International Supplements (2012) 2, 3; doi:10.1038/kisup.2012.3 Garabed Eknoyan, MD Norbert Lameire, MD, PhD Founding KDIGO Co-Chairs Kai-Uwe Eckardt, MD Bertram L Kasiske, MD KDIGO Co-Chair KDIGO Co-Chair Omar I Abboud, MD, FRCP Michel Jadoul, MD Sharon Adler, MD, FASN Simon Jenkins, MBE, FRCGP Rajiv Agarwal, MD Suhnggwon Kim, MD, PhD Sharon P Andreoli, MD Martin K Kuhlmann, MD Gavin J Becker, MD, FRACP Nathan W Levin, MD, FACP Fred Brown, MBA, FACHE Philip K-T Li, MD, FRCP, FACP Daniel C Cattran, MD, FRCPC Zhi-Hong Liu, MD Allan J Collins, MD, FACP Pablo Massari, MD Rosanna Coppo, MD Peter A McCullough, MD, MPH, FACC, FACP Josef Coresh, MD, PhD Rafique Moosa, MD Ricardo Correa-Rotter, MD Miguel C Riella, MD Adrian Covic, MD, PhD Adibul Hasan Rizvi, MBBS, FRCP Jonathan C Craig, MBChB, MM (Clin Epi), DCH, FRACP, PhD Bernardo Rodriquez-Iturbe, MD Angel de Francisco, MD Robert Schrier, MD Paul de Jong, MD, PhD Justin Silver, MD, PhD Ana Figueiredo, RN, MSc, PhD Marcello Tonelli, MD, SM, FRCPC Mohammed Benghanem Gharbi, MD Yusuke Tsukamoto, MD Gordon Guyatt, MD, MSc, BSc, FRCPC Theodor Vogels, MSW David Harris, MD Angela Yee-Moon Wang, MD, PhD, FRCP Lai Seong Hooi, MD Christoph Wanner, MD Enyu Imai, MD, PhD David C Wheeler, MD, FRCP Lesley A Inker, MD, MS, FRCP Elena Zakharova, MD, PhD NKF-KDIGO GUIDELINE DEVELOPMENT STAFF Kerry Willis, PhD, Senior Vice-President for Scientific Activities Michael Cheung, MA, Guideline Development Director Sean Slifer, BA, Guideline Development Manager Kidney International Supplements (2012) 2, 3 3
  • 7. http://www.kidney-international.org & 2012 KDIGO Reference Keys Kidney International Supplements (2012) 2, 4; doi:10.1038/kisup.2012.4 NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D. Implications Grade* Patients Clinicians Policy Level 1 Most people in your situation would Most patients should receive the The recommendation can be evaluated ‘‘We recommend’’ want the recommended course of action recommended course of action. as a candidate for developing a policy and only a small proportion would not. or a performance measure. Level 2 The majority of people in your situation Different choices will be appropriate for The recommendation is likely to require ‘‘We suggest’’ would want the recommended course different patients. Each patient needs substantial debate and involvement of action, but many would not. help to arrive at a management decision of stakeholders before policy can be consistent with her or his values and determined. preferences. *The additional category ‘‘Not Graded’’ was used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence. The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other clinical specialists. The ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations. Grade Quality of evidence Meaning A High We are confident that the true effect lies close to that of the estimate of the effect. B Moderate The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. C Low The true effect may be substantially different from the estimate of the effect. D Very low The estimate of effect is very uncertain, and often will be far from the truth. CONVERSION FACTORS OF METRIC UNITS TO SI UNITS Parameter Metric units Conversion factor SI units Amikacin (serum, plasma) mg/ml 1.708 mmol/l Blood urea nitrogen mg/dl 0.357 mmol/l Calcium, ionized (serum) mg/dl 0.25 mmol/l Creatinine (serum) mg/dl 88.4 mmol/l Creatinine clearance ml/min 0.01667 ml/s Gentamicin (serum) mg/ml 2.09 mmol/l Glucose mg/dl 0.0555 mmol/l Lactate (plasma) mg/dl 0.111 mmol/l Tobramycin (serum, plasma) mg/ml 2.139 mmol/l Urea (plasma) mg/ml 0.167 mmol/l Note: Metric unit  conversion factor = SI unit. 4 Kidney International Supplements (2012) 2, 4
  • 8. http://www.kidney-international.org & 2012 KDIGO Abbreviations and Acronyms Kidney International Supplements (2012) 2, 5; doi:10.1038/kisup.2012.5 AAMI American Association of Medical HF Hemofiltration Instrumentation HIT Heparin-induced thrombocytopenia ACCP American College of Chest Physicians HR Hazard ratio ACD-A Anticoagulant dextrose solution A i.a. Intraarterial ACE-I Angiotensin-converting enzyme inhibitor(s) ICU Intensive-care unit ADQI Acute Dialysis Quality Initiative IGF-1 Insulin-like growth factor-1 AHCPR Agency for Health Care Policy and Research IHD Intermittent hemodialysis AKD Acute kidney diseases and disorders IIT Intensive insulin therapy AKI Acute kidney injury i.v. Intravenous AKIN Acute Kidney Injury Network KDIGO Kidney Disease: Improving Global Outcomes ANP Atrial natriuretic peptide KDOQI Kidney Disease Outcomes Quality Initiative aPTT Activated partial thromboplastin time LOS Length of stay ARB Angiotensin-receptor blocker(s) MDRD Modification of Diet in Renal Disease ARF Acute renal failure MI Myocardial infarction ARFTN Acute Renal Failure Trial Network MIC Minimum inhibitory concentration ATN Acute tubular necrosis MRI Magnetic resonance imaging AUC Area under the curve MW Molecular weight BMI Body mass index NAC N-acetylcysteine BUN Blood urea nitrogen NICE-SUGAR Normoglycemia in Intensive Care Evaluation CDC Centers for Disease Control and Survival Using Glucose Algorithm CHF Congestive heart failure Regulation CI Confidence interval NKD No known kidney disease CI-AKI Contrast-induced acute kidney injury NKF National Kidney Foundation CIT Conventional insulin therapy NSF Nephrogenic Systemic Fibrosis CKD Chronic kidney disease OR Odds ratio CrCl Creatinine clearance PD Peritoneal dialysis CRF Chronic renal failure PICARD Program to Improve Care in Acute Renal CRRT Continuous renal replacement therapy Disease CT Computed tomography RCT Randomized controlled trial CVC Central venous catheters RIFLE Risk, Injury, Failure; Loss, End-Stage Renal CVVH Continuous venovenous hemofiltration Disease CVVHDF Continuous venovenous hemodiafiltration RR Relative risk eCrCl Estimated creatinine clearance RRT Renal replacement therapy EGDT Early goal-directed therapy SAFE Saline vs. Albumin Fluid Evaluation eGFR Estimated glomerular filtration rate SCr Serum creatinine ERT Evidence Review Team ScvO2 Central venous oxygen saturation ESRD End-stage renal disease SLED Sustained low-efficiency dialysis FDA Food and Drug Administration TCC Tunneled cuffed catheter GFR Glomerular filtration rate VISEP Efficacy of Volume Substitution and Insulin HDF Hemodiafiltration Therapy in Severe Sepsis HES Hydroxyethylstarch Kidney International Supplements (2012) 2, 5 5
  • 9. http://www.kidney-international.org & 2012 KDIGO Abstract Kidney International Supplements (2012) 2, 6; doi:10.1038/kisup.2012.6 The 2011 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury (AKI) aims to assist practitioners caring for adults and children at risk for or with AKI, including contrast-induced acute kidney injury (CI-AKI). Guideline development followed an explicit process of evidence review and appraisal. The guideline contains chapters on definition, risk assessment, evaluation, prevention, and treatment. Definition and staging of AKI are based on the Risk, Injury, Failure; Loss, End-Stage Renal Disease (RIFLE) and Acute Kidney Injury Network (AKIN) criteria and studies on risk relationships. The treatment chapters cover pharmacological approaches to prevent or treat AKI, and management of renal replacement for kidney failure from AKI. Guideline recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the GRADE approach. Limitations of the evidence are discussed and specific suggestions are provided for future research. Keywords: Clinical Practice Guideline; KDIGO; acute kidney injury; contrast-induced nephropathy; renal replacement therapy; evidence-based recommendation CITATION In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1–138. 6 Kidney International Supplements (2012) 2, 6
  • 10. http://www.kidney-international.org & 2012 KDIGO Foreword Kidney International Supplements (2012) 2, 7; doi:10.1038/kisup.2012.8 It is our hope that this document will serve several useful Some argue that recommendations should not be made purposes. Our primary goal is to improve patient care. We when evidence is weak. However, clinicians still need to make hope to accomplish this, in the short term, by helping clinical decisions in their daily practice, and they often ask, clinicians know and better understand the evidence (or lack ‘‘What do the experts do in this setting?’’ We opted to give of evidence) that determines current practice. By providing guidance, rather than remain silent. These recommendations comprehensive evidence-based recommendations, this guide- are often rated with a low strength of recommendation and a line will also help define areas where evidence is lacking and low strength of evidence, or were not graded. It is important research is needed. Helping to define a research agenda is an for the users of this guideline to be cognizant of this (see often neglected, but very important, function of clinical Notice). In every case these recommendations are meant to practice guideline development. be a place for clinicians to start, not stop, their inquiries into We used the GRADE system to rate the strength of evidence specific management questions pertinent to the patients they and the strength of recommendations. In all, there were only see in daily practice. 11 (18%) recommendations in this guideline for which the We wish to thank the Work Group Co-Chairs, Drs John overall quality of evidence was graded ‘A,’ whereas 20 (32.8%) Kellum and Norbert Lameire, along with all of the Work were graded ‘B,’ 23 (37.7%) were graded ‘C,’ and 7 (11.5%) Group members who volunteered countless hours of their were graded ‘D.’ Although there are reasons other than quality time developing this guideline. We also thank the Evidence of evidence to make a grade 1 or 2 recommendation, in Review Team members and staff of the National Kidney general, there is a correlation between the quality of overall Foundation who made this project possible. Finally, we owe a evidence and the strength of the recommendation. Thus, there special debt of gratitude to the many KDIGO Board members were 22 (36.1%) recommendations graded ‘1’ and 39 (63.9%) and individuals who volunteered time reviewing the guide- graded ‘2.’ There were 9 (14.8%) recommendations graded line, and making very helpful suggestions. ‘1A,’ 10 (16.4%) were ‘1B,’ 3 (4.9%) were ‘1C,’ and 0 (0%) were ‘1D.’ There were 2 (3.3%) graded ‘2A,’ 10 (16.4%) were ‘2B,’ 20 (32.8%) were ‘2C,’ and 7 (11.5%) were ‘2D.’ There were Kai-Uwe Eckardt, MD Bertram L. Kasiske, MD 26 (29.9%) statements that were not graded. KDIGO Co-Chair KDIGO Co-Chair Kidney International Supplements (2012) 2, 7 7
  • 11. http://www.kidney-international.org & 2012 KDIGO Summary of Recommendation Statements Kidney International Supplements (2012) 2, 8–12; doi:10.1038/kisup.2012.7 Section 2: AKI Definition 2.1.1: AKI is defined as any of the following (Not Graded): K Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) within 48 hours; or K Increase in SCr to X1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or K Urine volume o0.5 ml/kg/h for 6 hours. 2.1.2: AKI is staged for severity according to the following criteria (Table 2). (Not Graded) Table 2 | Staging of AKI Stage Serum creatinine Urine output 1 1.5–1.9 times baseline o0.5 ml/kg/h for 6–12 hours OR X0.3 mg/dl (X26.5 mmol/l) increase 2 2.0–2.9 times baseline o0.5 ml/kg/h for X12 hours 3 3.0 times baseline o0.3 ml/kg/h for X24 hours OR OR Increase in serum creatinine to X4.0 mg/dl (X353.6 mmol/l) Anuria for X12 hours OR Initiation of renal replacement therapy OR, In patients o18 years, decrease in eGFR to o35 ml/min per 1.73 m2 2.1.3: The cause of AKI should be determined whenever possible. (Not Graded) 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) 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) K If patients have CKD, manage these patients as detailed in the KDOQI CKD Guideline (Guidelines 7–15). (Not Graded) K 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) Section 3: Prevention and Treatment of AKI 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) 8 Kidney International Supplements (2012) 2, 8–12
  • 12. summary of recommendation statements Figure 4 | Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive- care unit. 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). 3.3.1: In critically ill patients, we suggest insulin therapy targeting plasma glucose 110–149 mg/dl (6.1–8.3 mmol/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) 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) 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. 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) 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) 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) Kidney International Supplements (2012) 2, 8–12 9
  • 13. summary of recommendation statements 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) Section 4: Contrast-induced AKI 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) 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) 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) 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) 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) Section 5: Dialysis Interventions for Treatment of AKI 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) 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) 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) 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) 10 Kidney International Supplements (2012) 2, 8–12
  • 14. summary of recommendation statements Impaired Yes Proceed without coagulation? anticoagulation Rec No 5.3.1.1 Underlying Yes Use anticoagulation condition requires adapted to this systemic anticoagulation? condition No Choose RRT CRRT Intermittent RRT Modality Recs No 5.3.2.2 Contraindication Regional Citrate & to Citrate? Anticoagulation 5.3.3.1 Yes No Rec Increased Heparin 5.3.2.3 Bleeding Risk? Yes Rec Proceed without 5.3.3.2 anticoagulation No Increased Heparin Bleeding Risk? Rec 5.3.2.1 Yes Proceed without anticoagulation Figure 17 | Flow-chart summary of recommendations. Heparin includes low-molecular-weight or unfractionated heparin. CRRT, continuous renal replacement therapy; RRT, renal replacement therapy. 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) Kidney International Supplements (2012) 2, 8–12 11
  • 15. summary of recommendation statements 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) 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): K First choice: right jugular vein; K Second choice: femoral vein; K Third choice: left jugular vein; K Last choice: subclavian vein with preference for the dominant side. 5.4.3: We recommend using ultrasound guidance for dialysis catheter insertion. (1A) 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) 5.5.1: We suggest to use dialyzers with a biocompatible membrane for IHD and CRRT in patients with AKI. (2C) 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) 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) 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) 12 Kidney International Supplements (2012) 2, 8–12
  • 16. http://www.kidney-international.org chapter 1.1 & 2012 KDIGO Section 1: Introduction and Methodology Kidney International Supplements (2012) 2, 13–18; doi:10.1038/kisup.2011.31 Chapter 1.1: Introduction The concept of acute renal failure (ARF) has undergone Volume depletion and hypotension are profound stimuli for significant re-examination in recent years. Mounting evi- vasopressin secretion. As a consequence the distal tubules and dence suggests that acute, relatively mild injury to the kidney collecting ducts become fully permeable to water. Concen- or impairment of kidney function, manifest by changes in trating mechanisms in the inner medulla are also aided urine output and blood chemistries, portend serious clinical by low flow through the loops of Henle and thus, urine consequences.1–5 Traditionally, most reviews and textbook volume is minimized and urine concentration maximized chapters emphasize the most severe reduction in kidney (4500 m Osmol/kg). Conversely, when the tubules are function, with severe azotemia and often with oliguria or injured, maximal concentrating ability is impaired and urine anuria. It has only been in the past few years that moderate volume may even be normal (i.e., nonoliguric renal failure). decreases of kidney function have been recognized as Analysis of the urine to determine tubular function has a potentially important, in the critically ill,2 and in studies long history in clinical medicine. Indeed, a high urine on contrast-induced nephropathy.4 osmolality coupled with a low urine sodium in the face of oliguria and azotemia is strong evidence of intact tubular Glomerular filtration rate and serum creatinine function. However, this should not be interpreted as The glomerular filtration rate (GFR) is widely accepted as the ‘‘benign’’ or even prerenal azotemia. Intact tubular function, best overall index of kidney function in health and disease. particularly early on, may be seen with various forms of renal However, GFR is difficult to measure and is commonly disease (e.g., glomerulonephritis). Sepsis, the most common estimated from the serum level of endogenous filtration condition associated with ARF in the intensive-care unit markers, such as creatinine. Recently, Chertow et al.1 found (ICU)7 may alter renal function without any characteristic that an increase of serum creatinine (SCr) of 40.3 mg/dl changes in urine indices.8,9 Automatically classifying these (426.5 mmol/l) was independently associated with mortality. abnormalities as ‘‘prerenal’’ will undoubtedly lead to Similarly, Lassnigg et al.3 saw, in a cohort of patients who incorrect management decisions. Classification as ‘‘benign underwent cardiac surgery, that either an increase of SCr azotemia’’ or ‘‘acute renal success’’ is not consistent with X0.5 mg/dl (X44.2 mmol/l) or a decrease 40.3 mg/dl available evidence. Finally, although severe oliguria and even (426.5 mmol/l) was associated with worse survival. The anuria may result from renal tubular damage, it can also be reasons why small alterations in SCr lead to increases in caused by urinary tract obstruction and by total arterial or hospital mortality are not entirely clear. Possible explanations venous occlusion. These conditions will result in rapid and include the untoward effects of decreased kidney function irreversible damage to the kidney and require prompt such as volume overload, retention of uremic compounds, recognition and management. acidosis, electrolyte disorders, increased risk for infection, and anemia.6 Although, these changes in SCr could simply be Acute tubular necrosis (ATN) colinear with unmeasured variables that lead to increased When mammalian kidneys are subjected to prolonged warm mortality, multiple attempts to control for known clinical ischemia followed by reperfusion, there is extensive necrosis variables has led to the consistent conclusion that decreased destroying the proximal tubules of the outer stripe of the kidney function is independently associated with outcome. medulla, and the proximal convoluted tubules become Furthermore, more severe reductions in kidney function tend necrotic as well.10 Distal nephron involvement in these to be associated with even worse outcome as compared to animal experiments is minimal, unless medullary oxygena- milder reductions. tion is specifically targeted.11 Although these animals develop severe ARF, as noted by Rosen and Heyman, not much else Oliguria and anuria resembles the clinical syndrome in humans.12 Indeed these Although urine output is both a reasonably sensitive authors correctly point out that the term ‘‘acute tubular functional index for the kidney as well as a biomarker of necrosis does not accurately reflect the morphological tubular injury, the relationship between urine output and changes in this condition’’.12 Instead, the term ATN is used GFR, and tubular injury is complex. For example, oliguria to describe a clinical situation in which there is adequate may be more profound when tubular function is intact. renal perfusion to largely maintain tubular integrity, but not Kidney International Supplements (2012) 2, 13–18 13
  • 17. chapter 1.1 to sustain glomerular filtration. Data from renal biopsies in patients with ATN dating back to the 1950s13 confirm the limited parenchymal compromise in spite of severe organ dysfunction.12 Thus, the syndrome of ATN has very little to do with the animal models traditionally used to study it. More recently, investigators have emphasized the role of endothelial dysfunction, coagulation abnormalities, systemic inflammation, endothelial dysfunction, and oxidative stress in causing renal injury, particularly in the setting of sepsis.14,15 True ATN does, in fact, occur. For example, patients with arterial catastrophes (ruptured aneurysms, acute dissection) can suffer prolonged periods of warm ischemia just like animal models. However, these cases comprise only a small fraction of patients with AKI, and ironically, these patients are often excluded from studies seeking to enroll patients with the more common clinical Figure 1 | The RIFLE criteria for AKI. ARF, acute renal failure; GFR, syndrome known as ATN. glomerular filtration rate; Screat, serum creatinine concentration; UO, urine output. Reprinted from Bellomo R, Ronco C, Kellum JA, ARF et al. Acute renal failure—definition, outcome measures, animal In a recent review, Eknoyan notes that the first description of models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis ARF, then termed ischuria renalis, was by William Heberden Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-212 with in 1802.16 At the beginning of the twentieth century, ARF, permission from Bellomo R et al.;22 accessed http://ccforum.com/ then named Acute Bright’s disease, was well described in content/8/4/R204 William Osler’s Textbook for Medicine (1909), as a consequence of toxic agents, pregnancy, burns, trauma, or operations on the kidneys. During the First World War the syndrome was named AKI: acute kidney injury/impairment ‘‘war nephritis’’,17 and was reported in several publications. Importantly, by defining the syndrome of acute changes in The syndrome was forgotten until the Second World War, renal function more broadly, RIFLE criteria move beyond when Bywaters and Beall published their classical paper on ARF. The term ‘‘acute kidney injury/impairment’’ has been crush syndrome.18 However, it is Homer W. Smith who is proposed to encompass the entire spectrum of the syndrome credited for the introduction of the term ‘‘acute renal failure’’, from minor changes in markers of renal function to in a chapter on ‘‘Acute renal failure related to traumatic requirement for renal replacement therapy (RRT).23 Thus, injuries’’ in his textbook The kidney-structure and function in the concept of AKI, as defined by RIFLE creates a new health and disease (1951). Unfortunately, a precise biochemical paradigm. AKI is not ATN, nor is it renal failure. Instead, it definition of ARF was never proposed and, until recently, there encompasses both and also includes other, less severe was no consensus on the diagnostic criteria or clinical conditions. Indeed, as a syndrome, it includes patients definition of ARF, resulting in multiple different definitions. without actual damage to the kidney but with functional A recent survey revealed the use of at least 35 definitions in the impairment relative to physiologic demand. Including such literature.19 This state of confusion has given rise to wide patients in the classification of AKI is conceptually attractive variation in reported incidence and clinical significance of because these are precisely the patients that may benefit from ARF. Depending on the definition used, ARF has been early intervention. However, it means that AKI includes both reported to affect from 1% to 25% of ICU patients and has injury and/or impairment. Rather than focusing exclusively lead to mortality rates from 15–60%.7,20,21 on patients with renal failure or on those who receive dialysis or on those that have a clinical syndrome defined by RIFLE criteria pathology, which is usually absent (ATN), the strong The Acute Dialysis Quality Initiative (ADQI) group developed association of AKI with hospital mortality demands that we a system for diagnosis and classification of a broad range of change the way we think about this disorder. In a study by acute impairment of kidney function through a broad Hoste et al.,2 only 14% of patients reaching RIFLE ‘‘F’’ consensus of experts.22 The characteristics of this system are received RRT, yet these patients experienced a hospital summarized in Figure 1. The acronym RIFLE stands for the mortality rate more than five times that of the same ICU increasing severity classes Risk, Injury, and Failure; and the two population without AKI. Is renal support underutilized or outcome classes, Loss and End-Stage Renal Disease (ESRD). delayed? Are there other supportive measures that should be The three severity grades are defined on the basis of the employed for these patients? Sustained AKI leads to profound changes in SCr or urine output where the worst of each alterations in fluid, electrolyte, acid-base and hormonal criterion is used. The two outcome criteria, Loss and ESRD, regulation. AKI results in abnormalities in the central are defined by the duration of loss of kidney function. nervous, immune, and coagulation systems. Many patients 14 Kidney International Supplements (2012) 2, 13–18
  • 18. chapter 1.1 with AKI already have multisystem organ failure. What is the (X0.3 mg/dl or X26.5 mmol/l) when they occur within a incremental influence of AKI on remote organ function and 48-hour period.23 Two recent studies examining large how does it affect outcome? A recent study by Levy et al. databases in the USA28 and Europe29 validated these examined outcomes for over 1000 patients enrolled in the modified criteria. Thakar et al. found that increased severity control arms of two large sepsis trials.24 Early improvement of AKI was associated with an increased risk of death (within 24 hours) in cardiovascular (P ¼ 0.0010), renal independent of comorbidity.28 Patients with Stage 1 (Po0.0001), or respiratory (P ¼ 0.0469) function was (X0.3 mg/dl or X26.5 mmol/l) increase in SCr but less than significantly related to survival. This study suggests that a two-fold increase had an odds ratio of 2.2; with Stage 2 outcomes for patients with severe sepsis in the ICU are (corresponding to RIFLE-I), there was an odds ratio of 6.1; closely related to early resolution of AKI. While rapid and in Stage 3 (RIFLE-F), an odds ratio of 8.6 for hospital resolution of AKI may simply be a marker of a good mortality was calculated. An additional modification to the prognosis, it may also indicate a window of therapeutic RIFLE criteria has been proposed for pediatric patients in opportunity to improve outcome in such patients. order to better classify small children with acute-on-chronic disease.32 Validation studies using RIFLE As of early 2010, over half a million patients have been Limitations to current definitions for AKI studied to evaluate the RIFLE criteria as a means of Unfortunately, the existing criteria—while extremely useful classifying patients with AKI.25–28 Large series from the and widely validated—are still limited. First, despite efforts to USA,28 Europe,29,30 and Australia,25 each including several standardize the definition and classification of AKI, there is thousand patients, have provided a consistent picture. AKI still inconsistency in application.26,27 A minority of studies defined by RIFLE is associated with significantly decreased have included urinary output criteria despite its apparent survival and furthermore, increasing severity of AKI defined ability to identify additional cases6,29 and many studies have by RIFLE stage leads to increased risk of death. excluded patients whose initial SCr is already elevated. An early study from Uchino et al. focused on the Preliminary data from a 20 000-patient database from the predictive ability of the RIFLE classification in a cohort University of Pittsburgh suggests that roughly a third of AKI of 20 126 patients admitted to a teaching hospital for cases are community-acquired33 and many cases may be 424 hours over a 3-year period.5 The authors used an missed by limiting analysis to documented increases in SCr. electronic laboratory database to classify patients into Indeed, the majority of cases of AKI in the developing world RIFLE-R, I, and F and followed them to hospital discharge are likely to be community-acquired. Thus, few studies can or death. Nearly 10% of patients achieved a maximum provide accurate incidence data. An additional problem RIFLE-R, 5% I, and 3.5% F. There was a nearly linear relates to the limitations of SCr and urine output for increase in hospital mortality with increasing RIFLE class, detecting AKI. In the future, biomarkers of renal cell injury with patients at R having more than three times the mortality may identify additional patients with AKI and may identify rate of patients without AKI. Patients with I had close to the majority of patients at an earlier stage. twice the mortality of R and patients with F had 10 times the mortality rate of hospitalized patients without AKI. Rationale for a guideline on AKI The investigators performed multivariate logistic regression AKI is a global problem and occurs in the community, in the analysis to test whether RIFLE classification was an hospital where it is common on medical, surgical, pediatric, independent predictor of hospital mortality. They found and oncology wards, and in ICUs. Irrespective of its nature, that class R carried an odds ratio of hospital mortality of 2.5, AKI is a predictor of immediate and long-term adverse I of 5.4, and F of 10.1. outcomes. AKI is more prevalent in (and a significant risk Ali et al. studied the incidence of AKI in Northern factor for) patients with chronic kidney disease (CKD). Scotland, a geographical population base of 523 390. The Individuals with CKD are especially susceptible to AKI incidence of AKI was 2147 per million population.31 Sepsis which, in turn, may act as a promoter of progression of the was a precipitating factor in 47% of patients. RIFLE underlying CKD. The burden of AKI may be most significant classification was useful for predicting recovery of renal in developing countries34,35 with limited resources for the function (Po0.001), requirement for RRT (Po0.001), length care of these patients once the disease progresses to kidney of hospital stay for survivors (Po0.001), and in-hospital failure necessitating RRT. Addressing the unique circum- mortality (P ¼ 0.035). Although no longer statistically stances and needs of developing countries, especially in the significant, subjects with AKI had a high mortality at 3 and detection of AKI in its early and potentially reversible stages 6 months as well. to prevent its progression to kidney failure requiring dialysis, More recently, the Acute Kidney Injury Network (AKIN), is of paramount importance. an international network of AKI researchers, organized a Research over the past decade has identified numerous summit of nephrology and critical care societies from around preventable risk factors for AKI and the potential of the world. The group endorsed the RIFLE criteria with improving their management and outcomes. Unfortunately, a small modification to include small changes in SCr these are not widely known and are variably practiced Kidney International Supplements (2012) 2, 13–18 15
  • 19. chapter 1.1 worldwide, resulting in lost opportunities to improve the care These criteria were formulated as follows: and outcomes of patients with AKI. Importantly, there is no K AKI is common. unifying approach to the diagnosis and care of these patients. K AKI imposes a heavy burden of illness (morbidity and There is a worldwide need to recognize, detect, and intervene mortality). to circumvent the need for dialysis and to improve outcomes K The cost per person of managing AKI is high. of AKI. The difficulties and disadvantages associated with an K AKI is amenable to early detection and potential prevention. increasing variation in management and treatment of K There is considerable variability in practice to prevent, diseases that were amplified in the years after the Second diagnose, treat, and achieve outcomes of AKI. World War, led in 1989 to the creation in the USA of the K Clinical practice guidelines in the field have the potential Agency for Health Care Policy and Research (now the Agency to reduce variations, improve outcomes, and reduce costs. for Healthcare Research and Quality). This agency was K Formal guidelines do not exist on this topic. created to provide objective, science-based information to improve decision making in health-care delivery. A major contribution of this agency was the establishment of a Summary systematic process for developing evidence-based guidelines. Small changes in kidney function in hospitalized patients are It is now well accepted that rigorously developed, evidence- important and associated with significant changes in short- based guidelines, when implemented, have improved quality, and long-term outcomes. The shift of terminology from ATN cost, variability, and outcomes.36,37 and ARF to AKI has been well received by the research and Realizing that there is an increasing prevalence of acute clinical communities. RIFLE/AKIN criteria provide a uni- (and chronic) kidney disease worldwide and that the form definition of AKI, and have become the standard for complications and problems of patients with kidney disease diagnostic criteria. AKI severity grades represent patient are universal, Kidney Disease: Improving Global Outcomes groups with increasing severity of illness as illustrated by an (KDIGO), a nonprofit foundation, was established in 2003 increasing proportion of patients treated with RRT, and ‘‘to improve the care and outcomes of kidney disease patients increasing mortality. Thus, AKI as defined by the RIFLE worldwide through promoting coordination, collaboration, criteria is now recognized as an important syndrome, and integration of initiatives to develop and implement alongside other syndromes such as acute coronary syndrome, clinical practice guidelines’’.38 acute lung injury, and severe sepsis and septic shock. The Besides developing guidelines on a number of other RIFLE/AKIN classification for AKI is quite analogous to the important areas of nephrology, the Board of Directors Kidney Disease Outcomes Quality Initiative (KDOQI) for of KDIGO quickly realized that there is room for improving CKD staging, which is well known to correlate disease international cooperation in the development, dissemi- severity with cardiovascular complications and other mor- nation, and implementation of clinical practice guide- bidities.39 As CKD stages have been linked to specific lines in the field of AKI. At its meeting in December of treatment recommendations, which have proved extremely 2006, the KDIGO Board of Directors determined that the useful in managing this disease,39 we have developed topic of AKI meets the criteria for developing clinical practice recommendations for evaluation and management of guidelines. patients with AKI using this stage-based approach. 16 Kidney International Supplements (2012) 2, 13–18
  • 20. http://www.kidney-international.org chapter 1.2 & 2012 KDIGO Chapter 1.2: Methodology INTRODUCTION surgery. We excluded studies on AKI from rhabdomyolysis, This chapter provides a very brief summary of the methods specific infections, and poisoning or drug overdose. Overall, used to develop this guideline. Detailed methods are we screened 18 385 citations. provided in Appendix F. The overall aim of the project was to create a clinical practice guideline with recommendations Outcome selection judgments, values, and preferences for AKI using an evidence-based approach. After topics and We limited outcomes to those important for decision making, relevant clinical questions were identified, the pertinent including development of AKI, need for or dependence on scientific literature on those topics was systematically RRT, and all-cause mortality. When weighting the evidence searched and summarized. across different outcomes, we selected as the ‘‘crucial’’ outcome that which weighed most heavily in the assessment of the Group member selection and meeting process overall quality of evidence. Values and preferences articulated The KDIGO Co-Chairs appointed the Co-Chairs of the Work by the Work Group included: i) a desire to be inclusive in Group, who then assembled the Work Group to be responsible terms of meeting criteria for AKI; ii) a progressive approach to for the development of the guideline. The Work Group consisted risk and cost such that, as severity increased, the group put of domain experts, including individuals with expertise in greater value on possible effectiveness of strategies, but nephrology, critical care medicine, internal medicine, pediatrics, maintained high value for avoidance of harm; iii) intent to cardiology, radiology, infectious diseases and epidemiology. For guide practice but not limit future research. support in evidence review, expertise in methods, and guideline development, the NKF contracted with the Evidence Review Grading the quality of evidence and the strength of Team (ERT) based primarily at the Tufts Center for Kidney recommendations Disease Guideline Development and Implementation at Tufts The grading approach followed in this guideline is adopted Medical Center in Boston, Massachusetts, USA. The ERT from the GRADE system.40,41 The strength of each recom- consisted of physician-methodologists with expertise in nephrol- mendation is rated as level 1 which means ‘‘strong’’ or level 2 ogy and internal medicine, and research associates and assistants. which means ‘‘weak’’ or discretionary. The wording corres- The ERT instructed and advised Work Group members in all ponding to a level 1 recommendation is ‘‘We recommend y steps of literature review, critical literature appraisal, and should’’ and implies that most patients should receive the guideline development. The Work Group and the ERT course of action. The wording for a level 2 recommendation collaborated closely throughout the project. The Work Group, is ‘‘We suggest y might’’ which implies that different choices KDIGO Co-Chairs, ERT, liaisons, and NKF support staff met for will be appropriate for different patients, with the suggested four 2-day meetings for training in the guideline development course of action being a reasonable choice in many patients. process, topic discussion, and consensus development. In addition, each statement is assigned a grade for the quality of the supporting evidence, A (high), B (moderate), C (low), Evidence selection, appraisal, and presentation or D (very low). Table 1 shows the implications of the We first defined the topics and goals for the guideline and guideline grades and describes how the strength of the identified key clinical questions for review. The ERT recommendations should be interpreted by guideline users. performed literature searches, organized abstract and article Furthermore, on topics that cannot be subjected to screening, coordinated methodological and analytic processes systematic evidence review, the Work Group could issue of the report, defined and standardized the search methodol- statements that are not graded. Typically, these provide ogy, performed data extraction, and summarized the guidance that is based on common sense, e.g., reminders of evidence. The Work Group members reviewed all included the obvious and/or recommendations that are not sufficiently articles, data extraction forms, summary tables, and evidence specific enough to allow the application of evidence. The profiles for accuracy and completeness. The four major topic GRADE system is best suited to evaluate evidence on areas of interest for AKI included: i) definition and comparative effectiveness. Some of our most important classification; ii) prevention; iii) pharmacologic treatment; guideline topics involve diagnosis and staging or AKI, and and iv) RRT. Populations of interest were those at risk for here the Work Group chose to provide ungraded statements. AKI (including those after intravascular contrast-media These statements are indirectly supported by evidence on risk exposure, aminoglycosides, and amphotericin) and those relationships and resulted from unanimous consensus of the with or at risk for AKI with a focus on patients with sepsis or Work Group. Thus, the Work Group feels they should not be trauma, receiving critical care, or undergoing cardiothoracic viewed as weaker than graded recommendations. Kidney International Supplements (2012) 2, 13–18 17
  • 21. chapter 1.2 Table 1 | Implications of the strength of a recommendation Implications Grade* Patients Clinicians Policy Level 1 Most people in your situation Most patients should receive the The recommendation can be evaluated as ‘‘We recommend’’ would want the recommended recommended course of action. a candidate for developing a policy or a course of action and only a performance measure. small proportion would not. Level 2 The majority of people in your Different choices will be appropriate for The recommendation is likely to require ‘‘We suggest’’ situation would want the different patients. Each patient needs help to substantial debate and involvement of recommended course of action, arrive at a management decision consistent stakeholders before policy can be but many would not. with her or his values and preferences. determined. SPONSORSHIP advertisements herein are the responsibility of the contributor, KDIGO gratefully acknowledges the following sponsors that copyright holder, or advertiser concerned. Accordingly, the make our initiatives possible: Abbott, Amgen, Belo Founda- publishers and the ISN, the editorial board and their respective tion, Coca-Cola Company, Dole Food Company, Genzyme, employers, office and agents accept no liability whatsoever for Hoffmann-LaRoche, JC Penney, NATCO—The Organization the consequences of any such inaccurate or misleading data, for Transplant Professionals, NKF—Board of Directors, opinion or statement. While every effort is made to ensure that Novartis, Robert and Jane Cizik Foundation, Shire, drug doses and other quantities are presented accurately, Transwestern Commercial Services, and Wyeth. KDIGO is readers are advised that new methods and techniques supported by a consortium of sponsors and no funding is involving drug usage, and described within this Journal, accepted for the development of specific guidelines. should only be followed in conjunction with the drug manufacturer’s own published literature. DISCLAIMER While every effort is made by the publishers, editorial board, and ISN to see that no inaccurate or misleading data, opinion SUPPLEMENTARY MATERIAL Appendix F: Detailed Methods for Guideline Development. or statement appears in this Journal, they wish to make it clear Supplementary material is linked to the online version of the paper at that the data and opinions appearing in the articles and http://www.kdigo.org/clinical_practice_guidelines/AKI.php 18 Kidney International Supplements (2012) 2, 13–18
  • 22. http://www.kidney-international.org chapter 2.1 & 2012 KDIGO Section 2: AKI Definition Kidney International Supplements (2012) 2, 19–36; doi:10.1038/kisup.2011.32 Chapter 2.1: Definition and classification of AKI INTRODUCTION Table 2 | Staging of AKI AKI is one of a number of conditions that affect kidney Stage Serum creatinine Urine output structure and function. AKI is defined by an abrupt decrease 1 1.5–1.9 times baseline o0.5 ml/kg/h for in kidney function that includes, but is not limited to, ARF. It OR 6–12 hours is a broad clinical syndrome encompassing various etiologies, X0.3 mg/dl (X26.5 mmol/l) increase including specific kidney diseases (e.g., acute interstitial 2 2.0–2.9 times baseline o0.5 ml/kg/h for nephritis, acute glomerular and vasculitic renal diseases); X12 hours non-specific conditions (e.g, ischemia, toxic injury); as well 3 3.0 times baseline o0.3 ml/kg/h for as extrarenal pathology (e.g., prerenal azotemia, and acute OR X24 hours postrenal obstructive nephropathy)—see Chapters 2.2 and Increase in serum creatinine to OR 2.3 for further discussion. More than one of these conditions X4.0 mg/dl (X353.6 mmol/l) Anuria for X12 hours OR may coexist in the same patient and, more importantly, Initiation of renal replacement therapy epidemiological evidence supports the notion that even mild, OR, In patients o18 years, decrease in reversible AKI has important clinical consequences, including eGFR to o35 ml/min per 1.73 m2 increased risk of death.2,5 Thus, AKI can be thought of more like acute lung injury or acute coronary syndrome. Furthermore, because the manifestations and clinical con- 2.1.2: AKI is staged for severity according to the following sequences of AKI can be quite similar (even indistinguish- criteria (Table 2). (Not Graded) able) regardless of whether the etiology is predominantly 2.1.3: The cause of AKI should be determined whenever within the kidney or predominantly from outside stresses on possible. (Not Graded) the kidney, the syndrome of AKI encompasses both direct injury to the kidney as well as acute impairment of function. RATIONALE Since treatments of AKI are dependent to a large degree on Conditions affecting kidney structure and function can be the underlying etiology, this guideline will focus on specific considered acute or chronic, depending on their duration. diagnostic approaches. However, since general therapeutic AKI is one of a number of acute kidney diseases and and monitoring recommendations can be made regarding all disorders (AKD), and can occur with or without other acute forms of AKI, our approach will be to begin with general or chronic kidney diseases and disorders (Figure 2). Whereas measures. CKD has a well-established conceptual model and definition that has been useful in clinical medicine, research, and public Definition and staging of AKI health,42–44 the definition for AKI is evolving, and the AKI is common, harmful, and potentially treatable. Even concept of AKD is relatively new. An operational definition a minor acute reduction in kidney function has an adverse of AKD for use in the diagnostic approach to alterations prognosis. Early detection and treatment of AKI may in kidney function and structure is included in Chapter 2.5, improve outcomes. Two similar definitions based on SCr with further description in Appendix B. and urine output (RIFLE and AKIN) have been proposed and The conceptual model of AKI (Figure 3) is analogous to validated. There is a need for a single definition for practice, the conceptual model of CKD, and is also applicable to research, and public health. AKD.42,45 Circles on the horizontal axis depict stages in the development (left to right) and recovery (right to left) of 2.1.1: AKI is defined as any of the following (Not Graded): AKI. AKI (in red) is defined as reduction in kidney function, K Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) including decreased GFR and kidney failure. The criteria for within 48 hours; or the diagnosis of AKI and the stage of severity of AKI are K Increase in SCr to X1.5 times baseline, which based on changes in SCr and urine output as depicted in the is known or presumed to have occurred within triangle above the circles. Kidney failure is a stage of AKI the prior 7 days; or highlighted here because of its clinical importance. Kidney K Urine volume o0.5 ml/kg/h for 6 hours. failure is defined as a GFR o15 ml/min per 1.73 m2 body Kidney International Supplements (2012) 2, 19–36 19
  • 23. chapter 2.1 surface area, or requirement for RRT, although it is Existing evidence supports the validity of both RIFLE and recognized that RRT may be required earlier in the evolution AKIN criteria to identify groups of hospitalized patients with of AKI. Further description is included in Chapter 2.5 and increased risk of death and/or need for RRT.2,5,25,28–30 Appendix A. Epidemiological studies, many multicentered, collectively It is widely accepted that GFR is the most useful overall enrolling more than 500 000 subjects have been used to index of kidney function in health and disease, and changes establish RIFLE and/or AKIN criteria as valid methods to in SCr and urine output are surrogates for changes in GFR. In diagnose and stage AKI. Recently, Joannidis et al.29 directly clinical practice, an abrupt decline in GFR is assessed from an compared RIFLE criteria with and without the AKIN increase in SCr or oliguria. Recognizing the limitations of the modification. While AKI classified by either criteria were use of a decrease in kidney function for the early detection associated with a similarly increased hospital mortality, the and accurate estimation of renal injury (see below), there is a two criteria identified somewhat different patients. The broad consensus that, while more sensitive and specific original RIFLE criteria failed to detect 9% of cases that were biomarkers are needed, changes in SCr and/or urine output detected by AKIN criteria. However, the AKIN criteria missed form the basis of all diagnostic criteria for AKI. The first 26.9% of cases detected by RIFLE. Examination of the cases international interdisciplinary consensus criteria for diag- missed by either criteria (Table 4) shows that cases identified nosis of AKI were the RIFLE criteria32 proposed by the by AKIN but missed by RIFLE were almost exclusively Stage 1 ADQI. Modifications to these criteria have been proposed in (90.7%), while cases missed by AKIN but identified by RIFLE order to better account for pediatric populations (pRIFLE)32 included 30% with RIFLE-I and 18% RIFLE-F; furthermore, and for small changes in SCr not captured by RIFLE (AKIN these cases had hospital mortality similar to cases identified criteria).23 Recommendations 2.1.1 and 2.1.2 represent the by both criteria (37% for I and 41% for F). However, cases combination of RIFLE and AKIN criteria (Table 3). missed by RIFLE but identified as Stage 1 by AKIN also had hospital mortality rates nearly twice that of patients who had no evidence of AKI by either criteria (25% vs. 13%). These data provide strong rationale for use of both RIFLE and AKIN criteria to identify patients with AKI. AKD AKI CKD Staging of AKI (Recommendation 2.1.2) is appropriate because, with increased stage of AKI, the risk for death and need for RRT increases.2,5,25,28–31 Furthermore, there is now Figure 2 | Overview of AKI, CKD, and AKD. Overlapping ovals accumulating evidence of long-term risk of subsequent show the relationships among AKI, AKD, and CKD. AKI is a subset development of cardiovascular disease or CKD and mortality, of AKD. Both AKI and AKD without AKI can be superimposed even after apparent resolution of AKI.47–49 upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases For staging purposes, patients should be staged accord- and disorders; AKI, acute kidney injury; CKD, chronic kidney ing to the criteria that give them the highest stage. Thus disease. when creatinine and urine output map to different stages, Stages defined by Complications creatinine and urine output are surrogates GFR Increased Kidney Normal Damage ↓ GFR Death risk failure Damage Antecedents Markers such Intermediate Stage as NGAL, KIM-1, AKI and IL-18 are Outcomes surrogates Figure 3 | Conceptual model for AKI. Red circles represent stages of AKI. Yellow circles represent potential antecedents of AKI, and the pink circle represents an intermediate stage (not yet defined). Thick arrows between circles represent risk factors associated with the initiation and progression of disease that can be affected or detected by interventions. Purple circles represent outcomes of AKI. ‘‘Complications’’ refers to all complications of AKI, including efforts at prevention and treatment, and complications in other organ systems. AKI, acute kidney injury; GFR, glomerular filtration rate. Adapted from Murray PT, Devarajan P, Levey AS, et al. A framework and key research questions in AKI diagnosis and staging in different environments. Clin J Am Soc Nephrol 2008; 3: 864–868 with permission from American Society of Nephrology45 conveyed through Copyright Clearance Center, Inc.; accessed http://cjasn.asnjournals.org/content/3/3/864.full 20 Kidney International Supplements (2012) 2, 19–36
  • 24. chapter 2.1 Table 3 | Comparison of RIFLE and AKIN criteria for diagnosis and classification of AKI AKI staging Urine output RIFLE Serum creatinine (common to both) Class Serum creatinine or GFR Stage 1 Increase of more than or equal to 0.3 mg/dl Less than 0.5 ml/kg/h for Risk Increase in serum creatinine  1.5 or GFR (X26.5 mmol/l) or increase to more than or equal to more than 6 hours decrease 425% 150% to 200% (1.5- to 2-fold) from baseline Stage 2 Increased to more than 200% to 300% Less than 0.5 ml/kg per hour Injury Serum creatinine  2 or GFR decreased (42- to 3-fold) from baseline for more than 12 hours 450% Stage 3 Increased to more than 300% (43-fold) Less than 0.3 ml/kg/h for Failure Serum creatinine  3, or serum creatinine from baseline, or more than or equal to 4.0 mg/dl 24 hours or anuria for 44 mg/dl (4354 mmol/l) with an acute (X354 mmol/l) with an acute increase of at least 12 hours rise 40.5 mg/dl (444 mmol/l) or GFR 0.5 mg/dl (44 mmol/l) or on RRT decreased 475% Loss Persistent acute renal failure=complete loss of kidney function 44 weeks End-stage kidney ESRD 43 months disease Note: For conversion of creatinine expressed in SI units to mg/dl, divide by 88.4. For both AKIN stage and RIFLE criteria, only one criterion (creatinine rise or urine output decline) needs to be fulfilled. Class is based on the worst of either GFR or urine output criteria. GFR decrease is calculated from the increase in serum creatinine above baseline. For AKIN, the increase in creatinine must occur in o48 hours. For RIFLE, AKI should be both abrupt (within 1–7 days) and sustained (more than 24 hours). When baseline creatinine is elevated, an abrupt rise of at least 0.5 mg/dl (44 mmol/l) to 44 mg/dl (4354 mmol/l) is sufficient for RIFLE class Failure (modified from Mehta et al.23 and the report of the Acute Dialysis Quality Initiative consortium22). AKI, acute kidney injury; AKIN, Acute Kidney Injury Network; ESRD, end-stage renal disease; GFR, glomerular filtration rate; RIFLE, risk, injury, failure, loss, and end stage; RRT, renal replacement therapy. Reprinted from Endre ZH. Acute kidney injury: definitions and new paradigms. Adv Chronic Kidney Dis 2008; 15: 213–221 with permission from National Kidney Foundation46; accessed http://www.ackdjournal.org/article/S1548-5595(08)00049-9/fulltext Table 4 | Cross-tabulation of patients classified by RIFLE vs. AKIN RIFLE AKIN Non-AKI Risk Injury Failure Total (AKIN) Non-AKI n* 8759 (12.9%) 781 (27.7%) 452 (37.4%) 271 (41.3%) 10 263 (15.9%) Stage1 n* 457 (25.2%) 282 (33.0%) 243 (44.0%) 95 (60.0%) 1077 (34.5%) Stage 2 n* 36 (30.6%) 21 (47.6%) 885 (25.9%) 91 (54.9) 1033 (29.0%) Stage 3 n* 11 (18.2%) 8 (12.5%) 16 (62.5%) 1948 (41.3) 1983 (41.2%) Total (RIFLE) n* 9263 (13.6%) 1092 (29.2%) 1596 (32.3%) 2405 (42.6%) 14 356 (21.7%) *Number of patients classified into the respective stages of AKI by AKIN or RIFLE are cross-tabulated against each other. Hospital mortality of each group is given in parentheses. Shaded fields denote patients assigned to the same degree of AKI by both classification systems. AKI, acute kidney injury; AKIN, Acute Kidney Injury Network; RIFLE, risk, injury, failure, loss, and end stage. With kind permission from Springer Science+Business Media: Intensive Care Med. Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. 35 (2009): 1692–1702. Joannidis M, Metnitz B, Bauer P et al.29; accessed http://www.springerlink.com/content/r177337030550120/ the patient is staged according to the highest (worst) stage. the definition of AKI in Recommendation 2.1.1). This is The changes in GFR that were published with the original problematic for smaller pediatric patients, including infants RIFLE criteria do not correspond precisely to changes in SCr. and children with low muscle mass who may not be able to As SCr is measured and GFR can only be estimated, achieve a SCr of 4.0 mg/dl (354 mmol/l). Thus, the pediatric- creatinine criteria should be used along with urine output modified RIFLE AKI criteria32 were developed using a change for the diagnosis (and staging) of AKI. One additional change in estimated creatinine clearance (eCrCl) based on the in the criteria was made for the sake of clarity and simplicity. Schwartz formula. In pRIFLE, patients automatically reach For patients reaching Stage 3 by SCr 44.0 mg/dl Stage 3 if they develop an eCrCl o35 ml/min per 1.73 m2. (4354 mmol/l), rather than require an acute increase of However, with this automatic pRIFLE threshold, the SCr X0.5 mg/dl (X44 mmol/l) over an unspecified time period, we change based AKI definition (recommendation 2.1.1) is instead require that the patient first achieve the creatinine- applicable to pediatric patients, including an increase of based change specified in the definition (either X0.3 mg/dl 0.3 mg/dl (26.5 mmol/l) SCr.32 [X26.5 mmol/l] within a 48-hour time window or an increase There are important limitations to these recommenda- of X1.5 times baseline). This change brings the definition and tions, including imprecise determination of risk (see Chapter staging criteria to greater parity and simplifies the criteria. 2.2) and incomplete epidemiology of AKI, especially outside Recommendation 2.1.2 is based on the RIFLE and AKIN the ICU. Clinical judgment is required in order to determine criteria that were developed for average-sized adults. The if patients seeming to meet criteria do, in fact, have disease, as creatinine change–based definitions include an auto- well as to determine if patients are likely to have AKI even if matic Stage 3 classification for patients who develop SCr incomplete clinical data are available to apply the diagnostic 44.0 mg/dl (4354 mmol/l) (provided that they first satisfy criteria. The application of the diagnostic and staging criteria Kidney International Supplements (2012) 2, 19–36 21
  • 25. chapter 2.1 Table 5 | Causes of AKI and diagnostic tests some patients with specific kidney diseases (e.g., glome- Selected causes of AKI requiring rulonephritis) for which a specific treatment is available. As immediate diagnosis and specific such, it is always necessary to search for the underlying cause therapies Recommended diagnostic tests of AKI (see Chapter 2.3). Decreased kidney perfusion Volume status and urinary diagnostic indices Research Recommendations Acute glomerulonephritis, vasculitis, Urine sediment examination, K The role of biomarkers other than SCr in the early interstitial nephritis, thrombotic serologic testing and microangiopathy hematologic testing diagnosis, differential diagnosis, and prognosis of AKI Urinary tract obstruction Kidney ultrasound patients should be explored. Some important areas in AKI, acute kidney injury. which to focus include: J Early detection where the gold standard is AKI by clinical diagnosis after the fact and the biomarker is compared to existing markers (SCr and urine is discussed in greater detail, along with specific examples in output) at the time of presentation. Chapter 2.4. J Prognosis where a biomarker is used to predict risk The use of urine output criteria for diagnosis and staging for AKI or risk for progression of AKI. has been less well validated and in individual patients J Prognosis where a biomarker is used to predict the need for clinical judgment regarding the effects of drugs recovery after AKI vs. death or need for long-term RRT. (e.g., angiotensin-converting enzyme inhibitors [ACE-I]), K The influence of urinary output criteria on AKI staging fluid balance, and other factors must be included. For very needs to be further investigated. Influence of fluid obese patients, urine output criteria for AKI may include balance, percent volume overload, diuretic use, and some patients with normal urine output. However, these differing weights (actual, ideal body weight, lean body recommendations serve as the starting point for further mass) should be considered. Also, it is currently not evaluation, possibly involving subspecialists, for a group of known how urine volume criteria should be applied (e.g., patients recognized to be at increased risk. average vs. persistent reduction for the period specified). Finally, it is axiomatic that patients always be managed K The influence of SCr or eGFR criteria on AKI staging according to the cause of their disease, and thus it is needs to be further investigated. The use of different important to determine the cause of AKI whenever possible. relative and absolute SCr increments or eGFR decrements In particular, patients with decreased kidney perfusion, acute at different time points and with differently ascertained glomerulonephritis, vasculitis, interstitial nephritis, throm- baseline values requires further exploration and valida- botic microangiopathy, and urinary tract obstruction require tion in various populations. immediate diagnosis and specific therapeutic intervention, in addition to the general recommendations for AKI in the SUPPLEMENTARY MATERIAL remainder of this guideline (Table 5). Appendix A: Background. Appendix B: Diagnostic Approach to Alterations in Kidney Function It is recognized that it is frequently not possible to deter- and Structure. mine the cause, and often the exact cause does not dictate a Supplementary material is linked to the online version of the paper at specific therapy. However, the syndrome of AKI includes http://www.kdigo.org/clinical_practice_guidelines/AKI.php 22 Kidney International Supplements (2012) 2, 19–36
  • 26. http://www.kidney-international.org chapter 2.2 & 2012 KDIGO Chapter 2.2: Risk assessment The kidney is a fairly robust organ that can tolerate exposure to Table 6 | Causes of AKI: exposures and susceptibilities for several insults without suffering significant structural or non-specific AKI functional change. For this reason, any acute change in kidney Exposures Susceptibilities function often indicates severe systemic derangement and predicts a poor prognosis. Risk for AKI is increased by exposure Sepsis Dehydration or volume depletion Critical illness Advanced age to factors that cause AKI or the presence of factors that increase Circulatory shock Female gender susceptibility to AKI. Factors that determine susceptibility of the Burns Black race kidneys to injury include dehydration, certain demographic Trauma CKD characteristics and genetic predispositions, acute and chronic Cardiac surgery (especially Chronic diseases (heart, lung, liver) with CPB) comorbidities, and treatments. It is the interaction between Major noncardiac surgery Diabetes mellitus susceptibility and the type and extent of exposure to insults that Nephrotoxic drugs Cancer determines the risk of occurrence of AKI. Radiocontrast agents Anemia Understanding individual ‘‘risk factors’’ may help in Poisonous plants and animals preventing AKI. This is particularly gratifying in the hospital CKD, chronic kidney disease; CPB, cardiopulmonary bypass. setting, where the patient’s susceptibility can be assessed before certain exposures as surgery or administration of However, the chances of developing AKI after exposure to the potentially nephrotoxic agents. Accordingly, some suscept- same insult differ among different individuals. This is ibility factors may be modified, and contemplated exposures attributed to a number of susceptibility factors which vary avoided or tailored to reduce the risk of AKI. widely from individual to individual. Our understanding of Risk assessment in community-acquired AKI is different susceptibility factors (Table 6) is based on many observa- from hospital-acquired AKI, for two main reasons: i) Available tional studies that address different settings with regards to evidence on risk factors is largely derived from hospital data and the type, severity, duration, and multiplicity of insults. While extrapolation to the community setting is questionable. ii) The this heterogeneity provides insight into some susceptibility opportunity to intervene, prior to exposure, is quite limited. factors that are common across various populations, the Most patients are seen only after having suffered an exposure generalizability of results from one particular setting to the (trauma, infection, poisonous plant, or animal). However, there next is uncertain. is still room to assess such patients, albeit after exposure, in The course and outcome of AKI are modified by other order to identify those who are more likely to develop AKI, factors, but since these are manifested within the context of thereby requiring closer monitoring and general supportive actual disease, they must be categorized as ‘‘prognostic’’ measures. It may also be helpful to identify such patients in rather than ‘‘risk’’ factors, hence being discussed separately in order to avoid additional injury. A more complete discussion of Appendix D. Lastly, the fact that some 30% of patients who the approach to identification and management of risk for AKI recover from AKI remain at increased risk of CKD, is provided in Appendices C and D. cardiovascular disease, and death calls for the identification of the risk factors that can identify such patients in the hopes 2.2.1: We recommend that patients be stratified for risk of AKI of providing them with timely preventive measures.50–52 according to their susceptibilities and exposures. (1B) Finally, it is important to screen patients who have 2.2.2: Manage patients according to their susceptibilities and undergone an exposure (e.g., sepsis, trauma) and to continue exposures to reduce the risk of AKI (see relevant monitor high-risk patients until the risk has subsided. Exact guideline sections). (Not Graded) intervals for checking SCr and in which individuals to 2.2.3: Test patients at increased risk for AKI with measure- monitor urine output remain matters of clinical judgment; ments of SCr and urine output to detect AKI. (Not however, as a general rule, high risk in-patients should have Graded) Individualize frequency and duration of SCr measured at least daily and more frequently after an monitoring based on patient risk and clinical course. exposure, and critically ill patients should have urine output (Not Graded) monitoring. This will necessitate urinary bladder catheteriza- tion in many cases, and the risks of infection should also be considered in the monitoring plan. RATIONALE A recent clinical practice assessment in the UK concluded There are many types of exposures that may cause AKI that only 50% of patients with AKI were considered to have (Table 6) and these are discussed in detail in Appendix C. received a ‘‘good’’ overall standard of care. This figure fell to Kidney International Supplements (2012) 2, 19–36 23
  • 27. chapter 2.2 just over 30% if AKI developed during a hospital admission K Studies are needed to develop and validate scoring systems rather than being diagnosed before admission.53 The authors for AKI risk prediction in various settings, in addition to also felt that there was an unacceptable delay in recognizing cardiac surgery and exposure to radiocontrast material. AKI in 43% of those that developed the condition after K Genome-wide association studies are needed to deter- admission, and that in a fifth of such patients its develop- mine risk of AKI in different hospital settings and with ment was predictable and avoidable. Their recommendations respect to long-term outcomes. were simple: risk assessment for AKI as part of the initial K Studies are needed on risk factors for the development of, evaluation of emergency admissions, along with appropriate recovery from, and long-term outcomes of community- serum biochemistry on admission and at frequent intervals acquired AKI, including sepsis, trauma, tropical infec- thereafter.53 tions, snake bites, and ingestion of toxic plants, etc. RESEARCH RECOMMENDATIONS SUPPLEMENTARY MATERIAL K Better delineation of risk for hospital- and community- Appendix C: Risk Determination. Appendix D: Evaluation and General Management Guidelines for acquired AKI is needed. Patients with AKI. K Better delineation of the effects of age on the risk for AKI Supplementary material is linked to the online version of the paper at is needed. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 24 Kidney International Supplements (2012) 2, 19–36
  • 28. http://www.kidney-international.org chapter 2.3 & 2012 KDIGO Chapter 2.3: Evaluation and general management of patients with and at risk for AKI Given that AKI is associated with significant morbidity and with AKI include both reducing kidney injury and complica- mortality, and because no specific treatment is available to tions related to decreased kidney function. reverse AKI, early recognition and management is para- mount. Indeed, recognition of patients at risk for AKI, or 2.3.1: Evaluate patients with AKI promptly to determine with possible AKI but prior to clinical manifestations, is the cause, with special attention to reversible likely to result in better outcomes than treating only causes. (Not Graded) established AKI. Chapter 2.2 introduced the approach to 2.3.2: Monitor patients with AKI with measurements of risk assessment with further detail provided in Appendix C. SCr and urine output to stage the severity, This chapter will concern itself with the evaluation according to Recommendation 2.1.2. (Not Graded) and general management of patients with, or even at risk 2.3.3: Manage patients with AKI according to the stage for, AKI. Further detail is provided in Appendix D. We (see Figure 4) and cause. (Not Graded) highlight the importance of beginning management at the 2.3.4: Evaluate patients 3 months after AKI for resolu- earliest point in the development of AKI—in patients with tion, new onset, or worsening of pre-existing CKD. suspected AKI or even in those at increased risk who have (Not Graded) been exposed to the various factors discussed in Chapters 2.2 K If patients have CKD, manage these patients as and Appendix C. detailed in the KDOQI CKD Guideline (Guide- Although much of the remaining chapters in this guide- lines 7–15). (Not Graded) line pertain to management of specific aspects of AKI, there K If patients do not have CKD, consider them to be are general management principles that are common to all at increased risk for CKD and care for them as patients and these will be discussed here and further detailed in the KDOQI CKD Guideline 3 for expounded upon in Appendix D. Treatment goals in patients patients at increased risk for CKD. (Not Graded) Figure 4 | Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive-care unit. Kidney International Supplements (2012) 2, 19–36 25
  • 29. chapter 2.3 RATIONALE The clinical evaluation of AKI includes a careful history As emphasized in Chapter 2.2, AKI is not a disease but and physical examination. Drug history should include over- rather a clinical syndrome with multiple etiologies. While the-counter formulations and herbal remedies or recreational much of the literature examining epidemiology and clinical drugs. The social history should include exposure to tropical consequences of AKI appear to treat this syndrome as a diseases (e.g., malaria), waterways or sewage systems, and homogeneous disorder, the reality is that AKI is hetero- exposure to rodents (e.g., leptospirosis, hantavirus). Physical geneous and often is the result of multiple insults. Figure 5 examination should include evaluation of fluid status, signs illustrates an approach to evaluation of AKI. Further for acute and chronic heart failure, infection, and sepsis. discussion of evaluation in clinical practice is provided in Measurement of cardiac output, preload, preload respon- Appendix D. siveness, and intra-abdominal pressure should be considered Figure 5 | Evaluation of AKI according to the stage and cause. 26 Kidney International Supplements (2012) 2, 19–36
  • 30. chapter 2.3 in the appropriate clinical context. Laboratory parameters— variables like central venous pressure are not nearly as useful including SCr, blood urea nitrogen (BUN), and electrolytes, as dynamic variables, such as pulse-pressure variation, complete blood count and differential—should be obtained. inferior vena cava filling by ultrasound and echocardio- Urine analysis and microscopic examination as well as graphic appearance of the heart (see also Appendix D). urinary chemistries may be helpful in determining the Note that while the actions listed in Figure 4 provide underlying cause of AKI. Imaging tests, especially ultrasound, an overall starting point for stage-based evaluation and are important components of the evaluation for patients with management, they are neither complete not mandatory for AKI. Finally, a number of biomarkers of functional change an individual patient. For example, the measurement of urine and cellular damage are under evaluation for early diagnosis, output does not imply that the urinary bladder catheteriza- risk assessment for, and prognosis of AKI (see Appendix D tion is mandatory for all patients, and clinicians should for detailed discussion). balance the risks of any procedures with the benefits. Individualize frequency and duration of monitoring based Furthermore, clinicians must individualize care decisions on patient risk, exposure and clinical course. Stage is a predictor based on the totality of the clinical situation. However, it is of the risk for mortality and decreased kidney function (see advisable to include AKI stage in these decisions. Chapter 2.4). Dependent on the stage, the intensity of future The evaluation and management of patients with AKI preventive measures and therapy should be performed. requires attention to cause and stage of AKI, as well as factors Because the stage of AKI has clearly been shown to that relate to further injury to the kidney, or complications correlate with short-term2,5,27,29 and even longer-term out- from decreased kidney function. Since AKI is a risk factor for comes,31 it is advisable to tailor management to AKI stage. CKD, it is important to evaluate patients with AKI for new Figure 4 lists a set of actions that should be considered for onset or worsening of pre-existing CKD. If patients have patients with AKI. Note that for patients at increased risk (see CKD, manage patients as detailed in the KDOQI CKD Chapters 2.2 and 2.4), these actions actually begin even Guideline (Guidelines 7–15). If patients do not have CKD, before AKI is diagnosed. consider them to be at increased risk for CKD and care for Note that management and diagnostic steps are both them as detailed in the KDOQI CKD Guideline 3 for patients included in Figure 4. This is because response to therapy is an at increased risk for CKD. important part of the diagnostic approach. There are few specific tests to establish the etiology of AKI. However, a RESEARCH RECOMMENDATIONS patient’s response to treatment (e.g., discontinuation of a K Clinical research aimed at testing early management possible nephrotoxic agent) provides important information strategies is urgently needed. Such trials should also as to the diagnosis. address the risks and benefits of commonly used fluid- Nephrotoxic drugs account for some part of AKI in 20–30% management strategies, including intravenous (i.v.) fluids of patients. Often, agents like antimicrobials (e.g., aminoglyco- and diuretics. sides, amphotericin) and radiocontrast are used in patients that K Methods to better assess fluid status in critically ill and are already at high risk for AKI (e.g., critically ill patients with other hospitalized patients at risk for AKI are needed. sepsis). Thus, it is often difficult to discern exactly what K Research is needed, with follow-up beyond hospital stay, contribution these agents have on the overall course of AKI. to better understand the clinical consequences of AKI in Nevertheless, it seems prudent to limit exposure to these agents patients with and without underlying CKD. whenever possible and to weigh the risk of developing or worsening AKI against the risk associated with not using the SUPPLEMENTARY MATERIAL agent. For example, when alternative therapies or diagnostic Appendix C: Risk Determination. Appendix D: Evaluation and General Management Guidelines for approaches are available they should be considered. Patients with AKI. In order to ensure adequate circulating blood volume, it is Supplementary material is linked to the online version of the paper at sometimes necessary to obtain hemodynamic variables. Static http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 19–36 27
  • 31. http://www.kidney-international.org chapter 2.4 & 2012 KDIGO Chapter 2.4: Clinical applications This chapter provides a detailed application of the AKI diagnose patients as rapidly as possible. For example, case A definition and staging for clinical diagnosis and management. can be diagnosed with AKI on day 2 by the first criterion, The definitions and classification system discussed in whereas the second criterion is not satisfied until day 3 Chapter 2.1 can be used easily in many patients and requires (increase from 1.3 to 1.9). However, this is only true because little clinical interpretation. However, in real time, clinicians the episode of AKI began prior to medical attention, and thus do not always have a complete dataset to work with the day 1 SCr level was already increased. If creatinine and individual patients present with unique histories. As measurements had available with 48 hours prior to day 1 and discussed in the previous chapter, it is difficult to distinguish if this level had been at baseline (1.0 mg/dl [88.4 mmol/l]), it AKI from CKD in many cases. In addition, as many as would have been possible to diagnose AKI on day 1 using the two-thirds of all cases of AKI begin prior to hospitali- second criterion. zation (community-acquired AKI). Therefore, clinicians Cases F-H do not have a baseline measurement of SCr may be faced with patients in whom kidney function available. Elevated SCr (reduced eGFR) on day 1 of the is already decreased and, during the hospitalization, hospitalization is consistent with either CKD or AKD improves rather than worsens. Finally, many patients without AKI. In Case F, baseline SCr can be inferred do not have a prior measurement of kidney function to be below the day 1 value because of the subsequent available for comparison. This chapter provides detailed clinical course; thus, we can infer the patient has had an examples of the application of these definitions to the clinical episode of AKI. In case G, AKI can be diagnosed by setting. application of criterion 2, but the patient may have under- lying CKD. Case H does not fulfill the definition for Examples of application of AKI definitions AKI based on either criteria, and has either CKD or AKD Table 7 illustrates a number of examples whereby patients without AKI. presenting with possible AKI can be diagnosed. Cases A-F The example of Case A raises several important issues. have a measurement of baseline SCr. To simplify decision- First, frequent monitoring of SCr in patients at increased risk making, baseline estimated glomerular filtration rate (eGFR) of AKI will significantly improve diagnostic time and exceeds 60 ml/min per 1.73 m2 in these patients, so none has accuracy. If Case A had not presented to medical attention pre-existing CKD. Cases A-F can all be diagnosed with AKI (or if SCr had not been checked) until day 7, the case of AKI by applying the first two criteria in Recommendation 2.1.1. (a would likely have been missed. Frequent measurement of SCr documented increase of at least 0.3 mg/dl (426.5 mmol/l) in high-risk patients, or in patients in which AKI is suspected, [within 48 hours or a 50% increase from presumed baseline). is therefore encouraged—see Chapter 2.3. The second issue Note that a patient can be diagnosed with AKI by fulfilling highlighted by Case A is the importance of baseline SCr either criterion 1 or 2 (or 3, urine output) and thus cases measurements. Had no baseline been available it would still B,C,D, and F all fulfill the definition of AKI. Note also that have been possible to diagnose AKI on day 3 (by either using patients may be diagnosed earlier using criterion 1 or 2. Early criterion 2 or by using criterion 1 and accepting the baseline diagnosis may improve outcome so it is advantageous to SCr as 1.3); however, not only would this have resulted in a Table 7 | AKI diagnosis Serum creatinine mg/dl (lmol/l) Diagnosis AKI? Criterion 1 Criterion 2 Case Baseline Day 1 Day 2 Day 3 Day 7 50% from baseline X0.3 mg/dl (X26.5 lmol/l) rise in p48 hours A 1.0 (88) 1.3 (115) 1.5 (133) 2.0 (177) 1.0 (88) Yes Yes B 1.0 (88) 1.1 (97) 1.2 (106) 1.4 (124) 1.0 (88) No Yes C 0.4 (35) 0.5 (44) 0.6 (53) 0.7 (62) 0.4 (35) Yes No D 1.0 (88) 1.1 (97) 1.2 (106) 1.3 (115) 1.5 (133) Yes No E 1.0 (88) 1.3 (115) 1.5 (133) 1.8 (159) 2.2 (195) Yes Yes F ? 3.0 (265) 2.6 (230) 2.2 (195) 1.0 (88) Yes No G ? 1.8 (159) 2.0 (177) 2.2 (195) 1.6 (141) ? Yes H ? 3.0 (265) 3.1 (274) 3.0 (265) 2.9 (256) ? No 28 Kidney International Supplements (2012) 2, 19–36
  • 32. chapter 2.4 Table 8 | Overview of the approaches to determine baseline SCr in the application of RIFLE classification in previous studies No. of pts Multi-/ Criteria % % Study analyzed single-center used Method to determine baseline SCr recorded estimated Bagshaw25 120123 multi cr+uo estimated by MDRD formula 0 100 Ostermann30 41972 multi cr estimated by MDRD formula 0 100 Uchino5 20126 single cr retrieved from hospital database, or estimated by MDRD formula N/A N/A Bell54 8152 single cr+uo retrieved from hospital database, or estimated by MDRD formula N/A N/A Hoste2 5383 single cr+uo estimated by MDRD formula, or admission creatinine value, N/A N/A whatever was lower Ali31 5321 multi cr retrieved from hospital database, or admission creatinine value 100 0 Cruz55 2164 multi cr+uo retrieved from hospital database, or estimated by MDRD formula 78 22 Perez-Valdivieso56 1008 single cr estimated by MDRD formula 0 100 Kuitunen57 813 single cr+uo preoperative value 100 0 Coca58 304 single cr the lowest s-creatinine value in the first 5 hospital days 100 0 Arnaoutakis59 267 single N/A N/A N/A N/A Abosaif60 247 single cr+uo retrieved from hospital database, or admission creatinine value 100 0 Maccariello61 214 multi cr+uo retrieved from hospital database, or estimated by MDRD formula N/A N/A Jenq62 134 single cr+uo admission creatinine value, or estimated by MDRD formula 90 10 cr, creatinine criteria; MDRD, Modification of Diet in Renal Disease; N/A, not available; pts, patients; SCr, serum creatinine; uo, urine output criteria. Reprinted from Zavada J, Hoste E, Cartin-Ceba R et al. A comparison of three methods to estimate baseline creatinine for RIFLE classification. Nephrol Dial Transplant 2010; 25(12): 3911–3918 (Ref. 64) by permission from The European Renal Association-European Dialysis and Transplant Association; accessed http://ndt.oxfordjournals.org/content/ 25/12/3911.long Table 9 | Estimated baseline SCr Age (years) Black males mg/dl (lmol/l) Other males mg/dl (lmol/l) Black females mg/dl (lmol/l) Other females mg/dl (lmol/l) 20–24 1.5 (133) 1.3 (115) 1.2 (106) 1.0 (88) 25–29 1.5 (133) 1.2 (106) 1.1 (97) 1.0 (88) 30–39 1.4 (124) 1.2 (106) 1.1 (97) 0.9 (80) 40–54 1.3 (115) 1.1 (97) 1.0 (88) 0.9 (80) 55–65 1.3 (115) 1.1 (97) 1.0 (88) 0.8 (71) 465 1.2 (106) 1.0 (88) 0.9 (80) 0.8 (71) Estimated glomerular filtration rate=75 (ml/min per 1.73 m2)=186 Â (serum creatinine [SCr]) À 1.154 Â (age) À 0.203 Â (0.742 if female) Â (1.210 if black)=exp(5.228 À 1.154 Â In [SCr]) À 0.203 Â In(age) À (0.299 if female) + (0.192 if black). Reprinted from Bellomo R, Ronco C, Kellum JA et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-212 with permission from Bellomo R et al.22; accessed http://ccforum.com/content/8/4/R204 delay in diagnosis, it would have resulted in a delay in staging Estimating baseline SCr (see Table 7). On day 7, it can be inferred that the patient’s Many patients will present with AKI without a reliable baseline was no higher than 1.0 mg/dl (88 mmol/l) and thus baseline SCr on record. Baseline SCr can be estimated using correct staging of Case A as Stage 2 (two-fold increase from the Modification of Diet in Renal Disease (MDRD) Study the reference SCr, see below and Table 7) on day 3 could have equation assuming that baseline eGFR is 75 ml/min per 1.73 been determined in retrospect. However, if a baseline SCr was m2 (Table 9).22 This approach has been used in many, but not available to use as the reference, the correct stage could be all, studies of AKI epidemiology using RIFLE2,5,25,30–32,54–63 determined on day 3. (see Table 8) and has recently been validated.64 Hence, most Case B illustrates why criterion 2 can detect cases of AKI current data concerning AKI defined by RIFLE criteria are missed by criterion 1. It also clarifies why these cases are based on estimated baseline SCr for a large proportion of unusual. Had the SCr increased to 1.5 mg/dl (132.6 mmol/l) patients. as opposed to peaking at 1.4 mg/dl (123.8 mmol/l), it would Table 9 shows the range of estimated SCr obtained by have been picked up by criterion 1 as well. By contrast back-calculation for various age, sex, and race categories. Cases C, D, and even F illustrate how criterion 2 may When the baseline SCr is unknown, an estimated SCr can be miss cases identified by criterion 1. Note that Case F can used provided there is no evidence of CKD (see Appendix B). only be diagnosed by inference. By day 7, it can be Fortunately, when there is a history of CKD, a baseline SCr is inferred that the baseline was no higher than 1.0 mg/dl usually available. Unfortunately, many cases of CKD are not (88 mmol/l) and thus it can be determined that the patient identified, and thus estimating the baseline SCr may risk presented with AKI. However, if the baseline SCr could labeling a patient with AKI when in reality the diagnosis was be estimated it would be possible to make this inference as unidentified CKD. As discussed further in Appendix B, it is early as day 1. essential to evaluate a patient with presumed AKI for Kidney International Supplements (2012) 2, 19–36 29
  • 33. chapter 2.4 Table 10 | AKI staging Serum creatinine mg/dl (lmol/l) Case Baseline Day 1 Day 2 Day 3 Day 7 Reference creatinine Max AKI stage A 1.0 (88) 1.3 (115) 1.5 (133) 2.0 (177) 1.0 (88) 1.0 (88) 2 B 1.0 (88) 1.1 (97) 1.2 (106) 1.4 (124) 1.0 (88) 1.0 (88) 1 C 0.4 (35) 0.5 (44) 0.6 (53) 0.7 (62) 0.4 (35) 0.4 (35) 1 D 1.0 (88) 1.1 (97) 1.2 (106) 1.3 (115) 1.5 (133) 1.0 (88) 1 E 1.0 (88) 1.3 (115) 1.5 (133) 1.8 (159) 2.2 (195) 1.0 (88) 2 F ? 3.0 (265) 2.6 (230) 2.2 (195) 1.0 (88) 1.0 (88) 3 G ? 1.8 (159) 2.0 (177) 2.2 (195) 1.6 (141) ? X1 H ? 3.0 (265) 3.1 (274) 3.0 (265) 2.9 (256) ? ? AKI, acute kidney injury. presence of CKD. Furthermore, CKD and AKI may coexist. 1.2 mg/dl (106 mmol/l) (Table 9) and his initial stage on By using all available clinical data (laboratory, imaging, admission (day 1) would be assumed to be 2. However, once history, and physical exam) it should be possible to arrive at his SCr recovered to 1.0 mg/dl (88 mmol/l) on day 7, it would both an accurate diagnosis as well as an accurate estimate of be possible to restage him as having had Stage 3. Once he has baseline SCr. Importantly, excluding some cases of hemo- recovered, there may be no difference between Stage 2 or 3 in dilution secondary to massive fluid resuscitation (discussed terms of his care plan. On the other hand, accurately staging below), the lowest SCr obtained during a hospitalization the severity of AKI may be important for intensity of follow- is usually equal to or greater than the baseline. This SCr up and future risk. should be used to diagnose (and stage) AKI. For example, if Note that Cases G and H can only be staged if the no baseline SCr was available in Case A, diagnosis of AKI reference SCr can be inferred. Case G may be as mild as stage could be made using the MDRD estimated SCr (Table 9). If 1 if the baseline is equal to the nadir SCr on day 7. On the Case A were a 70-year-old white female with no evidence or other hand, if this case were a 70-year-old white female with history of CKD, the baseline SCr would be 0.8 mg/dl no known evidence or history of CKD, the reference SCr (71 mmol/l) and a diagnosis of AKI would be possible would be 0.8 mg/dl (71 mmol/l) based on an estimated even on day 1 (criterion 1, X50% increase from baseline). baseline (Table 9). In this case, the severity on day 1 would However, if the patient was a 20-year-old black male, his already be stage 2. baseline SCr would be estimated at 1.5 mg/dl (133 mmol/l). Since his admission SCr is lower, this is assumed to be the Urine output vs. SCr baseline SCr until day 7 when he returns to his true baseline, Both urine output and SCr are used as measures of an acute and this value can be taken as the baseline. These dynamic change in GFR. The theoretical advantage of urine output changes in interpretation are not seen in epidemiologic over SCr is the speed of the response. For example, if GFR studies, which are conducted when all the data are present, were to suddenly fall to zero, a rise in SCr would not be but are common in clinical medicine. Note that the only detectable for several hours. On the other hand, urine output way to diagnose AKI (by SCr criteria) in Case H is to use an would be affected immediately. Less is known about the use estimated SCr. of urine output for diagnosis and staging compared to SCr, since administrative databases usually do not capture urine Examples of application of AKI stages output (and frequently it is not even measured, especially Once a diagnosis of AKI has been made, the next step is to outside the ICU). However, studies using both SCr and urine stage it (Recommendation 2.1.2). Like diagnosis, staging output to diagnose AKI show increased incidence, suggesting requires reference to a baseline SCr when SCr criteria are that the use of SCr alone may miss many patients. The use used. This baseline becomes the reference SCr for staging of urine output criteria (criterion 3) will also reduce the purposes. Table 10 shows the maximum stage for each number of cases where criterion 1 and criterion 2 are Case described in Table 7. Staging for Case A was already discordant (cases B,C,D, and F in Table 7), as many of these mentioned. The maximum stage is 2 because reference SCr is cases will be picked up by urine output criteria. 1.0 mg/dl (88 mmol/l) and the maximum SCr is 2.0 mg/dl (177 mmol/l). Had the reference SCr been 0.6 mg/dl (53 mmol/ Timeframe for diagnosis and staging l), the maximum stage would have been 3. Case F was staged The purpose of setting a timeframe for diagnosis of AKI is to by using the lowest SCr (1.0 mg/dl [88 mmol/l]) as the clarify the meaning of the word ‘‘acute’’. A disease process reference. Of course, the actual baseline for this case might that results in a change in SCr over many weeks is not AKI have been lower but this would not affect the stage, since it is (though it may still be an important clinical entity: see already Stage 3. Note that if this patient was a 35-year-old Appendix B). For the purpose of this guideline, AKI is white male, his MDRD estimated baseline SCr would be defined in terms of a process that results in a 50% increase in 30 Kidney International Supplements (2012) 2, 19–36
  • 34. chapter 2.4 SCr within 1 week or a 0.3 mg/dl (26.5 mmol/l) increase Clinical judgment within 48 hours (Recommendation 2.1.1). Importantly, there While the definitions and classification system discussed in is no stipulation as to when the 1-week or 48-hour time Chapter 2.1 provide a framework for the clinical diagnosis of periods can occur. It is stated unequivocally that it does not AKI, they should not be interpreted to replace or to exclude need to be the first week or 48 hours of a hospital or ICU stay. clinical judgment. While the vast majority of cases will Neither does the time window refer to duration of the fit both AKI diagnostic criteria as well as clinical judgment, inciting event. For example, a patient may have a 2-week AKI is still a clinical diagnosis—not all cases of AKI will fit course of sepsis but only develop AKI in the second week. within the proposed definition and not all cases fitting the Importantly, the 1-week or 48-hour timeframe is for definition should be diagnosed as AKI. However, exceptions diagnosis of AKI, not staging. A patient can be staged over should be very rare. the entire episode of AKI such that, if a patient develops a Pseudo-AKI. As with other clinical diagnoses defined by 50% increase in SCr in 5 days but ultimately has a three-fold laboratory results (e.g., hyponatremia), the clinician must be increase over 3 weeks, he or she would be diagnosed with AKI cautious to interpret laboratory data in the clinical context. and ultimately staged as Stage 3. The most obvious example is with laboratory errors or errors As with any clinical criteria, the timeframe for AKI is in reporting. Erroneous laboratory values should obviously somewhat arbitrary. For example, a disease process that not be used to diagnose disease and suspicious lab results results in a 50% increase in SCr over 2 weeks would not fulfill should always be repeated. Another example is when two SCr diagnostic criteria for AKI even if it ultimately resulted in measurements are obtained by different laboratories. While complete loss of kidney function. Similarly, a slow process the coefficient of variation for SCr is very small (o5%) by that resulted in a steady rise in SCr over 2 weeks, and then a various clinical testing methods, variation (bias) from one sudden increase of 0.3 mg/dl (26.5 mmol/l) in a 48-hour laboratory to the next may be considerably higher, although period, would be classified as AKI. Such are the inevitable it is unlikely to approach 50%. Given that the SCr definition vagaries of any disease classification. However, one scenario of AKI always uses at least two values, the variation and bias deserves specific mention, and that is the case of the patient between each measure is further magnified—the coefficient with an increased SCr at presentation. As already discussed, of variation for comparison of two lab tests is equal to the the diagnosis of AKI requires a second SCr value for square root of the sum of each coefficient squared. Although comparison. This SCr could be a second measured SCr the international standardization of SCr measurements will obtained within 48 hours, and if it is X0.3 mg/dl largely eliminate interlaboratory bias in the future, care is (X26.5 mmol/l) greater than the first SCr, AKI can be needed in interpreting lab values obtained from different diagnosed. Alternatively, the second SCr can be a baseline labs. Furthermore, daily variation in SCr due to differences in value that was obtained previously or estimated from the diet and activity may be as great as 10%. Finally, endogenous MDRD equation (see Table 9). However, this poses two chromogens (e.g., bilirubin, ascorbic acid, uric acid) and dilemmas. First, how far back can a baseline value be exogenous chromogens and drugs (e.g., cephalosporins, retrieved and still expected to be ‘‘valid’’; second, how can trimethoprim, cimetidine) may interfere with the creatinine we infer acuity when we are seeing the patient for the first assay. The cumulative effect of these various factors time? influencing precision, bias, and biological variation may Both of these problems will require an integrated approach the level at which it could impact the diagnosis of approach as well as clinical judgment. In general, it is AKI. A similar problem exists with urine output. Particularly reasonable in patients without CKD to assume that SCr outside the ICU, urine output is not often reported and urine will be stable over several months or even years, so that collections may be inaccurate, especially in noncatheterized a SCr obtained 6 months or even 1 year previously would patients. Finally, as discussed in Chapter 2.1, a weight-based reasonable reflect the patient’s premorbid baseline. However, criterion for urine output will mean that some very obese in a patient with CKD and a slow increasing SCr over several patients will fulfill the definition of AKI without any kidney months, it may be necessary to extrapolate the baseline SCr abnormality. Clinical judgment should always be exercised in based on prior data. In terms of inferring acuity it is most interpreting such data. reasonable to determine the course of the disease process Atypical AKI. A complementary problem to pseudo-AKI is thought to be causing the episode of AKI. For example, for a the situation where a case of AKI fails to meet the definition. patient with a 5-day history of fever and cough, and chest These cases should be distinguished from conditions in which radiograph showing an infiltrate, it would be reasonable to data are simply missing (discussed above) and refer to infer that the clinical condition is acute. If SCr is found to be situations in which existing data are unreliable. For example, X50% increased from baseline, this fits the definition of AKI. a patient might receive very large quantities of intravascular Conversely, a patient presenting with an increased SCr in the fluids such that SCr is falsely lowered.65 Similarly, massive absence of any acute disease or nephrotoxic exposure will blood transfusions will result in the SCr more closely require evidence of an acute process before a diagnosis can be reflecting the kidney function of the blood donors than the made. Evidence that the SCr is changing is helpful in patient. It is unusual for these cases not to result in oliguria establishing acuity. and, thus, most patients will be diagnosed with AKI even if Kidney International Supplements (2012) 2, 19–36 31
  • 35. chapter 2.4 SCr is not increased. Nevertheless, the clinician should is decreased. Creatinine production may also be decreased in be cognizant of possibility that SCr may be falsely lowered sepsis66 possibly due to decreased muscle perfusion. by large-volume fluid resuscitation or transfusion; thus, a normal value may not rule out AKI. Changes in creatinine SUPPLEMENTARY MATERIAL production are also well known in conditions such as muscle Appendix B: Diagnostic Approach to Alterations in Kidney Function and Structure. breakdown where production increases and in muscle Supplementary material is linked to the online version of the paper at wasting (including advanced liver disease) where production http://www.kdigo.org/clinical_practice_guidelines/AKI.php 32 Kidney International Supplements (2012) 2, 19–36
  • 36. http://www.kidney-international.org chapter 2.5 & 2012 KDIGO Chapter 2.5: Diagnostic approach to alterations in kidney function and structure Definitions of AKI, CKD and AKD GFR and SCr AKI and CKD were defined by separate Work Groups CKD, AKD, and AKI are defined by parameters expressing according to different criteria. The definition for each is the level of kidney function. Table 12 gives examples of each based on alterations in kidney function or structure. AKI and condition based on GFR and different magnitudes of increase CKD have many causes which may lead to alterations of in SCr. kidney function and structure that do not meet the criteria To illustrate the relationship of changes in SCr to changes for the definition of either AKI or CKD, yet patients with in eGFR, we simulated changes in eGFR that would result these diseases and disorders may need medical attention to from changes in SCr corresponding to the KDIGO definition restore kidney function and reverse damage to kidney of AKI in the Chronic Kidney Disease Epidemiology structure to avoid adverse outcomes. A uniform and Collaboration cohort.67,68 Figure 6 shows the relationship systematic nomenclature could enhance understanding and of these changes in eGFR to the definition and stages of AKI. communication about these diseases and disorders, and lead Not all patients with AKI would meet the eGFR criteria for to improved medical care, research, and public health. For the definition of AKD. these reasons, the Work Group proposed an operational definition for AKD to provide an integrated clinical approach GFR/SCr algorithm to patients with abnormalities of kidney function and Figure 7 provides a diagnostic algorithm based on a structure. sequential approach through three questions: i) Is GFR Table 11 compares the definitions for AKI, CKD, and decreased or is SCr increased (according to the criteria in AKD. We have also included an operational definition of ‘‘no Table 12)?; ii) Is SCr increasing or GFR decreasing (according known kidney disease’’ (NKD) for those who do not meet to the criteria in Table 12)?; and iii) Does the decrease in GFR these criteria, with the understanding that clinical judgment or increase in SCr resolve within 3 months? Based on a ‘‘yes’’ is required to determine the extent of the evaluation that is or ‘‘no’’ response to these three sequential questions, all necessary to assess kidney function and structure. In the combinations of AKI, AKD, and CKD can be identified. In following sections, we will elaborate on each component of this section, we review the algorithm and illustrate its use these definitions. for classification of patients with acute and chronic kidney disease in two previously reported cohorts. Table 11 | Definitions of AKI, CKD, and AKD Functional criteria Structural criteria Table 12 | Examples of AKI, CKD, and AKD based on GFR and AKI Increase in SCr by 50% within 7 days, OR No criteria increases in SCr Increase in SCr by 0.3 mg/dl (26.5 mmol/l) Baseline GFR Increase in GFR during within 2 days, OR (ml/min per SCr during next Oliguria 1.73 m2) 7 consecutive days 3 months Diagnosis CKD GFR o60 ml/min per 1.73 m2 for Kidney damage 43 months for 43 months 460 41.5 Â NA AKI AKD AKI, OR Kidney damage 460 o1.5 Â o60 AKD without AKI GFR o60 ml/min per 1.73 m2 for for o3 months 460 o1.5 Â 460 NKD o3 months, OR Decrease in GFR by X35% or increase Baseline GFR Change in SCr GFR during in SCr by 450% for o3 months (ml/min per during next next NKD GFR X60 ml/min per 1.73 m2 No damage 1.73 m2) 7 days 3 months Diagnosis Stable SCr o60 41.5 Â NA AKI + CKD GFR assessed from measured or estimated GFR. Estimated GFR does not reflect o60 o1.5 Â 435% decrease AKD without measured GFR in AKI as accurately as in CKD. Kidney damage assessed by pathology, AKI + CKD urine or blood markers, imaging, and—for CKD—presence of a kidney transplant. NKD o60 o1.5 Â o35% decrease CKD indicates no functional or structural criteria according to the definitions for AKI, AKD, or CKD. Clinical judgment is required for individual patient decision-making regarding GFR assessed from measured or estimated GFR. Estimated GFR does not reflect the extent of evaluation that is necessary to assess kidney function and structure. measured GFR in AKI as accurately as in CKD. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; SCr, serum creatinine. SCr, serum creatinine. Kidney International Supplements (2012) 2, 19–36 33
  • 37. chapter 2.5 Figure 6 | Chronic Kidney Disease Epidemiology Collaboration cohort changes in eGFR and final eGFR corresponding to KDIGO definition and stages of AKI. Panels (a) and (b) show the final eGFR and the percent changes in eGFR, respectively, corresponding to the KDIGO definition and stages of AKI. The horizontal line in panel a and b indicates the threshold value for AKD (o60 ml/min per 1.73 m2 and 435% reduction in initial GFR, respectively). Points above the horizontal line indicate subjects who meet the SCr criteria for the definition of AKI but do not meet eGFR criteria for the definition of AKD. AKD, acute kidney disorder/disease; AKI, acute kidney injury; eGFR, estimated glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes; SCr, serum creatinine. (Lesley Inker, personal communication.) GFR/S cr 1 Is GFR decreased or is serum creatinine increased ? No Yes Yes <3 mo or >3 mo unknown NKD AKD CKD 2 Is Scr increasing or GFR decreasing ? No Yes-D Yes-I No Yes-D Yes-I No Yes-D Yes-I AKD AKD AKD CKD+ CKD +AKD NKD without AKI without without AKI CKD without AKI AKI AKI AKI AKI Yes-D, change in Scr meets AKD criteria but not AKI criteria CKD+ AKD CKD+ AKD without without AKI AKI AKI AKI Does the decrease in GFR or increase in Scr 3 resolve within 3 months? No Yes No Yes No Yes No Yes CKD CKD CKD CKD CKD CKD NKD NKD Worse Stable Worse Stable New New Figure 7 | GFR/SCr algorithm. See text for description. AKD, acute kidney disease/disorder; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; NKD, no known kidney disease; SCr, serum creatinine. The answer to Question 1 requires ascertainment of an patients into three categories: NKD, AKD, and CKD. index GFR/SCr as well during the prior 3 months. The index Question 2 requires repeat ascertainment of kidney function GFR/SCr can be assigned as any of the GFR/SCr measures after the index measure. ‘‘No’’ indicates that the increase in during the interval of observation. The answer classifies SCr or decrease in GFR after the index measure does not 34 Kidney International Supplements (2012) 2, 19–36
  • 38. chapter 2.5 meet AKI or AKD criteria; ‘‘Yes-D’’ indicates that increase in Table 13 | Markers of kidney damage in AKD and CKD SCr and decrease in GFR meets the AKD criteria but not AKI Markers AKD CKD criteria; and ‘‘Yes-I’’ indicates that increase in SCr meets AKI Pathology X X criteria. Question 3 requires repeat ascertainment of GFR/ SCr 3 months after the index measure. ‘‘Yes’’ indicates GFR Urinary markers 460, indicating NKD. No indicates GFR o60, and based on RBC/casts X X prior level of GFR, may indicate stable, new, or worse CKD. WBC/casts X X RTE/casts X X Fine and coarse granular casts X X Oliguria as a measure of kidney function Proteinuria X X Although urine flow rate is a poor measure of kidney function, oliguria generally reflects a decreased GFR. If GFR Blood markers (tubular syndromes) X X is normal (approximately 125 ml/min, corresponding to Imaging approximately 107 ml/kg/h for a 70-kg adult), then reduction Large kidneys X X in urine volume to o0.5 ml/kg/h would reflect reabsorption Small kidneys — X of more than 99.5% of glomerular filtrate. Such profound Size discrepancy — X Hydronephrosis X X stimulation of tubular reabsorption usually accompanies Cysts X X circulatory disturbances associated with decreased GFR. Stones X X Oliguria is unusual in the presence of a normal GFR and is History of kidney transplantation — X usually associated with the non–steady state of solute balance Kidney damage is not required for diagnosis of AKI. In the presence of AKI, findings and rising SCr sufficient to achieve the criteria for AKI. As a of kidney damage do not indicate a separate diagnosis of AKD. corollary, if GFR and SCr are normal and stable over an AKD, acute kidney diseases and disorders; CKD, chronic kidney disease; RBC, red interval of 24 hours, it is generally not necessary to measure blood cells; RTE, renal tubular epithelial cells; WBC, white blood cells. urine flow rate in order to assess kidney function. In principle, oliguria (as defined by the criteria for AKI) Table 14 | Integrated approach to interpret measures of can occur without a decrease in GFR. For example, low kidney function and structure for diagnosis of AKI, AKD, and intake of fluid and solute could lead to urine volume of less CKD than 0.5 ml/kg/h for 6 hours or 0.3 ml/kg/h for 24 hours. On Measures the other hand, severe GFR reduction in CKD usually does Diagnosis GFR/SCr Oliguria Kidney damage Small kidneys not lead to oliguria until after the initiation of dialysis. AKI X X As described in Chapter 2.1, the thresholds for urine flow AKD X X for the definition of AKI have been derived empirically and CKD X X X X are less well substantiated than the thresholds for increase X indicates that the measures can contribute to the diagnosis indicated. in SCr. Urinary diagnostic indices, such as the urinary AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease. concentrations of sodium and creatinine and the fractional reabsorption of sodium and urea, remain helpful to distinguish among causes of AKI, but are not used in the definition (see Appendix D). the left side and 10.9 cm on the right side. Renal size decreased with age, almost entirely because of parenchymal Kidney damage reduction. The lowest 10th percentiles for length of the left Table 13 describes measures of kidney damage in AKD and and right kidney were approximately 10.5 and 10.0 cm, CKD. Kidney damage is most commonly ascertained by respectively, at age 30 years, and 9.5 and 9.0 cm, respectively, urinary markers and imaging studies. Most markers and at age 70 years. abnormal images can indicate AKD or CKD, based on the duration of abnormality. One notable exception is small Integrated approach to AKI, AKD, and CKD kidneys, either bilateral or unilateral, indicating CKD, which Clinical evaluation is necessary for all patients with are discussed separately below. Kidney damage is not a alterations in kidney function or structure. The expectation criterion for AKI; however, it may be present. Renal tubular of the Work Group is that the diagnostic approach will epithelial cells and coarse granular casts, often pigmented and usually begin with assessment of GFR and SCr. However, described as ‘‘muddy brown’’, remain helpful in distinguish- evaluation of kidney function and structure is not complete ing the cause of AKI, but are not part of the definition. unless markers of kidney damage—including urinalysis, examination of the urinary sediment, and imaging studies— Small kidneys as a marker of kidney damage have been performed. Table 14 shows a summary of the Loss of renal cortex is considered a feature of CKD, and is diagnostic approach using measures for kidney function often sought as a specific diagnostic sign of CKD. Kidney size and structure. Based on interpretation of each measure is most often evaluated by ultrasound. In a study of 665 separately, the clinical diagnosis indicated by an ‘‘X’’ can be normal volunteers,69 median renal lengths were 11.2 cm on reached. Kidney International Supplements (2012) 2, 19–36 35
  • 39. chapter 2.5 SPONSORSHIP contributor, copyright holder, or advertiser concerned. KDIGO gratefully acknowledges the following sponsors that Accordingly, the publishers and the ISN, the editorial board make our initiatives possible: Abbott, Amgen, Belo Founda- and their respective employers, office and agents accept no tion, Coca-Cola Company, Dole Food Company, Genzyme, liability whatsoever for the consequences of any such Hoffmann-LaRoche, JC Penney, NATCO—The Organization inaccurate or misleading data, opinion or statement. While for Transplant Professionals, NKF—Board of Directors, every effort is made to ensure that drug doses and other Novartis, Robert and Jane Cizik Foundation, Shire, Trans- quantities are presented accurately, readers are advised that western Commercial Services, and Wyeth. KDIGO is new methods and techniques involving drug usage, and supported by a consortium of sponsors and no funding is described within this Journal, should only be followed in accepted for the development of specific guidelines. conjunction with the drug manufacturer’s own published literature. DISCLAIMER While every effort is made by the publishers, editorial board, and ISN to see that no inaccurate or misleading data, opinion SUPPLEMENTARY MATERIAL Appendix D: Evaluation and General Management Guidelines for or statement appears in this Journal, they wish to make Patients with AKI. it clear that the data and opinions appearing in the articles Supplementary material is linked to the online version of the paper at and advertisements herein are the responsibility of the http://www.kdigo.org/clinical_practice_guidelines/AKI.php 36 Kidney International Supplements (2012) 2, 19–36
  • 40. http://www.kidney-international.org chapter 3.1 & 2012 KDIGO Section 3: Prevention and Treatment of AKI Kidney International Supplements (2012) 2, 37–68; doi:10.1038/kisup.2011.33 Chapter 3.1: Hemodynamic monitoring and support for prevention and management of AKI As discussed in Chapters 2.3 and Appendix D, patients with status and correction of any volume deficit will have a AKI and at increased risk for AKI require careful attention to salutary effect on kidney function, will help minimize further be paid to their hemodynamic status. This is first because extension of the kidney injury, and will potentially facilitate hypotension results in decreased renal perfusion and, if severe recovery from AKI with minimization of any residual func- or sustained, may result in kidney injury. Second, the injured tional impairment. AKI is characterized by a continuum kidney loses autoregulation of blood flow, a mechanism that of volume responsiveness through unresponsiveness maintains relatively constant flow despite changes in pressure (Figure 8),78,82 and large multicenter studies have shown above a certain point (roughly, a mean of 65 mm Hg). that a positive fluid balance is an important factor associated Management of blood pressure and cardiac output with increased 60-day mortality.78,83,84 require careful titration of fluids and vasoactive medication. The amount and selection of the type of fluid that should Vasopressors can further reduce blood flow to the tissues if be used in the resuscitation of critically ill patients is still there is insufficient circulating blood volume. Conversely, controversial. This guideline focuses on the selection of the patients with AKI are also at increased risk for fluid overload fluid (colloid vs. crystalloid fluid in the prevention and early (see Chapter 3.2) and continued fluid resuscitation despite management of AKI). The three main end-points of the increased intravascular volume can cause harm. Fluids and studies explored were the effects on mortality, need for RRT, vasoactive medications should be managed carefully and in and—if possible—the incidence of AKI. Although many concert with hemodynamic monitoring. Hemodynamic trials have been conducted to compare fluid types for evaluation and monitoring are discussed in Appendix D. resuscitation, studies without AKI outcomes were not In this chapter therapies aimed at correcting hemo- systematically reviewed for this Guideline. Suppl Table 1 dynamic instability will be discussed. Available therapies to summarizes the RCTs examining the effect of starch for the manage hypotension include fluids, vasopressors and proto- prevention of AKI. cols which integrate these therapies with hemodynamic goals. There is an extensive body of literature in this field and for a Albumin vs. Saline broader as well as more in depth review the reader is directed The role of albumin physiology in critically ill patients, and to the various reviews and textbooks devoted to critical care the pros and cons for administering albumin to hypoalbu- and nephrology.70–81 minemic patients, have recently been discussed.85 Results of the Saline vs. Albumin Fluid Evaluation (SAFE) study, a RCT FLUIDS comparing 4% human albumin in 0.9% saline with isotonic saline in ICU patients, seem to indicate that albumin is safe, 3.1.1: In the absence of hemorrhagic shock, we suggest albeit no more effective than isotonic saline (the standard of using isotonic crystalloids rather than colloids care choice of isotonic sodium chloride in most centers) for (albumin or starches) as initial management for fluid resuscitation. SAFE demonstrated further no difference expansion of intravascular volume in patients at in renal outcomes, at least based on the need for and risk for AKI or with AKI. (2B) duration of RRT.86 The SAFE study was a double-blind study and it was noted that patients in the albumin arm received 27% less study fluid compared to the saline arm (2247 vs. RATIONALE 3096 ml) and were approximately 1 l less positive in overall Despite the recognition of volume depletion as an important fluid balance.86 Furthermore, very few patients in the trial risk factor for AKI, there are no randomized controlled trials received large volume fluid resuscitation (45 l) and thus the (RCTs) that have directly evaluated the role of fluids vs. results may not be applicable to all patients. The Work Group placebo in the prevention of AKI, except in the field of noted that while isotonic crystalloids may be appropriate for contrast-induced acute kidney injury (CI-AKI) (see Chapter initial management of intravascular fluid deficits, colloids 4.4). It is accepted that optimization of the hemodynamic may still have a role in patients requiring additional fluid. Kidney International Supplements (2012) 2, 37–68 37
  • 41. chapter 3.1 and during the perioperative period’’ (for a summary of this controversy, see de Saint-Aurin et al.90 and Vincent91). The first major randomized trial in patients with sepsis compared HES 200/0.60 to 0.66 with gelatin and showed a greater incidence of AKI in the HES group, but no effect on survival.92 Criticisms of this study include a higher baseline SCr level in the HES group, small sample size, and short follow-up duration of 34 days. In the Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis (VISEP) study,93 patients with severe sepsis were randomly assigned to Figure 8 | Conceptual model for development and clinical receive a hypertonic (10%) solution of low MW HES (HES course of AKI. The concept of AKI includes both volume- 200/0.5), or an isotonic modified Ringer’s lactate solution. responsive and volume-unresponsive conditions. These conditions are not mutually exclusive, and a given patient may Patients in the HES group received a median cumulative dose progress from one to the other. Time runs along the x-axis, and of 70.4 ml per kilogram of body weight. The mortality was the figure depicts a closing ‘‘therapeutic window’’ as injury not significantly different, although showing a trend toward evolves and kidney function worsens. Biomarkers of injury and function will begin to manifest as the condition worsens, but greater mortality at 90 days. However, the hypertonic HES traditional markers of function (e.g., urea nitrogen and creatinine) group had a significantly higher rate of AKI (34.9% vs. will lag behind hypothetical ‘‘sensitive’’ markers of kidney injury. 22.8%) and more days on which RRT was required (Suppl Mortality increases as kidney function declines. AKI, acute kidney Table 1). Also, this study has been criticized for: i) using a injury. Reproduced from Himmelfarb J, Joannidis M, Molitoris B, et al. Evaluation and initial management of acute kidney injury. hyperoncotic colloid solution with potentially harmful renal Clin J Am Soc Nephrol 2008; 3: 962–967 with permission from effects as shown in experimental research;94 ii) markedly American Society of Nephrology82 conveyed through Copyright exceeding the pharmaceutically recommended daily dose Clearance Center, Inc; accessed http://cjasn.asnjournals.org/ limit for 10% HES 200/0.5 by more than 10% in 438% of content/3/4/962.long patients; and iii) pre-existing renal dysfunction in 10% of study patients, which represents a contra-indication for infusion of 10% HES 200/0.5.95 Posthoc analyses of the Hydroxyethylstarch vs. Saline VISEP study showed the cumulative dose of HES to be a Hydroxyethylstarch (HES) is a widely used, relatively significant independent predictor for both mortality and inexpensive alternative to human albumin for correcting RRT at 90 days. The median cumulative dose of HES in the hypovolemia. Different HES preparations are available that VISEP Study was 70 ml/kg compared to 31 ml/kg in the study vary with regard to concentration, mean molecular weight by Schortgen et al.92 (MW), molar substitution, and substitution of hydroxyethyl A systematic review of RCTs on the use of HES for fluid for hydroxyl groups. The mean MW of the different HES management in patients with sepsis totaling 1062 patients, preparations ranges between 70 000 and 670 000 Da. The including 537 patients from the VISEP study, showed an colloid osmotic pressure effect is strongly dependent upon almost two-fold increased risk of AKI with HES compared to the concentration of colloid in the solution; e.g., 6% HES is crystalloids.96 Given these limitations, the results of these iso-oncotic, whereas 10% HES is hyperoncotic. The number studies should be interpreted with caution. Furthermore, a of hydroxyethyl groups per glucose molecule is specified by large, prospective observational study found that HES the molar substitution, ranging between 0.4 (tetrastarch) infusion of any type (median volume 555 ml/d; intraquartile and 0.7 (heptastarch). Accordingly, HES solutions with a range 500–1000) did not represent an independent risk factor molar substitution of 0.5 or 0.6 are referred to as for renal impairment.97; however, recently in a large cohort of ‘‘pentastarch’’ or ‘‘hexastarch’’, respectively. More recently, critically ill patients (approximately 8000 subjects), infusion tetrastarches (HES 130/0.4 and HES 130/0.42) have also been of 10% HES 200/0.5 instead of HES 130/0.4 appeared to be introduced.87 High molecular substitution starch may impair an independent risk factor for RRT.87 Finally, a recent coagulation by reducing the concentration of factor VIII: comprehensive Cochrane review98 concluded that there is no VIIIc and von Willebrand factor. Platelet activity may also be evidence from RCTs that resuscitation with colloids, instead affected by blockade of the platelet fibrinogen receptor of crystalloids, reduces the risk of death in patients with glycoprotein IIb/IIIa. Smaller starch molecules and those trauma, burns, or following surgery. with less molecular substitution produce negligible coagula- The mechanisms of colloid-induced renal injury are tion defects.88 incompletely understood, but may involve both direct Aside from these negative effects on coagulation, develop- molecular effects and effects of elevated oncotic pressure.99 ment of renal dysfunction has been a concern associated with These concerns have led to the widespread adoption of lower the use of mainly hypertonic HES. Hypertonic HES may MW starches as iso-oncotic solution, as resuscitation fluids. induce a pathological entity known as ‘‘osmotic nephrosis’’ Theoretically, such solutions may have lower nephrotoxicity; with potential impairment of renal function.89 It has even however, as yet, no appropriately powered prospective been recommended that ‘‘HES should be avoided in ICUs randomized studies have reported the clinical benefit and 38 Kidney International Supplements (2012) 2, 37–68
  • 42. chapter 3.1 safety of such solutions in comparison with crystalloids. A VASOPRESSORS recent study by Magder et al. compared 10% 250/0.45 HES to isotonic saline in 262 patients who underwent cardiac 3.1.2: We recommend the use of vasopressors in conjunc- surgery.100 These investigators tested whether fewer patients tion with fluids in patients with vasomotor shock required catecholamines the morning after cardiac surgery with, or at risk for, AKI. (1C) (a chief determinant of ICU discharge) with HES compared to saline, and found indeed this was the case (10.9% vs. 28.8%; P ¼ 0.001). Importantly, the study found no evidence RATIONALE of nephrotoxicity: no difference in the daily creatinine, deve- Sepsis and septic shock are major contributing factors to lopment of AKI by RIFLE criteria during hospital stay (16% AKI7 and vasopressor requirement appears to be highly in both groups), or need for RRT (1% in each group). associated with AKI in this population. Despite the high Importantly, patients in the saline group received nearly 60% prevalence of AKI during critical illness in general, and severe more volume for fluid resuscitation in the ICU compared to sepsis specifically, success has been limited in improving the HES (887 vs. 1397 ml; Po0.0001). While overall volumes outcome of this complication.104 Septic shock is the proto- were small, advocates for colloid resuscitation will note that type of a high output–low resistance condition, although this is exactly the reason colloids are preferred for patients severe pancreatitis, anaphylaxis, burns, and liver failure requiring large-volume resuscitation. share similar physiologic alterations. Persistent hypotension, The tonicity of colloid preparations may also vary by despite ongoing aggressive fluid resuscitation or after agent. A recent meta-analysis101 described 11 randomized optimization of intravascular volume in patients with shock, trials with a total of 1220 patients: seven evaluating places patients at risk for development of AKI. In the setting hyperoncotic albumin and four evaluating hyperoncotic of vasomotor paralysis, preservation or improvement of starch. Hyperoncotic albumin decreased the odds of AKI by renal perfusion can only be achieved through use of 76% while hyperoncotic starch increased those odds by 92% systemic vasopressors once intravascular volume has been (odds ratio [OR] 1.92; CI 1.31–2.81; P ¼ 0.0008). Parallel restored.105 effects on mortality were observed. This meta-analysis con- It is not known which vasopressor agent is most effective cluded that the renal effects of hyperoncotic colloid solutions for prevention or treatment of patients with AKI and septic appear to be colloid-specific, with albumin displaying shock. Most studies have focused on norepinephrine, renoprotection and hyperoncotic starch showing nephro- dopamine, or vasopressin. Small open-label studies have toxicity. A 7000-patient study comparing 6% HES 130/0.4 in shown improvement in creatinine clearance (CrCl) following saline with saline alone was scheduled to begin in Australia a 6- to 8-hour infusion of norepinephrine106 or terlipres- and New Zealand in 2010. This study will provide further sin,107 while vasopressin reduced the need for norepinephrine high-quality data to help guide clinical practice.102 and increased urine output and CrCl.108 A large RCT109 Thus, the use of isotonic saline as the standard of care for comparing dopamine to norepinephrine as initial vasopres- intravascular volume expansion to prevent or treat AKI is sor in patients with shock showed no significant differences based upon the lack of clear evidence that colloids are between groups with regard to renal function or mortality. superior for this purpose, along with some evidence that However, there were more arrhythmic events among the specific colloids may cause AKI, in addition to higher costs. It patients treated with dopamine than among those treated is acknowledged that colloids may be chosen in some patients with norepinephrine, and a subgroup analysis showed that to aid in reaching resuscitation goals, or to avoid excessive dopamine was associated with an increased rate of death at fluid administration in patients requiring large volume 28 days among the patients with cardiogenic shock, but not resuscitation, or in specific patient subsets (e.g., a cirrhotic among the patients with septic shock or those with hypo- patient with spontaneous peritonitis, or in burns). Similarly, volemic shock. Thus, although there was no difference in although hypotonic or hypertonic crystalloids may be used in primary outcome with dopamine as the first-line vasopressor specific clinical scenarios, the choice of crystalloid with agent and those who were treated with norepinephrine, the altered tonicity is generally dictated by goals other than use of dopamine was associated with a greater number of intravascular volume expansion (e.g., hypernatremia or adverse events.109 hyponatremia). One of the concerns with isotonic saline is Vasopressin is gaining popularity in the treatment of that this solution contains 154 mmol/l chloride and that shock refractory to norepinephrine.110 Compared to nor- administration in large volumes will result in relative or epinephrine, it increases blood pressure and enhances absolute hyperchloremia (for a review, see Kaplan et al.103). dieresis, but has not as yet been proven to enhance survival Although direct proof of harm arising from saline-induced nor to reduce the need for RRT.111 A recent posthoc analysis hyperchloremia is lacking, buffered salt solutions approxi- of the above mentioned RCT used the RIFLE criteria for AKI mate physiological chloride concentrations and their admin- to compare the effects of vasopressin vs. norepinephrine.112 istration is less likely to cause acid-base disturbances. In patients in the RIFLE-R category, vasopressin as compared Whether use of buffered solutions results in better outcomes to norepinephrine was associated with a trend to a lower rate is, however, uncertain. of progression to F or L categories respectively, and a lower Kidney International Supplements (2012) 2, 37–68 39
  • 43. chapter 3.1 rate of use of RRT. Mortality rates in the R category patients septic shock.93,113,114 In 2001, Rivers et al.115 published the treated with vasopressin compared to norepinephrine were results of a small (n ¼ 263), open-label, single-center study 30.8 vs. 54.7%, P ¼ 0.01, but this did not reach significance in that compared a treatment protocol that the authors referred a multiple logistic regression analysis. This study suggests to as EGDT in the emergency management of septic shock. thus that vasopressin may reduce progression to renal failure EGDT is predicated upon the premise that an early, and mortality in patients at risk of kidney injury who have protocolized resuscitation program with predefined physio- septic shock. The Work Group concluded that current logic end-points will prevent organ failure and improve the clinical data are insufficient to conclude that one vasoactive outcome of patients presenting with septic shock. agent is superior to another in preventing AKI, but Hypotensive patients with severe infection are rapidly emphasized that vasoactive agents should not be withheld assessed for evidence of tissue hypoperfusion and micro- from patients with vasomotor shock over concern for kidney circulatory dysfunction by mean arterial blood pressure perfusion. Indeed, appropriate use of vasoactive agents can measurement and plasma lactate levels.115 Blood lactate levels improve kidney perfusion in volume-resuscitated patients are neither sensitive nor specific but are readily available with vasomotor shock. measures of tissue hypoperfusion and do correlate with adverse outcomes in sepsis.116,117 Early recognition of septic PROTOCOLIZED HEMODYNAMIC MANAGEMENT shock then initiates a protocol of resuscitation with the goal of reestablishing tissue perfusion in patients within 6 hours of 3.1.3: We suggest using protocol-based management of diagnosis. The physiologic goals are: i) return of mean hemodynamic and oxygenation parameters to arterial blood pressure to X65 mm Hg; ii) central venous prevent development or worsening of AKI in pressure between 8–12 mm Hg; iii) improvement in blood high-risk patients in the perioperative setting (2C) lactate levels; iv) central venous oxygen saturation (ScvO2) or in patients with septic shock (2C). 470%; and v) a urine output of X0.5 ml/kg/h. In the study by Rivers et al. the protocol-driven process resulted in more rapid use of fluids, more blood transfusions, RATIONALE and in a small number of patients, earlier use of dobutamine A resuscitation strategy devised for patients with hypotension over the 6-hour time period than standard emergency care. from septic shock that is based upon achieving specific The in-hospital mortality rate in the control group was physiologic end-points within 6 hours of hospital admis- 46.5% vs. 30.5% in the EGDT group (Po0.01).115 Follow-up, sion has been termed Early Goal-Directed Therapy (EGDT). predominantly observational studies, have found less dra- This approach has been endorsed by the ‘‘Surviving matic but generally similar effects,118–122 though not without Sepsis Campaign’’113 and has gained considerable acceptance exception.123 despite only one, single-center, RCT evaluating its effective- The Rivers study did not specifically look at AKI out- ness. This protocolized strategy, consisting of fluids, vaso- comes, but multiple-organ function-scoring systems (i.e., active medication, and blood transfusions targeting physio- APACHE II and SAPS 2) both showed significant improve- logical parameters, is recommended by many experts for the ments with EGDT. In a subsequent study, prevention of prevention of organ injury in septic-shock patients. AKI was significantly improved in patients randomized to a Similarly, protocolized care strategies in surgical patients modified EGDT strategy (without measurement of ScvO2) at high risk for postoperative AKI have been extensively compared to a standard-care group.119 Criticisms of the studied in an effort to provide optimal oxygen delivery to Rivers study include: i) a complex, multistep protocol for tissues in the perioperative period. In these patients, goal- which individual interventions have not been validated; ii) directed therapy is defined as hemodynamic monitoring with the use of a treatment team in the active-therapy arm, thus defined target values and with a time limit to reach these risking a Hawthorn effect; iii) high mortality in the standard- stated goals. Together these protocols with bundled, hemo- care arm; and iv) the study was a small single-center study. dynamic, and tissue-support measures have the potential to Three large multicenter clinical trials in the USA, UK, and reduce the risk of AKI following major surgical procedures Australia are currently underway to definitively evaluate this in high-risk patients (e.g., age 460 years, emergent surgery, promising therapy. elevated American Society of Anesthesiologists score, preoperative comorbid illnesses). Goal-directed therapy for hemodynamic support during the perioperative period in high-risk surgical patients Protocolized hemodynamic management strategies Efforts to improve tissue oxygen delivery by optimizing in septic shock hemodynamic support in high-risk surgical patients to Early fluid resuscitation in the management of hypotensive prevent AKI and other adverse patient outcomes have been patients with septic shock has been a standard treatment investigated for many years.124–126 A recent meta-analysis of paradigm for decades.93,113,114 What has not been clear, these studies by Brienza et al.127 concluded that protocolized however, is how much fluid to give, for how long, or what therapies (regardless of the protocol) with specific physio- type of fluid therapy is optimal in the physiologic support of logical goals can significantly reduce postoperative AKI. 40 Kidney International Supplements (2012) 2, 37–68
  • 44. chapter 3.1 A major problem in interpreting these studies is the lack of K Studies are needed that compare different types of standardized hemodynamic and tissue oxygenation targets vasopressors for prevention and treatment of AKI in and management strategies used to verify the efficacy of these hemodynamically unstable patients. Some evidence measures over standard perioperative care. A heterogeneous suggests that certain vasopressors may preserve renal collection of study populations, types of surgical procedures, function better than others (e.g., vasopressin analogues monitoring methods, and treatment strategies comprise this vs. catecholamines) and studies are needed to compare recent meta-analysis.127 The basic strategy of goal-directed them in this setting. therapy to prevent AKI in the perioperative period is based K The choice of a target mean arterial perfusion pressure on protocols that avoid hypotension, optimize oxygen range of 65–90 mm Hg as a component of resuscitation delivery, and include careful fluid management, vasopressors (perhaps in the context of age, chronic blood pressure, or when indicated, and inotropic agents and blood products if other comorbidities) also needs further study. needed.127 K The specific components of goal-directed therapy that The relative merits and risk:benefit ratio of each discrete accrue benefits for patients at risk for AKI need to be element of EGDT in the successful resuscitation of patients determined. Is it the timing of protocolized hemodynamic with septic shock requires further study. Given the limita- management that is beneficial: prophylactically in high- tions of the current studies and lack of comparative risk surgical patients, or early in the course of severe sepsis? effectiveness studies comparing individual protocols, we In contrast to the benefits of prophylactic or EGDT, can only conclude that protocols for resuscitation in the protocolized use of inotropes to normalize mixed venous setting of septic shock and high-risk surgery appear to be oxygen saturation or supranormalize oxygen delivery in superior to no protocol. ‘‘late’’ critical illness did not result in decreased AKI128 or improved outcomes.128,129 Alternatively, is it attention RESEARCH RECOMMENDATIONS to hemodynamic monitoring, the protocol itself that K Randomized trials of isotonic crystalloid vs. colloid standardizes supportive care to achieve the stated goals, or therapy for intravascular volume expansion to prevent a single or combination of the multiple possible interven- or treat AKI should be conducted in a variety of settings tions that improves outcome? Thus, further research is (critical illness, high-risk surgery, sepsis), including required to determine the specific components of goal- patient subsets. In particular, colloids may improve directed therapy that accrue benefits for patients at risk for efficiency of fluid resuscitation but some (starch) also AKI, if such benefits actually occur. carry some concerns regarding effects on the kidneys. If colloid results in less volume overload, it may lead to SUPPLEMENTARY MATERIAL improved outcomes. Supplementary Table 1: Summary table of RCTs examining the effect K Comparisons of specific solutions, with specific electrolyte of starch for the prevention of AKI. Appendix D: Evaluation and General Management Guidelines for composition or colloid type, for effectiveness in preventing Patients with AKI. AKI should be conducted. Specifically, there is a need to Supplementary material is linked to the online version of the paper at examine physiologic electrolyte solutions vs. saline. http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 37–68 41
  • 45. http://www.kidney-international.org chapter 3.2 & 2012 KDIGO Chapter 3.2: General supportive management of patients with AKI, including management of complications Supportive management to prevent AKI was discussed in the complications that arise from AKI130–133; the reader is referred previous chapter and, for many patients, many of the supportive to these sources. Particular attention should be given to the therapies will continue even if AKI develops. Furthermore, assessment of the circulating volume and fluid administration, an important goal of early management of AKI is to prevent the prevention and/or treatment of hyperkalemia and metabolic further injury and to facilitate recovery of renal function. These acidosis, the knowledge of the changes in pharmacokinetics of goals can often best be achieved by strict attention to supportive many drugs with discontinuation of all potentially nephrotoxic therapy. However, as renal function deteriorates, complications drugs, and dose adaptation of drugs excreted by the kidneys to arise that require different management. Some of these issues the patient’s renal function. Finally, many of the other chapters have been discussed in Chapter 2.3 and several books have in this section of the guideline deal with supportive measures been devoted, in large part, to management of the many (e.g., diuretics for fluid management). 42 Kidney International Supplements (2012) 2, 37–68
  • 46. http://www.kidney-international.org chapter 3.3 & 2012 KDIGO Chapter 3.3: Glycemic control and nutritional support GLYCEMIC CONTROL IN CRITICAL ILLNESS: RENAL EFFECTS patients), the primary end-point of in-hospital mortality AND OUTCOMES did not differ between groups (40% CIT group vs. 37.3% IIT group; P ¼ 0.33).141 As in the original surgical ICU study, a 3.3.1: In critically ill patients, we suggest insulin variety of secondary end-points were improved in this study, therapy targeting plasma glucose 110–149 mg/dl including a lower incidence of AKI and need for RRT. In the (6.1–8.3 mmol/l). (2C) original surgical ICU study, severe AKI (peak SCr 42.5 mg/dl [4221 mmol/l]) developed in 7.2% of the IIT group, compared to 11.2% of the CIT group (P ¼ 0.04); the RATIONALE incidence of RRT was also lower in the IIT group than the As outlined in a recent review,134 stress hyperglycemia is a CIT group (4.8% vs. 8.2%, respectively; P ¼ 0.007).138 In the distinctive clinical feature of critical illness. Stress mediators, medical ICU study, the IIT group similarly had a significantly and central and peripheral insulin resistance appears pivotal lower rate of AKI (doubling of SCr, 5.4%) than the CIT to the occurrence of stress hyperglycemia. Inflammatory group (8.9%, P ¼ 0.04), although RRT incidence was not mediators and counter-regulatory hormones have been decreased.141 In a recent analysis, Schetz et al.142 combined shown to impede crucial elements of the insulin-signaling the renal end-points of both of these trials and used a modi- pathway. Still, exogenous insulin administration normalizes fied version of the RIFLE classification of AKI to demonstrate blood glucose levels in this setting. Insulin treatment may that tight glycemic control reduced the incidence of severe counteract hepatic insulin resistance during acute critical AKI (peak SCr increments two- or three-fold increased from illness. Extensive observational data have shown a consistent, baseline) from 7.6% to 4.5% (P ¼ 0.0006) in a combined almost linear, relationship between blood glucose levels in patient population of 2707. The need for RRT was not patients hospitalized with MI and adverse clinical outcomes, decreased in the overall population or the medical ICU even in patients without established diabetes.135,136 population, but was significantly lower in the surgical ICU It has never been entirely clear, however, whether glycemia patients managed with IIT (4% vs. 7.4%, P ¼ 0.008). serves as a mediator of these outcomes or merely as a marker Several newer studies have provided additional insight of the sickest patients, who present with the well-known concerning the efficacy and safety of tight glycemic control in counter-regulatory stress response to illness.137 Interestingly, critically ill patients.93,95,143–146 Thomas et al.145 conducted a Kosiborod et al.135 recently showed, in a population with MI, systematic review of randomized trials of tight glycemic that while hypoglycemia was associated with increased control in 2864 critically ill patients, and found a 38% risk mortality, this risk was confined to patients who developed reduction of AKI with IIT, and a nonsignificant trend towards spontaneous hypoglycemia. In contrast, iatrogenic hypo- less acute dialysis requirement. However, IIT was also glycemia after insulin therapy was not associated with higher associated with a greater than four-fold increase in the risk mortality risk. of hypoglycemia. A body of literature demonstrating that Tight glycemic control is frequently used in patients at risk uncontrolled hyperglycemia was associated with increased of AKI, and in the management of those who develop AKI. It AKI following cardiac surgery led to the conduct of a 400- has been proposed that tight glycemic control can reduce the patient, single-center RCT of tight vs. conventional intra- incidence and severity of AKI. Since the landmark trial of Van operative glucose control.143,144 The investigators found that den Berghe et al.,138 additional studies provided initial this approach did not decrease perioperative morbidity or confirmation of the benefits (reduced morbidity and mortality (included in a composite end-point that included mortality), and some additional mechanistic insights of tight AKI within 30 days of surgery): the composite end-point glycemic control in critically ill patients.139 Further secondary occurred in 44% of the IIT group vs. 46% of the CIT group. analysis of the original trial, which was conducted in 1548 Although the incidence of hypoglycemia was similar in the mechanically ventilated surgical ICU patients, found that groups, there was a significantly higher incidence of stroke in intensive insulin therapy (IIT) target plasma glucose the IIT group (4.3%) compared to the CIT group (0.54%), as 80–110 mg/dl (4.44–6.11 mmol/l) was associated with sub- well as trends towards higher mortality and more post- stantial cost savings compared to conventional insulin operative heart block in the IIT group, raising concerns about therapy (CIT) target plasma glucose 180–200 mg/dl (9.99– the safety of this approach. 11.1 mmol/l).140 However, when Van den Berghe et al. Further prospective comparison of IIT vs. CIT in critically repeated their original study in a different population of ill septic patients was provided in the VISEP trial, which critically ill patients (medical rather than surgical ICU also incorporated a comparison on crystalloid vs. colloid Kidney International Supplements (2012) 2, 37–68 43
  • 47. chapter 3.3 infusions in a 2 Â 2 factorial design.93 Patients with severe p180 mg/dl [p9.99 mmol/l]).148 The primary outcome was sepsis or septic shock in 18 ICUs were randomized to IIT mortality from any cause within 90 days after randomization. (target glycemia 80–110 mg/dl [4.44–6.11 mmol/l]; n ¼ 247) The two groups had similar characteristics at baseline. A total or CIT (target glycemia 180–200 mg/dl [9.99–11.1 mmol/l]; of 829 patients (27.5%) in the intensive-control group and n ¼ 290) (Suppl Tables 2 and 3). There were no significant 751 (24.9%) in the conventional-control group died (OR differences in 28-day or 90-day mortality, Sequential Organ for intensive control, 1.14; 95% CI 1.02–1.28; P ¼ 0.02). The Failure Assessment scores, or AKI rates between the groups. treatment effect did not differ significantly between surgical However, hypoglycemia (blood glucose level o40 mg/dl patients and medical patients. There was no significant [o2.22 mmol/l]) was more frequent in the IIT group (12% difference between the two treatment groups in incidence of vs. 2%; Po0.001) and led to early termination of the IIT new RRT (15.4% vs. 14.5%), respectively. Severe hypo- study arm. Following publication of this study, Thomas et al., glycemia (blood glucose level p40 mg/dl [p2.22 mmol/l]) updated the meta-analysis (discussed above) to include these was reported in 6.8% in the intensive-control group and in data, and reported that, with the addition of the VISEP data, 0.5% in the conventional-control group (Po0.001). In the analysis of a 3397-patient group found a 36% risk summary, the largest randomized trial of intensive vs. reduction of AKI with IIT, but this pooled estimate was no conventional insulin therapy found that intensive glucose longer statistically significant (relative risk [RR] 0.74; 95% CI control actually increased mortality among adults in the ICU: 0.47–1.17).95 In a detailed review of the VISEP trial, Thomas a blood glucose target of p180 mg/dl (p9.99 mmol/l) et al., also noted that another multicenter mixed ICU trial of resulted in lower mortality than did a target of 81–108 mg/ intensive insulin therapy (the GLUCOCONTROL Study: dl (4.50–5.99 mmol/l). Furthermore, this trial confirmed the Comparing the effects of two glucose control regimens by consistent finding of an increased incidence of hypoglycemia insulin in intensive care unit patients; available at: http:// associated with IIT, without any proven benefit in reducing www.clinicaltrials.gov/ct/show/NCT00107601) was stopped mortality, organ dysfunction, or bacteremia. after 1101 patients were enrolled because of greater rates of There were some methodological differences between the hypoglycemia with IIT.95 Such data have raised significant Leuven and NICE-SUGAR studies, possibly explaining the concerns regarding the effectiveness and safety of using IIT different outcomes.149 These comprised different target with tight glycemic control to prevent or ameliorate ranges for blood glucose in control and intervention groups, morbidity and mortality in patients at high risk of AKI and different routes for insulin administration and types of infu- other forms of organ injury. sion pumps, different sampling sites, and different accuracies The recent meta-analysis of IIT vs. CIT by Wiener et al.146 of glucometers, as well as different nutritional strategies and continued to find a greater incidence of hypoglycemia with varying levels of expertise. Finally, Griesdale et al.150 per- IIT, but the balance of evidence now suggests no improve- formed a meta-analysis of trials of intensive vs. conventional ment in survival with this approach. Twenty-nine RCTs glycemic control that included most of the studies in the totaling 8432 patients contributed data for this meta-analysis. Wiener meta-analysis, in addition to some newer studies, Twenty-seven studies reported no difference in hospital including data supplied by the NICE-SUGAR investigators. mortality (21.6% in IIT vs 23.3% in CIT) with a pooled RR All 26 trials that reported mortality found a pooled RR of of 0.93 (95% CI 0.85–1.03; P ¼ NS). Nine studies reported no death with IIT compared to CIT of 0.93 (95% CI 0.83–1.04). difference in incidence of new RRT. There was a significant Among the 14 trials reporting hypoglycemia, the pooled RR benefit of tight glycemic control in reducing the incidence of with IIT was 6.0 (95% CI 4.5–8.0). However, in subset septicemia but this was associated with a significantly analysis, patients in surgical ICUs appeared to benefit from increased risk of hypoglycemia (blood glucose o40 mg/dl IIT while patients in the other ICU settings (medical or [o2.22 mmol/l]) in patients randomized to IIT with a pooled mixed) did not. Although results from the early trials were RR of 5.13 (95% CI 4.09–6.43; Po0.05). better in studies that included surgical138 rather than purely In summary, pooled analysis of early multicenter studies medical ICU patients141, and this latest meta-analysis appears has failed to confirm the early observations of beneficial to confirm that trend, it should be noted that no such effects of IIT on renal function; the risk of hypoglycemia with phenomenon was noted in the NICE-SUGAR trial. Overall, this approach is significant, and even the survival benefits of the data do not support the use of IIT aiming to control IIT are in doubt. More recently, the international Normogly- plasma glucose below 110 mg/dl (6.11 mmol/l) in critically ill cemia in Intensive Care Evaluation and Survival Using patients, although subset analyses suggest that further trials Glucose Algorithm Regulation (NICE-SUGAR) study, with a may disclose benefits in perioperative patients, and perhaps targeted enrolment of 6100 patients, set out to definitively through the use of less-intensive glucose control targets. determine the risk-benefit comparison of tight glycemic Considering the balance between potential benefits and control in critically ill patients (Suppl Table 3).147,148 In this harm (see Suppl Table 2), the Work Group suggests using trial, adult patients were randomized within 24 hours after insulin for preventing severe hyperglycemia in critically ill admission to an ICU to receive either intensive glucose patients, but in view of the danger of potentially serious control (target blood glucose range of 81–108 mg/dl [4.50– hypoglycemia, we recommend that the average blood glucose 5.99 mmol/l]), or conventional glucose control (target of should not exceed 150 mg/dl (8.33 mmol/l), but that insulin 44 Kidney International Supplements (2012) 2, 37–68
  • 48. chapter 3.3 therapy should not be used to lower blood glucose to less than 25–30 kcal/kg/d, equivalent to 100–130% of resting than 110 mg/dl (6.11 mmol/l). The Work Group recognizes energy expenditure. Energy provision should be composed of that these proposed thresholds have never directly been 3–5 (maximum 7) g per kilogram body weight carbohydrates examined in RCTs but are interpolated from the comparisons and 0.8–1.0 g per kilogram body weight fat. tested in the trials so far. 3.3.3: We suggest to avoid restriction of protein intake NUTRITIONAL ASPECTS IN THE PREVENTION AND with the aim of preventing or delaying initiation of TREATMENT OF CRITICALLY ILL PATIENTS WITH AKI RRT. (2D) Protein-calorie malnutrition is an important independent 3.3.4: We suggest administering 0.8–1.0 g/kg/d of protein predictor of in-hospital mortality in patients with AKI. In a in noncatabolic AKI patients without need for prospective study of 300 AKI patients, 42% presented with dialysis (2D), 1.0–1.5 g/kg/d in patients with AKI on signs of severe malnutrition on admission.151 RRT (2D), and up to a maximum of 1.7 g/kg/d in The nutritional management of AKI patients must patients on continuous renal replacement therapy consider the metabolic derangements and proinflammatory (CRRT) and in hypercatabolic patients. (2D) state associated with renal failure, the underlying disease process and comorbidities, as well as the derangements in nutrient balance caused by RRT. Very few systematic studies RATIONALE have assessed the impact of nutrition on clinical end-points Protein hypercatabolism driven by inflammation, stress, used in these guidelines (i.e., mortality, need for RRT, and acidosis is a common finding in critically ill and incidence of AKI). Recommendations are therefore patients.157,165,166 The optimal amount of protein supple- largely based on expert opinion. Several expert panels have mentation in AKI patients is unknown. Patients with AKI are developed clinical practice guidelines for the nutritional at high risk of malnutrition. Since malnutrition is associated management of patients with AKI, whether treated with or with increased mortality in critically ill patients, nutritional without RRT.152–156 A recent narrative review has also management should aim at supplying sufficient protein to provided updated information on this topic.157 maintain metabolic balance. Hence, nutritional protein administration should not be restricted as a means to 3.3.2: We suggest achieving a total energy intake of attenuate the rise in BUN associated with declining GFR. On 20–30 kcal/kg/d in patients with any stage of AKI. (2C) the other hand, there is little evidence that hypercatabolism can be overcome simply by increasing protein intake to supraphysiologic levels. While, in a crossover study of AKI RATIONALE patients, nitrogen balance was related to protein intake Carbohydrate metabolism in AKI is characterized by and was more likely to be positive with intakes larger than hyperglycemia due to peripheral insulin resistance158,159 2 g/kg/d,167 only 35% of patients achieved a positive nitrogen and accelerated hepatic gluconeogenesis, mainly from con- balance in a study applying a nutrient intake as high as version of amino acids released during protein catabolism 2.5 g/kg/d protein.168 No outcome data are currently that cannot be suppressed by exogenous glucose infusions.160 available concerning the clinical efficacy and the safety of In addition, hypertriglyceridemia commonly occurs due such high protein intakes, which may contribute to acidosis to inhibition of lipolysis. The clearance of exogenously and azotemia, and increase dialysis dose requirements. administered lipids can be reduced.161 The modifications of Due to their continuous nature and the high filtration energy metabolism are usually not caused by AKI per se but rates, CRRT techniques can better control azotemia and fluid related to acute comorbidities and complications.162 Energy overload associated with nutritional support but may also consumption is not increased by AKI. Even in multiple-organ result in additional losses of water-soluble, low-molecular- failure, the energy expenditure of critically ill patients weight substances, including nutrients.169 Normalized pro- amounts to not more than 130% of resting energy tein catabolic rates of 1.4 to 1.8 g/kg/d have been reported expenditure. The optimal energy-to-nitrogen ratio during in patients with AKI receiving CRRT.170–172 In a recent study AKI has not been clearly determined. In a retrospective study in critically ill cancer patients with AKI and treated with of AKI patients undergoing continuous venovenous hemofil- sustained low-efficiency dialysis (SLED), those with higher tration (CVVH), less negative or weakly positive nitrogen BUN and serum albumin levels, which were associated with balance was associated with an energy intake of approxi- infusion of higher amount of total parenteral nutrition, had a mately 25 kcal/kg/d.163 In a randomized trial in AKI patients lower mortality risk.173 comparing 30 and 40 kcal/kg/d energy provision, the higher In CRRT, about 0.2 g amino acids are lost per liter of energy prescription did not induce a more positive nitrogen filtrate, amounting to a total daily loss of 10–15 g amino balance but was associated with a higher incidence of acids. In addition, 5–10 g of protein are lost per day, hyperglycemia and hypertriglyceridemia and a more positive depending on the type of therapy and dialyzer membrane. fluid balance.164 These observations provide a rationale to Similar amounts of protein and amino acids are typically lost maintain a total energy intake of at least 20, but not more by peritoneal dialysis (PD). Nutritional support should Kidney International Supplements (2012) 2, 37–68 45
  • 49. chapter 3.3 account for the losses related to CRRT, including PD, by nutritional requirements in children with critical illness and providing a maximum of 1.7 g amino acids/kg/d. AKI is limited to observational studies. With respect to calorie provision, it is generally agreed that critically ill children, 3.3.5: We suggest providing nutrition preferentially via like adults, should receive 100–130% of the basal energy the enteral route in patients with AKI. (2C) expenditure, which can be estimated with acceptable precision and accuracy by the Caldwell-Kennedy equation179: (resting RATIONALE energy expenditure [kcal/kg/d] ¼ 22 þ 31.05 Â weight [kg] þ Enteral feeding may be more difficult in patients with AKI 1.16 Â age [years]). because of impaired gastrointestinal motility and decreased In a recent survey of the nutritional management of 195 absorption of nutrients secondary to bowel edema.174 children with AKI on CRRT, the maximal calorie prescription Moreover, multiple factors negatively affect gastrointestinal in the course of treatment averaged 53, 31, and 21 kcal/kg/d, function in critically ill patients, e.g., medications (sedatives, and that for protein intake 2.4, 1.9, and 1.3 g/kg/d in children opiates, catecholamines, etc.), glucose and electrolyte dis- aged o1, 1–13, and 413 years, respectively.180 Although not orders, diabetes, or mechanical ventilation. However, the validated by outcome studies, these figures provide an provision of nutrients via the gut lumen helps maintain gut orientation for the macronutrient supply typically achieved integrity, decreases gut atrophy, and decreases bacterial and in and tolerated by children with AKI receiving CRRT. endotoxin translocation. Furthermore, AKI is a major risk factor for gastrointestinal hemorrhage.175 Enteral nutrition RESEARCH RECOMMENDATIONS should exert protective effects on the risk of stress ulcers or K The risk-benefit ratio of diets with low, medium, and bleeding. Clinical studies have suggested that enteral feeding high protein contents in different stages of AKI should be is associated with improved outcome/survival in ICU addressed in RCTs. patients.176,177 Hence, enteral nutrition is the recommended K Given gastrointestinal tract dysfunction in AKI, the form of nutritional support for patients with AKI. If oral possible benefit of enteral vs. parenteral feeding in AKI feeding is not possible, then enteral feeding (tube feeding) patients should be further evaluated in prospective RCTs. should be initiated within 24 hours, and has been shown to be safe and effective.178 SUPPLEMENTARY MATERIAL Supplementary Table 2: Evidence profile of RCTs examining insulin vs. Pediatric considerations conventional glucose therapy for the prevention of AKI. Supplementary Table 3: Summary table of RCTs examining the effect In children with AKI, physiological macronutrient require- of insulin for the prevention of AKI. ments are age-dependent, reflecting the developmental Supplementary material is linked to the online version of the paper at dynamics of growth and metabolism. Research exploring http://www.kdigo.org/clinical_practice_guidelines/AKI.php 46 Kidney International Supplements (2012) 2, 37–68
  • 50. http://www.kidney-international.org chapter 3.4 & 2012 KDIGO Chapter 3.4: The use of diuretics in AKI Diuretics are frequently used in patients at risk of AKI, and in furosemide is beneficial for prevention or treatment of AKI. the management of those who develop AKI. Since fluid Specifically, prophylactic furosemide was found to be overload is one of the major symptoms of AKI, diuretics are ineffective or harmful when used to prevent AKI after cardiac often used for patients with AKI to facilitate fluid manage- surgery,189,190 and to increase the risk of AKI when given to ment. Recent observational studies showed that 59–70% of prevent CI-AKI.191 Epidemiologic data have suggested that patients with AKI were given diuretics at the time of the use of loop diuretics may increase mortality in patients nephrology consultation or before the start of RRT.181,182 with critical illness and AKI,181 along with conflicting data In addition, oliguric AKI has a worse prognosis than that suggest no harm in AKI.182 Finally, furosemide therapy nonoliguric AKI and physicians often prescribe diuretics to was also ineffective and possibly harmful when used to treat convert oliguric to nonoliguric AKI.183 Diuretics are also AKI.188,192 used to control fluid balance and permit administration of There is no evidence that the use of diuretics reduces the nutrition and medications. Furthermore, several diuretics incidence or severity of AKI. Ho et al.192,193 conducted two have potentially renoprotective effects that might prevent comprehensive systematic reviews on the use of the loop development of AKI and hasten its recovery. However, diuretic frusemide (furosemide) to prevent or treat AKI. diuretics can also be harmful, by reducing the circulating Furosemide had no significant effect on in-hospital mortality, volume excessively and adding a prerenal insult, worsening risk for requiring RRT, number of dialysis sessions, or even established AKI. Therefore, it is essential to evaluate the proportion of patients with persistent oliguria. Results usefulness of diuretics to improve outcome of patients with from the most recent review193 are shown in Figure 9 and AKI, not just for fluid management. Figure 10. The primary prevention studies included patients who underwent cardiac surgery,189 coronary angiography,191 3.4.1: We recommend not using diuretics to prevent and major general or vascular surgery.194 In two of these AKI. (1B) studies, all participants had mild pre-existing renal impair- 3.4.2: We suggest not using diuretics to treat AKI, except ment. Two of the three studies reported mortality in patients in the management of volume overload. (2C) randomized to furosemide (n ¼ 103) vs. placebo (n ¼ 99), with a pooled RR of 2.67 (95% CI 0.75–7.25; P ¼ 0.15). All three studies reported RRT incidence in patients randomized RATIONALE to furosemide (n ¼ 128) vs. placebo (n ¼ 127), with a pooled Loop diuretics have several effects that may protect against RR of 4.08 (95% CI 0.46–35.96; P ¼ 0.21). Thus, subanalysis AKI. They may decrease oxygen consumption in the loop of to separate primary and secondary prevention trials did not Henle by inhibiting sodium transport, thus potentially alter the conclusion that, within the sample size limitations lessening ischemic injury. Loop diuretics act at the luminal of this study, furosemide is not effective for the prevention surface of the thick ascending limb of the loop of Henle and of AKI. inhibit the Na-K-2Cl cotransporter,184,185 resulting in a loss The systematic review and meta-analysis by Ho and of the high medullary osmolality and decreased ability to Power193 also included six studies that used furosemide to reabsorb water. Inhibition of active sodium transport also treat AKI, with doses ranging from 600 to 3400 mg/d reduces renal tubular oxygen consumption, potentially (Figure 9 and Figure 10).192 No significant reduction was decreasing ischemic damage of the most vulnerable outer found for in-hospital mortality or for RRT requirement. The medullary tubular segments;183 therefore, furosemide might largest single study of furosemide for treating AKI was protect kidneys against ischemic injury.186 Furosemide also conducted by Cantarovich et al.,188 which included 338 might hasten recovery of AKI by washing out necrotic debris patients with AKI requiring dialysis. Patients were randomly blocking tubules, and by inhibiting prostaglandin dehydro- assigned to the administration of either furosemide (25 mg/ genase, which reduces renovascular resistance and increases kg/d i.v. or 35 mg/kg/d orally) or placebo. Although time to renal blood flow.186,187 Based on these properties, loop reach 2 l/d of diuresis was shorter with furosemide (5.7 days) diuretics might be expected to prevent or ameliorate AKI. than placebo (7.8 days, P ¼ 0.004), there was no difference in However, there are only minimal data to support this theory, survival and number of dialysis sessions. At present, the and there is some evidence of harm associated with loop current evidence does not suggest that furosemide can reduce diuretic use to prevent or treat AKI.188–191 Furosemide is the mortality in patients with AKI. most commonly prescribed diuretic in the acute-care Furosemide may, however, be useful in achieving fluid setting,183–185 and a number of RCTs have tested whether balance to facilitate mechanical ventilation according to the Kidney International Supplements (2012) 2, 37–68 47
  • 51. chapter 3.4 Figure 9 | Effect of furosemide vs. control on all-cause mortality. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283–293 with permission from John Wiley and Sons193; accessed http://onlinelibrary.wiley.com/ doi/10.1111/j.1365-2044.2009.06228.x/full Figure 10 | Effect of furosemide vs. control on need for RRT. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283–293 with permission from John Wiley and Sons193; accessed http://onlinelibrary.wiley.com/doi/ 10.1111/j.1365-2044.2009.06228.x/full lung-protective ventilation strategy in hemodynamically conclude that there is no evidence that the use of loop stable patients with acute lung injury. On the other hand, diuretics reduces the severity of AKI, or improves outcomes the literature also suggests that high-dose furosemide in this syndrome. Although the use of loop diuretics in early (41 g/d) may cause ototoxicity. In the first meta-analysis or established AKI facilitates management of fluid balance, by Ho and Sheridan,192 high doses of furosemide (range hyperkalemia, and hypercalcemia, and is indicated for these 1–3.4 g/d) caused deafness or tinnitus more frequently than clinical purposes, any putative role in the prevention or the control (RR 3.97; 95% CI 1.00–15.78; P ¼ 0.05). When amelioration of AKI course is unproven. administered as continuous infusion a dose of 0.5 mg/kg/ Two recent studies have investigated whether the admin- hour was not associated with ototoxicity.195 Taken together istration of furosemide to patients treated with CVVH could with several small studies showing that the prophylactic use be associated with a more rapid discontinuation of the of diuretics to prevent AKI actually increased AKI incidence, dialysis therapy. van der Voort et al., observed, as expected, these data raise significant concerns regarding use of loop an increased urinary volume and sodium excretion, but this diuretics to prevent or treat AKI in any setting. We similarly intervention did not lead to a shorter duration of renal failure 48 Kidney International Supplements (2012) 2, 37–68
  • 52. chapter 3.4 or more frequent renal recovery.195 The second study by renal dysfunction, but the results of these studies are not very Uchino et al.,196 analyzed data from the B.E.S.T. kidney and convincing.198 Two small randomized trials—one in patients found that, from a total of 529 critically ill patients who with pre-existing normal renal function,199 the second in survived during CRRT, 313 patients were removed success- patients with established renal dysfunction200—did not find fully from CRRT while 216 patients needed ‘‘repeat RRT’’ differences for any measured variable of renal function. after temporary discontinuation. Urine output (during the 24 More convincing are the results obtained with the preventive hours before stopping CRRT) was identified as a significant administration of mannitol, just before clamp release, during predictor of successful cessation, but the predictive ability of renal transplantation.201,202 The sparse controlled data urine output was negatively affected by the use of diuretics. available have shown that 250 ml of mannitol 20% given Thus, a beneficial role for loop diuretics in facilitating immediately before vessel clamp removal reduces the inci- discontinuation of RRT in AKI is not evident. dence of post-transplant AKI, as indicated by a lower require- ment of post-transplant dialysis. However, 3 months after Mannitol transplantation, no difference is found in kidney function Mannitol has been frequently used in the past for prevention compared to patients who did not receive mannitol.203 of AKI; however, most of the studies are retrospective, It has also been suggested that mannitol is beneficial in underpowered, and, overall, the studies did not meet the rhabdomyolysis by stimulating osmotic diuresis and by criteria of the Work Group to be included in formulation of lowering the intracompartmental pressure in the affected recommendations. Prophylactic mannitol has been promoted crushed limbs204–206; again, these studies were either not in patients undergoing surgery. While in most of these randomized or underpowered. A separate guideline on crush instances mannitol increases urine flow, it is highly probable injury associated with disasters, mainly earthquake victims, is that mannitol does not convey additional beneficial effects under preparation by the ISN Renal Disaster Relief Task beyond adequate hydration on the incidence of AKI. Force. In radiocontrast-induced nephropathy, loop diuretics In summary, despite experimental animal data and the and mannitol in one study have been shown to exacerbate anecdotal human evidence for the beneficial effects of ARF.191 Weisberg et al.,197 randomized patients under- mannitol, there are no adequately powered prospective RCTs going contrast-medium investigations to receive saline or comparing mannitol vs. other strategies. Based on these one of three renal vasodilator/diuretic drugs (dopamine considerations, the Work Group concludes that mannitol is [2 mg/kg/min], mannitol [15 g/dl in a one-half isotonic saline not scientifically justified in the prevention of AKI. solution given at 100 ml/h] or atrial natriuretic peptide). Dopamine, mannitol, and atrial natriuretic peptide were RESEARCH RECOMMENDATION associated with a much higher incidence of renal dysfunction K Given the potential to mitigate fluid overload but also to in diabetic subjects compared to patients receiving saline alone. worsen renal function and possibly cause kidney injury, Mannitol is often added to the priming fluid of the further study is required to clarify the safety of loop cardiopulmonary bypass system to reduce the incidence of diuretics in the management of patients with AKI. Kidney International Supplements (2012) 2, 37–68 49
  • 53. http://www.kidney-international.org chapter 3.5 & 2012 KDIGO Chapter 3.5: Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides DOPAMINE FOR THE PREVENTION OR TREATMENT OF AKI analyzed 61 randomized or quasi-randomized controlled Dopamine was once commonly used for renal protection in trials of low-dose dopamine, and found no improvement of the critically ill. However, with multiple negative studies, survival (Figure 11), no decrease in dialysis requirement including a randomized, double-blind, placebo-controlled (Figure 12), no improvement in renal function, and trial of adequate size and power,207 its use has been improved urine output only on the first day of dopamine abandoned by most. Low-dose dopamine administration therapy.212 Similarly, although there were trends towards (1–3 mg/kg/min) to healthy individuals causes renal vasodila- transiently greater urine output, lower SCr, and higher GFR tion, natriuresis, and increased GFR; because of these effects, in dopamine-treated patients on day 1 of therapy (but not it has been given as prophylaxis for AKI associated with days 2 and 3), there was no evidence of a sustained beneficial radiocontrast administration, repair of aortic aneurysms, effect on renal function. In an earlier systematic review, orthotopic liver transplantation, unilateral nephrectomy, Kellum et al.,210 performed an analysis of studies that renal transplantation, and chemotherapy with interferon.208 reported incidence of AKI as an outcome, which developed in The majority of prevention trials with low-dose dopamine 15.3% in the dopamine arms and 19.5% in the control arms have been small, inadequately randomized, of limited (RR 0.79 [0.54–1.13]). Similar to the earlier analysis by statistical power, and with end-points of questionable clinical Kellum et al., restriction of the Work Group’s analysis to significance. Furthermore, recent data suggest that the renal prevention trials did not disclose any benefit of dopamine vs. vasodilatory effect of dopamine found in healthy populations placebo therapy. Similarly, analysis of adequate trials is not preserved in patients with AKI. Using Doppler restricted to patients treated for AKI does not suggest a ultrasound, Lauschke et al.209 found that dopamine signi- benefit of dopamine therapy. Specifically, a relatively large ficantly increased renal vascular resistance in AKI patients. randomized, placebo-controlled trial in 328 critically ill Kellum and Decker210 found no benefit of dopamine for patients with early AKI sufficiently powered to detect a small prevention or therapy of AKI in an adequately-powered benefit was reported.207 There was no effect of low-dose meta-analysis, and Marik211 found no benefit in a systematic dopamine on renal function, need for dialysis, ICU or review. hospital length of stay (LOS), or mortality (Suppl Table 4). There is also limited evidence that the use of dopamine to Taken together, these analyses found no evidence that prevent or treat AKI causes harm. Although the meta-analysis dopamine therapy is effective in the prevention or treatment by Friedrich et al.,212 found no significant increase in adverse of AKI. events or evidence of harm from low-dose dopamine, there is significant literature demonstrating adverse effects of dopa- FENOLDOPAM FOR THE PREVENTION OR TREATMENT OF AKI mine, even at low doses. It can trigger tachyarrhythmias Fenoldopam mesylate is a pure dopamine type-1 receptor and myocardial ischemia, decrease intestinal blood flow, agonist that has similar hemodynamic renal effects as cause hypopituitarism, and suppress T-cell function.208 Taken low-dose dopamine, without systemic a- or b-adrenergic together with the lack of positive trials to support the use of stimulation.213 dopamine for AKI prevention or therapy, the aforementioned potential deleterious effects of this drug provide additional 3.5.2: We suggest not using fenoldopam to prevent or arguments for abandoning its use entirely for the prevention treat AKI. (2C) and therapy of AKI. 3.5.1: We recommend not using low-dose dopamine to RATIONALE prevent or treat AKI. (1A) The results of animal experiments and small human studies measuring perioperative GFR in patients undergoing coro- nary artery bypass graft and aortic cross-clamp surgery RATIONALE suggested that fenoldopam might prevent or ameliorate the In their meta-analysis, Friedrich et al.,212 did not specifically course of AKI.139 Cogliati et al.,214 conducted a double-blind, separate prophylactic trials from trials where dopamine was randomized trial of fenoldopam infusion for renal protec- used therapeutically in patients with established AKI, because tion in 193 high-risk cardiac surgery patients, who were many of the original trials failed to do so.210 The authors randomized to receive a continuous infusion of fenoldopam, 50 Kidney International Supplements (2012) 2, 37–68
  • 54. chapter 3.5 Figure 11 | Effect of low-dose dopamine on mortality. Reprinted from Friedrich JO, Adhikari N, Herridge MS et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510–524 with permission from American College of Physicians212; accessed http://www.annals.org/content/142/7/510.full 0.1 mg/kg/min (95 patients) or placebo (98 patients) for The fenoldopam group had a significantly lower rate of AKI 24 hours. AKI was defined as a postoperative SCr level of (29 vs. 51 patients, P ¼ 0.006; OR of 0.47, P ¼ 0.005), and X2 mg/dl (X177 mmol/l) with an increase in SCr level of shorter ICU stays, without any increase in complications. The X0.7 mg/dl (X61.9 mmol/l) from preoperative to maximum incidence of severe AKI, dialysis, and death were not different postoperative values. AKI developed in 12 of 95 (12.6%) between the groups. This study requires a larger confirmatory patients receiving fenoldopam and in 27 of 98 (27.6%) trial, which should be powered to test effectiveness in patients receiving placebo (P ¼ 0.02), and RRT was started in improving dialysis-free survival. 0 of 95 and 8 of 98 (8.2%) patients, respectively (P ¼ 0.004). Emerging data from experimental AKI models suggest These results suggested that a 24-hour infusion of that fenoldopam may have multiple protective effects in AKI, 0.1 mg/kg/min of fenoldopam prevented AKI in a high-risk including anti-inflammatory effects independent of any vaso- population undergoing cardiac surgery. A meta-analysis of dilatory action.217,218 Further large studies will be required 1059 patients in 13 studies that included this trial found that to determine if fenoldopam is an effective renoprotec- fenoldopam reduces the need for RRT and in-hospital death tive agent.213,219 As discussed elsewhere in this guideline in cardiovascular surgery patients.215 However, the pooled (Section 4), despite promising pilot study findings, fenoldo- studies included both prophylactic and early therapeutic pam was ultimately found to be ineffective for the prevention studies, as well as propensity-adjusted case-matched studies of CI-AKI,220 and as a potent antihypertensive (the only (rather than purely randomized trials). A 1000-patient RCT approved indication for the drug), fenoldapam carries a of fenoldopam to prevent the need for RRT after cardiac significant risk of hypotension. surgery is currently underway (ClinicalTrials.gov identifier: Fenoldopam mesylate has also been studied for early NCT00621790); meanwhile, this remains an unproven treatment of AKI. Tumlin et al.,221 conducted a randomized, indication for fenoldopam therapy. placebo-controlled pilot trial of low-dose fenoldopam Finally, Morelli et al.,216 in a prospective, double-blind mesylate in ICU patients with early AKI and found no trial, randomized 300 septic patients without renal dysfunc- benefit, though they did show a trend towards lower 21-day tion to receive infusions of fenoldopam (0.09 mg/kg/min) mortality and decreased need for dialysis in fenoldopam- and compared these individuals to a placebo group; the treated patients (11% difference in dialysis-free survival). treatment continued as long as the patient was in the ICU. In secondary analyses, fenoldopam tended to reduce the Kidney International Supplements (2012) 2, 37–68 51
  • 55. chapter 3.5 Figure 12 | Effect of low-dose dopamine on need for RRT. Reprinted from Friedrich JO, Adhikari N, Herridge MS et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510–524 with permission from American College of Physicians212; accessed http://www.annals.org/content/142/7/510.full primary end-point in patients without diabetes and post- other positive trends in the literature, these results add to the operative cardiothoracic surgery patients with early ATN. discourse around fenoldopam’s use to treat early AKI in Brienza et al.,222 conducted a prospective, multicenter, critically ill patients. Similarly, Landoni et al.,223 in a recently RCT of fenoldopam therapy for early AKI in critically ill published meta-analysis found that fenoldopam decreased patients. The study included hemodynamically stable adults the risk of requiring acute RRT and resulted in a lower all- with renal dysfunction. This 100- subject study compared 4- cause, in-hospital mortality (15.1%) compared to controls day infusions of fenoldopam (0.1 mg/kg/min) or dopamine (18.9%; OR 0.64; 95% CI 0.4–0.91), along with a non- (2 mg/kg/min); there was no placebo arm. The primary end- significant trend towards more hypotension or pressor use in point of the study was a between-group comparison of the the fenoldopam group. maximum change of SCr over time during the 4-day study Our analysis revealed three suitable prophylactic studies of period. The peak SCr values and maximum increments adequate size and study design (Suppl Tables 5 and 6) that during the study did not differ between the fenoldopam and reported AKI incidence in patients randomized to fenoldo- dopamine groups; however, in the fenoldopam group at the pam (n ¼ 1790) vs. placebo (n ¼ 1839). The pooled RR and end of infusion, SCr had decreased by 0.29 ± 0.77 mg/dl 95% CI was 0.96 (0.76–1.2), P ¼ NS. Only one study reported (25.6 ± 68.1 mmol/l), a value significantly different from the mortality (8-day) in sepsis patients randomized to fenoldo- dopamine group (0.09 ± 0.94 mg/dl [7.96 ± 83.1 mmol/l]; pam (35%, n ¼ 150) vs. placebo (44%, n ¼ 150), with a RR of P ¼ 0.05). Also, the maximum decreases of SCr levels from 0.79 (95% CI 0.59–1.05; P ¼ 0.1). study entry were significantly larger in the fenoldopam In our analysis of the two suitable studies of fenoldopam group. There was no difference in heart rate, blood pressure, therapy for AKI, only one study221 reported (21-day) incidence of hypotension, or urinary output (apart from a mortality in critically ill patients with early AKI randomized transiently higher value within the first study day in the to fenoldopam (11/80; 13.8%) vs. placebo (n ¼ 19/75, 25.3%; dopamine group). The authors concluded that, for critically P ¼ 0.068) (Suppl Tables 7 and 8). The other study222 ill patients with impaired renal function, a continuous reported the change in renal function in AKI patients infusion of fenoldopam 0.1 mg/kg/min improves renal func- randomized to fenoldopam (n ¼ 50) vs. dopamine (n ¼ 50), tion when compared to renal-dose dopamine, without defined by the absolute SCr change between the beginning significant adverse effects. The study has, however, a number and end of the study drug infusion and maximum decrease of deficiencies, including the lack of a true control, from study entry, which were significantly larger in the unblinding of the investigators, and an unorthodox AKI fenoldopam group with a pooled RR of 0.96 (95% CI definition, among other limitations, but taken together with 0.76–1.2; P ¼ NS). These two studies reported new RRT 52 Kidney International Supplements (2012) 2, 37–68
  • 56. chapter 3.5 incidence in patients with AKI randomized to fenoldopam ill patients with AKI was conducted.231 Patients received 24- (n ¼ 130) vs. placebo (n ¼ 125). In the study by Tumlin et al., hour i.v. infusion of either ANP (0.2 mg/kg/min) or placebo. no difference in requirement of RRT was found (with The primary outcome was dialysis-free survival for 21 days fenoldopam, 13 of 80 patients; 16.25%); with placebo (19 of after treatment. Despite the large size of the trial, ANP 75 patients; 25.3%; P ¼ 0.163). Requirement of RRT was very administration had no effect on 21-day dialysis-free survival, rare in the study of Brienza et al., and was prescribed in a mortality, or change in plasma creatinine concentration. Of total of only five patients; three in the dopamine group and note, the mean SCr at enrollment (anaritide group: 4.4 mg/dl two in fenoldopam group (P ¼ NS). Overall, no data from [389 mmol/l]; placebo group: 5.0 mg/dl [442 mmol/l]) in this adequately powered multicenter trials with clinically sig- study confirms that intervention in this trial was extremely nificant end-points and adequate safety are available to late in the course of AKI. In subgroup analysis, dialysis-free recommend fenoldopam to either prevent or treat AKI. The survival was higher in the treatment group for patients with guideline recommendation against using fenoldopam places a oliguria (o400 ml/d; ANP 27%, placebo 7%, P ¼ 0.008). A high value on avoiding potential hypotension and harm subsequent trial in 222 patients with oliguric renal failure, associated with the use of this vasodilator in high-risk however, failed to demonstrate any benefit of ANP.232 The perioperative and ICU patients, and a low value on potential dose and duration of ANP treatment and primary outcome benefit, which is currently only suggested by relatively low- were the same as the previous study. The dose of ANP might quality single-center trials. have been too high (0.2 mg/kg/min) in both studies: hypotension (systolic blood pressure o90 mm Hg) occurred RESEARCH RECOMMENDATION more frequently in the ANP groups of both trials (in the first K While randomized trials of fenoldopam to treat AKI in a study, 46% vs. 18%, Po0.001; and in the second study, 97% variety of settings (critical illness, high-risk surgery— vs. 58%, Po0.001), and this may have negated any potential particular cardiac, sepsis) may be considered, the benefit of renal vasodilation in these patients. In addition to pharmacologic strategy of renal vasodilatation has not an excessive dose, the failure of these large studies has also been successful to date and different approaches are likely been attributed in subsequent analyses to the late initiation of needed. the drug to patients with severe AKI and an inadequate duration of infusion (only 24 hours). A promising, but underpowered, study of ANP to treat NATRIURETIC PEPTIDES FOR THE PREVENTION OR AKI immediately following cardiac surgery showed a TREATMENT OF AKI decreased rate of postoperative RRT compared to placebo- Several natriuretic peptides are in clinical use or in treated patients.233 In this study, Sward et al. randomized 61 development for treatment of congestive heart failure patients with AKI following cardiac surgery (defined as a SCr (CHF) or renal dysfunction, and could potentially be useful to prevent or treat AKI. increase X50% from a baseline o1.8 mg/dl [o159 mmol/l]) to receive infusion of ANP or placebo until the SCr decreased Atrial natriuretic peptide (ANP) is a 28-amino-acid pep- below the baseline value at enrollment, the patient died, or tide with diuretic, natriuretic, and vasodilatory activity.224 one of four prespecified dialysis criteria was reached. Of note, ANP is mainly produced in atrial myocytes, and the rate of all patients received infusions of furosemide (20–40 mg/h) release from the atrium increases in response to atrial and oliguria, defined as a urine output p0.5 ml/kg/h for 3 stretch.225 Early animal studies showed that ANP decreases hours, was an exclusion criterion and an automatic dialysis preglomerular vascular resistance and increases postglomer- indication. The primary end-point was the rate of dialysis ular vascular resistance, leading to increased GFR.226 It also inhibits renal tubular sodium reabsorption. Increases in GFR within 21 days of enrollment. CrCl was significantly higher on the third study day in ANP-treated subjects (P ¼ 0.04). and diuresis have also been confirmed in clinical studies.227 It Using prespecified dialysis criteria, 21% of patients in the could thus be expected that ANP might be useful for ANP group and 47% in the placebo group were dialyzed treatment of AKI, and several RCTs have been conducted to within 21 days (hazard ratio [HR] 0.28; 95% CI 0.10–0.73; test this hypothesis. P ¼ 0.009). The combined secondary end-point of death-or- dialysis was similarly improved in the ANP group (28%) 3.5.3: We suggest not using atrial natriuretic peptide compared to placebo (57%; HR 0.35; 95% CI 0.14–0.82; (ANP) to prevent (2C) or treat (2B) AKI. P ¼ 0.017). The incidence of hypotension during the first 24 hours was 59% in the ANP group and 52% in controls RATIONALE (P ¼ NS). There have been several negative studies of prophylactic ANP It is intriguing to speculate on the potential reasons for the therapy; for example, ANP failed in two studies to prevent positive outcome of this trial, compared to larger prior primary renal transplant dysfunction228,229 and ANP pro- studies of ANP for AKI prevention and therapy. Apart from phylaxis also failed to prevent CI-AKI.230 Based on the the possibility that this is a false-positive, underpowered positive results of small clinical studies using ANP to treat study, possible explanations include the use of ANP earlier in AKI, a randomized placebo-controlled trial in 504 critically the course of AKI (the mean SCr in the prior ANP studies Kidney International Supplements (2012) 2, 37–68 53
  • 57. chapter 3.5 was much higher), and at lower doses (50 ng/kg/min vs. whereas it was significantly higher in the ANP group in the 200 ng/kg/min) that avoided the significant rate of hypoten- high-dose ANP studies (OR 4.13; 95% CI 1.38–12.41). sion observed in prior trials. The use of prespecified dialysis Finally, a pooled analysis of studies that examined oliguric criteria was another strength of this trial. More recently, AKI did not show any significant benefit from ANP for RRT Sward et al.,234 compared the renal hemodynamic effects requirement (OR 0.46; 95% CI 0.19–1.12; P ¼ 0.09) or of ANP and furosemide in 19 mechanically ventilated mortality (OR 0.94; 95% CI 0.62–1.43; P ¼ 0.79). Only two post–cardiac surgery patients with normal renal function, of the treatment studies included in the Nigwekar analy- measuring renal blood flow, GFR, and renal oxygen sis231,232 were of adequate size and quality to meet the criteria extraction. ANP infusion (25–50 ng/kg/min) increased GFR, for our systematic review (Suppl Tables 12 and 13), which filtration fraction, fractional excretion of sodium, and urine found no significant inconsistencies in the findings of both output, accompanied by a 9% increase in tubular sodium trials that (combined) included 720 subjects (351 treated absorption and a 26% increase in renal oxygen consumption. with ANP) (Suppl Table 12). Thus, although subset analyses Furosemide infusion (0.5 mg/kg/h) increased urine output separating low-dose from high-dose ANP trials suggest 10-fold and fractional excretion of sodium 15-fold, while potential benefits, the preponderance of the literature decreasing tubular sodium absorption by 28% and lowering suggests no benefit of ANP therapy for AKI. Therefore, the renal oxygen consumption by 23%. Furosemide also lowered Work Group suggests that these agents not be used to prevent GFR by 12% and filtration fraction by 7%. Thus, although or treat AKI. This conclusion is based on placing a high value the balance of renal hemodynamic and tubular effects of the on avoiding potential hypotension and harm associated with two drugs appears to favor furosemide for improving renal the use of a vasodilator in high-risk perioperative and ICU oxygen delivery-consumption balance, ANP is more likely to patients, and a low value on potential benefit which is acutely improve GFR. One might speculate that the use of supported by relatively low-quality evidence from retro- furosemide infusion in all of the subjects in the successful spective subset analyses from negative multicenter trials. ANP trial may have provided an important protection Urodilatin is another natriuretic peptide that is produced against renal ischemia by reducing tubular sodium absorp- by renal tubular cells, and was found to have the same renal tion and associated oxygen consumption, despite an increase hemodynamic effect as ANP without systemic hypotensive in GFR in the ANP group. A larger prospective trial of ANP effects.236 Limited data suggest that urodilatin improves the to improve dialysis-free survival in this setting is required, course of established postoperative AKI.237 Fifty-one patients perhaps with and without furosemide infusion. who received orthotopic heart transplants received urodilatin Pooled analysis of 11 studies involving 818 participants in (6–20 ng/kg/min) up to 96 hours postoperatively. AKI the prevention cohort showed a trend toward reduction in occurred in 6% of these patients, compared to 20% in a the need for RRT in the ANP group (OR 0.45; 95% CI historical control group that did not receive urodilatin.237 0.21–0.99; P ¼ 0.05). Restricting the analysis to studies that However, in another small, placebo-controlled study of 24 used low-dose ANP preparations did not change the overall patients who underwent orthotopic heart transplants, the effect for this outcome. There was no significant difference incidence of AKI was unchanged,238 although duration of noted between the ANP and control groups for mortality in hemofiltration (HF) was significantly shorter and the the prevention category (OR 0.67; 95% CI 0.19–2.35; frequency of intermittent hemodialysis (IHD) less in those P ¼ 0.53), and this effect was unchanged by restricting the who received urodilatin. Taken together, these data suggest analysis to studies that used low-dose ANP preparations. that natriuretic peptides may have a role in the therapy of However, these studies were generally of poor quality, several early AKI following cardiac surgery, but further prospective without reported baseline SCr values or clear definitions of trials are needed to confirm this potential indication. AKI or RRT indications (Suppl Tables 10 and 11), and only Nesiritide (brain natriuretic peptide) is the latest natriuretic one was of adequate quality. peptide introduced for clinical use, and is approved by the Nigwekar et al., recently conducted a systematic review Food and Drug Administration (FDA) only for the therapy and meta-analysis of ANP for management of AKI.235 They of acute, decompensated CHF. Meta-analysis of outcome found 19 relevant studies, among which 11 studies were for data from these and some other nesiritide CHF trials prevention and eight were for treatment of AKI. Pooled has generated some controversy.239–241 Sackner-Bernstein analysis of the eight treatment studies, involving 1043 et al.,239 analyzed mortality data from 12 randomized trials; participants, did not show significant difference for RRT in three trials that provided 30-day mortality data, they requirement between the ANP and control groups (OR 0.59; found a trend towards an increased risk of death in nesiritide- 95% CI 0.32–1.08; P ¼ 0.12). There was also no significant treated subjects. In another meta-analysis of five randomized difference for mortality (OR 1.01; 95% CI 0.72–1.43; trials that included 1269 subjects,240 the same investi- P ¼ 0.89). However, low-dose ANP preparations were gators also found that there was a relationship between associated with significant reduction in RRT requirement nesiritide use and worsening renal function, defined as (OR 0.34; 95% CI 0.12–0.96; P ¼ 0.04). The incidence of a SCr increase 40.5 mg/dl (444.2 mmol/l). Nesiritide doses hypotension was not different between the ANP and control p0.03 mg/kg/min significantly increased the risk of renal groups for low-dose studies (OR 1.55; 95% CI 0.84–2.87), dysfunction compared to non–inotrope-based controls or 54 Kidney International Supplements (2012) 2, 37–68
  • 58. chapter 3.5 compared to all control groups (including inotropes). Even Table 9). These trends were more pronounced in the small, at doses p0.015 mg/kg/min, nesiritide was associated with 62-patient subset with preoperative SCr values 41.2 mg/dl increased renal dysfunction compared to controls. There was (4106 mmol/l). Although SCr increased postoperatively in no difference in dialysis rates between the groups. Another both groups, it returned to baseline within 12 hours in the retrospective study determined independent risk factors for nesiritide group, and remained elevated throughout hospi- 60-day mortality by multivariate analysis in a cohort of 682 talization in the placebo group. Use of vasoactive drugs and elderly heart-failure patients treated with nesiritide vs. those hemodynamic parameters did not differ significantly between who were not.242 When patients were stratified according to the groups. Adverse events also were similar between the nesiritide usage, AKI emerged as an independent risk factor groups, as was 30-day and 180-day mortality (although for mortality only among patients who received the drug. capture of mortality data was incomplete). Thus, it appears Strikingly, among these heart-failure patients who developed that administration of nesiritide infusion during and after AKI, nesiritide usage emerged as the only independent cardiac surgery with cardiopulmonary bypass in patients predictor of mortality. with preoperative left ventricular dysfunction has favorable The manufacturers of nesiritide convened an expert panel, short-term effects on renal function, with short-term adverse which concluded that further trial data are needed to discern effects comparable to placebo infusion; however, as men- the effects of nesiritide therapy on renal function and survival tioned earlier, this is not an FDA-approved indication for this in patients with decompensated CHF. The panel also re- drug. It is interesting to speculate that, based upon these emphasized that the indication for nesiritide therapy is acute results, any renoprotective effect of this vasoactive drug decompensated CHF, not chronic intermittent therapy or during and after cardiopulmonary bypass is not mediated by other uses, and in particular noted that the drug should not effects on systemic perfusion (similar in both groups), but be used to improve renal function or in place of diuretic rather suggesting an effect on regional perfusion or a therapy in CHF patients, as there is no proof of the utility of pleiotropic phenomenon. Unfortunately, these promising the drug for these purposes. A 7000-patient multicenter RCT pilot study findings have not been followed up with a in acute decompensated heart failure is currently in progress confirmatory prospective clinical trial. to determine the clinical effectiveness of nesiritide therapy for A prospective, randomized clinical trial (the Nesiritide acute decompensated heart failure (the Acute Study of Study), found no benefit of nesiritide for 21-day dialysis and/ Clinical Effectiveness of Nesiritide in Decompensated Heart or death in patients undergoing high-risk cardiovascular Failure; Clinicaltrials.gov identifier NCT00475852). Mean- surgery.244 However, the study did demonstrate that the while, nesiritide is approved for treatment of symptomatic prophylactic use of nesiritide was associated with reduced acute decompensated heart failure. incidence of AKI, the latter defined by the AKIN Group, in Uncontrolled studies using nesiritide for cardiovascular the immediate postoperative period (nesiritide 6.6% vs. support of patients with CHF undergoing cardiac surgery placebo 28.5%, P ¼ 0.004). Recently, Lingegowda et al.245 have suggested beneficial effects on renal function. Mentzer investigated whether the observed renal benefits of nesiritide et al.,243 conducted a 303-patient, multicenter, randomized, had any long-term impact on cumulative patient survival and double-blind trial of a 24- to 96-hour infusion of 0.01 mg/kg/ renal outcomes. Data on all 94 patients from the Nesiritide min of nesiritide vs. placebo in patients with chronic left Study were obtained with a mean follow-up period of 20.8 ± ventricular dysfunction (ejection fraction p40%) under- 10.4 months. No differences in cumulative survival between going cardiac surgery using cardiopulmonary bypass. The the groups were noted, but patients with in-hospital Nesiritide Administered Peri-Anesthesia in Patients Under- incidence of AKI had a higher rate of mortality than those going Cardiac Surgery trial was an exploratory, safety- with no AKI (41.4% vs. 10.7%; P ¼ 0.002). It seemed, thus, oriented study with five primary end-points, including three that the possible renoprotection provided by nesiritide in the renal end-points and two hemodynamic end-points. There immediate postoperative period was not associated with were no significant differences between the groups in base- improved long-term survival in patients undergoing high- line patient characteristics; SCr values were B1.1 mg/dl risk cardiovascular surgery. (97.2 mmol/l), with eGFR B80 ml/min per 1.73 m2. The In summary, although evidence from a variety of small mean duration of study drug infusion was B40 hours in studies suggests the potential for therapy with natriuretic both groups. Perioperative renal function quantified by the peptides to be useful for the prevention or treatment of AKI three renal primary end-points was better in the nesiritide in a variety of settings, there are no definitive trials to support group (peak SCr increase of 0.15 mg/dl [13.3 mmol/l] vs. the use of ANP, BNP, or nesiritide for these purposes. Thus, placebo group 0.34 mg/dl [30.1 mmol/l]; Po0.001; eGFR the Work Group suggests that these agents not be used for decrease of À10.2 ml/min per 1.73 m2 vs. placebo À17.8 ml/ prevention or treatment of AKI. min per 1.73 m2, P ¼ 0.001; initial 24-hour urinary output 2.9 ± 1.2 l vs. placebo 2.3 ± 1 l; Po0.001). The RR of AKI in RESEARCH RECOMMENDATION the nesiritide group compared to placebo was 0.58 K We recommend further trials of ANP at doses below (0.27–1.21); the 180-day mortality was also reduced in the 0.1 mg/kg/min, for the prevention or treatment of AKI. nesiritide group (RR 0.48 [0.22–1.05]; P ¼ 0.046) (Suppl There is a possibility that ANP might be effective if it is Kidney International Supplements (2012) 2, 37–68 55
  • 59. chapter 3.5 given at a lower dose (0.01–0.05 mg/kg/min) in patients Supplementary Table 8: Summary table of RCTs of examining the prophylactically or with early AKI, and during a longer effect of fenoldopam for the treatment of AKI. Supplementary Table 9: Summary table of RCTs of nesiritide vs. control period than in previous large studies. for the prevention of AKI. Supplementary Table 10: Evidence profile of RCTs examining anaritide SUPPLEMENTARY MATERIAL vs. control for the prevention of AKI. Supplementary Table 4: Summary table of RCTs examining the effect Supplementary Table 11: Summary table of RCTs examining the effect of dopamine vs. placebo for the treatment of AKI. of anaritide vs. control for the prevention of AKI. Supplementary Table 5: Evidence profile of RCTs examining fenoldo- Supplementary Table 12: Evidence profile of RCTs examining anaritide pam vs. control for the prevention of AKI. vs. placebo for the treatment of AKI. Supplementary Table 6: Summary table of RCTs examining the effect Supplementary Table 13: Summary table of RCTs examining the effect of fenoldopam for the prevention of AKI. of ANP vs. placebo for the treatment of AKI. Supplementary Table 7: Evidence profile of RCTs of fenoldopam vs. Supplementary material is linked to the online version of the paper at placebo for the treatment of AKI. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 56 Kidney International Supplements (2012) 2, 37–68
  • 60. http://www.kidney-international.org chapter 3.6 & 2012 KDIGO Chapter 3.6: Growth factor intervention Recovery from AKI involves increased expression of various least equivocal, and considering that there is no benefit and growth factors acting via autocrine, paracrine, and endocrine the concern over potential harm and cost associated with this mechanisms. The advent of recombinant growth factors has drug, the Work Group recommends against its use in patients stimulated research exploring their therapeutic potential with AKI. in AKI. Experimental studies have yielded promising results with individual growth factors246 including insulin-like Erythropoietin growth factor-1 (IGF-1), hepatic growth factor, and, more A small pilot trial evaluated the effectiveness of erythro- recently, erythropoietin. The physiological basis for the use of poietin in the prevention of AKI after elective coronary erythropoietin in the prevention of AKI has recently been artery bypass graft.255 Patients received either 300 U/kg of described.247 erythropoietin or saline i.v. before surgery. AKI was defined as a 50% increase in SCr levels over baseline within the 3.6.1: We recommend not using recombinant human first five postoperative days. Of 71 patients, 13 developed (rh)IGF-1 to prevent or treat AKI. (1B) postoperative AKI: three of the 36 patients in the erythro- poietin group (8%) and 10 of the 35 patients in the placebo group (29%; P ¼ 0.035). The increase in postoperative SCr RATIONALE concentration and the decline in postoperative eGFR were IGF-1 is a peptide with renal vasodilatory, mitogenic and significantly lower in the erythropoietin group than in the anabolic properties. rhIGF-1 has been demonstrated to placebo group. accelerate the recovery of renal function in several animal More recently, Endre et al.,256 performed a pros- models of AKI.248–251 Three double-blind, placebo-controlled pective randomized trial with erythropoietin in the primary RCTs have addressed the usefulness of IGF-1 in adults prevention of AKI in ICU patients at risk for AKI (Suppl with imminent or established AKI.252–254 Franklin et al.,252 Table 14). As a guide for choosing the patients for treatment administered rhIGF-1 every 12 hours for 3 days post- the urinary levels of two biomarkers, the proximal tubular operatively to 54 patients undergoing abdominal aortic brush border enzymes c-glutamyl transpeptidase and alkaline surgery. While no patient developed ARF, a smaller propor- phosphatase were measured. Randomization to either tion of IGF-1–treated patients showed a decline in GFR as placebo or two doses of erythropoietin was triggered by an compared to the placebo group (22% vs. 33%). Hladunewich increase in the biomarker concentration product to levels et al.,254 administered rhIGF-1 or placebo in 43 patients above 46.3. The primary outcome was the relative average undergoing cadaveric renal transplantation at high risk of SCr increase from baseline over 4–7 days. The triggering delayed graft function. Treatment was started within 5 hours biomarker concentration product selected patients with of transplantation and continued for 6 days. On day 7, more severe illness and at greater risk of AKI, dialysis, neither inulin clearance, nor urine flow or fractional sodium or death; however, the urinary marker elevations were excretion differed between the treatment arms, nor did transient. The use of the biomarkers allowed randomization the nadir SCr after 6 weeks or the proportion of patients within an average of 3.5 hours of a positive sample. There require post-transplantation dialysis. Hirschberg et al.,253 was no difference in the incidence of erythropoietin-specific treated 72 patients suffering from AKI mainly due to sepsis or adverse events; however, there was also no difference hemodynamic shock with either rhIGF-1 or placebo for a in the primary outcome between the placebo and treatment mean of 10.6 days. No differences were observed with respect groups. to changes in GFR, urine output, need for RRT, and mortality. Hence, despite its therapeutic efficacy in various RESEARCH RECOMMENDATION animal models of ARF, rhIGF-1 largely failed to prevent K Recent animal studies suggest a potential clinical benefit or accelerate recovery from established AKI in humans. of erythropoietin in AKI. In various rodent models of In addition, the high cost of this treatment should be AKI, erythropoietin consistently improved functional mentioned. recovery. The renoprotective action of erythropoietin Based on an analysis of the three RCTs with rhIGF-1 that may be related to pleomorphic properties including are currently available and which were overall negative or at antiapoptotic and antioxidative effects, stimulation of cell Kidney International Supplements (2012) 2, 37–68 57
  • 61. chapter 3.6 proliferation, and stem-cell mobilization.247 Although SUPPLEMENTARY MATERIAL Supplementary Table 14: Summary table of RCTs examining the effect one recent RCT in the prevention of human AKI was of erythropoietin vs. placebo for the prevention of AKI. negative, the usefulness of erythropoietin in human AKI Supplementary material is linked to the online version of the paper at should be further tested in RCTs. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 58 Kidney International Supplements (2012) 2, 37–68
  • 62. http://www.kidney-international.org chapter 3.7 & 2012 KDIGO Chapter 3.7: Adenosine receptor antagonists The activation of tubuloglomerular feedback in response to is less evident in view of the complete long-term recovery of elevated luminal chloride concentrations in the distal renal renal function in the placebo-treated controls and the absence tubules is an early event in ischemic AKI. Adenosine released of an effect on patient survival. as part of the tubuloglomerular feedback loop binds to In recent years, the advent of selective adenosine A1 glomerular adenosine A1 receptor, causing vasoconstriction receptor antagonists has prompted the conduct of some of the afferent arteriole, decreased renal blood flow and GFR, interesting clinical trials, which to date have focused on the and sodium and water retention. This well-known role of prevention and treatment of cardiorenal syndrome. In a adenosine in this phenomenon has stimulated a body of double-blind placebo-controlled trial of 63 patients with research seeking to prevent or treat AKI with adenosine CHF, single doses of the adenosine A1 antagonist BG9719 receptor antagonists, primarily in three clinical syndromes had a marked stimulatory effect on diuresis and increased with increased risk of AKI: perinatal asphyxia, radiocontrast GFR.263 When coadministered with furosemide, BG9719 exposure, and cardiorenal syndrome. Theophylline is a showed a synergistic diuretic effect and prevented the nonselective adenosine receptor antagonist. decrease in GFR associated with the loop diuretic. Rolofylline, another adenosine A1 receptor antagonist, 3.7.1: We suggest that a single dose of theophylline may was tested in two double-blind placebo-controlled RCTs in be given in neonates with severe perinatal asphyxia, patients with acute decompensated heart failure. In the first who are at high risk of AKI. (2B) study, rolofylline or placebo was administered either concomitantly with furosemide for 3 days (146 patients), or as a single infusion in 35 diuretic resistant patients.264 In both RATIONALE substudies, rolofylline improved urine output and CrCl AKI occurs in 60% of neonates suffering from perinatal compared to placebo. The second trial involved 301 patients asphyxia.257 Experimental studies indicated an important role hospitalized for acute heart failure with renal impairment of adenosine-mediated vasoconstriction in neonatal kidneys who received either placebo or one of three doses of exposed to normocapnic hypoxemia.258 A potential renoprotec- rolofylline for 3 days.265 Rolofylline administration dose- tive effect of theophylline in perinatal asphyxia has been assessed dependently attenuated the rise in SCr observed in the in three randomized, placebo-controlled clinical trials,259–261 placebo group within 14 days, and tended to reduce 60-day including a total of 171 term neonates. Theophylline was mortality or readmission for cardiovascular or renal causes. uniformly administered in the first hour of life as a single i.v. Three pivotal phase III trials in a total of 2500 patients bolus at a dose of 5 mg/kg259,261 or 8 mg/kg.260 The three studies were recently completed, aiming to corroborate the reno- all observed significantly higher GFR, higher urine output with protective effects of rolofylline in patients with cardiorenal more negative fluid balance, and lower urinary b2-microglobu- syndrome, and to establish drug safety. The final results of the lin excretion, with theophylline as compared to placebo during PROTECT trial have recently been published.266 Rolofylline, the first 3–5 days of life. In each study, theophylline treatment as compared to placebo, did not provide a benefit with was associated with a significantly reduced risk of severe renal respect to the three primary end-points: survival, heart- dysfunction (17–25% vs. 55–60% in placebo group, RR failure status, and changes in renal function. Persistent renal 0.3–0.41). The beneficial effect was selective for kidney function, impairment developed in 15.0% of patients in the rolofylline whereas the incidence of central nervous system, cardiac, group and in 13.7% of patients in the placebo group pulmonary, and gastrointestinal complications was unaltered. (P ¼ 0.44). By 60 days, death or readmission for cardiovas- Patient survival was not affected by treatment. In line with these cular or renal causes had occurred in similar proportions of studies in mature neonates, a similar improvement of GFR and patients assigned to rolofylline and placebo (30.7% and urine output was observed during the first 2 days of life by 31.9%, respectively; P ¼ 0.86). Adverse-event rates were administration of 1 mg/kg theophylline vs. placebo in 50 very similar overall; however, only patients in the rolofylline preterm neonates with respiratory distress syndrome.262 The group had seizures, a known potential adverse effect of further evolution of renal function was followed throughout the A1-receptor antagonists. Thus, rolofylline does not appear to first year of life by Bhat et al.,260 who found equally normal be effective for treatment of cardiorenal AKI. glomerular and tubular function in both groups from 6 weeks of age onward. Hence, while theophylline clearly improves renal RESEARCH RECOMMENDATION function in the first week of life in postasphyctic neonates, the K It appears that if there are benefits of using adeno- overall benefit from this intervention in neonatal intensive care sine receptor antagonists to decrease tubuloglomerular Kidney International Supplements (2012) 2, 37–68 59
  • 63. chapter 3.7 feedback-mediated vasoconstriction and increase renal distal salt delivery might harmfully increase tubular blood flow and GFR in AKI, they may be limited to very oxygen consumption in the presence of ATN), and specific populations (e. g., asphyctic neonates). These nonrenal (lower seizure threshold). Thus, further studies benefits must be balanced against potential adverse are still needed to clarify the role for theophylline in drug effects: both renal (increased renal blood flow and neonates. 60 Kidney International Supplements (2012) 2, 37–68
  • 64. http://www.kidney-international.org chapter 3.8 & 2012 KDIGO Chapter 3.8: Prevention of aminoglycoside- and amphotericin-related AKI AMINOGLYCOSIDE NEPHROTOXICITY population studied)271–276,278 that they should no longer be Aminoglycoside antimicrobial agents are highly potent, used for standard empirical or directed treatment, unless no bactericidal antibiotics effective against multiple Gram- other suitable alternatives exist. The intrinsic risk of AKI with negative, and selected Gram-positive bacterial pathogens the administration of aminoglycosides has led some authors when administered with beta-lactams and other cell-wall to recommend the elimination of aminoglycosides as a active antimicrobial agents.267–269 Progressive antimicrobial clinical treatment option.277 Certainly their use should be resistance to other antimicrobial agents and lack of new restricted to treat severe infections where aminoglycosides are alternatives to aminoglycoside antibiotics have caused a the best, or only, therapeutic option. recent increase in their use. Aminoglycosides have many Aminoglycosides should be used for as short a period of favorable attributes, including their remarkable stability, time as possible. Repeated administration of aminoglycosides predictable pharmacokinetics, low incidence of immuno- over several days or weeks can result in accumulation of logically mediated side-effects, and lack of hematologic or aminoglycosides within the renal interstitium and within hepatic toxicity. Nephrotoxicity, and to a lesser degree the tubular epithelial cells.279 This can result in a higher ototoxicity and neuromuscular blockade, continue to be incidence of nephrotoxicity with repeated exposure to the major dose-limiting toxicities of the aminoglycosides. aminoglycosides over time. Older patients (465 years), Careful dosing and therapeutic drug monitoring of amino- patients with pre-existing renal dysfunction, and septic glycosides using pharmacokinetic and pharmacodynamic patients with intravascular volume depletion and rapid principles can mitigate the risk of AKI with these clinically alterations in fluid dynamics may be at greater risk for useful, yet nephrotoxic antibiotics.270 A number of meta- aminoglycoside nephrotoxicity. Other risk factors for ami- analyses and treatment guidelines have been published noglycoside-induced AKI are diabetes mellitus, concomitant recently indicating that the risk of AKI attributable to use of other nephrotoxic drugs, prolonged use, excessive aminoglycosides is sufficiently frequent that they should no blood levels, or repeated exposure to separate courses of longer be added to other standard antimicrobial agents for aminoglycoside therapy over a short time interval.267–279 the empirical or directed treatment of a number of severe Gram-positive or Gram-negative bacterial infections.271–276 3.8.2: We suggest that, in patients with normal kidney The intrinsic risk of AKI with the administration of function in steady state, aminoglycosides are aminoglycosides has led some authors to call for elimination administered as a single dose daily rather than of aminoglycosides as a therapeutic option in current clinical multiple-dose daily treatment regimens. (2B) management of infectious diseases.277 The anticipated demise of aminoglycosides from our therapeutic armamentarium has not occurred, however, in light of recent developments RATIONALE with progressive antimicrobial resistance to beta-lactams, Aminoglycoside demonstrates concentration-dependent bac- quinolones, and a number of other classes of antimicrobial tericidal activity, with a prolonged ‘‘postantibiotic effect’’, agents. thereby permitting extended interval dosing in an effort to optimize efficacy and minimize toxicity. This dosing strategy 3.8.1: We suggest not using aminoglycosides for the treat- and a number of other measures to limit aminoglycoside ment of infections unless no suitable, less nephro- uptake in renal tubular cells, prevent apoptosis, limit oxygen toxic, therapeutic alternatives are available. (2A) injury, and protect mitochondrial function have all been recommended to minimize the risk of AKI and preserve the therapeutic value of these important antimicrobial RATIONALE agents.280–296 Single-dose daily or extended-interval dosing Aminoglycosides exhibit a number of favorable pharmaco- of aminoglycosides offer a number of theoretical and kinetic and pharmacodynamic advantages, but a major dose- practical advantages to maintain antimicrobial activity while limiting toxicity of the aminoglycosides remains the risk limiting possible nephrotoxicity. This convenient and of drug-induced AKI.270 The risk of AKI attributable to inexpensive aminoglycoside dosing strategy has been widely aminoglycosides is sufficiently high (up to 25% in some adopted at many centers when using this potentially toxic, yet series, depending upon the definition of AKI used and the highly effective, class of antibiotics. Kidney International Supplements (2012) 2, 37–68 61
  • 65. chapter 3.8 When feasible in patients with normal and stable kidney The use of single-daily dosing of aminoglycosides is function, once-daily (often referred to as extended-interval) generally well-tolerated but bolus infusions of aminoglyco- dosing of aminoglycosides should be used to limit amino- sides should be avoided. The high-dose, once-daily amino- glycoside nephrotoxicity. The pharmacokinetic and pharma- glycoside regimens should be administered over 60 minutes codynamic properties of aminoglycosides favor high dosing to avoid untoward events such as neuromuscular blockade. strategies with extended intervals between doses. The key This recommendation is particularly important when therapeutic parameter for efficacy is peak blood level divided patients are receiving other potential neuromuscular block- by minimum inhibitory concentration (MIC) of the infecting ing agents, or have underlying disorders affecting neuro- organism (Cmax/MIC) in an effort to obtain 410-fold muscular transmission (e.g., myasthenia gravis). Cmax/MIC. Aminoglycosides induce a prolonged postanti- biotic effect (inhibition of bacterial growth after blood levels 3.8.3: We recommend monitoring aminoglycoside drug have fallen below the MIC of the organism). The length of the levels when treatment with multiple daily dosing is postantibiotic effect is directly related to the peak blood used for more than 24 hours. (1A) levels. These pharmacokinetic/pharmacodynamic parameters make single-dose daily strategies an attractive option when RATIONALE using aminoglycosides. Therapeutic drug monitoring has been the standard of care The nephrotoxicity of aminoglycosides has been very well when administering aminoglycosides for many years. Amino- studied280–282,284–293,295,296 and is primarily related to uptake glycoside levels are variable among individuals, and subtle of aminoglycosides through a receptor known as megalin, changes in the volume distribution, renal blood flow, and expressed on epithelial cells along the proximal convoluted filtration rate can affect renal handling of aminoglycosides tubule.293 Aminoglycosides are concentrated in the proximal and alter the risk of nephrotoxicity. For these reasons, convoluted tubules, where they bind avidly to polyanionic, therapeutic drug monitoring, in combination with or phospholipid-containing membranes. Aminoglycosides in- independent from, single-dose daily treatment regimens is duce myeloid body formation, impair protein synthesis, recommended.318–321 When using therapeutic drug monitor- degrade mitochondrial function, and culminate in apoptosis ing in single-dose or extended-dose treatment strategies, the and eventual necrosis of renal tubular epithelial cells. Direct Cmax should be at least 10-fold greater than the MIC of the glomerular injury can occur288 but is usually a secondary infecting microorganism. This Cmin (trough level) should be consequence of aminoglycoside-induced tubular impairment. undetectable by 18–24 hours to limit accumulation of As the receptor uptake of aminoglycosides is saturable, high- aminoglycosides in renal tubular cells and to minimize the level intermittent doses of aminoglycosides actually reduced risk of AKI. The usual dosing strategy for once-daily the daily uptake and accumulation of aminoglycosides when aminoglycosides is 5 mg/kg/d for gentamicin and tobramycin compared to multiple-daily dosing strategies. This should (with normal renal function); 6 mg/kg/d for netilmicin; and limit the risk of nephrotoxicity, at least in principle. 15 mg/kg/d for amikacin. The multiple-dose daily regimen The potential efficacy of single-dose daily regimens (or for gentamicin and tobramycin is usually 1.7 mg/kg every other extended dosing treatment programs) of aminoglyco- 8 hours with peak blood levels at 8 ± 2 mg/ml (17±4 mmol/l) sides vs. multiple-daily dosing strategies has been extensively and trough of 1–2 mg/ml (2–4 mmol/l). Amikacin levels with studied in numerous controlled and uncontrolled clinical the multiple-dose daily dosing strategy should be a peak studies over many years297–308, and the subject has been the of 20±5 mg/ml (34±9 mmol/l) and a trough of 5–8 mg/ml focus of a number of formal meta-analyses.309–314 These (9–14 mmol/l). We recommend therapeutic drug monitoring investigations include pediatric populations, elderly popula- when using prolonged courses of aminoglycosides to limit tions, empirical therapy, targeted therapy, treatment directed the risk of nephrotoxicity when using multiple-daily dosing, towards Gram-negative bacterial pathogens and Gram- and suggest therapeutic drug monitoring when using single- positive bacterial pathogens. daily dosing strategies. The cumulative results of this evidence-based review and numerous meta-analyses indicate that once-daily dosing 3.8.4: We suggest monitoring aminoglycoside drug levels strategies generally tend to result in less AKI when compared when treatment with single-daily dosing is used for to multiple-dose dosing strategies, although the benefit more than 48 hours. (2C) accrued by the single-daily dose strategy is modest and inconsistent across a number of these studies. For this reason, a level 2 recommendation is suggested in support of the RATIONALE use of single-daily dose strategies over multiple-dose daily The timing of measurement of peak doses of aminoglycosides strategies. It should be noted that multiple-daily dosing with single-daily dosing strategies is not standardized and strategies continue to be the standard of care for enterococcal remains somewhat controversial. Some investigators do not endocarditis; no detailed, randomized trials have been measure therapeutic drug levels at all in patients receiving reported comparing single-daily vs. multiple-daily regimens this dosing strategy. Others recommend at least a single peak for enterococcal endocarditis.272,315–317 measurement to ensure that the blood levels are 10-fold 62 Kidney International Supplements (2012) 2, 37–68
  • 66. chapter 3.8 greater than the MIC of the infecting organism. Many and method of therapeutic drug monitoring with single- investigators recommend at least one or at least a weekly daily dosing regimens, would be of great assistance.319 Cmin level obtained at either 12, 18, or 24 hours after the K It is generally recommended that patients receiving aminoglycoside dose.267–270 The Cmin level should be below extended-dosing interval aminoglycosides should have the limits of detection of the assay (o1 mg/ml) at these time aminoglycosides administered at even greater dosing intervals. intervals if mild or moderate degrees of underlying renal Measuring aminoglycoside levels with multiple-daily impairment exist. Optimal therapeutic monitoring in dosing strategies have been standardized for Cmax to be the setting of infrequent dosing intervals for patients obtained 30 minutes after a 30-minute infusion, and Cmin with underlying CKD needs to be standardized and right before the next dose for trough levels. The aminoglyco- uniform recommendations need to be provided by sides should be administered in patients who are volume- careful pharmacokinetic/pharmacodynamic observa- replete; volume depletion increases the risk of nephrotoxicity tional studies. in experimental studies and is suggested in clinical studies. K The impact of IHD and high-flux CRRT upon the efficacy Additionally, potassium repletion has been shown experi- and toxicity of extended-duration dosing of aminoglyco- mentally and clinically to diminish the risk of AKI related to sides needs further study. As membranes with greater aminoglycoside administration. sieving coefficients come into greater use, the impact on Single-dose daily regimens are difficult to apply in patients aminoglycoside elimination needs to be carefully con- with pre-existing kidney disease, and patients with vacillating sidered. This could be investigated by RCTs using eGFR and hemodynamics, such as critically ill patients in the standard dosing intervals vs. individualized dosing regi- ICU setting. The changing pharmacokinetics and pharma- mens, with frequent drug-level monitoring and the use codynamics of antibiotics in general and aminoglycosides in of efficacy measures and kidney injury markers as particular, in the critically ill patient, are such that the outcomes. avoidance of single-daily dosing and application of frequent K The interaction between aminoglycosides and other anti- therapeutic drug monitoring is indicated.322 microbial agents, and other therapeutic agents with nephrotoxic potential needs to be more carefully 3.8.5: We suggest using topical or local applications of quantified. The degree of aminoglycoside-induced aminoglycosides (e.g., respiratory aerosols, instilled nephrotoxicity alone vs. combination effects with such antibiotic beads), rather than i.v. application, when drugs as vancomycin, amphotericin B, cephalosporins, feasible and suitable. (2B) extended-spectrum penicillins, colistin, loop diuretics, clindamycin, cisplatin, and nonsteroidal anti-inflamma- tory agents needs to be more carefully examined in RATIONALE observational studies. Local instillation of aminoglycosides for a variety of indications is gaining more widespread use in a selected set AMPHOTERICIN B NEPHROTOXICITY of clinical situations where aminoglycoside levels can be Amphotericin B has been the standard of treatment for life- concentrated at specific tissue sites. The use of aminoglyco- threatening systemic mycoses for over 50 years. This polyene side-loaded beads for the prevention and treatment of bone antifungal agent is insoluble in water and needs to be and joint infections have become commonplace as a strategy solubilized with deoxycholate and given i.v. in the absence of to limit nephrotoxicity, while providing antimicrobial electrolyte solutions to maintain solubility. Despite its activity of aminoglycosides at the tissue level.323 Local broad-spectrum fungicidal activity against a large number concentrations of aminoglycoside are achieved for prolonged of invasive systemic mycoses, drug-induced nephrotoxicity is periods when administered by this route. Aminoglycoside common and remains the principal dose-limiting toxicity of aerosol delivery systems are now in use to provide high amphotericin B.328–330 Amphotericin B has numerous other intrapulmonary antibiotic levels with minimal systemic and significant toxicities, including thrombophlebitis, electrolyte kidney concentrations of the antibiotic. This strategy has disturbances, hypoplastic anemia, and systemic toxicity been used successfully in cystic fibrosis patients for the associated with fever, chills, hypotension, and cytokine management of difficult-to-treat Gram-negative bacillary release.331,332 AKI related to amphotericin B is clinically pneumonia.324,325 However, significant nephrotoxicity with significant and is associated with higher mortality rates, the use of inhaled tobramycin has been described in at least increased LOS, and increased total costs of health care when two cases.326,327 managing patients with systemic fungal infection.328,330 Over the past two decades, three major advances in RESEARCH RECOMMENDATIONS antifungal therapy have become clinically available: i) the K No standard method exists for therapeutic drug moni- lipid formulations of amphotericin B; ii) the introduction of toring of aminoglycosides by single daily dosing. Uniform the echinocandin class of antifungal agents; and iii) an guidance, based upon carefully performed pharmaco- expanding number of azoles with extended activity against kinetic/pharmacodynamic studies on the optimal timing a variety of fungal pathogens. Therapeutic alternatives to Kidney International Supplements (2012) 2, 37–68 63
  • 67. chapter 3.8 amphotericin B have been a welcome addition in the of volume repletion and potassium supplementation during management of systemic mycoses and selected, protozoan, amphotericin B therapy supports their routine use, despite parasitic infections, but their incremental costs and tradeoffs the relative lack of compelling clinical evidence to recom- in spectrum of activity against fungal pathogens need to be mend these maneuvers. considered, in addition to their favorable toxicity profiles and Various dosing strategies have also been instituted in an reduced potential for nephrotoxicity. A number of therapeu- attempt to limit amphotericin B–induced nephrotoxicity. tic options are now available to the clinician when deciding One strategy is to give amphotericin B as a continuous upon the choice for empiric or directed antifungal therapy. infusion rather than a 2- to 4-hour infusion to limit Avoidance of risk of nephrotoxicity is one of the major, but nephrotoxicity.329,334 While there is some suggestion that a not the only, determinants when selecting antifungal therapy continuous infusion may limit nephrotoxicity, enthusiasm at present. for this strategy is tempered by the potential loss of some antifungal activity. Amphotericin B exhibits concentration- 3.8.6: We suggest using lipid formulations of ampho- dependent antifungal activity, and continuous infusion of tericin B rather than conventional formulations of low-doses of amphotericin B could result in suboptimal amphotericin B. (2A) protection for some patients with invasive fungal infec- tions.334 Another common strategy is the administration of RATIONALE alternate-day doses of amphotericin B, rather than daily The broad-spectrum, polyene, antifungal agent amphotericin doses.335,336 This strategy is better tolerated and might reduce B deoxycholate has been the mainstay of treatment for nephrotoxicity without sacrificing efficacy in stable patients. systemic mycoses for decades. Despite its well-known toxicity However, clear evidence that this strategy reduces nephro- profile, the potent antifungal activity of amphotericin B, in toxicity is not supported by large, adequately controlled addition to its activity against certain protozoan parasites clinical trials as yet. (Plasmodium spp., Leishmania spp., Naegleria spp.), indicates One of the major innovations in amphotericin B therapy that this therapy will remain a standard agent in clinical over the last 15 years has been the introduction of lipid medicine for the foreseeable future. formulations of amphotericin to limit the problem of Amphotericin B–induced nephrotoxicity is related to nephrotoxicity associated with conventional amphotericin B multiple mechanisms, including ischemic injury and direct deoxycholate. Three lipid formulations are available includ- tubular- and glomerular-cell membrane toxicity. Amphoter- ing: amphotericin B colloidal dispersion, amphotericin B icin causes vasoconstriction of the afferent renal arteriole lipid complex, and liposomal amphotericin B. Amphotericin along with a systemic inflammatory response that may B colloidal dispersion is formulated by amphotericin B reduce renal blood flow. Amphotericin B also directly inserts complexed with cholesteryl sulfate. Amphotericin B lipid into human cellular membranes, where it disrupts membrane complex is composed of amphotericin B complexed with permeability and physiology.331,332 Tubular epithelial cells dimyristoyl phosphatidylcholine and dimyristoyl phospha- residing in the deep medullary regions of the kidney are tidylglycerol. Liposomal amphotericin consists of amphoter- particularly susceptible to injury where considerable osmotic icin B complexed with hydrogenated soy phosphatidyl- stress exists across cell membranes even under physio- choline, distearoylphosphatidylcholine, and cholesterol.337–340 logic conditions. The end result is enzymuria, loss of Other formulations that might further reduce the risk of AKI renal tubular concentrating ability, renal tubular acidosis, from amphotericin B include nanoparticle packaging in increasing urinary losses of potassium and magnesium, and micelles with polyaspartic acid.340 decreased glomerular function, resulting in azotemia and The safety and efficacy (in incidence of nephrotoxicity) of decreased synthesis of erythropoietin. Amphotericin B– lipid formulations of amphotericin have been studied in induced nephrotoxicity is often accompanied by concomitant numerous experimental and clinical trials with conventional administration of other potentially nephrotoxic agents amphotericin B deoxycholate as the comparator.337–339,341–350 such as cyclosporine A, aminoglycosides, chemotherapeutic A detailed analysis of these various trials, and a number of agents, and a number of other potentially nephrotoxic meta-analyses that have analyzed this clinical question, agents.328,329,333 concluded that the lipid formulations are less nephrotoxic Considerable efforts have been undertaken to try to limit than amphotericin B deoxycholate.344,346 When feasible, we nephrotoxicity and permit the continued use of amphotericin recommend that lipid formulations supplant the use of B deoxycholate for the management of systemic mycoses. conventional amphotericin B deoxycholate to reduce the risk Simple maneuvers, such as salt repletion and provision of of nephrotoxicity. adequate amounts of potassium, are beneficial in animal The incremental costs associated with the lipid formula- models in the prevention of amphotericin B nephrotoxicity. tions and their relative efficacy for systemic mycoses remains These measures have a mixed record in clinical practice, and the subject of considerable debate. The existing evidence their capacity to prevent AKI when treating severe fungal would suggest that the overall risk-benefit ratio and cost- infections remain unclear. The relative ease and simple logic effectiveness with these lipid formulations is essentially 64 Kidney International Supplements (2012) 2, 37–68
  • 68. chapter 3.8 cost-neutral with amphotericin B deoxycholate.337,339 There is currently insufficient evidence as to whether the Attempts to increase the doses of lipid formulations of echinocandins, the azoles, or the lipid formulations of amphotericin further to improve efficacy have resulted in amphotericin B differ significantly from each other with mixed results and are not recommended at present.342,343 respect to the risk of nephrotoxicity. No adequately Lipid formulations of amphotericin are less nephrotoxic but controlled, large, randomized studies have been reported to require different dosing strategies (three- to five-fold higher date comparing the relative risk of nephrotoxicity amphoter- doses than deoxycholate formulations of amphotericin B). icin B lipid formulations with either azole or echinocandin Some of these agents continue to induce general systemic antifungal agents. Such studies face the difficulty of recruiting toxicity reactions similar to those observed with the deoxy- sufficient numbers of patients with similar baseline risk for cholate formulation (e.g., amphotericin B colloidal dispersion). drug-induced AKI, and with a balance of exposure to other potentially nephrotoxic agents. Until such time as these 3.8.7: In the treatment of systemic mycoses or parasitic studies are completed, no evidence-based recommendations infections, we recommend using azole antifungal can be given about the relative risk of AKI attributable agents and/or the echinocandins rather than directly to these antifungal agents. conventional amphotericin B, if equal therapeutic efficacy can be assumed. (1A) RESEARCH RECOMMENDATIONS K Some studies indicate that the liposomal form of amphotericin B is less nephrotoxic than amphotericin B RATIONALE lipid complex or amphotericin B colloidal dispersion. Another approach to prevent amphotericin B nephrotoxicity RCTs in patients with systemic mycosis, with the rate of is to avoid polyene antifungal agents entirely and use alte- AKI as a primary or secondary end-point, should be rnative agents, such as the azoles and echinocandins.351–355 conducted to answer this question. Azole antifungal agents inhibit sterol synthesis in fungal cell K Innovative strategies to formulate amphotericin B in membranes by blocking the activity of the 14-demethylase microvesicles, nanoparticles, or micelles should be under- enzyme essential for ergosterol synthesis. Nephrotoxicity taken to limit nephrotoxicity in treating fungal infections. is an unusual event following the use of azole compounds. Clinical trials should compare existing formulations to The echinocandins are beta-glucan inhibitors that inter- these novel formulations, and could generate cost-effective, fere with cell-wall synthesis of fungal elements, and have an yet non-nephrotoxic derivatives of amphotericin B. entirely different mechanism of action from that of K Carefully selected combinations of antifungal therapies to amphotericin B. Both the azole compounds (voriconazole, enhance efficacy and shorten duration of therapy may fluconazole, itraconazole, and posaconazole) and the echi- limit toxicity and reduce costs in the treatment of fungal nocandins (caspofungin, anidulafungin, and micafungin) infections. Investigations need to be carried out in the compare favorably to amphotericin B with respect to their laboratory and in clinical studies to improve the care of efficacy against a variety of the systemic mycoses. Both patients with severe fungal infections. The costs and classes of antifungal agents have the advantage of lacking complication rates of AKI, and other toxicities of short- the intrinsic nephrotoxicity associated with amphotericin B course combination treatment, should be compared to deoxycholate. Both the azole compounds and echinocandins standard dosing regimens of antifungal therapy. have proven to be less nephrotoxic than conventional K Markers of early nephrotoxicity and mechanisms to avoid amphotericin B deoxycholate in observational studies, nephrotoxicity with amphotericin B formulations need historical control studies, and in small comparative trials.355 to be studied further in clinical investigations. These An important consideration in using these antifungal antifungal agents are given for prolonged periods, and agents is their relative efficacy with respect to the likely should allow ample opportunity to test the validity of pathogen that is targeted for treatment. Candida krusei is novel biomarkers of drug-induced nephrotoxicity. A intrinsically resistant to the azoles and Candida parapsilosis is group monitored with novel AKI biomarkers should be frequently resistant to the echinocandins. Amphotericin compared to conventional monitoring of AKI, to B-resistant strains of selected Aspergillus spp. and Pseudal- determine if one or more early biomarkers of kidney lescheria boydii are well described and require alternative injury add to standard clinical care in the prevention of therapies. drug-induced AKI. Kidney International Supplements (2012) 2, 37–68 65
  • 69. http://www.kidney-international.org chapter 3.9 & 2012 KDIGO Chapter 3.9: Other methods of prevention of AKI in the critically ill ON-PUMP VS. OFF-PUMP CORONARY ARTERY BYPASS [4133 mmol/l]) (Suppl Table 16). There was no significant SURGERY difference between off-pump and on-pump coronary artery The type of cardiac surgery is important in the discussion on bypass graft in the rate of the 30-day composite outcome. risk for kidney problems associated with this surgery. The rate of the 1-year composite outcome was higher for Valvular procedures or aorta surgery are associated with a off-pump than for on-pump coronary artery bypass graft. higher risk. One of the most controversial risk factors is Follow-up angiograms in the majority of the patients on-pump vs. off-pump coronary artery bypass surgery. revealed that the overall rate of graft patency was lower in Off-pump coronary artery bypass obviously removes the the off-pump group than in the on-pump group (82.6% vs. bypass circuit but can be associated with greater hemo- 87.8%, Po0.01). dynamic instability secondary to ventricular compression as A comprehensive meta-analysis including RCTs, and the heart is manipulated to access the coronary arteries.356 abstracts from the proceedings of scientific meetings through It is possible, with standard operative techniques, to perform February 2010, was recently published.358 AKI was defined coronary artery bypass surgery (but not valve surgery) by a mixture of criteria, including biochemical parameter, without using cardiopulmonary bypass. This technique is urine output, and dialysis requirement. Mortality was known as ‘‘off-pump’’ coronary artery bypass surgery. evaluated among the studies that reported kidney-related It has been hypothesized that preservation of physiologic outcomes. This analysis compared off-pump with the more renal perfusion by avoidance of cardiopulmonary bypass traditional on-pump technique. Off-pump coronary artery would partially nullify the risk of AKI in patients receiving bypass graft was associated with a statistically significant coronary artery bypass surgery. Potential benefits that have 40% lower odds of postoperative AKI and a nonsignificant been posited for off-pump coronary artery bypass (compared 33% lower odds for dialysis requirement. Within the to on-pump procedures) are reduced mortality, reduction of selected trials, off-pump coronary artery bypass graft surgery AKI risk (and in particular, acute dialysis, which is associated was not associated with a significant decrease in mortality. with a perioperative mortality of 42% in the Society of It is apparent from this meta-analysis that the trials Thoracic Surgeons database), reduced risk of cerebral were clinically heterogeneous, particularly in regards to dysfunction (due to stroke and neurocognitive dysfunction, their definitions of kidney outcomes, and mostly were of the latter sometimes referred to as ‘‘pump head’’), reduction poor to fair quality (based on the Jadad score). The very in ICU stay and days in hospital, and reduction in atrial low event rates (often 0–1 patients) make the estimates fibrillation. As in other areas covered by these guidelines only suspect and highly imprecise. There is also a question of mortality, risk for RRT, and AKI risk are addressed as end- publication bias. There are several large trials in progress point measures. It must, however, be remembered that the that are likely to generate more definitive data. In chronic potential benefits of off-pump coronary artery bypass might dialysis patients, there are observational US Renal Data be predominantly outside these areas of focus. Systems data to weakly support the use of off-pump technique (slightly lower mortality). However, with any 3.9.1: We suggest that off-pump coronary artery bypass technical advance that is introduced in certain centers, graft surgery not be selected solely for the purpose institutional familiarity with the technique, operator experi- of reducing perioperative AKI or need for RRT. (2C) ence, and characteristics of the population referred to the center are likely to be important modulators of out- comes. In conclusion, based on the analysis of the RCTs RATIONALE and the recent meta-analysis, the Work Group found As detailed in Suppl Tables 15 and 16, which summarize that there was not enough evidence to recommend off- RCTs, the balance of the potential benefit and harms is pump coronary artery bypass for reducing AKI or the need uncertain and the quality of the evidence is weak, that off- for RRT. pump surgery is associated with better outcomes of the three end-points used in these guidelines: incidence of AKI, need RESEARCH RECOMMENDATION for RRT, or mortality. K Further studies are needed to clarify the role of off-pump A recent good-quality RCT357 was performed in 2203 coronary artery bypass in patients with increased risk patients (only B8% of patients with SCr 41.5 mg/dl for AKI. 66 Kidney International Supplements (2012) 2, 37–68
  • 70. chapter 3.9 N-ACETYLCYSTEINE (NAC) tested the potentially confounding effect of NAC in a CKD population (Stages 3–5) following doses of NAC currently 3.9.2: We suggest not using NAC to prevent AKI in recommended for prophylaxis of AKI. There was no effect of critically ill patients with hypotension. (2D) NAC on either SCr or cystatin C levels. It is thus safe to conclude that NAC, in doses currently recommended for prophylaxis of AKI, has—by itself—no RATIONALE effect on SCr or cystatin C levels. In addition, NAC is NAC has been most frequently applied in the prevention inexpensive and appears to be safe, although it may have of CI-AKI, and this topic is discussed in more detail in some detrimental effects on myocardial and coagulation Chapter 4.4. function.371–373 The ‘‘safety’’ of NAC should further be NAC is a modified form of L-cysteine, an amino acid that amended, particularly when high i.v. doses are used, as in is a precursor to reduced glutathione that can regenerate some of the RCTs in CI-AKI. When prospectively studied in glutathione stores. It is known to be a potent antioxidant that acetaminophen poisoning, i.v. NAC produced anaphylactoid scavenges oxygen-free radicals in the body. It also has reactions in up to 48% of participants.374 Although most of vasodilatory properties derived from enhanced nitric oxide these reactions were mild, at least one death has been availability.359 NAC has been shown to attenuate ischemic reported in a patient with asthma.375 It should also be noted and nephrotoxic ARF in a number of animal studies,360–363 that the doses of acetaminophen used are still much higher and the pharmacological characteristics of NAC that could than in the ‘‘high doses’’ used, particularly in AKI trials. play a role in the prevention of AKI have recently been Besides the prevention of CI-AKI, NAC has also been tested summarized.364 NAC undergoes extensive first-pass metabo- in the setting of cardiothoracic surgery and liver transplanta- lization in the gastric mucosa and liver. This results in a very tion, and in hypotensive critically ill patients. low oral bioavailability, with substantial intrapatient varia- bility (3–20%), as well as inconsistency between available NAC IN CRITICALLY ILL PATIENTS oral products. The plasma half-life of acetylcysteine after i.v. injection is approximately 6–40 minutes, and there is 3.9.3: We recommend not using oral or i.v. NAC for extensive binding to plasma and tissue proteins through prevention of postsurgical AKI. (1A) the sulfhydryl group. Virtually no acetylcysteine can be detected in the systemic circulation after i.v. or oral administration, suggesting that any potential therapeutic RATIONALE benefit must be due to secondary effects such as the The above recommendation is based on an evaluation of induction of glutathione synthesis, rather than due to direct the available literature on prevention studies with NAC in effects. As these secondary effects are not directly measurable, cardiovascular and abdominal vascular surgery, and liver the determination of the optimal dosage schedule has been transplantation. necessarily empirical.365 The tables summarize the RCTs where either oral or i.v. A particularly important problem with NAC is whether it NAC was compared to placebo; only studies containing a can alter SCr independent of a change in GFR. NAC has been minimum of 50 patients in each study arm have been reported to decrease SCr levels in subjects with normal included. In addition, a recent meta-analysis is available,376 kidney function. This reduction in SCr was not accompanied containing 10 studies involving a total of 1193 adult patients by a change in serum cystatin C levels. This suggests an effect undergoing major surgery. Seven studies (1003 patients) independent of a change in GFR, such as an increase in evaluated the effects of NAC in patients undergoing cardiac tubular secretion of creatinine or a decrease in creatinine surgery, and three of these (508 patients) exclusively studied production.366 By contrast, in vitro analysis on the effect of patients with pre-existing renal impairment. Two studies NAC on SCr367 showed no analytical interference with the (111 patients) evaluated the effects of NAC on patients measurement of SCr by any of the commonly used analytical undergoing abdominal aneurysm repair surgery and one methods. Haase et al.,368 studied 30 patients with normal study (79 patients) was of patients undergoing major kidney function who received i.v. NAC for 24 hours in abdominal cancer surgery. End-points in most of the studies association with cardiac surgery. No change in the ratio of were mortality, need for RRT, or varying increases in SCr to cystatin C, compared to baseline values, was observed postoperative SCr concentrations compared to preoperative at the end of the 24-hour infusion or 48 hours after the SCr values. cessation of the infusion. In addition, there was no effect on Suppl Tables 17 and 18 summarize the five studies where urinary creatinine excretion during the infusion. However, in NAC was compared to placebo in patients undergoing clinical practice, NAC is generally recommended for patients cardiac surgery and who were not exposed to radiocontrast with CKD, with an eGFR o60 ml/min per 1.73 m2. Mainra media.377–381 All five studies analyzed the effects of NAC in et al.,369 observed no change in SCr or cystatin C at 4, 24, or patients with moderate, pre-existing renal functional impair- 48 hours after administration of a single 600-mg dose of NAC ment. Surgery included elective or emergency coronary artery to 30 patients with CKD Stage 3. Finally, Rehman et al.,370 bypass graft operations or heart valve surgery. NAC was given Kidney International Supplements (2012) 2, 37–68 67
  • 71. chapter 3.9 i.v. in most of the studies; mortality was evaluated at different SPONSORSHIP follow-up times; either in-hospital or at 30 or 90 days. Only KDIGO gratefully acknowledges the following sponsors that one study found a significantly lower mortality at 30 days.377 make our initiatives possible: Abbott, Amgen, Belo Founda- None of the studies found either a difference in need for RRT, tion, Coca-Cola Company, Dole Food Company, Genzyme, or in AKI defined as variable changes in SCr after surgery. All Hoffmann-LaRoche, JC Penney, NATCO—The Organization studies were of A-level quality. Two relatively small studies for Transplant Professionals, NKF—Board of Directors, evaluated the effects of NAC on patients undergoing Novartis, Robert and Jane Cizik Foundation, Shire, Trans- abdominal aneurysm repair surgery382,383 and did not find western Commercial Services, and Wyeth. KDIGO is any protective effect on renal function. supported by a consortium of sponsors and no funding is Further, one meta-analysis376 did not find evidence that accepted for the development of specific guidelines. NAC used perioperatively can alter mortality or renal outcomes after major cardiovascular or abdominal cancer DISCLAIMER surgery when radiocontrast agents are not used. In none of While every effort is made by the publishers, editorial board, the studies were significant treatment-related adverse effects and ISN to see that no inaccurate or misleading data, opinion of NAC reported. These reports suggest that NAC, in the or statement appears in this Journal, they wish to make it clear context of cardiovascular surgery, is not associated with that the data and opinions appearing in the articles and increased risk of mortality, surgical re-exploration, or advertisements herein are the responsibility of the contributor, allogeneic transfusion. copyright holder, or advertiser concerned. Accordingly, the Only one single study has compared NAC to placebo in publishers and the ISN, the editorial board and their respective critically ill patients (Suppl Table 18).384 One hundred and employers, office and agents accept no liability whatsoever for forty-two ICU patients with new-onset (within 12 hours) of the consequences of any such inaccurate or misleading data, at least X30 consecutive minutes of hypotension and/or opinion or statement. While every effort is made to ensure that vasopressor requirement were randomized to receive either drug doses and other quantities are presented accurately, oral NAC or placebo for 7 days, in addition to standard readers are advised that new methods and techniques supportive therapy. AKI was defined as X0.5 mg/dl involving drug usage, and described within this Journal, (X44 mmol/l) increase in SCr. Patients who received NAC should only be followed in conjunction with the drug had an incidence of AKI of 15.5%, compared to 16.9% in manufacturer’s own published literature. those receiving placebo (NS). There were no significant differences between treatment arms in any of the secondary SUPPLEMENTARY MATERIAL Supplementary Table 15: Evidence profile of RCT examining on vs. off outcomes examined, including incidence of a 50% increase in pump cardiothoracic surgery. SCr, maximal rise in creatinine, recovery of renal function, Supplementary Table 16: Summary table of RCTs examining the effect length of ICU and hospital stay, and requirement for RRT. of on vs. off pump CABG for the prevention of AKI. Mortality in both arms was 10%. Based on this single study, Supplementary Table 17: Evidence profile of RCTs examining NAC vs. which is underpowered but did not show any beneficial effect placebo in the prevention of AKI. Supplementary Table 18: Summary table of RCTs examining the effect on incidence of AKI, need for RRT, or patient mortality, we of NAC vs. placebo in the prevention of AKI. suggest not using NAC to prevent AKI in critically ill patients Supplementary material is linked to the online version of the paper at with hypotension. http://www.kdigo.org/clinical_practice_guidelines/AKI.php 68 Kidney International Supplements (2012) 2, 37–68
  • 72. http://www.kidney-international.org chapter 4.1 & 2012 KDIGO Section 4: Contrast-induced AKI Kidney International Supplements (2012) 2, 69–88; doi:10.1038/kisup.2011.34 Chapter 4.1: Contrast-induced AKI: definition, epidemiology, and prognosis BACKGROUND adverse cardiovascular events after percutaneous coronary Contrast-related acute kidney problems are frequent and intervention.385 The Society of Urogenital Radiology used the occur in both ambulatory and hospitalized patients. Since same definition, but the creatinine changes were said to occur there is accumulating evidence that many risk factors, within 3 days after intravascular administration of contrast preventive measures, and the immediate and long-term media without an alternative etiology.386 It should be prognosis of these problems are common to the other causes recognized that, in a minority of cases, the peak increase of of AKI, the Work Group believes that there is a need for a SCr may occur up until 5 days after contrast exposure. unifying definition for all forms of AKI and therefore However, a recent prospective study387 showed that the proposes that the term contrast-induced acute kidney injury percentage change of SCr 12 h after contrast vs. the basal (CI-AKI) be used for patients developing AKI secondary to value was the best predictor of CI-AKI (Po0.001). A 5% intravascular radiocontrast media exposure. increase of its value yielded 75% sensitivity and 72% The literature on CI-AKI is predominantly related to AKI specificity, with an area under the curve (AUC) of 0.80 and following iodinated contrast-media administration. As will an OR of 7.37 (95% CI 3.34–16.23) for early detection. be discussed in Appendix E, non–iodine contrast media— Furthermore, this 12-hour basal value strongly correlated notably Gd-containing contrast media—may also occasion- with the development of renal impairment at 30 days ally induce AKI. (P ¼ 0.002; sensitivity 87%, specificity 70%; AUC 0.85; OR 13.29; 95% CI 2.91–60.64). 4.1: Define and stage AKI after administration of intra- It has been shown that substantial variation in SCr may vascular contrast media as per Recommendations occur from day to day in hospitalized patients who do not 2.1.1–2.1.2. (Not Graded) receive contrast-media injections.388 Depending on the 4.1.1: In individuals who develop changes in threshold criterion for CI-AKI chosen, this variation can kidney function after administration of intra- lead to rates of 6–35% of inpatients, not exposed to contrast vascular contrast media, evaluate for CI-AKI media, who would be labeled as having CI-AKI had they as well as for other possible causes of AKI. received contrast media. The exact cause of this ‘‘hospital- (Not Graded) induced nephropathy’’389 is not known, but other studies have shown that AKI (various etiologies) is common in hospitalized patients. RATIONALE The magnitude of the impact of the ‘‘background Pending the validation of future biomarkers which would fluctuation of kidney function’’ in patients receiving iodinated allow a more straightforward comparison and integration of contrast has not been prospectively studied, but a recent retro- CI-AKI in the overall framework of AKI, we suggest that the spective study compared the incidence of AKI among patients same criteria, using the changes in SCr concentrations and undergoing enhanced computed tomography (CT) with i.v. urine output be used as for the other forms of AKI. The Work low-osmolar (iohexol) or iso-osmolar (iodixanol) contrast Group is not aware of any pathophysiological or epidemio- media to the AKI incidence among patients undergoing CT logical reason why the definition and staging of CI-AKI without contrast-media administration.390 The incidence of should be different from the RIFLE/AKIN criteria. It should, AKI (defined as an increase of SCr of 0.5 mg/dl [44 mmol/l] or however, be stressed that for the development of this a X25% decrease in eGFR within 3 days after CT) was similar guideline, the term contrast-induced nephropathy is widely in all three groups (two receiving contrast agents and one not) used in the literature and usually defined as a rise in SCr up to a baseline SCr level of 1.8 mg/dl (159 mmol/l). A high of X0.5 mg/dl (X44 mmol/l) or a 25% increase from base- incidence of ‘‘AKI’’ among control subjects undergoing line value, assessed at 48 hours after a radiological proce- noncontrast CT was thus identified. Given the results of this dure. This definition also consistently predicted major retrospective study, it is clear that AKI after i.v. administration Kidney International Supplements (2012) 2, 69–88 69
  • 73. chapter 4.1 of iodine contrast media cannot be automatically attributed increased risk of CI-AKI but, as recently summarized,396 to the contrast agent, but may, in fact, reflect AKI from other the published evidence to support this premise is rather causes, such as worsening underlying disease or drug toxicity. scarce.397 Therefore, the Work Group strongly recommends that individuals showing increases of SCr compatible with the Prognosis of CI-AKI definition of AKI after administration of intravascular contrast Many studies have now shown that patients who develop media be also evaluated for other possible causes of AKI. CI-AKI have a greater risk for death or prolonged hospitali- In a study using cystatin C as an early marker for AKI, zation, as well as for other adverse outcomes, including early a cut-off cystatin C increase concentration of X10% at 24 or late cardiovascular events. The latter are more common hours after contrast-media exposure was detected in 87 after, for example, percutaneous coronary interventions (for patients (21.2%), and was the best cut-off value for the early review, see McCullough398). In a retrospective analysis identification of patients at risk for CI-AKI with a negative including 27 608 patients who underwent coronary angio- predictive value of 100% and a positive predictive value of graphy at the University of Pittsburgh Medical Center during 39%. As in other cases of AKI, it appears that, in patients a 12-year period, discrete proportional odds models were with CKD, cystatin C may be a useful marker for the early used to examine the association between increases in SCr and diagnosis of CI-AKI. 30-day in-hospital mortality and LOS, respectively. It appea- red that small absolute (0.25–0.5 mg/dl [22–44 mmol/l]) and Epidemiology of CI-AKI relative (25–50%) increases in SCr were associated with Keeping the above-mentioned problems of definition in risk-adjusted OR for in-hospital mortality of 1.83 and 1.39, mind, it is not surprising that the reported incidence of respectively; larger increases in SCr generally were associated CI-AKI varies widely across the literature, depending on the with greater risks for these clinical outcomes.399 Moreover, definitions used, the patient population, and the baseline risk when patients with CI-AKI require dialysis, the mortality is factors. higher compared to those not requiring dialysis. For example, The. impact of different definitions on the incidence of in the study by McCullough et al.,400 the hospital mortality CI-AKI can be illustrated by the recent results of the Oxilan was 7.1% in CI-AKI and 35.7% in patients who required Registry.391 In this registry, CI-AKI was defined as either a dialysis. By 2 years, the mortality rate in patients who SCr increase 40.5 mg/dl (444 mmol/l), or a SCr increase required dialysis was 81.2%. 425%, or a decrease 425% of eGFR, or the composite of The more recent Cardiac Angiography in Renally all three definitions. The baseline SCr was 1.12 ± 0.3 mg/dl Impaired Patients study401—a large, multicenter, prospective, (99 ± 26.5 mmol/l) and 24% had an eGFR o60 ml/min. double-blind RCT of patients who had moderate to severe CI-AKI rates were 3.3% (SCr increase 40.5 mg/dl CKD and were undergoing cardiac angiography—also [444 mmol/l]), 10.2% (SCr increase 425%), 7.6% (eGFR showed that the adjusted incidence rate ratio for adverse decrease 425%), and 10.5% (composite), respectively. events was twice as high in those with CI-AKI. However, It is accepted that, in patients with normal renal function— these data demonstrating a temporal association between CI- even in the presence of diabetes—the risk for CI-AKI is low AKI and short or long-term prognosis do not establish a (1–2%).392 However, the incidence may be as high as 25% in causal relationship, since most of the patients in these patients with pre-existing renal impairment or in presence of observational studies have underlying risk factors that, in certain risk factors, such as the combination of CKD and addition to increasing the patient’s risk of CI-AKI, can diabetes, CHF, advanced age, and concurrent administration directly increase their overall risk for the complications of nephrotoxic drugs.393 CI-AKI was described as the third studied. Finally, many of the retrospective studies may also most common cause of new AKI in hospitalized patients have introduced selection bias for patients who presumably (after decreased renal perfusion and nephrotoxic medications) had a clinical reason for having their SCr concentration and was responsible for 11% of cases.394 followed. The epidemiology of de novo CI-AKI in critically ill Data on the association between risk of ESRD and CI-AKI patients is not known. In a group of 75 ICU patients with a are scarce. In contemporary studies, CI-AKI requiring normal baseline SCr who were exposed to CT scans with an dialysis developed in almost 4% of patients with underlying i.v. low-osmolar contrast medium, an increase in SCr 425% renal impairment and 3% of patients undergoing primary was recorded in 18% of the patients. There was no change of percutaneous coronary interventions for acute coronary the SCr in a control group of patients undergoing CT scans syndrome. However, only a small proportion of patients but not receiving contrast media.395 This rather small study continued on chronic dialysis.402,403 Although CI-AKI shows that in critically ill patients, even with an apparently requiring dialysis is relatively rare, the impact on patient ‘‘normal’’ renal function, i.v. administration of iodinated prognosis is considerable, with high hospital and 1-year contrast media is associated with a significant incidence of mortality rates (for a review, see McCullough398). Only one CI-AKI. study404 reported the incidence of new CKD Stage 4–5 It could be expected that radiological procedures (eGFRo30 ml/min) following percutaneous coronary inter- performed in an emergency would be associated with an ventions and found that this occurred in 0.3% of patients 70 Kidney International Supplements (2012) 2, 69–88
  • 74. chapter 4.1 with an eGFR 430 ml/min at baseline and newly diagnosed RESEARCH RECOMMENDATION kidney disease within 6 months after the procedure, and in K Large prospective RCTs examining the epidemiology of 0.9% of patients with an eGFR460 ml/min at baseline. These CI-AKI are needed, especially on long-term outcomes, percentages are higher than the estimated annual incidence of with attention to controlling for confounders. CKD at 0.17% that was found in a British general population cohort over a 5.5-year period of follow-up.405 Thus, careful SUPPLEMENTARY MATERIAL Appendix E: Risks with Gadolinium-Based Contrast Agents. long-term follow-up of SCr following contrast exposure is Supplementary material is linked to the online version of the paper at warranted. http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 69–88 71
  • 75. http://www.kidney-international.org chapter 4.2 & 2012 KDIGO Chapter 4.2: Assessment of the population at risk for CI-AKI At present, millions of doses of intravascular contrast be requested, but an emergent imaging/intervention, where media are being administered worldwide.406,407 Most of the benefit of very early imaging outweighs the risk of these radiological examinations are performed in ambu- waiting, should not be delayed. latory populations who do not need special preventive For its relative simplicity, only SCr is used at many measures. However, contrast media are also increasingly used hospitals to determine whether a patient is a candidate in an elderly population, many of whom have CKD and for intravascular contrast-media administration, but the diabetes—the principal risk factors for CI-AKI. It is, thus, thresholds used and the acceptable time between the of utmost importance to screen the population at risk for determined SCr value and administration of contrast media CI-AKI. to perform the radiology examination differs among radiology departments. 4.2.1: Assess the risk for CI-AKI and, in particular, screen for pre-existing impairment of kidney Risk-factor questionnaire function in all patients who are considered for a For outpatient radiological studies where renal function data procedure that requires intravascular (i.v. or i.a.) are unavailable, a simple survey or questionnaire may be administration of iodinated contrast medium. used to identify outpatients at higher risk for AKI in whom (Not Graded) appropriate precautions should be taken. Choyke et al.411 (Figure 13) used a questionnaire and could identify a high proportion of patients with normal SCr RATIONALE concentrations, and reduced by 67% the number of patients Screening for pre-existing impairment of kidney function in whom SCr measurement was necessary before imaging Pre-existing renal functional impairment is the most studies. important risk factor above all other risk factors for The European Society of Urogenital Radiology386 recom- developing CI-AKI408 and screening for both acute and mends a risk-factor analysis based on the Choyke ques- chronic kidney disease is highly recommended. There is no tionnaire to identify patients with a higher risk of abnormal sharp GFR threshold below which the risk for CI-AKI is clearly increasing. Both the KDOQI guideline and KDIGO renal function. The CI-AKI Consensus Working Panel410 considered that a survey or questionnaire may be a useful recommend that, in stable patients, an eGFR should be guide for identifying patients at higher risk for CI-AKI used.409 compared to the general population. A CI-AKI Consensus Working Panel410 agreed that the risk of CI-AKI becomes clinically important when the baseline SCr concentration is X1.3 mg/dl (X115 mmol/l) in men and Urinary protein screening X1.0 mg/dl (X88.4 mmol/l) in women, equivalent to an The CI-AKI Consensus Working Panel also supported the eGFR o60 ml/min per 1.73 m2. However, Bruce et al.390 use of dipstick testing for urine protein as a rapid screen to showed that the incidence of ‘‘true’’ AKI became significant identify patients who can undergo studies requiring contrast only between controls and contrast-media administered media without SCr measurement.410 Of 310 patients with a patients from a baseline SCr concentration of 41.8 mg/dl negative urine protein test and no history of diseases poten- (4159 mmol/l) onward. The CI-AKI Consensus Working tially associated with renal impairment, none had a SCr Panel410 recommended that precautions to reduce the risk level 42.0 mg/dl (4177 mmol/l), and only 1% had a level should be implemented in patients with a baseline 41.7 mg/dl (4150 mmol/l). eGFRo60 ml/min per 1.73 m2. In light of more recent Thus, the Work Group recommends that, when a recent information, this threshold could probably be lowered to SCr is not available, a simple questionnaire or a dipstick 45 ml/min per 1.73 m2. testing for urine protein may be useful for identifying In many institutions, point-of-care SCr testing is present, pre-existing kidney disease. Risk stratification hinges on age, and the results can be available quite fast. In places without baseline kidney function, other comorbidities, and other risk point-of-care laboratories, the appropriate blood tests should factors. 72 Kidney International Supplements (2012) 2, 69–88
  • 76. chapter 4.2 In the past 3 months have you been told there may have been a change in your kidney function? Y/N In the past 3 months have you been on any medications? Please list: Have you used any over-the-counter pain relievers within the last 10 days? Y/N Please list: In the past 3 months have you had any surgery? Y/N Describe: Do you feel dry or thirsty? Y/N Circle one *Have you ever been told you have kidney disease of any type? Y N Please describe: *Have you had kidney surgery? Y N *Do you have diabetes? Y N Do you use insulin? Y N Do you use metformin or glucophage? Y N *Do you have hypertension, heart disease, or vascular disease? Y N *Do you have gout? Y N Do you have multiple myleoma? Y N Have you ever had x-ray contrast media (dye) for CT, angiography, or IVP? Y N Have you had contrast media within the last 3 days? Y N Do you have any allergies to x-ray contrast media (dye)? Y N Please describe: Have you received pretreatment with medication for this study? Y N Do you have any allergies or asthma? Please describe: Y N Figure 13 | Sample questionnaire. Asterisks denote questions with the highest association with abnormal renal function. Adapted from Choyke PL, Cady J, DePollar SL et al. Determination of serum creatinine prior to iodinated contrast media: is it necessary in all patients? Tech Urol 1998; 4: 65–69 with permission.411 Other risk factors of CI-AKI Table 15 | CI-AKI risk-scoring model for percutaneous Besides pre-existing kidney disease with renal function coronary intervention impairment, other risk factors for developing CI-AKI Risk factors Integer score (calculate) include diabetes, hypertension, CHF, advanced age, volume Hypotension 5 depletion, hemodynamic instability, use of concurrent IABP 5 nephrotoxic medications, and large volume or high osmol- CHF 5 ality of the contrast agent.408,412 Although there is doubt that Age 475 years 4 Anemia 3 diabetes by itself is an independent risk factor, in a patient Diabetes 3 with CKD it acts as a risk multiplier.398 Metabolic syndrome, Contrast-media volume 1 per 100 ml prediabetes, and hyperuricemia have been identified as SCr 41.5 mg/dl (4132.6 mmol/l) 4 new risk factors for CI-AKI, while the use of ACE-I and or eGFR o60 ml/min per 1.73 m2 2 for 40–60 angiotensin-receptor blockers (ARB), renal transplantation, 4 for 20–39 diabetes mellitus with normal renal function, low-osmolar 6 for o20 contrast media, multiple myeloma, female gender, and Note: Low risk: cumulative score o5; high risk: cumulative score 416. cirrhosis have been classified as conflicting risk factors for CHF, congestive heart failure; eGFR, estimated glomerular filtration rate; IABP, intra- aortic balloon pump; SCr, serum creatinine. Reprinted from Mehran R, Aymong ED, CI-AKI.413 There are conflicting data on the impact of ACE-I Nikolsky E et al. A simple risk score for prediction of contrast-induced nephropathy or ARB but, overall, there is currently insufficient evidence to after percutaneous coronary intervention: development and initial validation. J Am recommend discontinuation of these medications prior to Coll Cardiol 2004; 44: 1393–1399 et al.,418 copyright 2004, with permission from American College of Cardiology Foundation; accessed http://content.onlinejacc.org/ contrast-media administration. cgi/content/full/44/7/1393 When possible, the administration of contrast media should be delayed in patients with circulatory collapse or CHF until their hemodynamic status is corrected. Repeated exposure should be delayed for 48 hours in patients doses of loop diuretics, and antiviral drugs like acyclovir without risk factors for CI-AKI, and for 72 hours in those and foscarnet—should preferably be stopped. A recent with diabetes mellitus or pre-existing chronic renal dysfunc- study using a so-called forced euvolemic diuresis protocol tion. If acute renal dysfunction develops after contrast-media including mannitol and furosemide led to a signi- administration, repeated exposure should preferably be ficantly increased risk of CI-AKI.415 It can be advised that delayed until the SCr level has returned to baseline levels.414 such strategy should be abandoned, and that furose- Concurrent nephrotoxic medication—including, in mide therapy should preferably be stopped before angio- particular, NSAIDs, aminoglycosides, amphotericin B, high graphy. Kidney International Supplements (2012) 2, 69–88 73
  • 77. chapter 4.2 Risk models of CI-AKI Nephrogenic systemic fibrosis (NSF) Most risk factors for CI-AKI can be detected by The risk of developing NSF with Gd, particularly in patients history-taking and physical examination, and the risk rises with severe AKI and CKD, is reviewed in detail in Appendix E. exponentially with the number of risk factors present.416 It should be noted here that the European Medicines Validated risk-prediction models using patient and proce- Agency stated a contraindication for use of gadodiamide in dural risk factors to assess for CI-AKI have been developed patients with a GFR o30 ml/min per 1.73 m2, and issued a for patients undergoing percutaneous coronary inter- warning for its use in patients who have a GFR between 30 vention.417,418 For example, the Mehran risk model418 is and 60 ml/min per 1.73 m2 (EMEA Public assessment report. given in Table 15. The overall occurrence of CI-AKI in the http://www.esur.org/fileadmin/NSF/Public_Assessment_Report_ development set of the score was 13.1% (range 7.5% to NSF_Gadolinium_26_June_2007.pdf; last accessed January 5, 57.3% for a low [p5] and high [X16] risk score, 2012). The US FDA requested that vendors add warnings respectively); the rate of CI-AKI increased exponentially about the risk for developing NSF to the full prescri- with increasing risk score. In the validation dataset, the bing information on the packaging for all Gd-containing increasing risk score was again strongly associated with contrast agents (gadopentetate dimeglumine, gadodiamide, CI-AKI (range 8.4% to 55.9% for the low and high risk score, gadoversetamide, gadoteridol, gadobenate dimeglumine).427 respectively). These models can help in counseling about the New labeling describes the risk for NSF following expo- risks of the procedure, selecting prophylactic interventions, sure to Gd in patients with a GFR o30 ml/min per and can also be used to characterize patients in studies of 1.73 m2 and in patients with AKI of any severity due to CI-AKI. hepato-renal syndrome or in the perioperative liver trans- plantation period. Additional recommendations were 4.2.2: Consider alternative imaging methods in patients recently proposed by Perazella420 and were endorsed by the at increased risk for CI-AKI. (Not Graded) Work Group: (a) Use of a macrocyclic chelate (gadoteridol in the USA), is preferred over linear chelates. The risk associated RATIONALE with the various Gd-containing agents is likely The selection and advantages and disadvantages of non- different. Gadodiamide, the linear nonionic chelate–- iodinated contrast media are beyond the scope of these based formulation, maintains the highest risk on the guidelines. Detailed discussions of all these techniques can basis of epidemiologic data and animal studies. be found in radiology textbooks and the radiology litera- Gadopentetate, the linear ionic chelate–based product ture. The Work Group suggests that, in patients at increased probably has a medium risk, less than the linear risk for CI-AKI, the risks and benefits of iodinated nonionic chelates but more than the macrocyclic contrast-media administration should be discussed with the chelates. Gadoteridol, the only FDA-approved macro- radiologist. cyclic chelate, maintains less risk. Clearly, high dosages Because of the great relevance for the nephrologist, and large cumulative dosages of all these agents will radiologist, and cardiologist of the side-effects of Gd chelates increase risk for NSF. used in magnetic resonance imaging (MRI), a short overview (b) Demonstration of significant quantities of insoluble of their nephrotoxicity is given here. Gd in the skin of NSF patients, months after expo- sure to Gd-based contrast material and after exten- Nephrotoxicity of Gd chelates sive tissue processing, suggests that Gd might have Gd chelates are widely used as MRI contrast agents, and undergone transmetallation in vivo. Supporting the are considered to have a good overall safety profile. Early importance of transmetallation, all NSF cases reported on, phase III trials and small studies in low-risk patients before 2009 have been associated with linear MRI suggested a benign renal profile; however, more recent contrast agents (for a review, see Kay428) that have studies raised the possibility of nephrotoxicity, although inferior thermodynamic stability and a kinetic or it is not clear whether it approaches the incidence of conditional stability that favors transmetallation. How- AKI associated with iodine-containing contrast media. ever, a recent case of NSF in a dialysis patient after Gd-related AKI appears to be a risk in patients with advanced exposure to a macrocyclic chelate has been described,429 kidney disease, especially those with diabetic nephro- and at least two additional cases are known.430 pathy.419,420 Perazella et al.420 have summarized studies (c) Use the lowest dosage of the agent possible to achieve showing Gd-induced nephrotoxic AKI compared to the image. CI-AKI.421–425 Studies in patients with underlying kidney (d) Avoid repeat exposures with Gd. disease demonstrate the importance of renal clearance in (e) Consider performing IHD after the exposure (and determining the pharmacokinetic profile of Gd chelates.426 the next 2 days) in patients who are already main- More details on the pharmacokinetics of Gd chelates and tained on IHD, recognizing that there are no data their dialyzability are provided in Appendix E. that support prevention of NSF with this modality. 74 Kidney International Supplements (2012) 2, 69–88
  • 78. chapter 4.2 This recommendation is based on the pharmaco- SUPPLEMENTARY MATERIAL Appendix E: Risks with Gadolinium-Based Contrast Agents. kinetics of Gd and the theoretical benefit of removing Supplementary material is linked to the online version of the paper at it with IHD (495% plasma clearance). PD clears these http://www.kdigo.org/clinical_practice_guidelines/AKI.php agents rather poorly. Kidney International Supplements (2012) 2, 69–88 75
  • 79. http://www.kidney-international.org chapter 4.3 & 2012 KDIGO Chapter 4.3: Nonpharmacological prevention strategies of CI-AKI There have been a large number of strategies/agents evaluated the experimentally measured AUC for the contrast agent to prevent CI-AKI. Sterling et al.431 have recently summa- iodixanol. The experimentally determined AUC data correlated rized most of these strategies and classified them as having highly with the dose:CrCl ratio. This ratio could thus be a rapid either definitive, possible, or doubtful value. From the many and accurate way to estimate AUC for an iodinated contrast strategies, these authors only retain parenteral volume medium, without the need for multiple blood samples. expansion, minimizing contrast-media volume, use of low- A recent study by Nyman et al.436 in patients undergoing osmolar and iso-osmolar contrast media, and administration coronary angioplasty calculated the probability of CI-AKI of non-iodinated contrast media as strategies with definitive (SCr rise 40.5 mg/dl [444.2 mmol/l] or oliguria/anuria) at value. A recent comprehensive meta-analysis by Kelly various eGFR levels based on g-I (grams iodine)/eGFR ratios et al.432—including RCTs that administered NAC, theophyl- of 1:2, 1:1, 2:1, and 3:1. At a ratio o1, the risk of CI-AKI line, fenoldopam, dopamine, iloprost, statins, furosemide, was 3%, while it was 25% at a ratio X1. This, and other or mannitol, and covering studies up to November 2006— preliminary studies, indicate that a g-I/GFR ratio o1 may be provides an excellent overview. relatively safe in a patient without multiple risk factors.436–438 Finally, the association between absolute and body weight- DOSE/VOLUME OF CONTRAST-MEDIA ADMINISTRATION and SCr-adjusted contrast-media volume, CI-AKI incidence (X25% SCr increase), and clinical outcome was prospec- 4.3.1: Use the lowest possible dose of contrast medium in tively investigated in patients with acute MI.439 For each patients at risk for CI-AKI. (Not Graded) patient, the maximum contrast-medium dose was calculated according to the formula (5 Â body weight [kg]) C SCr, and the contrast-medium ratio—defined as the ratio between the RATIONALE contrast-medium volume administered and the maximum The correlation between the volume of contrast media dose calculated—was assessed. Development of CI-AKI was administered and the risk of CI-AKI has been recognized. 433 associated with both contrast-medium volume and ratio. In the vast majority of papers dealing with CI-AKI after Additional radiological measures to reduce CI-AKI can be coronary procedures, contrast-media doses are only ex- found in Table 16. pressed in volumes. The Work Group feels that such expression can be misleading, since commercially available Route of administration of contrast media contrast-media concentrations range from 140 to 400 The risk of CI-AKI appears to be greater after arterial milligrams of iodine per milliliter, a difference with almost compared to venous administration of contrast media. a factor of 3. The Work Group recommends, therefore, that Indeed, in the rare studies where an appropriate control the dose of contrast medium should be better expressed in group without contrast media was included, no significant relation to both volume and concentration, e.g., grams difference was observed in the rate of CI-AKI between the iodine, which also directly relates to the diagnostic capacity, patients who received i.v. iodinated contrast media and the the primary purpose of the contrast medium. Such ‘‘double’’ control subjects who did not.440–442 Thus, the risk of CI-AKI expression would also facilitate the comparison between with i.v. contrast medium is probably very low. CI-AKI different studies on epidemiology and prognosis of CI-AKI. reportedly occurs after i.v. contrast-medium injection for CT It is well known that, when measuring the plasma in only 4% of patients with CKD.443 Katzberg and Lamba444 clearance of a GFR marker (e.g., with the contrast medium summarized the six studies on CI-AKI after i.v. contrast- iohexol), the AUC is directly related to the dose of iohexol medium administration in patients at risk and all suffering and inversely related to the GFR. Thus, by mathematically from moderate CKD. The overall incidence of CI-AKI in estimating the AUC and knowing the injected iodine these studies, using the current generation of low-osmolar dose, the GFR can be calculated by dose C AUC. Thus, contrast media, was about 5%. AUC ¼ dose C GFR, and AUC is directly related to the Given the logistic challenges in the outpatient setting, the systemic exposure of a drug, including the contrast medium, use of specific prophylactic measures prior to administration which, in turn, is mostly correlated with its efficacy and of i.v. contrast media could be limited to those subjects toxicity.434 An interesting experimental study435 investigated who are at higher levels of baseline risk than they would be the correlation between the calculated dose to CrCl ratio and when an i.a. procedure was planned.445 This conclusion, may 76 Kidney International Supplements (2012) 2, 69–88
  • 80. chapter 4.3 Table 16 | Additional radiological measures to reduce CI-AKI Some CT strategies in patients at risk of CI-AKI K Perform CT, when possible, without contrast media; scrutinize the examination and discuss with the referral physician-surgeon before deciding on the need for contrast media. K Dosing per kilogram body weight to reduce the amount of contrast media is needed in thin patients. K Adapt injection duration to scan duration when performing CT-angiography, so that the injection is not still running when the scan is finished. K Use a saline chaser to decrease the amount of contrast media, by using the contrast medium that otherwise would remain in the dead space of the arm veins; this may save 10–20 ml of contrast media. K Use 80 kVp; contrast-medium dose may be reduced by a factor of 1.5–1.7 compared to the dose used at 120 kVp since iodine attenuation increases, and combine with increased tube loading (mAs) to maintain signal-to-noise ratio. K Further reduction of contrast media may be instituted in patients with known decreased cardiac output (not unusual in patients with renal impairment) undergoing CT-angiographic studies. Some angiographic strategies in patients at risk of CI-AKI K Use biplane when appropriate. K Avoid test injections; the same amount may be enough for a diagnostic digital-subtraction angiography run. K Scrutinize each series before performing the next; avoid unnecessary projections. K Decrease kilovoltage in a thin patient; a lower iodine concentration may be used. K Assess the physiologic significance of a stenosis by measurement of translesional pressure gradient and fractional flow reserve, a technique well accepted and validated for the coronary circulation. For different arterial beds, perform manometry of a questionable stenosis instead of multiple projections. K Avoid ventriculography: echocardiography (and ‘‘echo contrast’’) is always a reasonable alternative. K Use plasma isotonic contrast-media concentrations for renal artery injections. K When renal artery stenosis is suspected, map the origin of major renal arteries with noninvasive procedures (e.g., CT without contrast media) for proper initial renal angiographic projections to avoid unnecessary runs, or perform primary manometry. K CO2 may be used as contrast medium in venous examinations and below the diaphragm for arterial examinations or alternatively use iodinated contrast media with the same contrast effect, i.e., about 40 mg iodine per milliliter. K Since the contrast effect of 0.5 M Gd-contrast media has been regarded as diagnostic by many investigators (coronary, renal, aortofemoral arteriography, etc.), iodinated contrast media may be diluted to the same density, i.e., about 75 mg iodine per milliliter. K Use selective or superselective catheterizations when appropriate, e.g., ‘‘single leg run-off’’. K Reduce aortic flow and amount of contrast medium by temporal occlusion of femoral arteries with tourniquets when performing aortography. Gd, gadolinium; kVp, peak kilovoltage. however, be too optimistic when applied to critically ill High-osmolar vs. iso-osmolar or low-osmolar contrast media patients undergoing emergency CT scans.395 The recommendation to avoid high-osmolar contrast media The majority of the literature covering CI-AKI and its is based on older literature, since recent RCTs comparing prevention involves i.a. iodinated contrast-medium admin- high- vs. low- and iso-osmolar iodine-based contrast media istration.445,446 The higher risk of CI-AKI after i.a. admin- are not available. In addition, high-osmolar contrast media istration is probably due to the more direct exposure of the have virtually been abandoned in modern radiological units. kidneys to contrast media,447 or to the fact that, in general, Both the review of Goldfarb et al.,448 and the meta-analysis of i.a. contrast-media examinations are performed in patients Barrett and Carlisle combining 24 randomized studies449 who carry a higher risk. suggest that the risk of CI-AKI is similarly low with high- osmolar and low-osmolar agents among otherwise stable RESEARCH RECOMMENDATIONS patients with normal renal function, but that in contrast to K Randomized trials should explore whether there is need high-osmolar contrast media, low-osmolar contrast media for discontinuation of ACE-I and/or ARBs in patients at are less nephrotoxic in patients with pre-existing kidney risk for CI-AKI. function impairment. K Additional studies are needed to better determine the exact relationship between the dose of contrast media and Low-osmolar vs. iso-osmolar contrast media the risk for CI-AKI. The present hotly debated question is whether iso-osmolar contrast media are safer than low-osmolar contrast media in SELECTION OF A CONTRAST AGENT high-risk patients. This question has been the subject of a 4.3.2: We recommend using either iso-osmolar or low- number of randomized trials as well as systematic reviews osmolar iodinated contrast media, rather than and meta-analyses (Suppl Tables 19–21). high-osmolar iodinated contrast media in patients We separated studies meeting our inclusion criteria (see at increased risk of CI-AKI. (1B) Chapter 1.2) into those administering i.a. or i.v. contrast media. We used the general definitions of CI-AKI provided in RATIONALE the studies (an increase in SCr by 425% or 0.5 mg/dl This recommendation is supported by the summary tables of [44.2 mmol/l]) occurring within 72 hours after contrast- the different RCTs and on the evidence profile tables (Suppl medium administration, in the absence of an alternative Tables 19–21). etiology for the decrease in kidney function. Kidney International Supplements (2012) 2, 69–88 77
  • 81. chapter 4.3 Figure 14 | Risk for contrast-induced nephropathy. (a) Iodixanol vs. iohexol and risk for contrast-induced nephropathy; (b) iodixanol vs. nonionic low-osmolar contrast media other than iohexol and risk for contrast-induced nephropathy. Reprinted from Heinrich MC, Haberle L, Muller V et al. Nephrotoxicity of iso-osmolar iodixanol compared with nonionic low osmolar contrast media: meta-analysis of randomized controlled trials. Radiology 2009; 250: 68–86 with permission, copyright 2009, from Radiological Society of North America457; accessed http://radiology.rsna.org/content/250/1/68.long In total, 14 RCTs fulfilling the search criteria were found. iodixanol was compared to other low-osmolar contrast Ten RCTs were found with i.a. and four RCTs with i.v. agents (RR 0.95; 95% CI 0.50–1.78; P ¼ 0.86). Iodixanol is injection, respectively (Suppl Tables 19–21). There is only thus not associated with a significantly reduced risk of CI- moderate quality of evidence and overall, no benefit—or, at AKI compared to the low-osmolar contrast media pooled least, no consistent benefit—was found of nonionic iso- together. However, in patients with decreased kidney osmolar (iodixanol) contrast media compared to low- function, iodixanol is associated with a reduced risk of CI- osmolar ionic or nonionic contrast media. In eight studies AKI compared to iohexol. comparing contrast media given i.a.401,450–456 some showed The clinical heterogeneity between all these studies, as far superiority of iso-osmolar contrast media (iodixanol), as basal kidney function and prevalence of diabetes mellitus compared to iohexol450 and iopromide.455 There was no are concerned, hampers the ability to compare the results difference when iodixanol was compared to iopamidol,401,452 across studies, but can widen the applicability of consistent iopromide,451,453 and ioversal.456 findings across different risk groups provided the mechan- The most recent prospective, multicenter, randomized, isms of contrast-induced nephrotoxicity are the same. One double-blind study compared the renal effects of iodixanol to should note, also, that in all these studies different definitions the nonionic, low-osmolar agent iopamidol, in 526 subjects of CI-AKI have been used and that the timing of SCr with CKD and diabetes mellitus undergoing diagnostic measurements after contrast-media injection was not uni- and/or therapeutic coronary angiography.454 The overall form. It has been shown that different time-points for the CI-AKI incidence was 10.5% (11.2% % in the iodixanol measurement of CI-AKI can give different results.458 One arm and 9.8% in the iopamidol arm, NS). The volume of may expect that those studies with a standardized and contrast medium, volume of saline administered, frequency simultaneous measurement of renal function between the of coronary interventional procedures, and severity of two arms are probably the most conclusive. Finally, different baseline kidney disease and of diabetes mellitus were similar types and amounts of volume expansion and different between treatments. pharmacological preventive strategies have been used Finally, a recent meta-analysis457 (Figure 14) analyzed throughout the studies, making conclusive comparisons studies comparing iodixanol with low-osmolar contrast virtually impossible. media. The pooled RR was 0.68 (95% CI 0.46–1.01; P ¼ 0.06). In studies that included patients with normal i.a. Iodixanol vs. ioxaglate renal function after i.a. contrast-media administration, the Two studies fulfilled our inclusion criteria; one study459 RR was 0.82 (95% CI 0.45–1.51; P ¼ 0.53). In the studies that showed a superiority of iodixanol vs. ioxaglate, but this was included only patients with decreased kidney function after not confirmed in the study by Mehran et al.,460 who found no i.a. contrast-media administration, the RR was 0.59 (95% CI difference between these two contrast agents. Although 0.33–1.07; P ¼ 0.08). However, in all three studies in which overall the number of patients is substantial, there is iohexol was the low-osmolar contrast medium used, the risk heterogeneity among the comparators with which iodixanol of CI-AKI was significantly lower with iodixanol (RR 0.38; has been compared. In addition, the cost of iodixanol is 95% CI 0.21–0.68; Po0.01). In contrast, the risk of CI-AKI probably higher than the cost of most of the low-osmolar did not significantly differ in the two studies in which contrast agents. No studies comparing a possible difference 78 Kidney International Supplements (2012) 2, 69–88
  • 82. chapter 4.3 among low-osmolar contrast media have been performed. iopromide, but not to iopamidol and iomeprol. It is, Based on evidence profiles (Suppl Tables 19 and 20) and however, difficult to determine whether this is simply due the most recent meta-analysis457 (Figure 14) of the studies to spurious findings in a smaller number of comparisons, or comparing i.a. administration of iso- vs. low-osmolar due to true differences between low-osmolar agents. Until contrast media, the Work Group found no evidence to better head-to-head comparative studies among the different recommend a preference for either type of agent. contrast media agents are available, the Work Group is unable to draw definite conclusions on the selection of i.v. Administration iso-osmolar vs. low-osmolar contrast media. There are four studies following i.v. injections fulfilling our inclusion criteria: Barrett et al.,443 Kuhn et al.,461 Thomsen RESEARCH RECOMMENDATION et al.,462 and Nguyen et al.463 The overall conclusion, based K Additional studies with head-to-head comparisons on the evidence profile summarized in Suppl Table 20 among the different contrast media should be performed comparing i.v. iso- vs. low-osmolar contrast media, is that in order to draw definite conclusions on the selection there is no benefit for the nonionic iso-osmolar agent of iso-osmolar vs. low-osmolar contrast media. A more (iodixanol); the overall quality of the evidence is moderate. uniform definition of CI-AKI, as suggested in this This conclusion is supported by the above-mentioned recent guideline, should be used as the end-point. meta-analysis457 which, in seven studies comparing i.v. contrast-media administration with iodixanol vs. low-osmolar SUPPLEMENTARY MATERIAL Supplementary Table 19: Evidence profile of RCTs examining the effect contrast media, showed no statistically significant difference of intrarterial isosmolar vs. low osmolar contrast agent on the for CI-AKI (RR 1.08; 95% CI 0.62–1.89; P ¼ 0.79). Subgroup prevention of CI-AKI. analysis did not show superiority of any agent in studies of Supplementary Table 20: Evidence profile of RCTs examining the effect individuals with normal kidney function (RR 1.12; 95% CI of intravenous isosmolar vs. low osmolar contrast agent on the 0.35–3.65; P ¼ 0.85) or in studies of individuals with reduced prevention of CI-AKI. Supplementary Table 21: Summary table of RCTs examining the effect of kidney function (RR 1.07; 95% CI 0.56–2.02; P ¼ 0.84). isosmolar vs. low osmolar contrast agent on the prevention of CI-AKI. In head-to-head comparisons with different low-osmolar Supplementary material is linked to the online version of the paper at agents, iodixanol has been shown to be superior to http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 69–88 79
  • 83. http://www.kidney-international.org chapter 4.4 & 2012 KDIGO Chapter 4.4: Pharmacological prevention strategies of CI-AKI FLUID ADMINISTRATION incidence of CI-AKI was lowest following CT (range, Extracellular volume expansion at the time of radiocontrast- 0.0–10.9%) and was highest following noncoronary angio- media administration may serve to counteract both the graphy (range, 1.9–34.0%). intrarenal hemodynamic alterations and the direct tubulo- The fluids that have been tested in the prevention of toxic effects that play a role in the pathophysiology of CI- CI-AKI are hypotonic saline (0.45%), isotonic saline (0.9%) AKI. Neurohumoral effects of volume expansion that may and isotonic sodium bicarbonate. The interpretation of all attenuate radiocontrast-induced medullary hypoxia include these studies is hampered by the fact that not all other risk suppression of vasopressin as well as inhibition of the renin- factors (susceptibilities) for CI-AKI were excluded or angiotensin axis; but an increased synthesis of vasodilatory considered in every study (i.e., age of the patient, presence renal prostaglandins may also play a role.464 of CKD and/or diabetes prior to contrast-media administra- Volume expansion may also directly reduce cellular tion, type and dose of contrast agent, associated therapy with damage by dilution of the contrast medium, particularly in NAC, and other risk factors [see Chapter 2.2]). the medullary tubular segments. Likewise, an effect of There is no clear evidence from the literature to guide the radiocontrast media to increase tubular fluid viscosity may choice of the optimal rate and duration of fluid infusion in be diminished by intravascular volume expansion.465 It is CI-AKI prevention, but most studies suggest that the fluids important to note that these potentially attenuating effects of should be started at least 1 h before and continued for 3–6 volume expansion are speculative, and the precise mechan- hours after contrast-media administration. A ‘‘good’’ urine isms by which volume expansion protects against CI-AKI output (4150 ml/h) in the 6 hours after the radiological remain unknown. procedure has been associated with reduced rates of AKI in one study.468 Since not all of i.v. administered isotonic 4.4.1: We recommend i.v. volume expansion with either crystalloid remains in the vascular space, in order to achieve isotonic sodium chloride or sodium bicarbonate a urine flow rate of at least 150 ml/h, X1.0–1.5 ml/kg/h of solutions, rather than no i.v. volume expansion, in i.v. fluid has to be administered for 3–12 hours before and patients at increased risk for CI-AKI. (1A) 6–12 hours after contrast-media exposure. Mueller et al.469 found that i.v. 0.9% saline solution, compared to 0.45% saline solution in dextrose, in 1620 RATIONALE patients undergoing coronary angiography significantly Despite the recognition of volume depletion as an important reduced CI-AKI. The sustained administration of isotonic risk factor for AKI, there are no RCTs that have directly saline before and after radiocontrast injection seems, thus, evaluated the role of fluids vs. placebo in the prevention of to be more protective than equivalent volumes of hypotonic AKI. However, RCTs have compared different fluids and have saline.464 Although the mechanism by which sodium combined fluids with other interventions.191 Furthermore, bicarbonate, beyond its volume-expanding effects, might comparisons between outcomes seen in these trials191 and further reduce CI-AKI remains poorly defined, it has been historical untreated control subjects466 suggest a large benefit postulated that sodium bicarbonate infusion may decrease from fluids. In particular, volume expansion and treatment of generation of free radicals mediated by the Haber-Weiss dehydration are well-established interventions in the preven- reaction by increasing tubular pH. The Haber-Weiss reaction tion of CI-AKI. A recent propensity analysis, however, noted is most active at lower pH levels.470 Sodium bicarbonate that strategies to prevent CI-AKI are implemented rather infusion may also scavenge the potent oxidant peroxynitrate, nonuniformly.467 Pre– and post–contrast-media administra- produced via a nitric oxide–mediated pathway.471 Reactive tion i.v. fluids were given to only 264 of 660 study patients oxygen species activate cytokine-induced inflammatory (40.0%), more commonly with coronary angiography than mediators, resulting in damage to proximal tubular cells,472 with CT (91.2% vs. 16.6%). Other preventive measures, such and it is likely that the activation of these mediators is as administration of NAC or discontinuation of NSAIDs, influenced by tissue hypoxia and intracellular medullary were equally rarely applied. Only 39.2% of patients received acidosis.473 NAC, while only 6.8% of patients were instructed to It is worth noting that, compared to i.v. bicarbonate, the discontinue NSAIDs. In a propensity analysis, the use of combination of oral azetazolamide inducing an alkaline i.v. fluids was associated with a reduced rate of CI-AKI. The urine, plus i.v. saline, was more effective for the prevention of 80 Kidney International Supplements (2012) 2, 69–88
  • 84. chapter 4.4 Figure 15 | Bicarbonate vs. saline and risk of CI-AKI. Reprinted from Zoungas S, Ninomiya T, Huxley R et al. Systematic review: sodium bicarbonate treatment regimens for the prevention of contrast-induced nephropathy. Ann Intern Med 2009; 151: 631–638 with permission from American College of Physicians481; accessed http://www.annals.org/content/151/9/631.full CI-AKI than saline alone, in a relatively small study in studies. Some heterogeneity was due to the difference in the children with stable chronic renal failure (CRF).474 It could estimates between published and unpublished studies: RR also be hypothesized that sodium bicarbonate has a stronger 0.43 (95% CI 0.25–0.75) vs. 0.78 (95% CI 0.52–1.17), impact in lowering the intratubular viscosity caused by the respectively. Meta-regression showed that small, poor-quality contrast medium, compared to isotonic saline, because it studies that assessed outcomes soon after contrast-media causes less tubular sodium reabsorption than saline. administration were more likely to suggest the benefit of Sodium bicarbonate solutions have been tested in the bicarbonate (Po0.05 for all). No clear effects of treatment on prevention of CI-AKI in comparison with isotonic saline, the risk for dialysis, heart failure, and total mortality were either with or without NAC. A number of systematic reviews identified. on the role of sodium bicarbonate compared to isotonic Suppl Tables 22 and 23 summarize the evidence from saline in the prevention of CI-AKI are available.475–481 RCTs where isotonic bicarbonate was compared to isotonic The most recent and probably the most complete saline alone, without concomitant other ‘‘preventive’’ inter- systematic review481 analyzed MEDLINE, PubMed, EMBASE, ventions. In all studies, a minimum of 50 patients in both and the Cochrane Central Register of Controlled Trials from arms and publication as full paper were required for 1950 to December 2008; conference proceedings; and inclusion in the tables. Only three studies directly compared ClinicalTrials.gov, without language restriction (Figure 15). isotonic bicarbonate to isotonic saline.470,482,483 In a fourth This systematic review included RCTs of i.v. sodium study by Brar et al.,484 NAC was included in 47% and 46% of bicarbonate that prespecified the outcome of CI-AKI as a the patients in both arms of the study (bicarbonate vs. 25% increase in baseline SCr concentration or an absolute saline), respectively. The first study was a small single-center increase of 0.5 mg/dl (44.2 mmol/l) after contrast-media RCT470 enrolling 119 patients with stable SCr of at least administration. Twenty-three published and unpublished 1.1 mg/dl (97.2 mmol/l), randomized to either infusion of trials with information on 3563 patients and 396 CI-AKI isotonic saline or isotonic sodium bicarbonate before and events were included. The pooled RR was 0.62 (95% CI after contrast-media administration. CI-AKI (defined as an 0.45–0.86), with evidence of significant heterogeneity across increase of 25% in SCr from baseline within 48 hours) Kidney International Supplements (2012) 2, 69–88 81
  • 85. chapter 4.4 developed in 1.7% in the bicarbonate group, compared to prophylactic administration of 0.9% saline infusion plus 13.6% in the saline solution group. NAC (n ¼ 111), sodium bicarbonate infusion plus NAC Ozcan et al.483 included three prophylactic regimens: (n ¼ 108), and 0.9% saline plus ascorbic acid plus NAC infusion of sodium bicarbonate, sodium chloride, and sodium (n ¼ 107). CI-AKI was defined as an increase of X25% in the chloride plus oral NAC (600 mg b.i.d.). The incidence of SCr concentration 48 hours after the procedure. CI-AKI CI-AKI, defined as an increase in SCr level 425% or 0.5 mg/dl occurred in 9.9% of the saline plus NAC group, in 1.9% of (44.2 mmol/l) after 48 hours was significantly lower in the the bicarbonate/NAC group (P ¼ 0.019 vs. saline plus NAC sodium bicarbonate group (4.5%) compared to sodium group), and in 10.3% of the saline plus ascorbic acid plus chloride alone (13.6%, P ¼ 0.036). After adjusting for the NAC group (P ¼ 1.00 vs. saline plus NAC group). There was Mehran nephropathy risk score, the risk of CI-AKI signifi- no difference in mortality nor in need for RRT among the cantly reduced with sodium bicarbonate compared to sodium different groups. While these two studies suggest that chloride alone (adjusted risk ratio 0.29; P ¼ 0.043). isotonic bicarbonate may provide greater benefit than By contrast, Adolph et al.482 did not find differences in CI- isotonic saline, either in association with NAC or not, neither AKI between the two fluid regimens on day 1 after study can be considered conclusive. angiography; even on day 2, most parameters were similar Maioli et al.487 prospectively compared the efficacy of in both groups. In none of the above-mentioned studies was sodium bicarbonate vs. isotonic saline in addition to NAC in there need for RRT. a larger population of 502 patients with an estimated CrCl Finally, a recent but retrospective study485 defined CI-AKI o60 ml/min, and undergoing coronary angiography or as an increase in SCr X25% within 48 hours of receiving intervention. CI-AKI was defined as an absolute increase of contrast media, and compared sodium bicarbonate to SCr X0.5 mg/dl (X44.2 mmol/l) measured within 5 days. CI- normal saline in patients exposed to cardiac angiography. AKI occurred in 10.8%; 10% were treated with sodium One group of patients (n ¼ 89) received prophylactic bicarbonate and 11.5% with saline. In patients with CI-AKI, bicarbonate; a second group, normal saline (n ¼ 98). The the mean increase in creatinine was not significantly different patients in the bicarbonate group had more severe renal in the two study groups. Based on this last prospective study, disease with higher baseline SCr (1.58 ± 0.5 mg/dl; 140 ± bicarbonate does not seem to be more efficient than saline. 44.2 mmol/l) vs. (1.28 ± 0.3 mg/dl; 113 ± 26.5 mmol/l), Furthermore, a retrospective cohort study at the Mayo Clinic P ¼ 0.001 and a lower eGFR, compared to the normal saline assessed the risk of CI-AKI associated with the use of sodium group. After contrast-media exposure, there was significant bicarbonate, NAC, or the combination. Surprisingly, i.v. drop in eGFR (6.4%) and increase in SCr (11.3%) in the sodium bicarbonate was associated with an increased normal saline group and no significant change in the incidence of CI-AKI.489 bicarbonate group. Three patients (3.4%) in the bicarbonate While one might take the position that, if in doubt, one group, as opposed to 14 patients (14.3%) in the normal saline should choose the regimen that is potentially superior, the group, developed CI-AKI (P ¼ 0.011). Two patients in the Work Group also considered the potential harm. In addition, normal saline group and none in the bicarbonate group isotonic bicarbonate solutions are usually composed by needed dialysis. This study suggests that the use of i.v. adding 154 ml of 8.4% sodium bicarbonate (i.e., 1 mmol/ sodium bicarbonate is more effective than normal saline in ml) to 846 ml of 5% glucose solution, resulting in a final preventing CI-AKI. sodium and bicarbonate concentration of 154 mmol/l each. Three studies compared bicarbonate and saline solutions Since this mixing of the solution is often done at the bedside associated with the administration of NAC in both study or in the hospital pharmacy, there is the possibility for errors arms.486–488 Recio-Mayoral et al.488 conducted a prospective leading to the infusion of a hypertonic bicarbonate solution. single-center RCT in 111 consecutive patients with acute The potential for harm from dosing errors, and the added coronary syndrome undergoing emergency angioplasty. One burden from preparation of the bicarbonate solution, has to group of patients received an infusion of sodium bicarbonate be taken into account in clinical practice when making a plus NAC started just before contrast-media injection and choice between using bicarbonate rather than standard continued for 12 hours after angioplasty. The second isotonic saline solutions. Taken together, the Work Group (control) group received the standard fluid protocol consist- concluded that there is a possible but inconsistent benefit of ing of i.v. isotonic saline for 12 hours after angioplasty. In bicarbonate solutions based on overall moderate-quality both groups, two doses of oral NAC were administered the evidence (Suppl Table 22). As discussed above, the potential next day. A SCr concentration 40.5 mg/dl (444.2 mmol/l) of harm and the additional burden for preparing the from baseline after emergency angioplasty was observed in bicarbonate solutions led the Work Group not to express a 1.8% in the bicarbonate group and in 21.8% of the saline preference for or against one solution (isotonic saline or group. Mortality and need for RRT were not significantly isotonic bicarbonate). Thus, either can be used for the different between both groups. Briguori et al.486 randomized prevention of CI-AKI. 326 CKD patients (SCr X2 mg/dl [X177 mmol/l] and/or eGFR o40 ml/min per 1.73 m2), and referred for coronary 4.4.2: We recommend not using oral fluids alone in and/or peripheral procedures to three different protocols: patients at increased risk of CI-AKI. (1C) 82 Kidney International Supplements (2012) 2, 69–88
  • 86. chapter 4.4 RATIONALE intoxication. A meta-analysis497 of studies using high doses Oral volume expansion may have some benefit, but there is of NAC defined the latter as a daily dose greater than 1200 mg not enough evidence to show that it is as effective as i.v. or a single periprocedural dose greater than 600 mg volume expansion.490 One small RCT of 53 patients491 who (periprocedural being described as immediately or within 4 underwent nonemergent cardiac catheterization found that hours of the planned contrast exposure). It should also be i.v. volume expansion with saline was more effective than remembered that no FDA label is available for NAC as a unrestricted oral fluid intake. A more recent trial492 examined preventive drug of AKI. the effects of oral volume intake on renal function in 180 Suppl Tables 24 and 25 summarize the quite numerous patients with preserved renal function referred for coronary RCTs where NAC has been compared to placebo on the CT angiography. The patients were divided into two groups: impact of patient mortality, need for RRT, or prevention of 106 subjects with an increase in SCr after coronary CT CI-AKI. In most of the studies, i.v. fluids, either with isotonic angiography; and 74 without. Significant correlations were saline or with isotonic bicarbonate, was used in both arms. observed between the amount of oral fluid intake and the Moreover, the impact of NAC on important ‘‘hard’’ patient percentage changes in SCr as well as the absolute changes in outcomes, such as all-cause mortality, need for RRT, or eGFR. In multiple regression analysis, the amount of oral doubling of SCr level has only rarely been studied. At present, fluid intake was the only independent predictor for an there is no current evidence that either oral or i.v. NAC can increase in SCr. However, a recent study compared oral fluids alter mortality or need for RRT after contrast-media (water with or without bicarbonate) to i.v. fluids (isotonic administration to patients at risk for CI-AKI. The only study saline or bicarbonate) and did not find differences in showing a significant decrease in hospital mortality is the incidence of CI-AKI patients with mild CKD. If confirmed three-arm study of Marenzi et al.498 in patients undergoing in larger studies, this regimen could offer an equivalent and primary angioplasty. Overall in-hospital mortality was higher more practical approach in preventing a decline in renal in patients with CI-AKI, defined as a 25% increase in SCr, function after contrast exposure, without accruing additional than in those without CI-AKI (26 % vs. 1 %; Po0.001). delay in hospital days or in-hospital mortality.493 Thirteen patients (11%) in the control group died, as did five (4%) in the standard-dose NAC and three (3%) in the high- ROLE OF NAC IN THE PREVENTION OF CI-AKI dose NAC group (P ¼ 0.02). All other studies did not show a beneficial effect on mortality (Suppl Table 25). Overall, this 4.4.3: We suggest using oral NAC, together with i.v. iso- evidence was deemed to be of moderate quality and the tonic crystalloids, in patients at increased risk of possible positive effect on mortality dubious. CI-AKI. (2D) The effect of NAC on the incidence of CI-AKI is quite variable. As is shown in the evidence profile (Suppl Table 24), the evidence that NAC reduces CI-AKI, as defined in the RATIONALE different trials, comes from studies with rather heterogeneous NAC—in many, but not all, studies—has been shown to have results; most of the studies were of either high or modest a protective effect on CI-AKI when administered before the quality. In one study, a protective—even dose-dependent— onset of renal insult; for a review, see McCullough.494 In effect was observed.498 In that study, the risk for CI-AKI was addition, NAC is inexpensive and appears to be safe, reduced by 54.5% in the standard-dose NAC group and by although it may have some detrimental effects on myocardial 75.8% in the high-dose NAC group. These findings are in and coagulation function.371–373 The ‘‘safety’’ of NAC should sharp contrast to many other studies showing no effect and, further be amended, particularly when high i.v. doses are in particular, with the large study of Webb et al.,499 which was used, as in some of the RCTs in CI-AKI. When prospectively terminated early after enrollment of 487 patients because studied in acetaminophen poisoning, i.v. NAC produced of a determination of futility by the Data Safety Monitoring anaphylactoid reactions in up to 48% of participants.374 Committee. As mentioned earlier, combination studies of Although most of these reactions were mild, at least one NAC with bicarbonate administration486 have found a death has been reported in a patient with asthma.375 It should moderate benefit for this combination, compared to the be noted that the doses used in acetaminophen intoxication combination of NAC-saline. are still much higher than in the ‘‘high doses’’ used in CI-AKI As recently remarked by Fishbane,364 most of the studies prevention trials. In a recent review,495 doses of NAC 300 mg/ published on NAC for the prevention of CI-AKI are quite kg i.v. over 21 hours, 980 mg/kg i.v. over 48 hours, and small in size, and meta-analyses have been performed to 1330 mg/kg p.o. over 72 hours were mentioned to have been increase the probability of explaining the full spectrum of all comparably effective at preventing hepatotoxicity in most utility for NAC. To date, seven out of the 11 meta-analyses uncomplicated early-presenting acute acetaminophen over- that have been published on this subject found a net benefit doses. Although a variety of doses of NAC has been for NAC in the prevention of CI-AKI.364 However, as pointed administered in the prevention of CI-AKI, the i.v. ‘‘high out before, marked heterogeneity in the studies, and doses’’ used in one study496 are mostly 2 Â 1200 mg NAC per publication bias must lead to the conclusion that ‘‘pooling day for 2–3 days, far below the doses used in acetaminophen of data to arrive at a summary estimate for treatment efficacy Kidney International Supplements (2012) 2, 69–88 83
  • 87. chapter 4.4 should generally be avoided in situations where the trials NAC alone; one study compared combination therapy to exhibit significant statistical and/or clinical hetero- NAC with normal saline, and a separate arm with NAC and geneity’’.500,501 A recent prospective RCT502 was performed in ascorbic acid. Collectively, combination treatment of NAC patients with decreased kidney function (CrCl p60 ml/min with i.v. sodium bicarbonate reduced CI-AKI by 35% and/or SCr level of X1.1 mg/dl [X97.2 mmol/l]), comparing a compared to the other above-mentioned combinations (RR high oral dose of NAC with high doses of vitamin C. All 0.65; 95% CI 0.40–1.05). However, the combination of NAC patients underwent a coronary angiography. The primary end- plus sodium bicarbonate did not significantly reduce renal point was the maximum increase of SCr level, and the failure requiring dialysis (RR 0.47; 95% CI 0.16–1.41). It was secondary end-point was the incidence of CI-AKI, defined as a concluded that combination prophylaxis with NAC and relative increase in baseline SCr level of X25% and/or an sodium bicarbonate substantially reduced the occurrence absolute increase of X0.5 mg/dl (X44.2 mmol/l) within 48 of CI-AKI overall, but not dialysis-dependent renal failure. hours after contrast-media administration. The maximum This paper suggests that combination prophylaxis should increase of SCr level was significantly lower in the NAC group be incorporated for all high-risk patients (emergent cases than in the ascorbic acid group (À0.03±0.18 mg/dl [À2.65± or patients with pre-existing CKD). Most of the studies 15.9 mmol/l] vs. 0.04 ± 0.20 mg/dl [3.54±17.7 mmol/l]), administered NAC orally; some studies used the i.v. route or respectively (P ¼ 0.026). The incidence of CI-AKI tended to even a combination of oral and i.v. There was also a substantial be in favor of NAC rather than ascorbic acid, 1.2% vs. 4.4%, variation in doses and timing of NAC administration. respectively, although this difference was not significant One additional study was recently published and was thus (P ¼ 0.370). It was concluded that an oral high dose of NAC not included in the meta-analysis discussed above. Koc seemed to be more beneficial than ascorbic acid in preventing et al.,504 investigated the efficacy of prophylactic i.v. NAC and CI-AKI, particularly in diabetic patients with pre-existing CKD. fluids for the prevention of CI-AKI in patients with mild to Finally, a randomized, single-blind, controlled trial was moderate renal dysfunction (SCr X1.1 mg/dl [X97.2 mmol/l] recently published to assess NAC effects on CI-AKI and or a CrCl p60 ml/min) who were undergoing coronary reperfusion injury in ST-segment elevation myocardial angiography. A group of patients was assigned to i.v. NAC infarction (MI) patients undergoing primary angioplasty (bolus of 600 mg twice daily before and on the day of the with moderate contrast-media volumes (between 120–230 ml procedure) plus high-dose normal saline, a second group to of an iso-osmolar contrast medium).496 The patients under- only high-dose saline, and a third (control) group received going primary angioplasty were randomized to either high- standard saline. Patients in the NAC plus high-dose saline dose NAC (two times 1200 mg/d for 48 hours; or placebo group received an i.v. bolus of 600 mg of NAC twice daily plus fluids). CI-AKI occurred in 14% of the NAC group and before and on the day of the coronary procedure (total 2.4 g) in 20% of the placebo group (P ¼ 0.28). The myocardial plus i.v. 0.9% saline 1 ml/kg/h before, on, and after the day of salvage index was also not different between both treatment the coronary procedure. Patients in the high-dose arm groups. Activated oxygen protein products and oxidized low- received the same amount of isotonic saline, while patients density lipoprotein as markers for oxidative stress were in the control group received an i.v. dose of 0.9% saline reduced by as much as 20% in the NAC group, whereas no 1 ml/kg/h for 12 hours before and 12 hours after the coronary change was evident in the placebo group. procedure. The rate of CI-AKI in the NAC plus high-dose Thus, despite high-dose i.v. NAC reducing oxidative stress, saline group was lower than in the high-dose saline group it does not provide an additional clinical benefit, compared without NAC. No significant differences in the primary and to placebo, with respect to CI-AKI and myocardial reper- secondary end-points were found between the high-dose fusion injury in nonselected patients undergoing angioplasty. saline and control groups. A recent meta-analysis of all prospective trials of individuals In conclusion, based on the evidence tables and even randomized to either orally or i.v. administered high doses of taking the last recent study into account, the overall benefit of NAC, defined as a daily dose greater than 1200 mg or a single NAC is not consistent or overwhelming. On the other hand, periprocedural dose (within 4 hours of contrast-media oral NAC has a low risk of adverse events and usually a low exposure) 4600 mg, was published by Trivedi et al.497 The cost. overall effect size, assuming a common OR, was 0.46 (95% CI 0.33–0.63) for the occurrence of CI-AKI with the use of high- THEOPHYLLINE AND FENOLDOPAM IN PREVENTION OF CI-AKI dose NAC. The results of the more conservative random- Theophylline effects approach were similar (OR 0.52; 95% CI 0.34–0.78). Another recently published meta-analysis of RCTs inclu- 4.4.4: We suggest not using theophylline to prevent ded published trials and conference abstracts (Figure 16).503 CI-AKI. (2C) The primary and secondary outcomes of interest were CI-AKI, and renal failure requiring dialysis, respectively. Ten RCTs met the inclusion criteria. Nine studies compared RATIONALE combination treatment (bicarbonate and NAC) to NAC and A rationale for the prophylactic use of adenosine antago- normal saline; one study compared combination therapy to nists in patients undergoing radiocontrast procedures was 84 Kidney International Supplements (2012) 2, 69–88
  • 88. chapter 4.4 Figure 16 | NAC and bicarbonate vs. NAC for risk of CI-AKI. Reprinted from Brown, JR, Block CA, Malenka DJ et al. Sodium bicarbonate plus N-acetylcysteine prophylaxis: a meta-analysis. JACC Cardiovasc Interv 2009; 2: 1116–1124,503 copyright 2009, with permission from American College of Cardiology Foundation; accessed http://interventions.onlinejacc.org/cgi/content/full/2/11/1116 suggested by results showing increased serum levels and Neither meta-analysis included a RCT published in 2006 urinary excretion of adenosine occurring after intravascular in 150 contrast-media examinations in 91 patients, in which administration of contrast media.505 The efficacy of theo- the renoprotective effects of theophylline, NAC, and the phylline in preventing CI-AKI has been addressed by a combination of both were directly compared.507 All patients systematic review and meta-analysis in 2005 (nine RCTs, 585 had at least one risk factor for developing CI-AKI, and patients),506 and another meta-analysis in 2008 (six RCTs, received more than 100 ml of low-osmolar radiocontrast 629 patients).432 Both meta-analyses indicated a nonsigni- agent. The incidence of CI-AKI was significantly lower with ficant trend toward a renoprotective effect of theophylline theophylline as compared to NAC pretreatment (2% vs. 12%; prophylaxis. The incidence of CI-AKI tended to be P ¼ 0.045), and did not differ between theophylline mono- lower (Bagshaw: OR 0.4, CI 0.14–1.16, P ¼ 0.09; Kelly: OR therapy and the combination treatment. The renoprotective 0.49, CI 0.23–1.06, P ¼ 0.14), SCr concentrations 48 hours superiority of theophylline, which was given as a single i.v. after intervention were significantly lower (À0.17 mg/dl; 200 mg dose 30 minutes prior to the procedure, was even 95% CI À0.2 to À0.06 mg/dl [À15.0 mmol/l, CI À17.7 to more significant in patients with pre-existing renal damage as À5.30 mmol/l]; P ¼ 0.002) with theophylline compared to indicated by an SCr 41.5 mg/dl (4133 mmol/l) (P ¼ 0.008). control therapies. However, the overall benefit was small and Moreover, a recent study508 randomized 217 patients with findings were inconsistent across studies. The benefit eGFR between 30 and 60 ml/min who were undergoing attributable to the use of theophylline tended to be less coronary angiography to one of three prophylactic treat- marked in patients receiving iso-osmolar, nonionic contrast ments: i.v. isotonic saline (1 ml/kg/h for 12 hours before and media, and in patients undergoing a predefined saline after contrast media (group 1, n ¼ 72); isotonic saline as in protocol. group 1 together with NAC (600 mg p.o. twice daily the Kidney International Supplements (2012) 2, 69–88 85
  • 89. chapter 4.4 preceding day and the day of angiography (group 2, n ¼ 73); were randomized to saline alone or with fenoldopam or isotonic saline and NAC as in group 2 together with (0.1 mg/kg per minute for 4 hours before and after the 200 mg theophylline orally twice daily for the preceding day procedure); a third arm was treated with NAC. The incidence and the day of angiography (group 3, n ¼ 72). The incidence of CI-AKI was similar in the fenoldopam (15.7%) and of CI-AKI (0.5 mg/dl or 44.2 mmol/l SCr increase within 48 control (15.3%) groups, and there was no benefit over hours of intravascular contrast-media injection) was 6.9% in saline alone. A second, larger trial220 also confirmed the group 1, 9.6% in group 2, and 0% in group 3 (Po0.03), lack of benefit with fenoldopam. In this double-blind trial suggesting a beneficial effect of adding theophylline to a of 315 patients, all with saline 0.45%, were randomized to standard regimen in the prevention of CI-AKI. Notably, at fenoldopam (0.05 mg/kg per minute titrated to 0.1 mg/kg least in this study, NAC administration had no additive per minute) or placebo starting 1 h before the procedure and protective effect compared to isotonic saline alone. continuing for 12 hours afterward. There was no significant A very recent study509 randomly assigned patients to difference in the incidence of CI-AKI within 96 hours in prophylactic administration of saline with sodium bicarbo- the two groups (fenoldopam, 33.6%; placebo, 30.1%) or in nate plus theophylline (either orally or i.v.) or sodium the rates of dialysis, rehospitalization, or death at 30 days. bicarbonate only. Theophylline plus bicarbonate prophylaxis significantly reduced the incidence of CI-AKI (1.6% vs. 7.9%; Statins in the prevention of CI-AKI P ¼ 0.015) compared to bicarbonate alone. Theophylline was Two recent studies examined the use of statins in the administered either orally (200 mg b.i.d. starting the day prevention of CI-AKI patients with CKD. In the first study,514 before the contrast administration and continuing for 24 31 patients were prospectively randomized to receive atorvas- hours thereafter) or i.v. 200 mg in a short infusion before tatin 80 mg/d or placebo for 48 hours before and 48 hours contrast administration and continuing orally at 200 mg after contrast-medium administration. All patients received i.v. b.i.d. for 48 hours. Theophylline prophylaxis significantly saline and oral NAC. CI-AKI occurred in 16 patients (11%) in reduced the incidence of CI-AKI in moderate and high-risk the placebo group and 15 patients (10%) in the atorvastatin patients (0% vs. 8.8%; P ¼ 0.022 and 9.1% vs. 42.1%; group. Persistent kidney injury, defined as 1-month increase P ¼ 0.014, respectively). This study did not mention side- from baseline creatinine value 425%, was observed in 30% effects of theophylline. in the placebo group and in 31% in the atorvastatin group. Although these data suggest that preinterventional theo- The second study515 followed 431 patients, 194 of whom were phylline administration might be helpful in patients at receiving pravastatin treatment for hypercholesterolemia. SCr increased risk for CI-AKI, the possibility of cardiovascular levels were measured at baseline (preprocedure) and within 48 side-effects and the interactions with numerous drugs hours after contrast-medium exposure (peak postprocedure). associated with theophylline510,511 should be recognized Logistic regression analysis revealed that pravastatin treatment, (Suppl Tables 26 and 27). As can be noted from the evidence preprocedure SCr, and contrast volume were independently profile tables, the evidence is low and the balance of benefits related to the decreased risk of CI-AKI. However, such studies vs. harm is uncertain. In view of the low evidence and the are susceptible to the so-called ‘‘healthy user effect’’ where uncertain balance of benefits vs. harm, the Work Group certain groups may have reduced risk, not because of the does not support the use of theophylline for prevention of drug but because of healthier lifestyles, for which use of the CI-AKI. medication is a marker. For example, patients taking statins may also be more compliant with other medical-care regimens Fenoldopam that may reduce adverse events. 4.4.5: We recommend not using fenoldopam to prevent SUPPLEMENTARY MATERIAL CI-AKI. (1B) Supplementary Table 22: Evidence profile of RCTs examining effect of i.v. sodium bicarbonate vs. control for the prevention of CI-AKI. Supplementary Table 23: Summary table of RCTs examining the effect RATIONALE of i.v. sodium bicarbonate on the prevention of CI-AKI. Supplementary Table 24: Evidence profile of RCTs examining the effect Fenoldopam is a selective dopamine A1 receptor agonist of NAC vs. placebo on the prevention of CI-AKI. that might theoretically increase blood flow, especially to the Supplementary Table 25: Summary table of RCTs examining the effect renal medulla. Several uncontrolled studies (historical of NAC vs. placebo on the prevention of CI-AKI. controls, retrospective review) suggested that it is effective Supplementary Table 26: Evidence profile of RCTs examining the effect in reducing the risk for contrast-induced nephropathy, and of theophylline vs. placebo on the prevention of CI-AKI. Supplementary Table 27: Summary table of RCTs examining the effect the results of a pilot trial were promising (for review, see of theophylline vs. placebo on the prevention of CI-AKI. Stacul et al.512). However, two prospective randomized trials Supplementary material is linked to the online version of the paper at showed negative results.220,513 In the first trial,513 patients http://www.kdigo.org/clinical_practice_guidelines/AKI.php 86 Kidney International Supplements (2012) 2, 69–88
  • 90. http://www.kidney-international.org chapter 4.5 & 2012 KDIGO Chapter 4.5: Effects of hemodialysis or hemofiltration 4.5.1: We suggest not using prophylactic intermittent By contrast, Lee et al.521 presented a prospective RCT hemodialysis (IHD) or hemofiltration (HF) for indicating that prophylactic IHD might be useful in patients contrast-media removal in patients at increased scheduled for coronary angiography or coronary intervention risk for CI-AKI. (2C) with severely impaired renal function (baseline CrCl of 13 ml/ min per 1.73 m2). Patients were treated with normal saline at 1 ml/kg/h for 6 hours before and 12 hours after contrast- RATIONALE media administration and randomized to receive IHD for Contrast media are excreted mainly by glomerular filtration 4 hours as soon as possible after angiography or control and there is a significant correlation between both total body treatment. Four days after angiography, SCr concentrations and renal clearances of contrast media and GFR; the renal were lower in the IHD group compared to the control group. excretion of contrast media will thus be delayed in patients Out of 42 patients, one patient (2%) in the IHD group but 14 with renal failure (for review, see Deray).516 Contrast media (35%) out of 40 patients in the control group required can be efficiently removed from blood by IHD and a single temporary IHD after coronary angiography. Furthermore, session effectively removes 60–90% of contrast media.516,517 none of the 42 patients in the IHD group, but five (13%) out On the basis of these observations, several studies have of 40 patients in the control group, required maintenance explored the prophylactic value of IHD in patients at high IHD after discharge from the hospital (Po0.05). risk, but most of these studies have not demonstrated a A recent meta-analysis of studies using periprocedural reduced incidence of CI-AKI.516,518 For example, Vogt extracorporeal blood purification techniques517 concluded et al.518 recorded renal function and other parameters, IHD that such treatments did not decrease the incidence of requirements, and relevant clinical events before and during 6 CI-AKI. It could theoretically be anticipated that high-flux days after administration of contrast media in 113 patients membranes used in HF or hemodiafiltration (HDF) moda- with a baseline SCr 42.3 mg/dl (4203 mmol/l). Eight out of lities should be able to remove contrast media more 55 patients in the prophylactic IHD group and three in the efficiently than low-flux membranes used in routine IHD. non-IHD group (P ¼ 0.12), required IHD after contrast- However, recent publications on this topic have added to the media examination. Reinecke et al.519 performed a prospec- controversy about the role of IHD or HF to prevent CI-AKI tive single-center trial in 424 consecutive patients with (Suppl Tables 28 and 29). Marenzi et al.522 studied 114 SCr concentrations between 1.3–3.5 mg/dl (115–309 mmol/l) consecutive patients with CRF (SCr concentration 42 mg/dl who underwent elective coronary angiography. Patients were or 4177 mmol/l) who were undergoing coronary interven- randomized to one of three treatment strategies with all tions. Fifty-eight patients were assigned to either HF starting patients receiving pre- and postprocedural fluids: one group before the contrast-medium administration and continuing received no additional therapy, patients in the second group for up to 24 hours after, while 56 patients were treated with were hemodialyzed once, and the third group received oral isotonic saline at a rate of 1 ml per kilogram of body weight NAC. The frequency of CI-AKI (defined as an increase in SCr per hour, given in a step-down unit over the same time X0.5 mg/dl or X44.2 mmol/l) from 48 to 72 hours after interval. In-hospital mortality was 2% in the HF group and catheterization was 6.1% in the fluids-only group, 15.9% with 14% in the control group (P ¼ 0.02), and the cumulative IHD treatment, and 5.3% in the NAC group (intention- 1-year mortality was 10% and 30%, respectively (P ¼ 0.01). to-treat analysis; P ¼ 0.008). There were no differences Temporary RRT was required in 25% of the control group between the treatment groups with regard to increased SCr and in only 3% of the patients in the HF group. An increase X0.5 mg/dl (X44.2 mmol/l) after 30–60 days (4.8%, 5.1%, and in the SCr concentration of 425% from the baseline value 3.1%, respectively; P ¼ 0.700). Analyses of long-term follow- after the coronary intervention occurred less frequently up (range 63–1316 days) by Cox regressions models of the among patients in the HF group than among the control study groups found quite similar survival rates (P ¼ 0.500). patients (5% vs. 50%, Po0.001). The effective removal of This large study concluded that IHD, in addition to fluids, for creatinine during HF or IHD makes it difficult to be certain the prevention of CI-AKI provided no evidence for any that an observed lower incidence of CI-AKI is not related to outcome benefit but showed evidence for probable harm. the transport removal of creatinine during the procedure. A retrospective but important cohort study of 391 patients In a subsequent study, the same authors523 randomized (age 69 ± 8 years, with chronic renal insufficiency [SCr 92 patients with CKD (CrCl p30 ml/min) to three different X1.3 mg/dl; X115 mmol/l]) who underwent cardiac cathe- prophylactic treatments: i.v. isotonic saline (control group); terization, also did not find any beneficial preventive effect.520 i.v. saline for 12 hours before contrast-media exposure, Kidney International Supplements (2012) 2, 69–88 87
  • 91. chapter 4.5 followed by HF for 18–24 hours after contrast-media Novartis, Robert and Jane Cizik Foundation, Shire, exposure; and a third group where HF was performed for 6 Transwestern Commercial Services, and Wyeth. KDIGO is hours before and for 18–24 hours after contrast-media supported by a consortium of sponsors and no funding is exposure. The incidence of CI-AKI (425% increase in accepted for the development of specific guidelines. SCr) and the in-hospital clinical course were compared in the three groups. In-hospital mortality was 20%, 10%, and 0%, DISCLAIMER respectively, in the three groups; IHD was required in nine While every effort is made by the publishers, editorial (30%), 3 (10%), and zero (0%) patients, respectively board, and ISN to see that no inaccurate or misleading data, (P ¼ 0.002). According to these results, pre-HF is required opinion or statement appears in this Journal, they wish to obtain the full clinical benefit, suggesting that among to make it clear that the data and opinions appearing in different mechanisms possibly involved, high-volume con- the articles and advertisements herein are the responsibility trolled volume expansion before contrast-media exposure of the contributor, copyright holder, or advertiser concerned. plays a major role in prevention. This study further suggests Accordingly, the publishers and the ISN, the editorial board that bicarbonate exposure with HF may ultimately have been and their respective employers, office and agents accept the mechanism for the lower CI-AKI incidence (Suppl Table no liability whatsoever for the consequences of any such 29). In summary, the evidence profile for IHD vs. HF showed inaccurate or misleading data, opinion or statement. While low-quality evidence and an uncertain benefit vs. harm every effort is made to ensure that drug doses and other balance of HF/IHD in preventing CI-AKI in patients with quantities are presented accurately, readers are advised that severe CKD. Given the costs and logistical difficulties, the use new methods and techniques involving drug usage, and of HF modalities for CI-AKI prevention can only be described within this Journal, should only be followed in advocated if future studies will convincingly show clear conjunction with the drug manufacturer’s own published benefit. literature. SPONSORSHIP SUPPLEMENTARY MATERIAL KDIGO gratefully acknowledges the following sponsors that Supplementary Table 28: Evidence profile of RCTs examining the effect make our initiatives possible: Abbott, Amgen, Belo Founda- of hemodialysis or hemofiltration on the prevention of CI-AKI. Supplementary Table 29: Summary table of RCTs examining the effect tion, Coca-Cola Company, Dole Food Company, Genzyme, of hemodialysis or hemofiltration on the prevention of CI-AKI. Hoffmann-LaRoche, JC Penney, NATCO—The Organization Supplementary material is linked to the online version of the paper at for Transplant Professionals, NKF—Board of Directors, http://www.kdigo.org/clinical_practice_guidelines/AKI.php 88 Kidney International Supplements (2012) 2, 69–88
  • 92. http://www.kidney-international.org chapter 5.1 & 2012 KDIGO Section 5: Dialysis Interventions for Treatment of AKI Kidney International Supplements (2012) 2, 89–115; doi:10.1038/kisup.2011.35 Chapter 5.1: Timing of renal replacement therapy in AKI Whether or not to provide RRT, and when to start, are two of infusion, and beta-2 agonists) are exhausted, an excess of the fundamental questions facing nephrologists and inten- potassium can only be eliminated with RRT. On the other sive-care practitioners in most cases of severe AKI. In recent hand, when intermittent dialysis is used after these publications, the timing of initiation of RRT was listed as one therapeutic interventions, the extracorporeal removal of of the top priorities in research on AKI.524 However, this potassium will be reduced and the post-treatment rebound dimension has not been included as a factor in any of the of serum potassium will be more pronounced.526 large RCTs in this area. The optimal timing of dialysis for Metabolic acidosis is a frequent clinical problem in AKI is not defined. In current practice, the decision to start patients with severe AKI. Although the discussion as to RRT is based most often on clinical features of volume when metabolic acidosis in critically ill patients should be overload and biochemical features of solute imbalance corrected is outside the scope of this guideline, metabolic (azotemia, hyperkalemia, severe acidosis). However, in the acidosis associated with AKI can usually be corrected with absence of these factors there is generally a tendency to avoid bicarbonate and should rarely require urgent dialysis if not dialysis as long as possible, a thought process that reflects the accompanied by volume overload or uremia.527 As the pH decisions made for patients with CKD Stage 5. and bicarbonate values to initiate dialysis for metabolic Clinicians tend to delay RRT when they suspect that acidosis are not supported by evidence, no standard criteria patients may recover on their own, and because of concern for initiating dialysis for acidosis exist. A variety of poisons, for the well-known risks associated with the RRT procedure, drug overdoses, and toxic compounds (e.g., salicylates, including hypotension, arrhythmia, membrane bioincom- ethylene glycol, methanol, metformin) can contribute to patibility, and complications of vascular access and anti- acid-base problems and also lead to AKI. In these circum- coagulant administration. There is also some concern that stances, RRT may also facilitate removal of the offending RRT may compromise recovery of renal function, and drug.528–530 increase the progression of CKD.525 Whether these risks Only one RCT has evaluated the effect of timing of outweigh the potential benefits of earlier initiation of RRT is initiation of RRT on outcome. Bouman et al.531 randomized still unclear. 106 critically ill patients with AKI to early vs. late initiation of RRT. The early initiation group started RRT within 5.1.1: Initiate RRT emergently when life-threatening 12 hours of oliguria (o30 ml/h for 6 hours, not respond- changes in fluid, electrolyte, and acid-base balance ing to diuretics or hemodynamic optimization), or CrCl exist. (Not Graded) o20 ml/min. The late-initiation group started RRT when 5.1.2: Consider the broader clinical context, the presence classic indications were met. The study did not find of conditions that can be modified with RRT, and differences in ICU or hospital mortality, or in renal recovery trends of laboratory tests—rather than single BUN among survivors, but was clearly too small to allow for and creatinine thresholds alone—when making the definitive conclusions (Suppl Table 30). decision to start RRT. (Not Graded) The remaining data come from observational studies. The association of early initiation of dialysis with survival benefit was first suggested by case series with historical controls RATIONALE conducted in the 1960 s and 1970 s.532–535 In these studies, While no RCTs exist for dialysis for life-threatening levels of blood urea or BUN were used to distinguish early vs. indications, it is widely accepted that patients with severe late start of dialysis. However, these studies mostly combined hyperkalemia, severe acidosis, pulmonary edema, and uremic early start with more-intensive dialysis and late start with complications should be dialyzed emergently. In the absence less-intensive dialysis. More recent studies have continued the of kidney function, and when therapeutic measures that trend focusing on BUN as a biomarker for starting RRT. promote the intracellular shift of potassium (such as Single-center observational studies that were restricted to correction of acidosis with bicarbonate, glucose and insulin AKI after trauma536 and coronary artery bypass surgery537,538 Kidney International Supplements (2012) 2, 89–115 89
  • 93. chapter 5.1 suggested a benefit to RRT initiation at lower BUN concen- a causal relationship remains to be proven, although a trations. A prospective multicenter observational cohort randomized trial in hemodynamically stable patients with study performed by the Program to Improve Care in Acute acute respiratory distress syndrome seems to suggest that Renal Disease (PICARD) analyzed dialysis initiation—as it is.549 Randomizing patients according to RRT initiation on inferred by BUN concentration—in 243 patients from five the basis of fluid status would allow this question to be geographically and ethnically diverse clinical sites. Adjusting answered. A secondary analysis of a randomized trial for age, hepatic failure, sepsis, thrombocytopenia, and SCr, comparing IHD to CRRT showed that patients receiving and stratified by site and initial dialysis modality, initiation of RRT predominantly for solute control experienced better RRT at higher BUN (476 mg/dl [blood urea427.1 mmol/l]) outcomes than those predominantly treated for volume was associated with an increased risk of death (RR 1.85; 95% overload. Patients dialyzed for control of both azotemia and CI 1.16–2.96).539 In a prospective multicenter observational volume overload experienced the worst outcome.550 Analysis study conducted at 54 ICUs in 23 countries, timing of RRT of a multicenter observational cohort showed that mean was stratified into ‘‘early’’ or ‘‘late’’ by median urea at the daily fluid balance in AKI patients was significantly more time RRT started (24.2 mmol/l [BUN 67.8 mg/dl]), and also positive among nonsurvivors than survivors.84 Data from categorized temporally from ICU admission into early (less the PICARD group examining 396 ICU patients with AKI than 2 days), delayed (between 2–5 days), or late (more than requiring RRT further supports these findings. Survivors had 5 days). Timing by serum urea showed no significant lower fluid accumulation at dialysis initiation compared to difference in mortality. However, when timing was analyzed nonsurvivors (8.8% vs. 14.2% of baseline body weight; in relation to ICU admission, late RRT was associated with P ¼ 0.01 adjusted for dialysis modality and severity score). greater crude mortality (72.8% late vs. 62.3% delayed vs. 59% The adjusted OR for death associated with fluid overload at early, P ¼ 0.001) and covariate-adjusted mortality (OR 1.95; dialysis initiation was 2.07 (95% CI 1.27–3.37).83 These data 95% CI 1.30–2.92; P ¼ 0.001). Overall, late RRT was asso- suggest that fluid overload should be further evaluated as ciated with a longer duration of RRT and stay in hospital, and parameter to guide the initiation of RRT (see also Pediatric greater dialysis dependence.540 It is, however, not clear Considerations). whether AKI occurring later in the course of ICU stay has the Other factors that might influence the decision of when to same pathophysiology and prognosis than AKI present on or start RRT are the severity of the underlying disease (affecting early after admission. The most recent study on this subject is the likelihood of recovery of kidney function), the degree of the analysis of surgical ICU patients with AKI, showing that dysfunction in other organs (affecting the tolerance to e.g., late initiation of RRT (defined as RIFLE-I or -F) was an inde- fluid overload), the prevalent or expected solute burden (e.g., pendent predictor of mortality (HR 1.846; CI 1.07–3.18).541 in tumor lysis syndrome), and the need for fluid input related Traditional indications for RRT, developed for patients to nutrition or drug therapy (Table 17). Early detection and with advanced CKD, are not necessarily valid in the context accurate prediction of patients that ultimately will require of AKI. For instance, massive volume overload resulting from RRT may allow earlier initiation in those who need it and, at volume resuscitation may be an indication for RRT even in the same time, prevent harm in those who do not. Recent the absence of significant elevations in BUN or SCr. In this evidence suggests a potential role for biomarkers in this field. instance, it may be more appropriate to consider dialytic Plasma neutrophil gelatinase-associated lipocalin was shown intervention in the ICU patient as a form of renal support to have an area under the receiver operating characteristic rather than renal replacement. Indeed, some of the curve of 0.82 for the prediction of RRT requirement.551 traditional indications for dialysis (e.g., uremic pericarditis, pleuritis, encephalopathy, coagulopathy) would be consid- Pediatric considerations ered ‘‘complications’’ of AKI rather than indications for RRT. Provision of acute RRT to children requires special consi- Additionally, the decision to start RRT should recognize the derations. Pediatric and adolescent patients range in age from goals of therapy, keeping in mind the therapeutic potential of the premature neonate to 25 years of age, with a size range of dialysis in general, and each dialysis modality in particular. 1.5–200 kg. In addition, the epidemiology of the pediatric The treatment of AKI with RRT has the following goals: i) to AKI has changed from primary kidney disease in the 1980 s to maintain fluid and electrolyte, acid-base, and solute homeo- injury resulting from another systemic illness or its treatment stasis; ii) to prevent further insults to the kidney; iii) to (e.g., sepsis and nephrotoxic medications).552,553 Newborns permit renal recovery; and iv) to allow other supportive with inborn errors of metabolism who do not respond to measures (e.g., antibiotics, nutrition support) to proceed dietary and pharmacologic management require expeditious without limitation or complication. Ideally, therapeutic inter- dialytic removal of ammonia to decrease the risk of death and ventions should be designed to achieve the above goals and a long-term neurologic dysfunction,554 and infants who receive systematic assessment of all these factors is key to determi- surgical correction of congenital heart disease, often receive ning the optimal timing for initiating dialysis (Table 17). PD early after cardiopulmonary bypass to prevent fluid There is increasing evidence that fluid overload in critical overload and/or minimize the proinflammatory response. illness and AKI is associated with adverse outcomes, Finally, children develop multiorgan dysfunction very rapidly especially in the pediatric setting.83,84,542–549 Whether this is in their ICU course, with the maximal organ dysfunction 90 Kidney International Supplements (2012) 2, 89–115
  • 94. chapter 5.1 Table 17 | Potential applications for RRT Applications Comments Renal replacement This is the traditional, prevailing approach based on utilization of RRT when there is little or no residual kidney function. Life-threatening indications No trials to validate these criteria. Hyperkalemia Dialysis for hyperkalemia is effective in removing potassium; however, it requires frequent monitoring of potassium levels and adjustment of concurrent medical management to prevent relapses. Acidemia Metabolic acidosis due to AKI is often aggravated by the underlying condition. Correction of metabolic acidosis with RRT in these conditions depends on the underlying disease process. Pulmonary edema RRT is often utilized to prevent the need for ventilatory support; however, it is equally important to manage pulmonary edema in ventilated patients. Uremic complications In contemporary practice it is rare to wait to initiate RRT in AKI patients until there are uremic complications. (pericarditis, bleeding, etc.) Nonemergent indications Solute control BUN reflects factors not directly associated with kidney function, such as catabolic rate and volume status. SCr is influenced by age, race, muscle mass, and catabolic rate, and by changes in its volume of distribution due to fluid administration or withdrawal. Fluid removal Fluid overload is an important determinant of the timing of RRT initiation. Correction of acid-base No standard criteria for initiating dialysis exist. abnormalities Renal support This approach is based on the utilization of RRT techniques as an adjunct to enhance kidney function, modify fluid balance, and control solute levels. Volume control Fluid overload is emerging as an important factor associated with, and possibly contributing to, adverse outcomes in AKI. Recent studies have shown potential benefits from extracorporeal fluid removal in CHF. Intraoperative fluid removal using modified ultrafiltration has been shown to improve outcomes in pediatric cardiac surgery patients. Nutrition Restricting volume administration in the setting of oliguric AKI may result in limited nutritional support and RRT allows better nutritional supplementation. Drug delivery RRT support can enhances the ability to administer drugs without concerns about concurrent fluid accumulation. Regulation of acid-base Permissive hypercapnic acidosis in patients with lung injury can be corrected with RRT, without inducing fluid overload and electrolyte status and hypernatremia. Solute modulation Changes in solute burden should be anticipated (e.g., tumor lysis syndrome). Although current evidence is unclear, studies are ongoing to assess the efficacy of RRT for cytokine manipulation in sepsis. AKI, acute kidney injury; BUN, blood urea nitrogen; CHF, congestive heart failure; SCr, serum creatinine; RRT, renal replacement therapy. Table 18 | Fluid overload and outcome in critically ill children with AKI Author Cohort (N) Outcome P 545 Goldstein 2001 Single-center (22) Survivors 16% FO Nonsurvivors 34% FO 0.03 Gillespie 2004544 Single-center (77) % FO 410% with OR death 3.02 0.002 Foland 2004543 Single-center (113) 3 organ MODS patients 0.01 Survivors 9% FO Nonsurvivors 16% FO 1.78 OR death for each 10% FO increase Goldstein 2005546 Multicenter (116) 2+ organ MODS patients 0.002 Survivors 14% FO Nonsurvivors 25% FO o20% FO: 58% survival 420% FO: 40% survival Hayes 2009547 Single-center (76) Survivors 7% FO Nonsurvivors 22% FO 0.001 OR death 6.1 for 420% FO Sutherland 2010548 Multicenter (297) o10% FO: 70% survival 0.001 10–20% FO: 57% survival 420% FO: 34% survival OR 1.03 (1.01–1.05) per % FO AKI, acute kidney injury; FO, fluid overload; MODS, multiple-organ dysfunction syndrome; OR, odds ratio. Reprinted from Goldstein SL. Advances in pediatric renal replacement therapy for acute kidney injury. Semin Dial 2011; 24: 187–191 with permission from John Wiley and Sons560; accessed http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2011.00834.x/full occurring with 72 hours and mortality occurring within 7 Both recommendations in this section of the guideline are days of ICU admission, respectively.555,556 Thus, the issue of applicable to pediatric patients. A detailed discussion of the timing of dialysis initiation is critically important in children. specific pediatric clinical situations is beyond the scope of Kidney International Supplements (2012) 2, 89–115 91
  • 95. chapter 5.1 this guideline, and the reader is referred to in-depth in 297 children treated with RRT: 29.6% mortality with less reviews.557,558 than 10% fluid overload, 43.1% with 10–20% fluid overload, Importantly, fluid overload has emerged as a significant and 65.6% with 420% fluid overload.548 However, strong factor associated with mortality in children with AKI evidence to suggest that preventing this fluid overload with requiring CRRT (Table 18), although the physiological link earlier RRT will improve outcome remains absent. between increasing percent volume overload and mortality is not completely clear.543–548,559 The largest trial to assess this RESEARCH RECOMMENDATIONS relationship in children is a multicenter prospective study K Determine reproducible criteria (e.g., fluid overload, showing that the percentage fluid accumulation at CRRT biomarker level, severity score) to inform the decision to initiation is significantly lower in survivors vs. non-survivors start RRT in adult and pediatric AKI patients. Such (14.2 ± 15.9% vs. 25.4 ± 32.9%; Po0.03) even after criteria may also permit the identification of patients who adjustment for severity of illness. This study also found a will ultimately require RRT and hence limit uncertainty significantly higher mortality in patient with 420% fluid around whether to begin therapy. overload (58%) vs. o20% fluid overload (40%) at CRRT K Determine whether early vs. late start of RRT, based on initiation.546 One retrospective study, in pediatric patients the above-mentioned criteria, results in improved clinical who received stem-cell transplantation and developed AKI, outcomes (e.g., mortality, evolution to CKD Stage 5) of suggested that survival may be improved by an aggressive use AKI patients. of diuretics and early initiation of RRT. All survivors (n ¼ 11) maintained or remained with percentage fluid accumulation o10%, with diuretics and RRT. Among the 15 nonsurvivors, SUPPLEMENTARY MATERIAL Supplementary Table 30: Summary table of RCTs examining the effect only 6 (40%) had percentage fluid accumulation o10% at of early vs. late CVVH in the treatment of AKI. the time of death.559 The latest analysis on this issue Supplementary material is linked to the online version of the paper at confirmed increased mortality with increasing fluid overload http://www.kdigo.org/clinical_practice_guidelines/AKI.php 92 Kidney International Supplements (2012) 2, 89–115
  • 96. http://www.kidney-international.org chapter 5.2 & 2012 KDIGO Chapter 5.2: Criteria for stopping renal replacement therapy in AKI Although many patients with AKI recover kidney function solute levels prevent achieving a steady state and thus exclude sufficiently to be independent of RRT, discontinuation of the use of clearance measurements. Native kidney function RRT in AKI has received little attention in the literature. The can only be assessed during the interdialytic period by decision whether or when to stop RRT in a patient with AKI evaluating urine volume, urinary excretion of creatinine, and needs to consider an improvement in kidney function changes in SCr and/or BUN values. However, one must adequate to meet demand, an improvement in the disorder realize that intermittent treatment will be associated with that prompted kidney support or futility. It is evident post-treatment rebound in solute levels, and that changes that each of these events is influenced by the initial in BUN and creatinine levels can also be modified by indication for starting RRT and is subject to individual nonrenal factors, such as volume status and catabolic rate. variation. The strategy for stopping RRT requires considera- In CRRT, continuous solute clearance of 25–35 ml/min will tion of additional factors and often involves a modality stabilize serum markers after 48 hours. This allows more transition. reliable measurements of CrCl by the native kidneys during CRRT. 5.2.1: Discontinue RRT when it is no longer required, Very few investigators have looked at urine CrCl values as either because intrinsic kidney function has recov- a guide for CRRT withdrawal. One small retrospective study ered to the point that it is adequate to meet patient (published as abstract) demonstrated that a CrCl (measured needs, or because RRT is no longer consistent with over 24 hours) 415 ml/min was associated with successful the goals of care. (Not Graded) termination of CRRT, defined as the absence of CRRT requirement for at least 14 days following cessation.567 Further prospective trials will be needed to support these RATIONALE findings. A large prospective observational study showed Many, but not all, patients requiring RRT will recover that, in 529 patients who survived the initial period of CRRT, enough function not to require long-term RRT. 21,394,561 313 were successfully removed from RRT, whereas 216 The mean duration of RRT in two recent large RCTs patients needed ‘‘repeat CRRT’’ within 7 days of discontinua- was 12–13 days.562,563 Thus, daily assessment of both tion. Multivariate logistic regression identified urine output intrinsic kidney function and the ongoing appropriate- as the most significant predictor of successful termination ness of RRT consistent with the goals of therapy for the (OR 1.078 per 100 ml/d). Not surprisingly, the predictive patient are required. More than 50% of patients with severe ability of urine output was negatively affected by the use AKI will not improve, despite appropriate therapy. The of diuretics.196 Another retrospective observational analysis incidence of withdrawal of life-support treatments in showed that, of a total of 304 patients with postoperative critically ill patients with multiorgan failure has increased AKI requiring RRT (IHD), 31% could be weaned for more over the last decade.564 In addition to vasoactive medication, than 5 days and 21% were successfully weaned for at least mechanical ventilation, and artificial nutrition, RRT is one of 30 days. Independent predictors for restarting RRT within the therapies most likely to be discontinued during with- 30 days were longer duration of RRT, a higher Sequential drawal of life support. In general, decisions to withdraw Organ Failure Assessment score, oliguria, and age 465 therapy occur in 10% of all patients from general ICUs, and years.568 In other words, urine output seems to be a very are responsible for roughly 40% of all deaths. Analysis of a important predictor of successful discontinuation of RRT. database of 383 AKI patients shows withdrawal of life Whether too-early discontinuation of RRT, requiring support in 72% of deaths.565 In another single-center reinstitution, is by itself harmful has not been properly retrospective study involving 179 AKI patients requiring investigated. The above-mentioned observational studies RRT, therapy was withheld or withdrawn in 21.2%.566 A found a higher mortality in patients who needed to be posthoc analysis of the BEST KIDNEY database showed that retreated with RRT (42.7% vs. 28.5%196 and 79.7% vs. CRRT was withdrawn in 13% of the patients, representing 40%568). It is, however, not clear whether failure to wean is 29% of those who died while on CRRT and 21% of all simply a marker of illness severity or contributed by itself to nonsurvivors.196 the adverse outcome. Assessment of kidney function during RRT is not easy and The process of stopping RRT may consist of simple will depend on the modality used. In IHD, the fluctuations of discontinuation of RRT, or may include a change in the Kidney International Supplements (2012) 2, 89–115 93
  • 97. chapter 5.2 modality, frequency, or duration of RRT. For example, Pediatric considerations switching from CRRT to IHD, or decreasing the frequency of The medical indications guiding discontinuation of RRT in IHD from daily to every other day, represents different children do not differ from adults, except in those instances methods of testing the ability of the patient’s own kidney to where RRT is initiated for pediatric-specific disease, such as take over. No specific guidance can be provided for how to inborn errors of metabolism to treat hyperammonemia557 or manage the transition of RRT from continuous to inter- immediately after surgical correction of congenital heart mittent. Evidence from large observational studies suggests disease to maintain euvolemia, and/or possibly mitigate the that large variation in practice exists.196 postbypass proinflammatory response.558 Prognosis in children who survive an AKI episode is 5.2.2: We suggest not using diuretics to enhance kidney significantly better than in adults, and many children may have function recovery, or to reduce the duration or several decades of life expectancy. Askenazi demonstrated nearly frequency of RRT. (2B) 80% 3- to 5-year survival for children discharged after an AKI episode from a tertiary center,569 yet two-thirds of deaths occur- red in the first 2 years after discharge, suggesting a high prob- RATIONALE ability of greater life expectancy after that period. In addition, no The role of diuretics in the prevention and treatment of AKI data exist to define a maximal RRT duration; even data from the has already been discussed in Chapter 3.4. Only one RCT has Prospective Pediatric CRRT Registry show 35% survival in evaluated the potential role of diuretics in resolving AKI in children receiving CRRT for 428 days.570 Finally, since pediatric patients receiving RRT. After the end of the CVVH session, AKI now results more often as a secondary phenomenon from the urine of the first 4 hours was collected for measuring another systemic illness or its treatment,552,553 determination of CrCl. Seventy one patients were subsequently randomized to the overall goals of therapy for children, as in for adults, must receive furosemide (0.5 mg/kg/h) or placebo by continuous take into consideration local standards, patient and family infusion, continued until CrCl reached 30 ml/min. Urinary wishes, as well as the probability of recovery of the underlying fluid losses were compensated by i.v. infusion. The primary illness leading to AKI and the need for RRT. end-point was renal recovery (CrCl 430 ml/min or stable SCr without RRT) in the ICU and in the hospital. CVVH RESEARCH RECOMMENDATIONS was restarted based on predefined criteria. Patients treated K Determine clinical parameters (e.g., parameters of kidney with furosemide (n ¼ 36) had a significantly increased function, fluid overload, hypercatabolism) that predict urinary volume and greater sodium excretion compared to successful discontinuation of RRT in AKI patients. placebo-treated patients (n ¼ 35). However, there were no K Determine biomarkers that may indicate renal recovery, differences in need for repeated CVVH, or renal recovery and whether their levels can be used to guide disconti- during ICU or hospital stay.195 An observational study of nuation of RRT. discontinuation of RRT also found no difference in diuretic K Determine more reliable predictors of long-term out- use between patents with successful or unsuccessful dis- comes (e.g., mortality, quality of life) in AKI patients continuation of IHD.568 In summary, diuretics may improve (including clinical severity scores, biomarkers, machine urine volume after RRT, but do not appear to have any learning techniques, or combinations of these), that— significant benefit in reducing the need for RRT or promoting after validation in large cohorts—could be helpful renal recovery from AKI. adjuncts in the decision to withdraw treatment. 94 Kidney International Supplements (2012) 2, 89–115
  • 98. http://www.kidney-international.org chapter 5.3 & 2012 KDIGO Chapter 5.3: Anticoagulation In patients with AKI requiring RRT, the contact of blood with flow rates, diffusive treatment, the reduction of blood-air the foreign surface of the extracorporeal circuit results in contact in the bubble trap, and assuring prompt reaction to activation of both the intrinsic and the extrinsic pathway of alarms.577,578 plasmatic coagulation and activation of platelets.571 Preven- Many patients with AKI require systemic anticoagulation tion of dialyzer/hemofilter clotting often requires some for their underlying diseases (e.g., artificial heart valve, acute form of anticoagulation, which may represent a particular coronary syndrome, atrial fibrillation). It is evident that, in challenge in patients with AKI. The need for continuous most instances, these patients will not require additional anticoagulation represents a potential drawback of CRRT. anticoagulation for RRT; however, this should be assessed on a case-by-case basis. 5.3.1: In a patient with AKI requiring RRT, base the 5.3.2: For patients without an increased bleeding decision to use anticoagulation for RRT on assess- risk or impaired coagulation and not already ment of the patient’s potential risks and benefits receiving effective systemic anticoagulation, we from anticoagulation (see Figure 17). (Not Graded) suggest the following: 5.3.1.1: We recommend using anticoagulation 5.3.2.1: For anticoagulation in intermittent RRT, during RRT in AKI if a patient does we recommend using either unfractio- not have an increased bleeding risk or nated or low-molecular-weight heparin, impaired coagulation and is not already rather than other anticoagulants. (1C) receiving systemic anticoagulation. (1B) 5.3.2.2: For anticoagulation in CRRT, we sug- gest using regional citrate anticoagula- tion rather than heparin in patients RATIONALE who do not have contraindications for The goal of anticoagulation with RRT is to prevent clotting of citrate. (2B) the filter and/or reduction in membrane permeability, and 5.3.2.3: For anticoagulation during CRRT in thus to achieve adequate RRT and to prevent blood loss in patients who have contraindications for the clotted filter. These benefits have to be weighed against citrate, we suggest using either unfractio- the risk of bleeding, and economic issues, such as workload nated or low-molecular-weight heparin, and costs. rather than other anticoagulants. (2C) Patients with impaired coagulation (e.g., thrombocytopenia, or prolonged prothrombin time or activated partial thrombo- plastin time [aPTT]), due to underlying diseases such as liver RATIONALE failure or dilution coagulopathy, may not benefit from Worldwide, unfractionated heparin is still the most widely additional anticoagulation for RRT. In two recent large trials used anticoagulant. Many European centers, however, have 50–60% of AKI patients requiring RRT were treated without switched from unfractionated to low-molecular-weight anticoagulant.562,563 While filter performance was not assessed, heparin for routine anticoagulation during IHD.579 Advan- adequate CRRT filter survival without anticoagulation has tages and disadvantages of each type of heparin are mostly been described in patients with coagulopathies.572–575 summarized in Table 19. However, no specific cut-off points have been determined for A recent meta-analysis of 11 RCTs comparing unfractio- platelet count, aPTT, International Normalized Ratio, fibrino- nated to low-molecular-weight heparin in chronic IHD gen, or other coagulation factors that would indicate the concluded that both are equally safe in terms of bleed- possibility to perform RRT without anticoagulation. On the ing complications (RR 0.96; CI 0.27–3.43) and as effective other hand, prolonged clotting times can also point to a con- in preventing extracorporeal thrombosis (RR 1.15; CI sumptive coagulopathy based on the presence of an activated 0.7–1.91).586 Mainly because of the convenience of using a coagulation. In these patients, frequent filter clotting will occur single bolus injection at the start of IHD, the reduced risk of and necessitate a switch to some form of anticoagulation.576 heparin-induced thrombocytopenia (HIT), and of long-term In patients that are treated without anticoagulation, side-effects such as abnormal serum lipids, osteoporosis, and special attention is required to non-anticoagulant strategies hypoaldosteronism, the European practice guideline for to prolong filter survival. These include a good functioning prevention of dialyzer clotting suggests using low-molecu- vascular access, the reduction of blood viscosity and lar-weight rather than unfractionated heparin in chronic hemoconcentration by saline flushes, predilution, high blood dialysis patients.587 Many European centers have extrapolated Kidney International Supplements (2012) 2, 89–115 95
  • 99. chapter 5.3 Impaired Yes Proceed without coagulation? anticoagulation Rec No 5.3.1.1 Underlying Yes Use anticoagulation condition requires adapted to this systemic anticoagulation? condition No Choose RRT CRRT Intermittent RRT Modality Recs No 5.3.2.2 Contraindication Regional Citrate & to Citrate? Anticoagulation 5.3.3.1 Yes No Rec Increased Heparin 5.3.2.3 Bleeding Risk? Yes Rec Proceed without 5.3.3.2 anticoagulation No Increased Heparin Bleeding Risk? Rec 5.3.2.1 Yes Proceed without anticoagulation Figure 17 | Flow-chart summary of recommendations. Heparin includes low-molecular-weight or unfractionated heparin. CRRT, continuous renal replacement therapy; RRT, renal replacement therapy. this to IHD for AKI, although studies in this setting are on the degree of kidney injury, and the dose and type of lacking. In patients with AKI, the dose of heparin for IHD low-molecular-weight heparin.590 The American College of and the target aPTT should be individualized according to Chest Physicians (ACCP) guidelines for antithrombotic and the presence or absence of coagulation abnormalities and/or thrombolytic therapy therefore suggest using unfractionated risk of bleeding.588,589 Monitoring should also include instead of low-molecular-weight heparin in patients with platelet count, allowing timely detection of HIT.581 Since severe renal insufficiency (CrCl o30 ml/min) who require low-molecular-weight heparins rely on the kidney as primary therapeutic anticoagulation, or to reduce the dose of low- route of elimination, patients with kidney injury are at risk molecular-weight heparin by 50%.580 The doses of low- of accumulation and bleeding complications, depending molecular-weight heparin that are required for IHD are 96 Kidney International Supplements (2012) 2, 89–115
  • 100. chapter 5.3 Table 19 | Overview of the advantages and disadvantages of different anticoagulants in AKI patients Anticoagulant Advantage Disadvantage References Heparin (unfractionated) Wide availability Narrow therapeutic index – risk of bleeding Large experience Unpredictable kinetics – monitoring required Short half-life HIT Antagonist available Heparin resistance 580,581 Monitoring with routine tests (aPTT or ACT) Low costs Low-molecular-weight More predictable kinetics Risk of accumulation in kidney failure heparin – Weight-based dosing possible More reliable anticoagulant response Monitoring requires nonroutine test (anti–Factor Xa) 580,582–584 – No monitoring required Single predialysis dose may be Different drugs not interchangeable sufficient in IHD Reduced risk of HIT Incomplete reversal by protamine In most countries more expensive than unfractionated heparin Citrate Strict regional anticoagulation Risk of accidental overdose with potentially fatal consequences – reduced bleeding risk Insufficient citrate metabolism in patients with reduced liver function and shock states resulting in accumulation with metabolic acidosis and hypocalcemia 585 Other metabolic complication (acidosis, alkalosis, hypernatremia, hypocalcemia, hypercalcemia) Increased complexity Requires strict protocol aPTT, activated partial thromboplastin time; ACT, activated clotting time; HIT, heparin-induced thrombocytopenia; IHD, intermittent hemodialysis lower than those required for therapeutic anticoagulation. The anticoagulant effect of sodium citrate relies on The doses of low-molecular-weight heparin, as provided by forming a complex with ionized calcium, thus removing an the manufacturers, should be adapted to the bleeding risk of essential component of the coagulation cascade. Part of the the individual patient. Dose reduction may also be required citrate is removed in the extracorporeal circuit. Citrate in patients receiving daily dialysis, which increases the risk reaching the systemic circulation is rapidly metabolized in of accumulation. Since many patients with AKI require the liver, muscle, and kidney, liberating the calcium and prophylaxis for deep-vein thrombosis, scheduling this producing bicarbonate. The buffering effect of sodium citrate prophylactic (or a slightly higher) dose at the beginning of is proportional to the sodium ions it contains: a mole of the dialysis session may serve the two purposes. Periodic trisodium citrate produces the same buffering effect as measurement of anti–Factor Xa levels may be useful with 3 moles of sodium bicarbonate; whereas preparations of prolonged use. citrate, including hydrogen citrate, have proportionally less Alternative anticoagulants for IHD include protease buffering effect. Extracorporeal losses of calcium have to be inhibitors such as nafamostate and platelet inhibitors such compensated by an exogenous infusion. Additional compli- as prostacyclin or its analogues. Randomized trials compar- cations of citrate are summarized in Table 19. Regional citrate ing these anticoagulants/antiaggregants with heparin in the anticoagulation requires a strict protocol, adapted to the local setting of IHD for AKI are not available, and their use in treatment modality and flow settings. The protocol should clinical practice is limited. Nafamostat is a protease inhibitor include instructions for the infusion of citrate and calcium, that is mainly used in Japan and not available in the USA or for the composition of the dialysate/replacement fluid, and Europe. Small observational trials in chronic dialysis patients for intensive metabolic monitoring, including acid-base with increased bleeding risk suggest a reduced bleeding status, sodium, and total and ionized calcium levels. incidence.591–593 Concerns with nafamostat include the Five randomized trials have compared citrate to heparins absence of an antidote, and side-effects such as anaphylaxis, during CRRT (Suppl Tables 31 and 32). For ethical reasons, hyperkalemia, and bone marrow suppression.594–596 Cross- these trials were performed in patients without increased over comparisons of prostacyclin with low-molecular-weight bleeding risk. The first trial by Monchi et al. used a crossover heparin in chronic dialysis patients show reduced effi- design to compare anticoagulation with unfractionated ciency.597 A small trial showed reduced bleeding complica- heparin or citrate in 20 patients treated with postdilution tions compared to low-dose heparin; however, at the expense CVVH. Patients with high bleeding risk, liver cirrhosis, and of slightly more premature terminations.598 Additional sensitivity to heparin were excluded. Forty-nine filters were drawbacks are systemic hypotension and the high costs. evaluated. Citrate was titrated to achieve a postfilter ionized Therefore, the routine use of alternative anticoagulants can calcium level below 1.20 mg/dl (0.3 mmol/l). The dosing not be recommended in patients with AKI. regimen of heparin consisted of a bolus of 2000 to 5000 U, Kidney International Supplements (2012) 2, 89–115 97
  • 101. chapter 5.3 followed by a continuous infusion of 500–2000 U/h, aiming the low-molecular-weight heparin, nadroparin. Again, patients at an aPTT of 60–80 seconds. Despite this rather high heparin with bleeding risk or liver cirrhosis were excluded. Nadroparin dose, the citrate group had a longer filter lifetime and less was started with a bolus of 2850 U followed by 380 U/h without spontaneous filter failure. Fewer patients in the citrate group further monitoring. Citrate (500 mmol/l) was administered at a required transfusion, and the number of transfused units was dose of 3 mmol per liter blood flow, without monitoring of also lower. One patient in the heparin group experienced postfilter ionized calcium. The primary outcomes were safety, bleeding and one patient in the citrate group had metabolic defined as the absence of adverse events necessitating disconti- alkalosis.599 nuation of the study anticoagulant, and efficacy, defined as circuit The second trial randomized 30 patients with AKI survival. Safety was significantly better in the citrate group with undergoing predilution continuous venovenous hemodiafil- only two patients requiring a change in anticoagulation regimen tration (CVVHDF) to anticoagulation with citrate or vs. 20 patients in the nadroparin group (P40.001). Adverse unfractionated heparin. Patients with contra-indications to events were citrate accumulation (n ¼ 1) and early clotting due to one of the two anticoagulants (mainly high bleeding risk/ protocol violation (n ¼ 1) in the citrate group, and bleeding severe coagulopathy or metabolic problems that might be (n ¼ 16) or severe thrombocytopenia (n ¼ 4) in the nadroparin aggravated by citrate) or who required systemic antic- group. Circuit survival did not significantly differ. A computer- oagulation for medical reasons were excluded. Heparin was driven combination of buffered and nonbuffered replacement titrated to achieve an aPTT of 45–65 seconds. Citrate was fluids was used in the citrate group, explaining why metabolic titrated to a postfilter ionized calcium between 1.0–1.40 mg/dl alkalosis occurred more frequently in the nadroparin group. (0.25–0.35 mmol/l). Two patients in each group crossed over Rather surprisingly, the authors also found an improved renal to the other anticoagulant and these filters were not included recovery and an improved hospital survival in the citrate group. in the analysis. The trial was stopped early after 79 filters This could not be attributed to differences in severity of illness, because of an advantage using citrate, which resulted in a nor in bleeding or transfusion requirement, and requires further significantly improved filter survival (124.5 hours vs. 38.3 investigation.603 hours; Po0.001). In addition, significantly less citrate- Metabolic complications were infrequent in these rando- anticoagulated filters were terminated for clotting (16.7% mized trials. In observational trials, the most frequent vs. 53.5%). The incidence of bleeding also tended to be lower metabolic complication is metabolic alkalosis, occurring in with citrate (RR 0.17; CI 0.03–1.04; P ¼ 0.06), but transfusion up to 50% of the patients.604–606 In recently published surveys requirement was not significantly different. Three patients in or large clinical trials, the use of regional citrate antic- the citrate group had metabolic alkalosis and two had oagulation is still limited to 0–20% of the patients/ hypocalcemia.600 treatments.562,563,607 The third trial randomized 48 patients with AKI, treated A major contra-indication for the use of citrate antic- with CVVH, to citrate or unfractionated heparin. Patients oagulation is severely impaired liver function or shock with requiring systemic anticoagulation for medical reasons and muscle hypoperfusion, both representing a risk of citrate patients with high bleeding risk, severe coagulopathy, circulatory accumulation. Markedly reduced citrate clearances and lower failure, liver failure, or hypocalcemia were excluded (n ¼ 12). ionized calcium levels have been found in patients with acute A total of 142 circuits was analyzed. Heparin was administered liver failure or with severe liver cirrhosis.608–610 These patients as a bolus of 3000–5000 U followed by a continuous infusion of were excluded in all the randomized trials. In patients at risk, 1500 U/h adjusted to achieve an aPTT of 50–70 seconds. Citrate intensified monitoring is recommendable. The ratio of total (500 mmol/l) was titrated to a postfilter ionized calcium to ionized calcium appears to be the best parameter to detect between 1.0–1.20 mg/dl (0.25–0.30 mmol/l). Neither circuit citrate accumulation611,612 with an optimal cutoff at 2.1.613 survival nor the reasons for disconnecting the CVVH circuit Another important drawback of citrate anticoagulation, that differed significantly between the two groups. However, the might influence the decision to implement it in routine number of major bleedings and the need for transfusion was clinical practice, is the increased complexity of the procedure, significantly greater in the heparin group. Two cases of with risk of metabolic complications and the need for a strict metabolic alkalosis were noted in the heparin group and two protocol adapted to the local RRT modality. We, therefore, episodes of hypocalcemia in the citrate group.601 Findings from only recommend the use of citrate for anticoagulation during two studies published after the cut-off date for our literature CRRT in patients that do not have shock or severe liver review are consistent with recommendation 5.3.2.2.601a,601b failure, and in centers that have an established protocol for A small randomized crossover study compared citrate citrate anticoagulation. anticoagulation to regional heparinization in 10 CVVH Unfractionated heparin still remains the most widely used patients. Both treatment arms had a relatively short filter life anticoagulant during CRRT,562,563,607 mostly administered as (13 hours for regional heparinization and 17 hours for a prefilter infusion, with large variability in the administered citrate) that did not differ significantly. No bleeding occurred doses. When choosing a dose of heparin, the clinician should in either group.602 realize that the relationship among heparin dose, aPTT, filter In the largest and most recent randomized trial, 200 patients survival, and bleeding complications is not straightfor- treated with postdilution CVVH were randomized to citrate or ward,574,614–619 but it is common practice to measure aPTT 98 Kidney International Supplements (2012) 2, 89–115
  • 102. chapter 5.3 for safety reasons and to adapt the target to the bleeding risk 5.3.3: For patients with increased bleeding risk who are of the patient. not receiving anticoagulation, we suggest the Only two small prospective RCTs have compared un- following for anticoagulation during RRT: fractionated to low-molecular-weight heparin for anti- 5.3.3.1: We suggest using regional citrate anti- coagulation during CRRT in patients with AKI and, thus, coagulation, rather than no anticoagula- no firm recommendations can be made. The first trial tion, during CRRT in a patient without randomized 47 patients with AKI or systemic inflammatory contraindications for citrate. (2C) response syndrome undergoing CVVHDF to heparin, start- 5.3.3.2: We suggest avoiding regional heparini- ing with a bolus of 2000–5000 U followed by an infusion of zation during CRRT in a patient with 10 U/kg/h titrated to an aPTT of 70–80 seconds, or to increased risk of bleeding. (2C) dalteparin administered as bolus of 20 U/kg followed by an infusion of 10 U/kg/h. The mean aPTT in the heparin group was 79 seconds. The mean anti–Factor Xa level, determined in RATIONALE six patients in the dalteparin group, was 0.49 U/ml. Only 37 The risk of bleeding is considered high in patients with recent of the 82 tested filters were stopped for coagulation. There (within 7 days) or active bleeding, with recent trauma or was no difference in filter survival (with electively discon- surgery (especially in head trauma and neurosurgery), recent tinued filters being censored). The mean time to filter failure stroke, intracranial arteriovenous malformation or aneurysm, was 46.8 hours in the dalteparin group and 51.7 hours in the retinal hemorrhage, uncontrolled hypertension, or presence heparin group (NS). Three patients in each group had of an epidural catheter. In these patients, the benefit of bleeding, with no difference in transfusion requirement anticoagulation may not outweigh the risk of bleeding, between the two groups. Daily costs, including the coagula- and they should (at least initially) be treated without tion assays, were 10% higher with dalteparin.620 anticoagulation, or with CRRT with regional citrate anti- The second trial used a crossover design in 40 patients coagulation. with normal coagulation parameters undergoing predilution We suggest performing RRT without anticoagulation in CVVH. Patients treated with unfractionated heparin received patients with increased bleeding risk. A possible exception a bolus of 30 U/kg followed by a continuous infusion of can be made for patients who do not have contraindications 7 U/kg/h titrated to achieve an aPTT of 40–45 seconds. for citrate. Randomized trials comparing citrate with Enoxaparin was given as an initial bolus of 0.15 mg/kg heparins have been performed in patients without increased followed by a continuous infusion of 0.05 mg/kg/h, adjusted bleeding risk. However, since citrate results in strictly regional to an anti–Factor Xa level of 0.25–0.30 U/ml. In the 37 anticoagulation, it seems reasonable to also suggest its use patients that completed both treatment arms, mean filter life during CRRT in AKI patients with increased bleeding risk. was 21.7 hours with heparin and 30.6 hours with enoxaparin Another approach to achieve regional anticoagulation is (P ¼ 0.017). A similar difference was found in the per- regional heparinization combining a prefilter dose of heparin, protocol analysis. The incidence of bleeding was low and not aiming at a prolongation of the extracorporeal aPTT, with different between the two anticoagulants. Filter life did not postfilter neutralization with protamine, aiming at normali- correlate with aPTT or anti–Factor Xa level. Costs were zing the systemic aPTT. This procedure has been described in similar in the two groups.616 Interestingly, these clinical chronic dialysis and CRRT,572,573,624,627,628 but has not been studies did not find a correlation between anti–Factor Xa studied with much scrutiny. It is cumbersome and difficult to levels and filter life, questioning the value of anti–Factor Xa titrate because heparin has a much longer half-life than monitoring with regard to efficacy.616,621 However, if used for protamine, inducing a risk of rebound. In addition, it exposes more than a few days, monitoring might be useful to detect the patient to the side-effects of both heparin (mainly the risk accumulation. of HIT) and protamine (mainly anaphylaxis, platelet dysfunc- Alternative anticoagulants for use during CRRT include tion, hypotension, and pulmonary vasoconstriction with right the protease inhibitor nafamostate and the platelet inhibitors, ventricular failure)629 and is therefore not recommended. prostacyclin and analogues. Both have a short half-life and a low MW, with the theoretical advantage of extracorporeal elimination and reduced systemic anticoagulation. Nafamo- 5.3.4: In a patient with heparin-induced thrombocytopenia stat is not available in the USA and Europe; there is no (HIT), all heparin must be stopped and we antidote and several side-effects (agranulocytosis, hyperkale- recommend using direct thrombin inhibitors (such mia, anaphylactoid reactions) have been described.594–596 A as argatroban) or Factor Xa inhibitors (such as few small trials showed improved filter survival during CRRT danaparoid or fondaparinux) rather than other or when adding prostaglandins to heparin compared to heparin no anticoagulation during RRT. (1A) alone.622–624 However, prostaglandins appear to have a 5.3.4.1: In a patient with HIT who does not have limited efficacy when used alone, induce systemic hypoten- severe liver failure, we suggest using sion,625,626 and are expensive. Their use during CRRT can argatroban rather than other thrombin therefore not be recommended. or Factor Xa inhibitors during RRT. (2C) Kidney International Supplements (2012) 2, 89–115 99
  • 103. chapter 5.3 RATIONALE frequently studied pediatric citrate protocol636–638 uses Immune-mediated HIT results from antibodies directed Anticoagulant Dextrose solution A (ACD-A, Baxter Health- against the complex of heparin and platelet factor 4, and care, USA), prescribed based on the blood flow rate: occurs in 1–3% of heparin-exposed patients. Its main clinical complication is the development of thrombocytopenia with ACD rate ðml=hÞ ¼ blood pump rate ðml= min  min =hÞÂ1:5 or without thrombosis.581 In patients with AKI undergoing CRRT, the diagnosis should therefore also be suspected in ACD-A is infused via a stopcock at the catheter-CRRT patients with repeated premature filter clotting.630 The circuit connection leading to the CRRT machine. Since our likelihood of having HIT can be predicted by the so-called prescribed blood pump flow is 200 ml/min, the resulting 4 T score, that includes the degree of thrombocytopenia, the ACD-A rate would be 300 ml/h. The second aspect of the timing of onset of the fall in platelet count, the presence citrate protocol provides prevention of citrate-induced of thrombosis or acute systemic symptoms, and the presence systemic hypocalcemia by providing a calcium chloride of other etiologies of thrombocytopenia.631 If HIT is likely, all continuous infusion (8 g calcium chloride per liter normal heparins have to be stopped, including any ‘‘heparin lock’’ saline) to the patient via a central line. The calcium chloride solutions for dialysis or other catheters. rate is also based on the blood pump rate: With regard to the diagnosis and management of HIT, we refer to the recent guideline of the ACCP581 and the Calcium chloride ðml=hÞ ¼ blood pump rate ðml= min  min =hÞÂ0:6 European best practice guideline on chronic dialysis.587 These guidelines recommend the use of therapeutic doses of an The goals of regional citrate anticoagulation are to alternative nonheparin anticoagulant in patients with strong maintain the circuit ionized calcium between 0.8 and suspicion of HIT. Candidates are the direct thrombin 1.6 mg/dl (0.2 and 0.4 mmol/l), and the patient’s systemic inhibitors lepirudin, argatroban, or bivaluridin, or the anti- ionized calcium in the normal physiologic range 4.4–5.2 mg/ thrombin-dependent Factor Xa inhibitors, danaparoid or dl (1.1–1.3 mmol/l). The circuit ionized calcium concentra- fondaparinix. Pharmacokinetic data and dosing guidelines tion is managed by adjustment of the citrate rate, while the for these alternative anticoagulants have been published for patient’s systemic ionized calcium concentration is managed IHD588,632 and CRRT.633 by adjustment of the calcium chloride rate. Argatroban is a direct thrombin inhibitor, is eliminated by the liver, has a short half-life, and can be monitored RESEARCH RECOMMENDATIONS with aPTT.634 A recent observational study on the use of K Randomized trials should compare unfractionated to argatroban for anticoagulation during continuous dialysis in low-molecular-weight heparin during IHD in patients 30 patients with AKI and HIT derived a dosing equation, with AKI. based on illness severity scores or by use of indocyanine green K Randomized trials should compare unfractionated to plasma clearance.635 Regional citrate anticoagulation has low-molecular-weight heparin during CRRT in patients been used along with reduced doses of argatroban or other with AKI. nonheparin anticoagulants in cases where bleeding occurs. K Randomized trials should compare citrate to unfractio- However, there are no published reports on this practice. nated to low-molecular-weight heparin during CRRT in patients with AKI. Pediatric considerations K Future trials should compare a strategy without anti- Standardized protocols have been well established for both coagulation against one of anticoagulation during CRRT. heparin and regional citrate anticoagulation in children K Outcomes of interest for trials testing different anti- receiving dialysis. The ppCRRT Registry Group has shown coagulation strategies with RRT in AKI are clinical that heparin- and citrate-based anticoagulation protocols end-points, including bleeding, renal recovery, mortality, have been shown to confer equitable filter survival in incidence of HIT, and surrogates such as circuit survival pediatric CRRT, and the use of either is clearly supported and efficiency of dialysis, metabolic complications, and over the use of no anticoagulation schemes.636 The main effects on the coagulation system. advantage of citrate anticoagulation was the prevention of systemic pharmacological anticoagulation of the patient, SUPPLEMENTARY MATERIAL which can be an issue in patients with multiorgan failure and Supplementary Table 31: Evidence profile of RCTs examining the effect sepsis. Calcium is a requisite cofactor in both the intrinsic of citrate vs. heparin/nadroparin in CRRT for AKI. Supplementary Table 32: Summary table of RCTs examining the effect and extrinsic coagulation cascades. Citrate functions by of citrate vs. heparin/nadroparin in CRRT for AKI. binding free calcium, thereby inhibiting coagulation in both Supplementary material is linked to the online version of the paper at the intrinsic and extrinsic coagulation pathways. The most http://www.kdigo.org/clinical_practice_guidelines/AKI.php 100 Kidney International Supplements (2012) 2, 89–115
  • 104. http://www.kidney-international.org chapter 5.4 & 2012 KDIGO Chapter 5.4: Vascular access for renal replacement therapy in AKI Functional vascular access is essential for adequate RRT. Basic duration of RRT for AKI was 12–13 days.562,563 This probably requirements are to ensure adequate and regular flow with does not justify the burden of an initial tunneled catheter in all low morbidity. Most studies on indwelling tunneled dialysis patients with AKI receiving RRT. Rather, selected use of tunneled catheters have been performed in chronic dialysis patients. catheters in patients who require prolonged RRT is warranted. For individuals requiring acute dialysis, the evidence on No recommendation can be given regarding the optimal dialysis catheters is more limited, but there is a body of timing to change the nontunneled-uncuffed catheter to a more literature on nondialysis central venous catheters (CVC) in permanent access. It seems reasonable to create a more intensive-care patients. Many of the recommendations for permanent access when recovery of kidney function is unlikely. patients requiring acute dialysis are, therefore, based on The optimal timing should take into account the increased risk extrapolation of evidence from tunneled dialysis catheters or of infection with untunneled catheters, but also the practical from nondialysis nontunneled CVC. issues related to the insertion of a tunneled catheter. Several configurations of dialysis catheter lumen and tip 5.4.1: We suggest initiating RRT in patients with AKI via have emerged over the years with no proven advantage of one an uncuffed nontunneled dialysis catheter, rather design over another. The outer diameter varies between 11 than a tunneled catheter. (2D) and 14 French and it is self-evident that larger sizes decrease the risk of inadequate blood flow. In order to provide an adequate blood flow and reduce the risk of recirculation, RATIONALE the tip of the catheter should be in a large vein (see Since most early catheter-related infections have a cutaneous Recommendation 5.4.2). This means that the optimal length origin, tunneling the catheter under the skin together with a is 12–15 cm for the right internal jugular vein, 15–20 cm for subcutaneous anchoring system, may reduce the risk of the left internal jugular vein, and 19–24 cm for the femoral infection. Tunneling also increases mechanical stability of vein.642–644 the catheter. On the other hand, the insertion of a tunneled In PD, the Tenckhoff catheter, a soft, silicone rubber cuffed catheter (TCC) is a cumbersome procedure that catheter with a polyester cuff, reduced early complications such requires expertise (mostly performed by surgeons or inter- as bowel perforation, massive bleeding, or leakage, and has ventional radiologists), time, and effort (mostly performed in become the standard for PD. Further modifications, including the operating room or radiology department), thus poten- the use of swan-neck catheters, T-fluted catheters, curled tially delaying initiation of RRT. The removal of TCCs is also intraperitoneal portions, dual cuffs, and insertion through the technically more difficult. rectus muscle instead of the midline, have been made to reduce A randomized trial compared the initial use of tunneled remaining complications such as peritonitis, exit/tunnel vs. nontunneled femoral catheters in 34 patients with AKI. infection, cuff extrusion, obstruction, and dialysate leaks.645,646 Failure to insert the TCC occurred in four patients (12%) Blind placement has been largely replaced by surgical that were excluded from the final analysis. In the remaining placement or placement guided by ultrasound/fluoroscopy, 30 patients, those with tunneled catheters had an increased laparoscopy, or peritoneoscopy.647–649 Continuous-flow PD insertion time and more femoral hematomas, but also less dictates the need for an efficient dual-lumen catheter or two dysfunction, fewer infectious and thrombotic complications, separate catheters with ports separated maximally.646 Outside and a significantly better catheter survival.639 The small size the pediatric setting, no investigations have specifically looked of this study and the absence of an intention-to-treat analysis at peritoneal catheters in the setting of AKI. preclude firm conclusions (Suppl Table 33). In addition, the use of tunneled catheters for starting acute dialysis is not 5.4.2: When choosing a vein for insertion of a dialysis widespread practice. catheter in patients with AKI, consider these Both the Centers for Disease Control (CDC) guidelines for preferences (Not Graded): prevention of catheter-related infections and the KDOQI K First choice: right jugular vein; guideline for vascular access in chronic dialysis patients K Second choice: femoral vein; recommend using a cuffed catheter for dialysis if a prolonged K Third choice: left jugular vein; (e.g., 41–3 weeks) period of temporary access is antici- K Last choice: subclavian vein with preference for pated.640,641 In two recent large randomized trials, the mean the dominant side. Kidney International Supplements (2012) 2, 89–115 101
  • 105. chapter 5.4 RATIONALE for femoral) but the study was not powered for this end- Although generally associated with the lowest rate of point. This was also the case for thrombotic complications infectious complications, the CDC guideline as well as the (Suppl Table 34).658 KDOQI guideline recommend avoiding the subclavian vein Malfunction is another issue that needs to be considered for RRT access,640,641 because this may lead to central vein when choosing between a jugular and femoral vascular stenosis and jeopardize subsequent permanent access. This access. Observational trials show more malfunctioning and a recommendation is mainly derived from observational data shorter actuarial survival for femoral than for jugular dialysis in ESRD patients showing a higher incidence of central vein catheters],659–661 and more malfunction with left-sided stenosis with subclavian than with jugular dialysis cathe- jugular catheters compared to right-sided.662 Recirculation ters.650,651 On the other hand, central vein stenosis has also has been shown to be more frequent in femoral than been described after jugular catheterization.652,653 Contact of subclavian or jugular dialysis catheters, especially with the catheter with the vessel wall is considered a primary shorter femoral catheters.642,643 A secondary analysis of the initiating event for catheter-related thrombosis and stenosis. French multicenter trial did not find a difference in catheter Catheters in the right internal jugular vein have a straight dysfunction between jugular and femoral catheters in the course into the right brachiocephalic vein and superior vena intention-to-treat analysis. However, a separate analysis of cava, and, therefore, the least contact with the vessel wall. A the right and left jugular catheters showed a trend toward catheter inserted through the subclavian or the left jugular more dysfunction with femoral than with right jugular vein has one or more angulations. explaining the higher risk catheters, but significantly more dysfunction with left jugular of vessel contact and thrombosis/stenosis with subclavian compared to femoral catheters.663 compared to jugular catheters,650,651 and with left-sided Another point to consider is that any patient who has the compared to right-sided jugular catheters.654–656 The sub- option of undergoing a kidney transplantation should not clavian vein should, therefore, be considered the last choice have a femoral catheter placed to avoid stenosis of the iliac for insertion of a dialysis catheter in patients with AKI, vein, to which the transplanted kidney’s vein is anato- especially when the risk of nonrecovery of kidney function is mized.640 The presence of a femoral catheter also reduces the substantial. Whether this recommendation should be ex- patient’s mobilization, especially when the RRT is contin- tended to the left jugular vein remains unclear. In patients uous. where the subclavian vein remains the only available option, In summary, the right jugular vein appears to be the best preference should be given to the dominant side in order to option for insertion of a dialysis catheter. Femoral catheters spare the nondominant side for eventual future permanent are preferred over left jugular catheters because of reduced access. malfunction, and the subclavian vein should only be Because the subclavian vein should be avoided, the considered a rescue option. It is evident that individual remaining options are the jugular and femoral veins. The patient characteristics may require deviations from this order use of femoral catheters is thought to be associated with the of preferences. Catheter insertion should be performed with highest risk of infection, and avoidance of femoral lines is strict adherence to infection-control policies, including part of many ‘‘central line bundles’’ that intend to reduce the maximal sterile barrier precautions (mask, sterile gown, incidence of catheter-related bloodstream infection.657 sterile gloves, large sterile drapes) and chlorhexidine 2% skin This dogma was questioned in a concealed, randomized, antisepsis.641,664,665 multicenter, evaluator-blinded, parallel-group trial of 750 AKI patients, comparing the femoral with the jugular site for 5.4.3: We recommend using ultrasound guidance for first catheter insertion for RRT. Ultrasound was seldom used, dialysis catheter insertion. (1A) probably explaining the somewhat higher rate of failure on one side and crossover in the jugular group. The rate of hematoma formation was also higher in the jugular group. RATIONALE In both groups, 20% of the catheters were antiseptic- For several decades, techniques involving the use of anatomic impregnated. Mean duration of catheterization was 6.2 days landmarks have been the traditional mainstay of accessing the for the femoral and 6.9 days for the jugular group. The major central venous system. Using the ‘‘blind’’ landmark technique reasons for catheter removal were death or ‘‘no longer is not without significant morbidity and mortality. Compli- required’’. The incidence of catheter colonization at removal cations of central venous catheterization include arterial (the primary end-point) was not significantly different puncture (0.5–6%), hematoma (0.1–4.4%), hemothorax between the femoral and jugular group. When stratified (0.4–0.6%), pneumothorax (0.1–3.1%), and up to 10–20% according to body mass index (BMI), those within the lowest of insertion attempts are not successful.666,667 In view of their BMI tertile had a higher incidence of colonization with the large size, the risk of complications of dialysis catheters is jugular site, whereas those within the highest BMI tertile had expected to be even higher. Two meta-analyses have the highest colonization rate with femoral catheters. Blood- addressed the role of real-time two-dimensional ultrasound stream infection did not differ between the groups (2.3 per for central vein cannulation, and concluded that, compared 1000 catheter-days for jugular and 1.5 per 1000 catheter-days to the landmark method, ultrasound-guided venous access 102 Kidney International Supplements (2012) 2, 89–115
  • 106. chapter 5.4 increases the probability of successful catheter placement and instructions on catheter care, the reader is referred to pub- reduces the risk of complications, the need for multiple lished guidelines.640,641,664,665 These guidelines also recom- catheter placement attempts, and the time required for the mend not using dialysis catheters for applications other than procedure. The advantage appears most pronounced for the RRT, except under emergency circumstances.641 jugular vein, whereas the evidence is scarce for the subclavian A recent meta-analysis of five RCTs confirmed that topical and femoral vein.668,669 Subsequent large randomized trials antibiotics (mainly mupirocin) reduce the risk of bacteremia, have confirmed the superiority of ultrasound guidance.670,671 exit-site infection, need for catheter removal, and hospitali- Trials evaluating the placement of dialysis catheters in ESRD zation for infection in ESRD patients.682 The majority of the patients, mostly with observational design, yield a similar catheters in the included studies were tunneled. However, the conclusion.672–678 The KDOQI guideline for vascular access CDC, National Health Service, and Infectious Diseases also recommends using ultrasound-assisted insertion.640 Society of America guidelines strongly recommend against topical antibiotic ointment for the care of CVC, because of 5.4.4: We recommend obtaining a chest radiograph their potential to promote fungal infections and antimicro- promptly after placement and before first use of an bial resistance.641,664,665 For patients with AKI that are treated internal jugular or subclavian dialysis catheter. (1B) in an ICU, it seems reasonable to follow this last recommen- dation. No recommendations can be given for AKI patients that are treated outside an ICU. RATIONALE Uncuffed, nontunneled dialysis catheters are semirigid. Their 5.4.6: We suggest not using antibiotic locks for preven- tip should not be in the heart, because of the risk of atrial tion of catheter-related infections of nontunneled perforation and pericardial tamponade. On the other hand, a dialysis catheters in AKI requiring RRT. (2C) position too high in the brachiocephalic vein, especially with subclavian and left-sided catheters, should also be avoided, because it allows a narrow contact between the catheter tip RATIONALE and the vessel wall, which may result in improper catheter Four meta-analyses have evaluated the efficacy of various function and vessel thrombosis.655,679,680 The correct position antibiotic lock solutions in chronic dialysis patients, and of the tip of a semirigid dialysis catheter is at the junction of conclude that they significantly reduce catheter-related the superior vena cava and the right atrium, allowing the bloodstream infection. Drawbacks are the overall moderate catheter to run in parallel with the long axis of the superior trial quality and the short follow-up that does not allow vena cava.679 Tunneled catheters are usually softer and can be excluding the development of resistance.682–685 However, the positioned into the right atrium, thus allowing a higher CDC, National Health Service, and Infectious Diseases blood flow.680 Society of America guidelines strongly recommend against To confirm the correct position and to assess for potential routinely using antibiotic lock solutions in CVC, because of complications, a postprocedural chest radiograph is conven- their potential to promote fungal infections, antimicrobial tionally performed. Although this procedure has been debated resistance, and systemic toxicity.641,664,665 Mentioned excep- after uneventful placement of a CVC, the high blood flows tions are long-term cuffed and tunneled catheters with used during RRT and the administration of anticoagulants history of multiple catheter-related bloodstream infections necessitate confirming the correct position before initiating despite maximal adherence to aseptic technique,641,665 dialysis therapy.640 It should, however, be remembered that patients with limited venous access and history of recurrent none of the radiographic landmarks (carina, right tracheo- catheter-related bloodstream infection, or patients with bronchial angle, etc) that are used to exclude intra-atrial tip heightened risk of severe sequelae from a catheter-related position are 100% reliable.679,680 Echocardiography might be bloodstream infection.664 another tool to confirm the correct position of the catheter.681 Pediatric considerations 5.4.5: We suggest not using topical antibiotics over the Most of the guidelines for adults are applicable to children. skin insertion site of a nontunneled dialysis cathe- Functional CRRT circuit survival in children is favored by ter in ICU patients with AKI requiring RRT. (2C) larger catheter size686 that should be adapted to patient size (Table 20).687 Recent data from the Prospective Pediatric CRRT Registry group shows that internal jugular catheters RATIONALE may be associated with longer functional CRRT circuit The incidence of catheter-related bloodstream infection can survival, compared to femoral and subclavian access.686 In be reduced by implementing education-based programs and addition, the Prospective Pediatric CRRT Registry group so-called central-line bundles, that emphasize the importance showed extremely poor circuit survival with two single- of hand hygiene, maximal barrier precautions upon inser- lumen 5 F catheters; these catheters should therefore be tion, chlorhexidine skin antisepsis, optimal catheter site avoided. Future permanent access in the form of an arterio- selection, and daily review of line necessity.657 For detailed venous graft or fistula for patients who develop CKD may be Kidney International Supplements (2012) 2, 89–115 103
  • 107. chapter 5.4 Table 20 | Catheter and patient sizes catheters.689 A more recent retrospective analysis with Patient size Catheter size Site of insertion historical controls reports that, compared to the surgically placed Tenckhoff catheter, using a more flexible catheter for Neonate Double-lumen 7F Femoral artery or vein percutaneous insertion may achieve a comparable catheter 3–6 kg Double- or triple-lumen 7F Jugular, subclavian, survival and complication rate.690 or femoral 6–30 kg Double-lumen 8F Jugular, subclavian, RESEARCH RECOMMENDATIONS or femoral 415 kg Double-lumen 9F Jugular, subclavian, K Determine whether the initial use of a tunneled vs. or femoral nontunneled catheter for RRT in AKI patients results in a 430 kg Double-lumen 10F or Jugular, subclavian, beneficial effect on catheter function and catheter-related triple-lumen 12F or femoral complications, including infections and number of Reprinted from Bunchman TE, Brophy PD, Goldstein SL. Technical considerations for additional access procedures. renal replacement therapy in children. Semin Nephrol 2008; 28: 488–492 687, copyright 2008, with permission from Elsevier; accessed http://www.seminarsinnephrology.org/ K Develop better means of predicting the need for long- article/S0270-9295(08)00117-4/fulltext term access and better methods to select access site in individual patients by balancing various risks and benefits. compromised if acute access is placed in a subclavian vein. Clinicians must therefore consider the potential long-term SUPPLEMENTARY MATERIAL vascular needs of patients who may be expected to develop Supplementary Table 33: Summary table of RCTs examining the effect CKD, especially children who have demonstrated excellent of access placement with tunneled versus non-tunneled catheters on long-term survival with CKD and ESRD.688 AKI. Supplementary Table 34: Summary table of RCTs examining the effect Analysis of a pediatric database (1989–1999) showed of jugular vs. femoral access placement on AKI. that surgically placed Tenckhoff catheters for PD induce Supplementary material is linked to the online version of the paper at less complications than more stiff percutaneously placed http://www.kdigo.org/clinical_practice_guidelines/AKI.php 104 Kidney International Supplements (2012) 2, 89–115
  • 108. http://www.kidney-international.org chapter 5.5 & 2012 KDIGO Chapter 5.5: Dialyzer membranes for renal replacement therapy in AKI Semipermeable hollow-fiber dialyzers are used as standard the synthetic membranes to cuprophane, there was a trend of care for both solute clearance and ultrafiltration in towards reduced mortality with the synthetic membranes. IHD and CRRT circuits. Membrane composition and This meta-analysis also did not assess the side-effects of clearance characteristics vary among the commercially different membrane compositions on more proximal, available dialyzers. While no RCTs exist to provide definitive temporal associations, such as acute hypotension or fever. recommendations for a particular dialyzer type, the charac- As a result, we agree with the authors’ conclusion that the use teristics and potential side-effects of each dialyzer type of either a biocompatible or modified cellulose acetate require consideration. membrane appears to be appropriate. Recent observations reveal specific potential side-effects 5.5.1: We suggest to use dialyzers with a biocompatible when using certain dialyzer membranes. Bradykinin release membrane for IHD and CRRT in patients with syndrome has been observed at the start of CRRT with AKI. (2C) uncoated AN-69 membranes.703 Bradykinin release syn- drome is characterized by acute hypotension and pulmonary vascular congestion. The syndrome is usually self-limited and RATIONALE is pH-dependent, and therefore more pronounced in patients Semipermeable hollow-fiber dialyzers currently represent the with severe acidosis. Also, priming of the circuit with banked standard of care for IHD or CRRT for patients with AKI. All blood (that is acidotic and contains a large amount of citrate, dialyzer membranes induce some degree of activation of inducing hypocalcemia) may evoke bradykinin release blood components, a phenomenon called bioincompati- syndrome. Numerous measures have been published to bility.691 Earlier-generation dialyzer membranes composed of prevent or mitigate this syndrome, including zero-balance cuprophane or unmodified cellulose were more bioincom- HF to normalize the banked blood pH and calcium,704 or a patible and had the potential to cause a ‘‘dialyzer membrane bypass maneuver in which the blood prime is given to the reaction’’, mediated by complement activation, release of patient instead of the circuit, while the patient is bled on to proinflammatory markers, and oxidative stress, and mani- the circuit with the saline prime discarded.705 Finally, a form fested clinically by acute hypotension, vasodilatation, leuco- of bradykinin release syndrome has been reported in patients penia, hypoxia and fever.692–697 More recently, modified receiving ACE-I and IHD with AN-69 membranes,706–708 cellulosic membranes (with substitution of the hydroxyl since ACE-I prevent the conversion of bradykinin and groups) and synthetic membranes composed of polyacyl- thereby prolong the hypotensive response when acidic blood nitrile, polysulfone, or poly(methyl methacrylate) have been comes in contact with the AN-69 membrane. However, developed. These ‘‘biocompatible membranes’’ (or less others have disputed this interaction.704,705 Nevertheless, bioincompatible membranes) produce less complement and clinicians should be aware of the potential for bradykinin cytokine activation, and decrease oxidative stress.697,698 release syndrome if an uncoated AN-69 membrane is Recent studies suggest that platelet activation might also employed for RRT, especially in acidotic patients or in those be involved in the bioincompatibility phenomenon.698–701 receiving ACE-I. Neutralizing the electronegativity of the Another membrane characteristic that might have clinical AN-69 membrane by coating with polyethyleneimine sig- importance is the flux property, with membranes generally nificantly reduces bradykinin generation.709 being divided in low-flux and high-flux, the latter having Whether conventional dialysis membranes are able to larger pores and thus the potential to clear larger solutes. affect clinical outcomes in sepsis by removal of inflammatory The question of whether membrane bioincompatibility or mediators remains highly controversial. Until further evi- flux has clinical relevance in the setting of AKI has been the dence becomes available, the use of RRT to treat sepsis should subject of many clinical trials. A recent meta-analysis of 10 be considered experimental. randomized or quasi-randomized controlled trials in 1100 patients could not establish any advantage for biocompatible or high-flux membranes.702 Of note, the authors chose to RESEARCH RECOMMENDATIONS include modified cellulose membranes in the bioincompa- K Future research should assess the impact of middle- tible group, although other investigators consider modified molecule clearance by high-flux membranes and/or cellulosic membranes to be biocompatible. When comparing membrane adsorption on patient outcome in sepsis. Kidney International Supplements (2012) 2, 89–115 105
  • 109. chapter 5.5 The comparator group should be patients with sepsis that remains unsettled, due to the relatively small size of trials. do not receive extracorporeal treatment (if no AKI) or It would be useful to conduct larger trials comparing conventional RRT (if AKI). different membranes and examining patient-centered K The potential impact of dialyzer membrane composition outcomes include survival, renal recovery, and resource (material, flux, etc.) on outcomes in patients with AKI utilization. 106 Kidney International Supplements (2012) 2, 89–115
  • 110. http://www.kidney-international.org chapter 5.6 & 2012 KDIGO Chapter 5.6: Modality of renal replacement therapy for patients with AKI Controversy exists as to which is the optimal RRT modality of toxins and the restricted treatment period, allowing for patients with AKI. In current clinical practice, the down-time for diagnostic and therapeutic interventions. choice of the initial modality for RRT is primarily based IHD may, therefore, be the preferred treatment in patients on the availability of, and experience with, a specific where immediate removal of small solutes is required, such as treatment and on the patient’s hemodynamic status. Transi- severe hyperkalemia, some cases of poisoning, and tumor tions between CRRT and IHD are also frequent, mostly lysis syndrome. Hybrid treatments, such as SLED, may share determined by the hemodynamic status of the patient or some of the advantages of both IHD and CRRT without coagulation problems. Experience with PD in AKI is limited, having their disadvantages (Table 22). except in the pediatric setting and in regions with limited Several RCTs have compared CRRT to IHD in AKI resources. patients. The most inclusive meta-analysis was performed by the Cochrane Collaboration, analyzing 15 RCTs in 1550 AKI 5.6.1: Use continuous and intermittent RRT as comple- patients. This analysis concluded that outcomes were similar mentary therapies in AKI patients. (Not Graded) in critically ill AKI patients treated with CRRT and IHD for hospital mortality (RR 1.01; 95% CI 0.92–1.12; n ¼ 1245), ICU mortality (RR 1.06; 95% CI 0.90–1.26; n ¼ 515), length RATIONALE of hospitalization (mean deviation À6.1; 95% CI À26.45 Current modalities of RRT for AKI include IHD, CRRT, and to À14.25; n ¼ 25), and renal recovery (free of dialysis on PD. An overview of the different modalities of RRT and their discharge) in survivors (RR 0.99; 95% CI 0.92–1.07; commonly used settings is given in Table 21. n ¼ 161).713 Comparable results have been reported by other Since the introduction of CRRT into clinical practice in meta-analyses.714,715 Individual studies used different defini- the early 1980 s, its use in critically ill patients with AKI has tions of AKI and were underpowered. Most of the trials increased steadily.710–712 The theoretical advantages of CRRT excluded patients with hypotension or maximized efforts to over IHD are the slower fluid removal, resulting in more improve the hemodynamic tolerance of IHD. The high rate of hemodynamic stability and better control of fluid balance, crossover between the treatment modalities also complicates the slower control of solute concentration, avoiding large the interpretation of the results. In addition, in some of the fluctuations and fluid shifts (including a reduced risk trials, IHD patients were treated with bioincompatible [worsening] of cerebral edema), the great flexibility (allowing membranes and studies were not standardized for treatment adaptation of the treatment to the patient’s need at any time), dose. A subsequent RCT not included in the Cochrane meta- and the ability to perform the treatment with relatively analyses reported similar outcomes.716 Two recent studies, simple and user-friendly machines (allowing ICU nurses to confined to single geographic regions, showed reduced costs monitor the treatment). Disadvantages include the need for with IHD compared to CRRT.717,718 However, an analysis of immobilization, the use of continuous anticoagulation, the cost ranges from a multicenter, multinational observational risk of hypothermia and, in some settings, higher costs. study found considerable heterogeneity in costs related to Major advantages of IHD over CRRT are the fast removal IHD and CRRT, and concluded that either therapy might be Table 21 | Typical setting of different RRT modalities for AKI (for 70-kg patient) SCUF CVVH CVVHD CVVHDF PD SLED IHD Blood flow (ml/min) 100–200 150–250 150–250 150–250 N/A 100–300 200–300 Predominant solute transport convection convection diffusion diffusion þ convection diffusion diffusion diffusion principle Ultrafiltrate (ml/h) 100–300 1500–2000 variable 1000–1500 variable variable variable Dialysate flow (ml/h) 0 0 1500–2000 1000–1500 1–2 l per exchange 100–300 ml/min 300–500 ml/min Effluent volume (l/d) 2–8 36–48 36–48 36–72 24–48 N/A N/A Replacement fluid for zero 0 1500–2000 0 1000–1500 0 0 0 balance (ml/h) Urea clearance (ml/min) 1–5 25–33 25–33 25–33 variable 80–90 variable CVVH, continuous venovenous hemofiltration; CVVHD, continuous venovenous hemodialysis, CVVHDF, continuous venovenous hemodialfiltration; IHD, intermittent hemodialysis; N/A, not applicable; PD, peritoneal dialysis; SCUF, slow continuous ultrafiltration; SLED, slow low-efficiency dialysis. Kidney International Supplements (2012) 2, 89–115 107
  • 111. chapter 5.6 Table 22 | Theoretical advantages and disadvantages of CRRT, IHD, SLED, and PD Modality Potential setting in AKI Advantages Disadvantages IHD Hemodynamically stable Rapid removal of toxins and low-molecular-weight Hypotension with rapid fluid removal substances Dialysis disequilibrium with risk of cerebral Allows for ‘‘down time’’ for diagnostic and edema therapeutic procedures Technically more complex and demanding Reduced exposure to anticoagulation Lower costs than CRRT CRRT Hemodynamically unstable Continuous removal of toxins Slower clearance of toxins Patients at risk of increased Hemodynamic stability Need for prolonged anticoagulation intracranial pressure Easy control of fluid balance Patient immobilization No treatment-induced increase of intracranial Hypothermia pressure Increased costs User-friendly machines SLED Hemodynamically unstable Slower volume and solute removal Slower clearance of toxins Hemodynamic stability Technically more complex and demanding Allows for ‘‘down time’’ for diagnostic and therapeutic procedures Reduced exposure to anticoagulation PD Hemodynamically unstable Technically simple Poor clearance in hypercatabolic patients Coagulopathy Hemodynamic stability Protein loss Difficult access No anticoagulation No control of rate of fluid removal Patients at risk of increased No need for vascular access Risk of peritonitis intracranial pressure Lower cost Hyperglycemia Under-resourced region Gradual removal of toxins Requires intact peritoneal cavity Impairs diaphragmatic movement, potential for respiratory problems CRRT, continuous renal replacement therapy; IHD, intermittent hemodialysis; PD, peritoneal dialysis; SLED, sustained low-efficiency dialysis. more or less costly depending on local practices, especially 95% CI 0.72–1.16; n ¼ 514). On the other hand, the mean staffing.719 arterial pressure at the end of the treatment was significantly Some large observational studies, including all patients higher with CRRT than with IHD (mean deviation 5.35; 95% receiving RRT, suggest that CRRT is an independent predic- CI 1.41–9.29; n ¼ 112) and the number of patients requiring tor of renal recovery among survivors.720–722 This evidence, escalation of vasopressor therapy was significantly lower however, is insufficient to fully elucidate the impact of choice with CRRT compared to IHD (RR 0.49; 95% CI 0.27–0.87; of therapy on this outcome. Appropriately planned prospec- n ¼ 149).713 In general, the number of patients included in tive trials will be required to address this issue. these analyses of the hemodynamic tolerance of RRT remains In conclusion, no RRT is ideal for all patients with AKI. limited, and none of the RCTs has specifically looked at the Clinicians should be aware of the pros and cons of different effect of different modalities of RRT in patients with shock. RRTs, and tailor RRT on the basis of the individual and SLED has been proposed as an alternative to other forms potentially changing needs of their patients. Besides the of RRT and is used in many centers worldwide for logistical individual patient’s characteristics, the available expertise and reasons. A recent review723 summarizes the results obtained resources may also be an important determinant of the with SLED in several studies and discusses in detail the ultimate choice. technical aspects of this dialysis method. However, rando- mized trials comparing IHD with SLED have not been 5.6.2: We suggest using CRRT, rather than standard performed. Also, clinical experience is far more limited with intermittent RRT, for hemodynamically unstable SLED compared to CRRT, and very few randomized studies patients. (2B) have compared SLED to CRRT. A first small trial in 39 AKI patients did not find any difference in hemodynamics, and less need for anticoagulation with SLED compared to RATIONALE CRRT.724 An (even smaller) Australian study showed similar Many clinicians prefer CRRT in critically ill AKI patients with control of urea, creatinine, and electrolytes, but a better severe hemodynamic instability, because of better hemo- control of acidosis and less hypotension during the first dynamic tolerance due to the slower fluid removal and hours of the treatment with CRRT.725,726 A recent retro- the absence of fluid shifts induced by rapid solute removal. spective analysis examined the mortality data from three The Cochrane meta-analysis could not establish a difference general ICUs in different countries that have switched their in the number of patients with (however poorly defined) predominant therapeutic dialysis approach from CRRT to hemodynamic instability (RR 0.48; 95% CI 0.10–2.28; SLED. This change was not associated with a change in n ¼ 205) nor with (variably defined) hypotension (RR 0.92; mortality.727 In addition, Fieghen et al.728 examined the 108 Kidney International Supplements (2012) 2, 89–115
  • 112. chapter 5.6 relative hemodynamic tolerability of SLED and CRRT in protocols: fixed dialysate sodium (140 mEq) and fixed ultra- critically ill patients with AKI. This study also compared the filtration rate vs. variable dialysate sodium (160 to 140 mEq) feasibility of SLED administration with that of CRRT and and variable ultrafiltration rate (50% in first third of the IHD. Relatively small cohorts of critically ill AKI patients in treatment and 50% in the last two-thirds of the treatment). four critical-care units included 30 patients treated with The variable sodium and ultrafiltration rate protocol CRRT, 13 patients with SLED, and 34 patients with IHD. achieved better hemodynamic stability, needed fewer inter- Hemodynamic instability occurred during 22 (56.4%) SLED ventions, and induced lesser relative blood volume changes, and 43 (50.0%) CRRT sessions (P ¼ 0.51). In a multivariable despite higher ultrafiltration rates. analysis that accounted for clustering of multiple sessions Schortgen et al.734 evaluated the effects of implementing within the same patient, the OR for hemodynamic instability specific guidelines aiming to improve IHD hemodynamic with SLED was 1.20 (95% CI 0.58–2.47) compared to CRRT. tolerance. The clinical practice algorithm included priming Significant session interruptions occurred in 16 (16.3%), the dialysis circuit with isotonic saline, setting dialysate 30 (34.9%), and 11 (28.2%) of IHD, CRRT, and SLED sodium concentration at 145 mEq/l, discontinuing vasodi- therapies, respectively. This study concluded that, in critically lator therapy, and setting dialysate temperature to below ill patients with AKI, the administration of SLED is feasible 37 1C. A total of 289 RRT sessions were performed in 76 and provides hemodynamic control comparable to CRRT. patients and compared to a historical series of 248 sessions in In conclusion, in the presence of hemodynamic instability 45 patients. Hemodynamic tolerance was better in the in patients with AKI, CRRT is preferable to standard IHD. guideline patients. They developed less systolic drop at and SLED may also be tolerated in hemodynamically unstable during RRT. They also had less hypotensive episodes and the patients with AKI in settings where other forms of CRRT are need for therapeutic interventions was less frequent. The not available, but data on comparative efficacy and harm are adoption of guidelines did not influence ICU mortality, but limited. Once hemodynamic stability is achieved, treatment death rate was significantly lower than predicted from illness may be switched to standard IHD. severity in the guideline patients, but not in the historical series subjects. Length of ICU stay was also reduced for 5.6.3: We suggest using CRRT, rather than intermittent survivors in the protocol-oriented group, as compared to the RRT, for AKI patients with acute brain injury or historical series of patients. other causes of increased intracranial pressure or generalized brain edema. (2B) Peritoneal dialysis In the developing world, the development of CRRT techniques has resulted in a substantial decline in the RATIONALE expertise with, and use of, PD for treatment of AKI. The In a patient with acute brain injury, IHD may worsen use of PD in AKI is mainly confined to pediatrics and in neurological status by compromising cerebral perfusion regions with limited resources, because of its ease of use, low pressure. This may be the result of a decrease of mean cost, and minimal requirements on infrastructure. Other arterial pressure (dialysis-induced hypotension) or an advantages include the lack of a need for vascular access and increase of cerebral edema and intracranial pressure (dialysis anticoagulation, the absence of a disequilibrium syndrome disequilibrium), and may jeopardize the potential for and the relatively good hemodynamic tolerance compared to neurologic recovery. Dialysis disequilibrium results from IHD. Disadvantages are the overall lower effectiveness the rapid removal of solutes, resulting in intracellular fluid (especially in patients with splanchnic hypoperfusion or shifts. Both hypotension and disequilibrium can be avoided who are on vasopressors), the risk of protein loss, the by the slow progressive removal of fluids and solutes that unpredictability of solute and fluid removal, the need for an occurs during CRRT.729 Small observational trials and case intact peritoneal cavity, risk of peritonitis, diaphragmatic reports in patients with intracranial pressure monitoring splinting leading to ventilatory compromise and fluctuating indeed reported increases in intracranial pressure with blood glucose levels. Recent developments in the technique of IHD.730,731 Using CT scans to measure brain density, Ronco PD (use of flexible and cuffed catheters, automatic cycling, et al.732 showed an increase of brain water content after IHD, and continuous flow PD) have increased its potential to whereas no such changes were observed after CRRT. become an acceptable alternative to other forms of RRT in AKI,735–737 but direct comparative effectiveness trials are Protocols for decreasing hemodynamic instability with extremely limited. Earlier reports on PD in AKI are mainly intermittent RRT uncontrolled observations. Only two relatively recent rando- Intradialytic hypotension is a major problem during RRT in mized trials have compared PD to other modalities of RRT in AKI patients, limiting its efficacy and causing morbidity. AKI. Phu randomized 70 patients with septic AKI to PD or Surprisingly, there are only a few studies assessing this highly continuous venovenous hemofiltration (CVVH) and found relevant clinical problem. Paganini et al.733 performed a a better survival with CVVH. However, the PD treat- small-sample (10 subjects) randomized crossover controlled ment appeared not to be ‘‘up to date’’ with use of a rigid trial in AKI patients. They evaluated two different RRT catheter, manual exchanges with open drainage and acetate Kidney International Supplements (2012) 2, 89–115 109
  • 113. chapter 5.6 buffering.738 The second trial compared daily IHD to high- use of adaptive CRRT equipment to production of high-flow volume PD (with Tenckhoff catheter and automated cycler) machines with volumetric control allowing for accurate and showed no difference in survival or recovery of kidney ultrafiltration flows has likewise lead to a change in pediatric function. The duration of RRT was significantly shorter in the RRT modality prevalence patterns in the USA. Accurate PD group (Suppl Table 35).739 However, this trial has not ultrafiltration and blood flow rates are crucial for pediatric been published in a peer-reviewed journal and the randomi- RRT, since the extracorporeal circuit volume can comprise zation process is unclear. Currently indications for PD in more than 15% of a small pediatric patient’s total blood patients with AKI may include bleeding diathesis, hemo- volume, and small ultrafiltration inaccuracies may represent a dynamic instability and difficulty in obtaining a vascular large percentage of a small pediatric patient’s total body access. Extremely high catabolism, severe respiratory failure, water. Polls of USA pediatric nephrologists demonstrate severe ileus, intra-abdominal hypertension, recent abdominal increased CRRT use over PD as the preferred modality for surgery and diaphragmatic peritoneum-pleura connections treating pediatric ARF. In 1995, 45% of pediatric centers are contraindications to PD. ranked PD and 18% ranked CRRT as the most common modality used for initial ARF treatment. In 1999, 31% of Pediatric considerations centers chose PD vs. 36% of centers reported CRRT as their RRT modality choice for children with AKI is guided by many primary initial modality for ARF treatment.745 of the same principles used for adult patients. However, since In the 1990 s, survival rates stratified by RRT modality were severe AKI is relatively rare in children compared to adults, better for children receiving IHD (73–89%) than those receiving occurring in less than 1% of hospitalized children740 and only PD (49–64%) or CRRT (34–42%).545,746 However, this analysis 4.5% of children admitted to an intensive care unit,741 the did not correct for illness severity. More recent data demon- impact of local expertise and resource restrictions may be strate much improved survival in children receiving greater for pediatric acute RRT modality decisions. As noted CRRT,543,544,546,570 with survival rates ranging from 50–70% below, each modality of acute RRT can be successfully for children with multiple-organ dysfunction who receive provided to pediatric patients of all sizes. Thus, with rare CRRT. While no RCT exists to assess the impact of CRRT exception driven by medical indication or contraindication, modality on survival, convective modalities were associated with no form of acute RRT can be recommended above another at increased survival in children with stem-cell transplants in a the present time. Each program should evaluate which prospective cohort study (59% vs. 27%, Po0.05).747 modality is provided most optimally and feasibly in its particular setting. RESEARCH RECOMMENDATIONS Provision of RRT as IHD, PD, or CRRT is now a mainstay K Large RCTs should compare SLED against other forms of of treatment for the child with severe AKI. The widely RRT in patients with AKI. These trials should be varying size range of pediatric patients imparts technical standardized for treatment dose, buffer, membrane, considerations in selection of a modality. Given their small anticoagulant, and timing of treatment. size and associated low blood volume, PD may provide the K The effects of different modalities of RRT on the long- least technically challenging option for infants and small term need for chronic dialysis, along with mortality, children. However, technological advances aimed at provid- should be evaluated in prospective randomized trials. ing accurate ultrafiltration with volumetric control incorpo- rated into IHD and CRRT equipment, and disposable lines, SUPPLEMENTARY MATERIAL Supplementary Table 35: Summary table of RCTs examining the effect circuits, and dialyzers sized for the entire pediatric weight of dialysis modality (continuous vs. intermittent RRT) in AKI. spectrum have made IHD and CRRT safer and feasible for Supplementary material is linked to the online version of the paper at children of all ages and sizes.570,742–744 Transition from the http://www.kdigo.org/clinical_practice_guidelines/AKI.php 110 Kidney International Supplements (2012) 2, 89–115
  • 114. http://www.kidney-international.org chapter 5.7 & 2012 KDIGO Chapter 5.7: Buffer solutions for renal replacement therapy in patients with AKI One goal of CRRT is to maintain normal or near-normal that lactate may not be rapidly metabolized in the setting of acid-base balance, thus preventing detrimental effects of multiple-organ failure.749 Since lactate is a strong anion, acidosis on cardiovascular performance and hormonal insufficient lactate conversion will result in worsening response. Options for correction of metabolic acidosis acidosis, especially since bicarbonate losses are ongoing in include the use of acetate-, lactate-, and bicarbonate- the extracorporeal circuit. Hyperlactatemia has also been containing replacement solutions or dialysate. Some centers linked to impaired cellular function and catabolism due to use citrate anticoagulation, and the citrate load provides an lowering of the cellular redox state and phosphorylation adequate supply of anionic base to control metabolic potential.750 In addition, iatrogenic increases in lactate levels acidosis. Dialysate solutions for IHD are produced on-line may lead to misinterpretation of the clinical situation. The by the dialysis machine, by mixing specially treated risk of ‘‘lactate intolerance’’ is highest in patients with liver municipal water with electrolytes. Dialysate or replacement failure (impaired lactate clearance) or circulatory shock solutions for CRRT are produced commercially or locally in (increased endogenous lactate production). hospital pharmacies. Few adequately designed trials have compared different buffers during RRT in AKI patients, and most of them have 5.7.1: We suggest using bicarbonate, rather than lactate, been performed during CRRT. Barenbrock et al.751 rando- as a buffer in dialysate and replacement fluid for mized 117 AKI patients to CVVH with lactate or bicarbonate RRT in patients with AKI. (2C) replacement fluid. The use of bicarbonate resulted in better 5.7.2: We recommend using bicarbonate, rather than correction of acidosis and lower lactate levels. Also, the lactate, as a buffer in dialysate and replacement incidence of hypotension and other cardiovascular events was fluid for RRT in patients with AKI and circulatory lower with bicarbonate. In the subgroup of patients with shock. (1B) cardiac failure, mortality tended to be lower with bicarbo- 5.7.3: We suggest using bicarbonate, rather than lactate, nate, whereas in the subgroup of septic patents no difference as a buffer in dialysate and replacement fluid for in outcome was found (Suppl Table 36). A nonrandomized RRT in patients with AKI and liver failure and/or crossover study in 54 patients with multiple-organ dysfunc- lactic acidemia. (2B) tion undergoing CVVHDF confirmed the superior control of acidosis and better hemodynamic tolerance with bicarbo- nate.752 However, another RCT in 40 patients treated with RATIONALE CVVH could not find a difference in hemodynamic Options for correction of metabolic acidosis in patients with tolerance, despite the higher lactate levels in the lactate- AKI include acetate, lactate, bicarbonate, and citrate. The use buffered group.753 Differences in the case-mix may explain of acetate has been largely abandoned in view of the these different results. associated hemodynamic instability and weight loss, probably Two small prospective randomized crossover comparisons related to excessive nitric oxide production and cytokine of bicarbonate- and lactate-buffered solutions in AKI patients synthesis.748 Citrate, used for regional anticoagulation of the treated with CVVH or CVVHDF found elevated serum extracorporeal circuit, is alkalinizing, and most patients lactate levels with lactate, an effect that was more pronounced receiving citrate anticoagulation do not need an additional in patients with hepatic insufficiency.754,755 An observational buffer in the dialysate or replacement fluid. trial in 27 patients found a compromised lactate tolerance in Original HF solutions contained lactate as a buffer. Under patients with coincidental liver disease, those on inotropic normal circumstances, this lactate is metabolized, resulting in support, and in patients with initial blood lactate measure- adequate correction of acidosis in most patients. A survey in ments of 490.1 mg/dl (410 mmol/l) and large base 34 Australian ICUs concluded that 55% of the ICU patients deficits.756 with AKI were treated with lactate-based solutions710 that, in In conclusion, the use of bicarbonate as a buffer in the most countries, are less expensive than bicarbonate solutions. dialysate or replacement fluid of AKI patients results in better In addition, bicarbonate solutions have a higher risk of correction of acidosis, lower lactate levels, and improved bacterial contamination and the solution is unstable in the hemodynamic tolerance. This effect is most pronounced in presence of calcium and magnesium. However, in recent patients with circulatory problems and in those with liver years, bicarbonate has gained popularity because of concerns dysfunction. Kidney International Supplements (2012) 2, 89–115 111
  • 115. chapter 5.7 Table 23 | Microbiological quality standards of different regulatory agencies ANSI/AAMI/ISO763–765 ERA-EDTA guidelines765a Water for dialysis Bacteria (CFU/ml) o100 (action level at 50) o100 Endotoxin (EU/ml) o0.5 o0.25 Dialysate Bacteria (CFU/ml) o100 (action level at 50) o100 Endotoxin (EU/ml) o0.5 o0.25 Ultrapure dialysate Bacteria (CFU/ml) o0.1 o0.1 Endotoxin (EU/ml) o0.03 o0.03 Substitution fluid for infusion Bacteria (CFU/ml) Sterile o10À6 Endotoxin (EU/ml) Undetectable o0.03 AAMI, Association for the Advancement of Medical Instrumentation; ANSI, American National Standards Institute; CFU, colony-forming units; ERA-EDTA, European Renal Association—European Dialysis and Transplant Asssociation; EU, endotoxin units; ISO, International Organization for Standardization. 5.7.4: We recommend that dialysis fluids and replacement commercial) fluids and circuitry during CRRT.760,761 Dialysate fluids in patients with AKI, at a minimum, comply for CRRT should preferably be ultrapure, and should at least with American Association of Medical Instrumen- comply with quality standards for dialysis water and dialysis tation (AAMI) standards regarding contamination fluids that may differ worldwide (Table 23).762 with bacteria and endotoxins. (1B) Finally, an international quality standard for dialysis fluid is in preparation by the International Society for Standardi- zation. Until international standards are in place, we RATIONALE recommend that dialysis fluids and replacement fluids in Replacement fluids for HF or HDF are infused directly into patients with AKI, at a minimum, comply with AAMI the patient’s circulation and should be sterile. A potential standards for bacteria and endotoxins. When local standards major step forward in acute RRT, reducing the costs and the exceed AAMI standards, local standards should be followed need for storage of fluids, is the on-line production of (Table 23). replacement fluids, which is achieved by passing water and/or dialysate through two or three ultrafilters before being RESEARCH RECOMMENDATION infused.757,758 On-line production of replacement fluids has K Further studies are required to explore the impact of on- not yet been approved by the FDA or by some regulatory line preparation of replacement fluid for HDF on clinical authorities in Europe. outcomes (incidence of sepsis, renal recovery, mortality) Conventional IHD uses nonsterile dialysate, as there is no in AKI patients requiring RRT. direct contact between blood and dialysate. However, with the use of high-permeability membranes, the lower blood side SUPPLEMENTARY MATERIAL pressures at the end of the dialyzer filter may allow back- Supplementary Table 36: Summary table of RCTs examining the effect of bicarbonate vs. lactate as buffer for CVVH replacement fluid on filtration of dialysate to the blood,759 raising the possibility of acidosis in AKI. endotoxin or other contaminant exposure. Two studies Supplementary material is linked to the online version of the paper at confirmed microbial contamination of (locally prepared and http://www.kdigo.org/clinical_practice_guidelines/AKI.php 112 Kidney International Supplements (2012) 2, 89–115
  • 116. http://www.kidney-international.org chapter 5.8 & 2012 KDIGO Chapter 5.8: Dose of renal replacement therapy in AKI The first report of RRT in AKI was published in 1965.766 nutrition, presence of liver disease, sepsis, muscle injury, Despite more than six decades of clinical experience and drugs, etc. research, controversy remains about the best way to measure Several clinical investigations have shown that the actual and what constitutes optimal dose of RRT for patients with delivered dose of RRT in AKI patients is frequently smaller AKI. Indeed, three of the top five questions considered most than the prescribed dose, and even smaller than the relevant by an international expert’s panel on RRT delivery in recommended minimum for CKD patients.771,773,776–778 AKI were about dose.767 Impediments to adequate dose delivery were hemodynamic The methods used for RRT dose quantification in AKI instability, patient size, access problems, technical problems, have several limitations, and have not been fully validated in need for patient transportation, and early filter clotting. this specific population. Earlier single-center trials assessing Trials studying dose in CRRT have used the amount the effects of RRT dose in AKI provided conflicting of effluent volume normalized by the patient’s weight results.531,768–772 Considering the complexity of AKI patients, and procedure time as a parameter for dose evaluation. RRT dose, by itself, may have less impact on mortality both However, the actual effluent flow will be influenced by in patients with very high or very low chance of surviving, interruptions of CRRT, and effluent flow will exceed actual but may be most important in patients with intermediate dose with use of predilution or with reductions in mem- scores of disease severity.773 In addition, it is possible that brane permeability during the treatment. In summary, it is dose and timing are closely linked factors, i.e., a high RRT essential to check very carefully if the prescribed RRT dose dose may not work adequately if provided late, or an early is really being delivered to AKI patients. Increasing filter RRT starting may not be able to change outcomes if the dose size, dialysis time, blood flow rate, dialysate flow rate, and/or is not optimized. Currently, only one small RCT considered effluent flow rate should be considered in case of dose both variables at the same time.531 inadequacy. In determining a prescription of RRT it is mandatory to 5.8.1: The dose of RRT to be delivered should be consider parameters other than small-solute clearance, such prescribed before starting each session of RRT. as patients’ fluid balance, acid-base and electrolyte home- (Not Graded) We recommend frequent assessment ostasis, and nutrition, among others, as possible components of the actual delivered dose in order to adjust the of an optimal RRT dose. In fact, positive fluid balance prescription. (1B) appears to be an independent risk factor for mortality in AKI 5.8.2: Provide RRT to achieve the goals of electrolyte, patients.83 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) RATIONALE 5.8.4: We recommend delivering an effluent volume of The judgment and awareness of how much of a particular 20–25 ml/kg/h for CRRT in AKI (1A). This will therapeutic procedure should be, and actually it is, delivered usually require a higher prescription of effluent is essential for a good medical practice. However, recent volume. (Not Graded) surveys have shown a disappointingly low number of physicians that report being aware of, or calculating, RRT dose in AKI.774 RATIONALE Although widely used for evaluation of RRT in CKD, Kt/V Three RCTs evaluated the dose of IHD in AKI (Suppl Tables urea has important limitations as a tool for RRT dosing in 37 and 38). Schiffl et al.771 compared daily to alternate-day AKI. AKI patients are metabolically unstable, with variations IHD in 146 ICU patients with AKI. RRT was started with in urea generation. In addition, their urea volume of rather high values of SCr (over 4.5 mg/dl [398 mmol/l]) and distribution appears to exceed the patient’s total body-water BUN (around 90 mg/dl [32.1 mmol/l urea]). The daily arm volume.775 Different ways to measure Kt/V obtained received a weekly Kt/V approximately two times higher than significantly different results in AKI patients.776 In the same the alternate-day arm (5.8 ± 0.6 vs. 3 ± 0.6, respectively). way, the selection of a target serum urea level as an indicator Daily IHD resulted in lower mortality (28% vs. 46%, of dialysis dose is highly arbitrary, as serum urea is influenced P ¼ 0.01) and faster recovery of kidney function (9 ± 2 vs. by several extrarenal factors, such as ethnicity, age, gender, 16 ± 6 days, P ¼ 0.001). Major limitations of this study were Kidney International Supplements (2012) 2, 89–115 113
  • 117. chapter 5.8 inadequate randomization, a ‘‘very low dose’’ in the control compared to 1.16.781 If we assume that AKI patients should group (actually less than that recommended for CKD). Also receive at least the same dose as CKD patients, it seems overall mortality in the study (34%) was lower than in other reasonable to recommend a thrice-weekly Kt/V of 1.3 or a studies in this population, suggesting that the results may not weekly Kt/V of 3.9 (assuming at least thrice-weekly generalize. Moreover, alternate-day IHD was associated with treatment), which also represents the lowest dose in the significant differences in fluid removal and dialysis-associated largest randomized trial in AKI (ARFTN study). Whether hypotension, suggesting that aspects other than solute specific subgroups of AKI patients, such as those with control might modify patient outcomes. hypercatabolism, may benefit from higher doses will require The Veterans Affairs/National Institutes of Health Acute further investigation. Renal Failure Trial Network (ARFTN) study563 was a RCT In conclusion, there are only two adequately designed and assessing the effects of intensive compared to less-intensive executed RCTs testing intermittent or extended RRT dose in RRT in 1124 ICU patients with AKI in 27 Veterans Affairs– AKI. Neither study showed improvement in mortality or renal and university-affiliated North-American centers. Within recovery when the dialysis dose was increased, either by each randomization arm patients were switched between increasing Kt/V above 3.9 weekly or by achieving a plasma urea IHD and CRRT or SLED, based on their hemodynamic target below 90 mg/dl (15 mmol/l) in AKI patients. However, status, reflecting average clinical practice in the USA. consistent with the data on dose of IHD in CKD, and consistent Intermittent treatments were prescribed at a Kt/V of 1.4, with the lower-dose arm in the ARFTN study, we recommend with a delivered Kt/V averaging 1.3, and were performed thrice-weekly Kt/V of 1.3 or a weekly Kt/V of 3.9 for IHD in AKI. three (less-intensive arm) or six (more-intensive arm) times Seven RCTs have investigated the role of CRRT dose in per week. Consequently, the weekly Kt/V was approximately AKI (Suppl Tables 37 and 38).531,562,563,768–770,772 While 6.5 in the intensive and 3.9 in the less-intensive arm. earlier single-center trials showed mixed results, two large Mortality at 60 days was similar in both groups (53.6% and multicenter trials have reached remarkably consistent con- 51.5%) as was the percentage of patients recovering kidney clusions concerning the dose of CRRT that should be function (15.4% and 18.4%). Limitations of this study provided to critically ill patients with AKI. include the predominance of males, and the nonstandardized The ARFTN study563 compared standard-intensity timing for initiating RRT. In addition, a significantly higher predilution CVVHDF with a prescribed effluent flow of frequency of hypotension and electrolyte disturbances were 20 ml/kg/h to high-intensity CVVHDF at 35 ml/kg/h. As dis- seen in the more-intensive arm. Similar to what has been cussed in Recommendation 5.8.3 rationale, there were no reported in chronic dialysis, acute IHD results in under- differences in outcomes between the two study arms. dosing when Kt/V is not measured. In the ARFTN study, the Importantly, more than 95% of the prescribed dose of CRRT first session of IHD had an average delivery of 1.1 Kt/V, while was delivered in the less-intensive group. This represents a the prescribed dose was 1.4. considerably greater intensity of delivered dose than is The Hannover Dialysis Outcome Study768 randomized typically seen in clinical practice. As in chronic dialysis, 148 ICU patients with AKI to two different doses of SLED: a studies in CRRT have shown that delivery usually falls standard-dialysis arm dosed to maintain plasma urea levels substantially short of the prescribed dose.782 Thus, it will between 120–150 mg/dl (20–25 mmol/l), or an intensified- usually be necessary to prescribe a high dose of CRRT in dialysis arm dosed to maintain plasma urea levels o90 mg/dl order to achieve a specific target. For example, in order to (o15 mmol/l). Patients were included with SCr around achieve a delivered dose of 20–25 ml/kg/h, it is likely that the 3 mg/dl (265 mmol/l) and plasma urea around 60 mg/dl prescription will need to be in the range of 25–30 ml/kg/h. (10 mmol/l). The mean plasma urea was kept at 68 ± The Randomized Evaluation of Normal vs. Augmented Level 24 mg/dl (11.3 ± 4 mmol/l) in the intensified and 114 ± of RRT study was conducted in 35 centers in Australia and 36 mg/dl (19 ± 6 mmol/l) in the standard group. Mortality New Zealand.562 It compared the effects of postdilution at 28 days was not statistically different between groups CVVHDF at doses of 25 and 40 ml/kg/h on 28- and 90-day (38.7% and 44.4%) and the frequency of survivors recovering mortality rates in 1464 AKI patients. The delivered dose was kidney function at day 28 was very similar (63% and 60%). 88% and 84% of prescribed in the low- and high-dose In CKD, the analysis by Gotch and Sargent779 of the groups, respectively. As in the ARFTN study, there was no National Cooperative Dialysis Study showed that survival difference in 28- or 90-day mortality between the two groups. could be increased by increasing Kt/V to 1.0–1.2. Analysis of a Apart from a higher incidence of hypophosphatemia in the large database of 2311 Medicare IHD patients also showed a high-dose group, the complication rate was similar.562 strong association between the delivered IHD dose and In conclusion, there are now consistent data from two mortality, with a decreased mortality risk of 7% for each 0.1 large multicenter trials showing no benefits of increa- higher level of delivered Kt/V in CKD patients. However, sing CRRT doses in AKI patients above effluent flows of above a Kt/V of 1.3, no further decrease in mortality was 20–25 ml/kg/h. In clinical practice, in order to achieve a noted.780 The HEMO study, a large RCT comparing two delivered dose of 20–25 ml/kg/h, it is generally necessary to different dialysis doses in CKD, also could not demonstrate a prescribe in the range of 25–30 ml/kg/h, and to minimize further reduction of mortality with equilibrated Kt/V of 1.43 interruptions in CRRT. 114 Kidney International Supplements (2012) 2, 89–115
  • 118. chapter 5.8 Additional considerations necessarily mean efficiency), assessing control of BUN, In patients who do not achieve the target dose of RRT, creatinine, fluid balance, and acid-base and electrolyte despite optimization of the initial modality, a switch to status. The comparators might be different efficiency another modality or the combination of different modalities targets. The suggested outcomes are 60- to 90-day morta- should be considered. lity, need for vasopressor drugs, time on mechanical Although there are insufficient data supporting a ventilation, ICU and hospital stay, and renal recovery. recommendation for elevated RRT doses in patients with AKI and septic shock, limited data suggest that a higher SPONSORSHIP dose might be beneficial in some patients. A small single- KDIGO gratefully acknowledges the following sponsors that center RCT was conducted in 20 patients with septic shock make our initiatives possible: Abbott, Amgen, Belo Founda- and AKI. Patients were randomized to either high- tion, Coca-Cola Company, Dole Food Company, Genzyme, volume (effluent flow of 65 ml/kg/h) or low-volume CVVH Hoffmann-LaRoche, JC Penney, NATCO—The Organization (effluent flow of 35 ml/kg/h). The primary end-point was for Transplant Professionals, NKF—Board of Directors, vasopressor dose required to maintain mean arterial pressure Novartis, Robert and Jane Cizik Foundation, Shire, at 65 mm Hg. Mean norepinephrine dose decreased more Transwestern Commercial Services, and Wyeth. KDIGO is rapidly after 24 hours of high-volume as compared to supported by a consortium of sponsors and no funding is low-volume CVVH treatment. Survival on day 28 was not accepted for the development of specific guidelines. affected.783 DISCLAIMER RESEARCH RECOMMENDATIONS While every effort is made by the publishers, editorial board, K Determine the optimal dose parameter that should be and ISN to see that no inaccurate or misleading data, opinion used in future trials comparing different intensities of or statement appears in this Journal, they wish to make it dialysis in AKI patients. Some possible methods to clear that the data and opinions appearing in the articles and explore are on-line Kt/V urea, urea reduction ratios, or advertisements herein are the responsibility of the contri- application of the concept of corrected equivalent renal butor, copyright holder, or advertiser concerned. Accord- urea clearance for solute removal measurement and ingly, the publishers and the ISN, the editorial board and ultrafiltration effluent volume, or substitution fluid their respective employers, office and agents accept no volume normalized by body weight and time for CRRT. liability whatsoever for the consequences of any such Other aspects of intensity should also be studied, e.g., inaccurate or misleading data, opinion or statement. While fluid control and acid-base and electrolyte balance. The every effort is made to ensure that drug doses and other comparators might be the standard ways to measure dose quantities are presented accurately, readers are advised that as Kt/V or prescribed effluent volume. Suggested outcome new methods and techniques involving drug usage, and parameters are 60- to 90-day mortality, ICU and hospital described within this Journal, should only be followed in LOS, and recovery of kidney function. conjunction with the drug manufacturer’s own published K Determine the optimal dose of RRT in AKI in homo- literature. geneous subpopulations, such as cardiac surgery or sepsis patients, and separately in ICU and non-ICU patients. SUPPLEMENTARY MATERIAL Future RCTs should be controlled for timing of RRT Supplementary Table 37: Evidence profile of RCTs examining the effect initiation and, perhaps, for general care of patients of dose of continuous and intermittent RRT on AKI. Supplementary Table 38: Summary table of RCTs examining the effect (antibiotics, nutrition, kind and indication for vasoactive of dose of continuous and intermittent RRT on AKI. drugs, mode of mechanical ventilation). Studies should Supplementary material is linked to the online version of the paper at also assess the efficiency of RRT (since dose does not http://www.kdigo.org/clinical_practice_guidelines/AKI.php Kidney International Supplements (2012) 2, 89–115 115
  • 119. biographic and disclosure information http://www.kidney-international.org & 2012 KDIGO Biographic and Disclosure Information Kidney International Supplements (2012) 2, 116–121; doi:10.1038/kisup.2011.36 John A Kellum, MD, FCCM, FACP (Work Group Co-Chair), contributions to improving and implementing KDOQI is Professor of Critical Care Medicine, Medicine, Bio- Guidelines. He also served as the KDIGO Co-Chair from engineering and Clinical and Translational Science, and Vice 2004 to 2007. Chair for Research within the Department of Critical Care Dr Lameire reported no relevant financial relationships. Medicine at the University of Pittsburgh. In addition, he is the Director of the Program on Bioengineering and Organ Peter Aspelin, MD, PhD, received his basic training in Support for the CRISMA (Clinical Research Investigation ¨ radiology at Malmo University Hospital (Lund University) and Systems Modeling of Acute Illness) Center at the and was Associate Professor there for 13 years. In 1989 he University of Pittsburgh. became Professor and Chairman of the Department of Dr Kellum is actively involved in education, research, and Radiology at Karolinska Institutet, Huddinge University administration. His research interests span various aspects Hospital. Professor Aspelin was Vice Dean of the Medical of critical-care medicine, but center in critical-care nephro- School at Karolinska Institutet from 1993 to 1995 and served logy, sepsis, multiorgan failure, and clinical epidemiology, as Vice President at the institution from 1995 to 2001. He was including consensus development and research methodology. also Head of Research & Development at Huddinge He has authored more than 300 publications and served as University Hospital in 2002 and Vice Chairman of Research editor and contributor to recent texts including Continuous & Development at the Karolinska University Hospital. Other Renal Replacement Therapy, Critical Care Nephrology, and notable accomplishments also include his roles as President Management of Acute Kidney Problems. Dr Kellum has won for the Scientific Board of the Swedish Council of Technology several awards for teaching and has given more than 400 Assessment in Health Care (1999–2005); Chairman of the seminars and invited lectures worldwide related to his Swedish Society of Medical Radiology (2003–2005); and past research. Vice Chairman and current Chairman of the Swedish Advisor/Consultant: Abbott; Alere; Astute Medical; Baxter; Medical Association. CytoSorbents; EBI; Eli Lilly; Fresenius; Gambro; Siemens; Professor Aspelin has conducted research on contrast Spectral Diagnostics media since 1972 when he studied under the tutelage of Speaker: Baxter; Fresenius; Gambro ´ Professor Torsten Almen. He has written more than 170 Grant/Research Support: Astute Medical; Baxter; CytoSorbents; scientific publications to date and his primary research Gambro centers on the development of nonionic contrast media and the examination of their effects on medical imaging and Norbert Lameire, MD, PhD (Work Group Co-Chair), is patient safety. Professor of Internal Medicine and former Chief of Renal Speaker: GE Healthcare Division at the University of Ghent where he also received his Expert witness: GE Healthcare medical degree and PhD. Dr Lameire’s interests include basic research topics such as renal circulation in experimental ARF Rashad S Barsoum, MD, FRCP, FRCPE, is Emeritus and peritoneal circulation, as well as clinical topics spanning Professor of Medicine at Cairo University and current clinical ARF, PD, and organizational and economic aspects Chairman of Cairo Kidney Center and Medical Sector of chronic RRT and transplantation. He currently oversees Committee for Supreme Council for Egyptian Universities. the worldwide continuing medical education programs of He received his medical degree from Cairo University, where COMGAN of the International Society of Nephrology, and he also completed his fellowship in nephrology in 1967. serves as current Editor-in-Chief for Acta Clinica Belgica Dr Barsoum has been a primary investigator in clinical trials and is emeritus Editor-in-Chief for Nephrology Dialysis involving the study of immunosuppression agents in kidney Transplantation. For his activities in the Renal Sister Program transplantation and treatment of HCV infection in dialysis of the International Society of Nephrology and his leadership patients. He has also authored more than 200 journal articles of the Renal Disaster Relief Task Force, he was awarded and book chapters and currently serves as Associate Editor Doctor Honoris Causa at the Kaunas Medical Academy in for Nephron Clinical Practice and editorial board member for Lithuania and an honorary membership of the International American Journal of Kidney Diseases. Dr Barsoum is also Society of Nephrology (ISN). Dr Lameire also received the active in numerous medical societies, having served as Past Garabed Eknoyan Award from the NKF (USA) in 2007 for his President for the Arab Society of Nephrology and Renal continuing work to improve dialysis therapy and PD, and his Transplantation and Egyptian Society of Nephrology. Among 116 Kidney International Supplements (2012) 2, 116–121
  • 120. biographic and disclosure information his noted achievements include the International Award from Charles A Herzog, MD, is Director of the Cardiovascular the NKF (USA), the Roscoe Robinson Award from the Special Studies Center, United States Renal Data System International Society of Nephrology, and the Distinguished (USRDS). An investigator at the USRDS since 1999, Researcher Award from Cairo University. Dr Herzog has been a cardiologist at Hennepin County Advisor/Consultant: Wyeth Medical Center (HCMC) in Minneapolis and a member of the Speaker: Amgen; B. Braun; Fresenius; Janssen Cilag; University of Minnesota faculty for 27 years. He has been Novartis; Roche; Wyeth a professor of medicine at the University of Minnesota since 2004 and the cardiology consultant to the ESRD program Emmanuel A Burdmann, MD, PhD, is Head of Intensive Care (dialysis and renal transplant) at HCMC since 1985. He Unit and Associate Professor, Division of Nephrology at founded the program in interventional cardiology and served ˜ University of Sao Paulo Medical School. He received his as the director of the cardiac catheterization laboratory at ˜ medical degree from the University of Sao Paulo, where he also HCMC from 1985 to 1991. Since 1997, Dr Herzog has been completed his fellowship. He was the Past President of the the director of the cardiac ultrasound laboratory at HCMC. Latin American Society of Nephrology and Hypertension and He participated in the development of the National Kidney current President of Brazilian Society of Nephrology. Dr Foundation’s K/DOQI Clinical Practice Guidelines for Cardio- Burdmann has authored over 150 journal articles and book vascular Disease in Dialysis Patients, and co-chaired the 2010 chapters and is currently on the editorial boards of Clinical KDIGO Controversies Conference, ‘‘Cardiovascular Disease in Journal of the American Society of Nephrology, Clinical CKD: What is it and What Can We Do About It?’’ The author Nephrology, Kidney International, Nephrology Dialysis Trans- or co-author of more than 100 published papers and reviews, plantation, and Nephron Clinical Practice. He is also a member Dr Herzog has served on the Editorial Board for the American of numerous professional societies and has served on the Heart Journal since 2005 and as liaison editor (cardiology) for Council of the International Society of Nephrology and Nephrology Dialysis Transplantation since 2007. His areas of KDIGO Board. In addition to his research interest in AKI, research and special interests include cardiac disease and Dr Burdmann is also a coinvestigator in the TREAT study. chronic kidney disease, and echocardiography. Dr Burdmann reported no relevant financial relationships. Advisor/Consultant: Abbott; Affymax; Amgen; CorMedix; FibroGen; Fresenius Stuart L Goldstein, MD, is Professor of Pediatrics and Director, Board of Trustees: Roche Foundation for Anemia Research Center for Acute Care Nephrology at Cincinnati Children’s Honorarium: UpToDate Hospital Medical Center. He received his medical degree from Grant/Research Support: Johnson & Johnson; National Institutes Columbia University and completed both clinical and research of Health fellowships in pediatric nephrology at the Children’s Hospital Equity Interest: Boston Scientific; Cambridge Heart; Johnson in Boston, Massachusetts. Dr Goldstein is a member of the & Johnson; Merck American Academy of Pediatrics, the American Society of Nephrology, the International Pediatric Nephrology Asso- Michael Joannidis, MD, is Associate Professor in Medicine ciation, the American Society of Pediatric Nephrology, the and serves as Director of the Medical Intensive Care Unit, International Society of Nephrology, and the Society for Dept. Internal Medicine I at Medical University Innsbruck in Pediatric Research. In addition, he is Chairman of the Medical Austria. He is a certified specialist in critical-care medicine, Advisory Committee to the FORUM of ESRD Networks and a nephrology, and cardiology, and his research interests cover member of the Medical Review Board for the ESRD Networks several aspects of critical-care medicine with a major focus on 9 and 10, is the Pediatric Nephrologist Representative for the AKI, renal tubular epithelial pathophysiology, RRT, and sepsis. International Society of Nephrology Commission of Acute Dr Joannidis currently serves as chair of the section Acute Renal Failure, and has been elected to the Council of the Kidney Injury of the European Society of Intensive Care American Society of Pediatric Nephrology. Dr Goldstein has Medicine (ESICM), President of the Austrian Society of developed and validated the pediatric modified RIFLE Medical and General Intensive Care Medicine (OEGIAIM) (pRIFLE) AKI criteria, is Founder and Principal Investigator and associate editor of Intensive Care Medicine. for the Prospective Pediatric Continuous Renal Replacement Speaker: Baxter; Fresenius; Gambro Therapy (ppCRRT) Registry Group, and has evaluated novel urinary AKI biomarkers in the pediatric critical care setting. He Andreas Kribben, MD, is Professor of Medicine and Head of has written over 110 journal articles and contributed book the Department of Nephrology at the University Hospital chapters to numerous texts including, Critical Care Nephrology, Essen at the University of Duisburg-Essen. He received his Evidence-Based Nephrology, Handbook of Dialysis Therapy, medical degree at the Johann-Wolfgang Goethe University Management of Acute Kidney Problems, Pediatric Critical Care, Frankfurt, Germany in 1983. Dr Kribben was trained in Pediatric Nephrology, and Pediatric Nephrology in the ICU. Internal Medicine and Nephrology at the Department of Advisor/Consultant: Baxter; Gambro Nephrology of the University Hospital Klinikum Steglitz, Speaker: Gambro Free University of Berlin, Germany and at the University Grant/Research Support: Amgen; Baxter; Gambro Hospital Essen, University Duisburg-Essen, Germany. From Kidney International Supplements (2012) 2, 116–121 117
  • 121. biographic and disclosure information 1990 to 1993, he was a research fellow at the Renal Division systematic literature reviews and she is a member of the of the University of Colorado Health Sciences Centre in Editorial Board of the Cochrane Review Group. Dr MacLeod Denver, Colorado, USA. His major scientific interests include is a current committee member of the European Renal all aspects of AKI, CRF, as well as transplantation and Registry Executive Committee, Anemia Management in hypertension. Chronic Kidney Disease–National Institute for Health and Dr Kribben is member of numerous professional organi- Clinical Excellence, Scientific Committee, and European zations, including the International Society of Nephrology, Renal Association Congress. In addition, she is Chairman the American Society of Nephrology, the European Dialysis of the Scottish Intercollegiate Guidelines Network, Diagnosis and Transplantation Association, and he is a member of the and Management of Chronic Renal Failure and was a Board of Directors of the German Society of Nephrology. member of the Executive Committee of KDIGO. He is an editorial member of Clinical Nephrology and served Dr MacLeod reported no relevant financial relationships. as subject editor of Nephrology Dialysis Transplantation. Dr Kribben is also a member of the World Health Ravindra L Mehta, MD, FACP, FASN, FRCP, is Professor Organization Work Group for the 11th revision of ICD. of Medicine in the Division of Nephrology and Associate Advisor/Consultant: Roche; Shire; Teva Chair for Clinical Research in the Department of Medicine Speaker: Amgen; Apherese ForschungsInstitut; Baxter; at the University of California, San Diego (UCSD) where Bayer-Schering; Berlin-Chemie; Fresenius; GE Healthcare; he directs the Acute Dialysis Program and the UCSD Genzyme; Roche; Shire CREST and Masters in Clinical Research Program. He Grant/Research Support: B. Braun; Biosite; Fresenius; received the M.B.B.S. degree (1976) from the Government Koehler; Roche; Teva Medical School in Amritsar, India, and the M.D. (1979) and D.M. (1981) degrees from the Post-Graduate Institute Andrew S Levey, MD, is Dr Gerald J. and Dorothy R. of Medical Education and Research in Chandigarh, India. Friedman Professor of Medicine at Tufts University School He subsequently completed a nephrology fellowship at of Medicine, Chief of the William B. Schwartz, MD Division the University of Rochester in Rochester, New York and of Nephrology at Tufts Medical Center, Senior Scientist at obtained his boards in internal medicine (1986) and the US Department of Agriculture Human Nutrition Nephrology (1988). He has been on the faculty at UCSD Research Center on Aging at Tufts University, and Professor, since 1988. Clinical Research at the Sackler School of Graduate Dr Mehta is an internationally recognized expert in the Biomedical Sciences at Tufts University. His research is field of ARF and has directed several clinical studies in the mainly in the areas of epidemiology of CKD and cardio- management of patients with kidney disease including vascular disease in CKD, controlled trials to slow the comparing different dialytic modalities in the treatment of progression of CKD, clinical assessment of kidney function, AKI, conducting large multicenter observational studies of assessment and improvement of outcomes in dialysis and AKI with the PICARD group, evaluating different predictive transplantation, and clinical practice guideline develop- models for outcomes in AKI, investigating the role of ment and implementation. Dr Levey is currently Program cytokine removal by dialysis membranes in sepsis and AKI, Director for an NIDDK-funded clinical research training and evaluating techniques for determining the amount of program, ‘‘Clinical Trials, Epidemiology and Outcomes excess fluid in dialysis patients. In addition to his clinical and Research in Nephrology’’. He is also the Director of the research activities, he has worked with the American Society Tufts Center for Guideline Development and Implementation of Nephrology, NKF, Society of Critical Care Medicine, and and Editor of the American Journal of Kidney Disease. the International Society of Nephrology in developing Dr Levey is past Chair of the NKF’s Task Force on courses for fellows and practicing physicians in clinical Cardiovascular Disease in Chronic Renal Disease, KDOQI nephrology and dialysis techniques. Dr Mehta chairs the Work Group on Chronic Kidney Disease: Evaluation, annual International Conference on CRRT that is now in its Classification and Stratification, and KDOQI Work Group 15th year and he is also the Chair of the International Society on Hypertension and Antihypertensive Agents in Chronic of Nephrology Committee on AKI, founding member of the Kidney Disease. ADQI and AKIN. He has authored over 150 scientific articles, Grant/Research Support: Amgen; National Institutes of papers and book chapters, and has been actively involved in Health; National Kidney Foundation resident and scholar teaching. He won the house staff teaching award on four occasions and was awarded School of Alison M MacLeod, MBChB, MD, FRCP London and Medicine Faculty teaching award in 2003. He has been Edinburgh, is Professor in the Department of Medicine recognized as one of the Best Doctors in San Diego and the and Therapeutics at the University of Aberdeen Medical USA. In 2008, he was recognized by the American School, UK. She completed her fellowship at the Royal Nephrologists of Indian Origin for his achievements in Colleges of Physicians of London and Edinburgh, and has nephrology. In March 2009, he was elected as a Fellow of the interests in epidemiology of CKD, AKI, and evidence based Royal College of Physicians in the UK. Over the course of his medicine in nephrology. Her research group also conducts academic career, he has trained over 50 postdoctoral fellows 118 Kidney International Supplements (2012) 2, 116–121
  • 122. biographic and disclosure information in nephrology, of whom 15 have carried out their research Medal of NKF of the USA in 2005 and was awarded the projects with him. prestigious Roscoe Robinson award for nephrology education Advisor/Consultant: Astute Medical; Eli Lilly; Takeda by the ISN at its World Congress in Milan in May 2009. She Speaker: Baxter; Gambro has hosted the nephrology training of ISN Fellows from Grant/Research Support: Eli Lilly Ethiopia, Nigeria, Botswana, Tanzania, Rwanda, Kenya and Zambia as well as ISPD trainees from Nigeria and Tanzania. Patrick T Murray, MD, FASN, FRCPI, FJFICMI, is a During her period as Chair of the Africa Committee of ISN nephrologist and clinical pharmacologist at the Mater COMGAN from 2000 to 2007, she made site visits and Misericordiae University Hospital and University College participated in continuing medical education programs in Dublin, Ireland. Dr Murray received his medical education at many African countries. Her research interests include areas University College Dublin, Ireland and following his intern- related to HIV and kidney disease, prevention of CKD, CVD ship at the Mater Misericordiae University Hospital in in renal disease, and medical education. Dublin, he completed his residency in internal medicine Advisor/Consultant: Amgen; Novartis; Roche at Hennepin County Medical Center in Minneapolis, Minnesota, USA and fellowship training programs in nephrology, critical Steven M Opal, MD, is Professor of Medicine at The Warren care medicine, and clinical pharmacology at the University of Alpert Medical School of Brown University and Chief of the Chicago Hospitals in Chicago, Illinois, USA. Infectious Disease Division, Memorial Hospital of Rhode Dr Murray is board-certified in internal medicine, Island. He received his medical degree from Albany Medical nephrology, critical care medicine, and clinical pharmacology School, Albany, New York and completed his fellowship and practiced as an intensivist, nephrologist, and clinical training in infectious diseases at Walter Reed Army Medical pharmacologist at the University of Chicago Hospitals from Center in Washington, DC. Dr Opal is a member of 1996 to 2008, serving as the fellowship training program numerous national and international committees including, director in nephrology and also directing the Acute Dialysis International Steering Committee for Sepsis Clinical Trials; Service. Since 2008, he has been the Professor of Clinical Steering Committee FDA Meta-analysis Committee on Pharmacology at University College Dublin, and a Con- Sepsis; International Endotoxin Society; and International sultant in Nephrology & Clinical Pharmacology at the Mater Sepsis Forum. He has written extensively with over 300 Misericordiae University Hospital. Dr Murray has published publications and has given more than 100 invited presenta- extensively with contributions in numerous books inclu- tions. Dr Opal currently serves on the editorial boards of ding, Critical Care Nephrology, Evidence-Based Nephrology, Advances in Sepsis, Critical Care Forum, Current Opinion in Evidence-Based Practice of Critical Care, and Intensive Care in Critical Care, and Shock. In recognition for his work, he was Nephrology. He has a long-standing interest in research and awarded the Brown Medical School Infectious Disease education to improve the prevention, diagnosis, and therapy Fellowship Teacher of the Year Award in 2008 and was of AKI. acknowledged in Best Doctors in America from 2003 to 2009. Advisor/Consultant: Abbott; Alere; AM Pharma; Argutus Dr Opal reported no relevant financial relationships. Medical; FAST Diagnostics; Reata; Sanofi-Aventis Grant/Research Support: Abbott; Alere; Argutus Medical Franz Schaefer, MD, is Professor of Pediatrics and Chief of the Pediatric Nephrology Division at Heidelberg University Saraladevi Naicker, MBChB, MRCP, FRCP, FCP (SA), PhD, Hospital. Dr Schaefer received his M.D. at Wurzburg ¨ is currently Academic Head of the Department of University Medical School and performed research scholar- Internal Medicine and Professor of Renal Medicine and head ships at the Institute of Child Health, London, University of of the Division of Nephrology at the University of the Virginia, and Stanford University. His research interests Witwatersrand in Johannesburg. She completed her under- include topics on physiopathology of growth failure, graduate and postgraduate medical training primarily at the cardiovascular and endocrine disorders in CKD and the role University of Natal in Durban, South Africa and spent short of genetic abnormalities in congenital kidney disorders. In periods training in nephrology at the Universities of the clinical research, he conducted numerous collaborative Witwatersrand, Johannesburg and Newcastle on Tyne in the clinical trials and established several international consortia UK. She currently chairs the Postgraduate (Higher Degrees) such as the the European Study Group on Progressive CKD Committee of the Faculty of Health Sciences at the University in Children, the International Pediatric Peritoneal Dialysis of the Witwatersrand and is a member of the Council of the Network, and the PodoNet Registry for Steroid Resistant College of Physicians of the Colleges of Medicine of South Nephrotic Syndrome. Dr Schaefer has published over 280 Africa. She is also a Council member of the International articles and book chapters, and co-edited the standard Society of Nephrology (ISN) and chairs its Education textbooks Comprehensive Pediatric Nephrology and Pediatric Committee. Dialysis. He received several prestigious awards for innovative Dr Naicker was the recipient of the Philip Tobias/Convo- research including the Recklinghausen Prize and the IBM cation Distinguished Teachers Award at the University of the Faculty Award. Dr Schaefer is a current council member of Witwatersrand in 2006, the International Distinguished the International Pediatric Nephrology Association and the Kidney International Supplements (2012) 2, 116–121 119
  • 123. biographic and disclosure information International Society of Peritoneal Dialysis. He is a member Disorders. Dr Eckardt is a member of the executive committee of several editorial boards and serves as Section Editor for of KDIGO. Nephrology Dialysis Transplantation and Pediatric Nephrology. Advisor/Consultant: Affymax; Amgen; Hexal Sandoz; Dr Schaefer reported no relevant financial relationships. Johnson & Johnson; Roche Speaker: Amgen; Janssen Cilag; Johnson & Johnson; Roche Miet Schetz, MD, PhD, graduated from the faculty Grant/Research Support: Roche of Medicine of the Catholic University of Leuven, Belgium, after which she specialized in anesthesiology and later in Bertram L Kasiske, MD, is Professor of Medicine at the intensive care medicine. Since 1981 she is staff member of University of Minnesota, USA. He received his medical the department of Intensive Care Medicine at the University degree from the University of Iowa and completed his Hospital Leuven (Chair: Greet Van den Berghe) and has Internal Medicine residency and fellowship training in been Associate Professor at the Catholic University Leuven Nephrology at Hennepin County Medical Center where he since 2000. Dr Schetz completed her PhD thesis on the is currently Director of Nephrology. subject, ‘‘The Hemostatic System and Continuous Renal Dr Kasiske is former Deputy Director of the United States Replacement Therapy: Mutual Effects’’. Her main field of Renal Data System and former Editor-in-Chief of The interest is AKI and its treatment, on which she published American Journal of Kidney Diseases. He has served as several articles. Secretary/Treasurer and on the Board of Directors of the Grant/Research Support: Gambro American Society of Transplantation, and on the Organ Procurement and Transplantation Network/United Network Shigehiko Uchino, MD, PhD, is Associate Professor and Staff of Organ Sharing Board of Directors, and the Scientific Intensivist in the Department of Anesthesiology at Jikei Advisory Board of the National Kidney Foundation. He is University School of Medicine in Tokyo, Japan. He received currently serving on the Board of Councilors of the his medical degree from Tokyo Medical and Dental International Society of Nephrology. He is the Principal University and his PhD from Jikei University School of Investigator for a National Institutes of Health-sponsored, Medicine. Dr Uchino is a member of the Japanese Society of multi-center study of long term outcomes after kidney Intensive Care Medicine, Japanese Association for Acute donation. He is the Director of the Scientific Registry of Medicine, Society of Critical Care Medicine, and the Transplant Recipients. He has over 160 scientific publications European Society of Intensive Care Medicine. In addition in major peer reviewed journals, and 230 review articles, to serving as a reviewer for numerous journals, he has written editorials and textbook chapters. Dr Kasiske is also a recipient book chapters in recent texts such as Critical Care Nephrology, of the NKF’s Garabed Eknoyan Award in 2003. Evidence-Based Practice of Critical Care, and Intensive Care Advisor/Consultant: Litholink in Nephrology. Dr Uchino is also a coinvestigator in the Grant/Research Support: Bristol-Myers Squibb; Merck-Schering BEST Kidney study. Plough Dr Uchino reported no relevant financial relationships. EVIDENCE REVIEW TEAM KDIGO CHAIRS Katrin Uhlig, MD, MS, is the Director, Guideline Develop- Kai-Uwe Eckardt, MD, is Professor of Medicine and Chief ment at the Tufts Center for Kidney Disease Guideline of Nephrology and Hypertension at the University of Development and Implementation, Boston, MA, Associate Erlangen—Nuremberg, Germany. He received his MD from Professor of Medicine at Tufts University School of Medicine, ¨ ¨ ¨ the Westfalische Wilhelms-Universitat Munster, Germany. In and a staff nephrologist at Tufts Medical Center. Dr Uhlig 1993, following postgraduate training in internal medicine, completed her training in internal medicine, nephrology, and pathology and physiology, he was appointed Assistant rheumatology in Germany (Aachen University Hospital and Professor of Physiology at the University of Regensburg, Munich University Hospital) and the USA (Georgetown Germany. Subsequently, he continued his training in internal University Medical Center and Tufts Medical Center). Since ´ medicine and nephrology at the Charite, Humboldt Uni- 2001, she has been participating in or directing the evidence versity in Berlin, where he was appointed Associate Professor review for KDOQI and KDIGO guidelines. In 2005, she of Nephrology in 2000. His major scientific interests are in co-chaired the KDIGO Evidence Rating Group to develop the molecular mechanisms and physiological/pathophysio- a consensus on grading of KDIGO guidelines. From 2006 logical relevance of oxygen sensing and the management of to 2007, she served as Co-Editor of the American Journal anemia. As such, he has contributed to the development of of Kidney Diseases. Her focus in teaching and research is in the European Best Practice Guidelines for Anemia Manage- evidence-based medicine, systematic review, clinical practice ment and participated in the CREATE and TREAT studies. guideline development, and critical literature appraisal. Professor Eckardt is subject editor of Nephrology Dialysis Dr Uhlig reported no relevant financial relationships. Transplantation and serves on the editorial board of several other journals. He has also authored book chapters and most Jose Calvo-Broce, MD, MS, served as a research fellow at the recently served as a Co-Editor of the text, Studies on Renal Tufts Center for Kidney Disease Guideline Development and 120 Kidney International Supplements (2012) 2, 116–121
  • 124. biographic and disclosure information Implementation in Boston, MA and participated in the conduct of systematic reviews and critical literature appraisals conduct of systematic reviews and critical literature apprai- for this guideline. Dr Deo was awarded a Master of Science sals for this guideline. Dr Calvo-Broce was recently awarded in Clinical Research for her thesis on ‘‘Loss to Analysis in a Master of Science in Clinical Research for his thesis Randomized Controlled Trials of Chronic Kidney Disease’’. on ‘‘Hospital-Acquired AKI: An Analysis of Nadir-to-Peak Dr Deo reported no relevant financial relationships. Serum Creatinine Increments Stratified by Baseline Estimated GFR’’. Amy Earley, BS, is a project coordinator at the Tufts Center Dr Calvo-Broce reported no relevant financial relationships. for Kidney Disease Guideline Development and Implementa- tion in Boston, MA. She assists in the development of clinical Aneet Deo, MD, MS, served as a research fellow at the practice guidelines and conducts systematic reviews and Tufts Center for Kidney Disease Guideline Development critical literature appraisals. and Implementation in Boston, MA. She participated in the Ms Earley reported no relevant financial relationships. Kidney International Supplements (2012) 2, 116–121 121
  • 125. acknowledgments http://www.kidney-international.org & 2012 KDIGO Acknowledgments Kidney International Supplements (2012) 2, 122–123; doi:10.1038/kisup.2011.37 A special debt of gratitude is owed to the current KDIGO Hemmelgarn (Canadian Society of Nephrology), Hallvard Co-Chairs Kai-Uwe Eckardt and Bertram Kasiske and the Holdaas (National Hospital - Norway), Lai Seong Hooi KDIGO Board for their invaluable guidance throughout (Hospital Sultanah Aminah), Atsuko Ikemori (St. Marianna the development of this guideline. In particular, we thank the University School of Medicine), Enyu Imai (Nagoya Uni- ERT members: Katrin Uhlig, Jose Calvo-Broce, Aneet Deo, versity School of Medicine), Lesley Inker (Tufts-New England and Amy Earley, for their substantial contribution to the Medical Center), Sarwar Iqbal (BIRDEM Hospital), Kuni- rigorous assessment of the available evidence. We are also toshi Iseki (Ryukyn University), Simon Jenkins, Svend especially grateful to the Work Group members for their Lorentz Jorgensen (Pharmacosmos A/S), Takei Kake (Chugai expertise throughout the entire process of literature review, Pharmaceutical), Nada Kanaan (Cliniques Universitaires data extraction, meeting participation, the critical writing Saint Luc), Markus Ketteler (Klinikum Coburg GGmbH), and editing of the statements and rationale, which made the Mahmoud El-Khatib (University of Cincinnati), Pradeep publication of this guideline possible. The generous gift of Kumar Rai (Opal Hospital, Varanasi, India), Hanife Kurtal their time and dedication is greatly appreciated. Finally, and ´ ¨ (Charite-Universitatsmedizin, Berlin), Craig B Langman on behalf of the Work Group, we gratefully acknowledge (Children’s Memorial Hospital, Chicago), Ingrid Ledebo the careful assessment of the draft guideline by external (Gambro AB), Edgar Lerma (University of Illinois at Chicago reviewers. The Work Group considered all of the valuable College of Medicine), Nathan W Levin (Renal Research comments made and where appropriate, suggested changes Institute), Andrew Lewington (The Renal Association, UK), were incorporated into the final publication. The following Visnja Lezaic (Clinical Centre of Serbia), Zhi-Hong Liu individuals and organizations provided review of the draft (Nanjing University School of Medicine), Raul Lombardi guideline: (Latin American Society of Nephrology & Hypertension), Omar Abboud, Mona Al–Rukhaimi (Dubai Hospital), ´ ´ ´ Gerard London (ERA/EDTA), Jose Antonio Lopes (Hospital Mustafa Arici (Hacettepe University Faculty of Medicine), de Santa Maria), Robert Mactier (The Renal Association, Mariano Arriola (Clinica de Nefrologia, Urologia y UK), Constantine Manthous (American Thoracic Society), Enfermedades Cardiovasculares, Argentina), Adanze Asinobi Omar Maoujoud (Mohammed V Military Hospital), Pablo U (University of Ibadan, Nigeria), Alper Azak (Ankara Educa- Massari, John McIlwaine (American College of Chest tion and Research Hospital), Gavin Becker (Royal Melbourne Physicians), Cecilia Mengarelli (Fresenuis Mansilla), Gong Hospital), Rudy Bilous (The James Cook University Hospi- Mengchun (Peking Union Medical College Hospital), Walid tal), Yousef Boobes (Tawam Hospital, UAE), Catherine Mohamed (Alexandria University Hospital), Rafique Moosa Bouman (Dutch Society of Intensive Care Medicine), Carlo (University of Stellenbosch), Jose M Morales (Hospital 12 de Briguori (Clinica Mediterranea), Eric S Cantor (GE Health- Octubre, Spain; European Society for Organ Transplanta- care), Maria Ines Carvallo, William R Clark (Gambro), tion), Sameh K Morcos (Northern General Hospital), Adrian Covic (Hospital CI Parhon, Romania), Daniel Coyne Toshiki Moriyama (Osaka University Health Care Center), (Washington University School of Medicine), Joe Dasta Abdou Niang (Cheikh Anta Diop University), Eisei Noiri (Society of Critical Care Medicine), Jane S Davis (University (Japanese Society of Nephrology), Fernando Nolasco of Alabama at Birmingham), Angel de Francisco (Spanish (Portuguese Society of Nephrology), Maurizio Nordio Society of Nephrology), Jean-Yves De Vos (AZ Werken (Dirigente Medico), Michał Nowicki (Medical University of Glorieux Dialysis Unit), Pierre Delanaye (University of Lodz), Ercan Ok (Turkish Society of Nephrology), Suzanne ` Liege), Sarah Faubel (American Society of Nephrology), Oparil (University of Alabama at Birmingham), Heleen ˜ Ana Elizabeth Figueiredo (Hospital Sao Lucas), Thorsten Oudemans (Danish Society of Intensive Care), Erling Feldkamp ¨ (Universitatsklinikum Essen, ¨ Universitat Pedersen (Holstebro Hospital and University of Aarhus), Duisburg-Essen), Kevin Finkel (Society of Critical Care Momir Polenakovic (Balkan Cities Association of Nephro- Medicine), Lui G Forni (European Society of Intensive Care logy, Dialysis, Transplantation and Artificial Organs), Manuel Medicine), Heidi Frankel (Society of Critical Care Medicine), Praga (Hospital 12 de Octubre, Spain), Wajeh Qunibi Gerard Fulda (Society of Critical Care Medicine), (University of Texas Health Science Center), Enrique Andres´ Mohammed Benghanem Gharbi (University Hospital Ibn ´ Ribes (Fundacio Puigvert), Eduardo Rocha (Rio de Janeiro Rochd), Richard J Glassock (UCLA), Robert S Gold (DCBA), Federal University Medical School), Cibele Rodrigues Basu Gopal (Christian Medical College), Jeff Harder ˜ (Catholic University of Sao Paulo), Guillermo Rosa-Diez (University of Washington Medical Center), Brenda (Hospital Italiano de Buenos Aires - Argentina), Brad Rovin 122 Kidney International Supplements (2012) 2, 122–123
  • 126. acknowledgments (Ohio State University), Nestor Schor (Universidade Federal Raymond Vanholder (University Hospital Ghent), Rowan de Sao Paulo-UNIFESP), Mehmet Sukru Sever (European Walker (Royal Melbourne Hospital), Michael Walsh Renal Best Practice), Amma Sewaah-Bonsu (Nephrology (McMaster University), HaiYan Wang (Beijing University), Associates of Central Florida), Deepak Sharma (Mil Hospital Jiandong Wei (SUNY Downstate Medical Center), Colin Jalandhar, India), Justin Silver (Hadassah University Hospi- White (University of British Columbia), Hitoshi Yokoyama tal), Richard Solomon (Fletcher Allen Health Care), Peter (Kanazawa Medical University), Luis Yu (University of Spiro (American College of Chest Physicians), Takeshi ˜ Sao Paulo), Elena Zakharova (Moscow City Hospital), Sugaya (St. Marianna University School of Medicine), Cem Carmine Zoccali (CNR-IBIM Clin Research Unit Ospedali Sungur (Anadolu Medical Center), Charles Swanepoel Riuniti, Italy), Kim Zuber (Metropolitan Nephrology (University of Cape Town), Seng Hoe Tan (Gleneagles Associates). Medical Centre, Singapore), Samuel A Tisherman (Society Participation in the review does not necessarily constitute of Critical Care Medicine), Charles Tomson (Southmead endorsement of the content of this report by above indivi- ´ ˆ Hospital), Stephan Troyanov (Hopital du Sacre-Coeur,´ duals or the organization or institution they represent. Montreal), Hung-Bin Tsai (Buddhist Dalin Tzu Chi General Hospital), Hirokazu Tsukahara (Okayama University John A Kellum, MD, FCCM, FACP, Work Group Co-Chair Hospital), Wim Van Biesen (University Hospital Ghent), Norbert Lameire, MD, PhD, Work Group Co-Chair Kidney International Supplements (2012) 2, 122–123 123
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