KDIGO Clinical Practice Guideline for Acute Kidney Injury

OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF NEPHROLOGY

KDIGO Clinical Practice Guideline for Acute Kidney Injury

VOLUME 2 | ISSUE 1 | MARCH 2012



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& 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:

13

Chapter 1.1:

17

Chapter 1.2:

19

Section 2:

Introduction and Methodology

Introduction

Methodology

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:

37

Section 3:

Diagnostic approach to alterations in kidney function and structure

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:

69

Section 4:

Other methods of prevention of AKI in the critically ill

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:

89

Section 5:

Effects of hemodialysis or hemofiltration

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

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& 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

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Kidney International Supplements (2012) 2, iv



& 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

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& 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

University of Pittsburgh School of Medicine

Pittsburgh, PA

Norbert Lameire, MD, PhD

Ghent University Hospital

Ghent, Belgium

WORK GROUP

Peter Aspelin, MD, PhD

Karolinska University Hospital

Stockholm, Sweden

Alison M MacLeod, MBChB, MD, FRCP

University of Aberdeen

Aberdeen, United Kingdom

Rashad S Barsoum, MD, FRCP, FRCPE

Cairo University

Cairo, Egypt

Ravindra L Mehta, MD, FACP, FASN, FRCP

UCSD Medical Center

San Diego, CA

Emmanuel A Burdmann, MD, PhD

University of Sa?o Paulo Medical School

Sa?o Paulo, Brazil

Patrick T Murray, MD, FASN, FRCPI, FJFICMI

UCD School of Medicine and Medical Science

Dublin, Ireland

Stuart L Goldstein, MD

Cincinnati Children¡¯s Hospital & Medical Center

Cincinnati, OH

Saraladevi Naicker, MBChB, MRCP, FRCP,

FCP(SA), PhD

University of the Witwatersrand

Johannesburg, South Africa

Charles A Herzog, MD

Hennepin County Medical Center

Minneapolis, MN

Steven M Opal, MD

Alpert Medical School of Brown University

Pawtucket, RI

Michael Joannidis, MD

Medical University of Innsbruck

Innsbruck, Austria

Franz Schaefer, MD

Heidelberg University Hospital

Heidelberg, Germany

Andreas Kribben, MD

University Duisburg-Essen

Essen, Germany

Miet Schetz, MD, PhD

University of Leuven

Leuven, Belgium

Andrew S Levey, MD

Tufts Medical Center

Boston, MA

Shigehiko Uchino, MD, PhD

Jikei University School of Medicine

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

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Kidney International Supplements (2012) 2, 2

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