Today’s Approach to the Critically Ill Patient with Acute Kidney Injury

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Abstract

The present review describes recent evidence on all aspects relating to acute kidney injury (AKI): epidemiology, definition, diagnosis, medical and extracorporeal therapy. AKI is often underrecognized, but its outcome still remains unfavorable. In this light, definition, classification and diagnosis of AKI are fundamental today and may be reliably based on recently proposed RIFLE (risk, injury, failure, loss of function, end-stage kidney disease) classification. Pharmacological therapy of AKI is still scarcely effective, but renal replacement therapy has progressed to a more accurate and safe treatment and new interesting high-level trials and observational studies have been performed and are reviewed and commented. In the near future, however, only increased awareness of AKI incidence and early treatment or prevention of kidney injury progression will hopefully improve outcome of critically ill patients with renal failure.

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The RIFLE criteria and mortality in acute kidney injury: A systematic review.

Z Ricci, D. Cruz, C. Ronco (2008)

In 2004, the Acute Dialysis Quality Initiative workgroup proposed a multilevel classification system for acute kidney injury (AKI) identified by the acronym RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Several studies have been published aiming to validate and apply it in clinical practice, verifying whether outcome progressively worsened with the severity of AKI. A literature search from August 2004 to June 2007 was conducted: 24 studies in which the RIFLE classification was used to define AKI were identified. In 13 studies, patient-level data on mortality were available for Risk, Injury, and Failure patients, as well as those without AKI (non-AKI). Death was reported at ICU discharge, hospital discharge, 28, 30, 60, and 90 days. The pooled estimate of relative risk (RR) for mortality for patients with R, I, or F levels compared with non-AKI patients were analyzed. Over 71 000 patients were included in the analysis of published reports. With respect to non-AKI, there appeared to be a stepwise increase in RR for death going from Risk (RR=2.40) to Injury (RR=4.15) to Failure (6.37, P<0.0001 for all). There was significant intertrial heterogeneity as expected with the varying patient populations studied. The RIFLE classification is a simple, readily available clinical tool to classify AKI in different populations. It seems to be a good outcome predictor, with a progressive increase in mortality with worsening RIFLE class. It also suggests that even mild degrees of kidney dysfunction may have a negative impact on outcome. Further refinement of RIFLE nomenclature and classification is ongoing.

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Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial.

K Beauregard, Christophe Vinsonneau, Christophe Camus … (2006)

Whether continuous renal replacement therapy is better than intermittent haemodialysis for the treatment of acute renal failure in critically ill patients is controversial. In this study, we compare the effect of intermittent haemodialysis and continuous venovenous haemodiafiltration on survival rates in critically ill patients with acute renal failure as part of multiple-organ dysfunction syndrome. Our prospective, randomised, multicentre study took place between Oct 1, 1999, and March 3, 2003, in 21 medical or multidisciplinary intensive-care units from university or community hospitals in France. Guidelines were provided to achieve optimum haemodynamic tolerance and effectiveness of solute removal in both groups. The two groups were treated with the same polymer membrane and bicarbonate-based buffer. 360 patients were randomised, and the primary endpoint was 60-day survival based on an intention-to-treat analysis. Rate of survival at 60-days did not differ between the groups (32% in the intermittent haemodialysis group versus 33% in the continuous renal replacement therapy group [95 % CI -8.8 to 11.1,]), or at any other time. These data suggest that, provided strict guidelines to improve tolerance and metabolic control are used, almost all patients with acute renal failure as part of multiple-organ dysfunction syndrome can be treated with intermittent haemodialysis.

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A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients.

Sean M Bagshaw, Carol George, Irina Dinu … (2008)

The Acute Dialysis Quality Initiative Working Group recently developed the RIFLE criteria, a consensus definition for acute kidney injury (AKI). We sought to evaluate the RIFLE criteria on the day of ICU admission in a large heterogenous population of critically ill patients. Retrospective interrogation of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. We evaluated 120 123 patients admitted for >/=24 h from 1 January 2000 to 31 December 2005 from 57 ICUs across Australia. The median (IQR) age was 64.3 (50.8-75.4) years, 59.5% were male, 28.6% had co-morbid disease, 50.3% were medical admissions and the initial mean (+/-SD) APACHEII score was 16.9 (+/-7.7). According to the RIFLE criteria, on the day of admission, AKI occurred in 36.1%, with a maximum RIFLE category of Risk in 16.3%, Injury in 13.6%, and Failure 6.3%. AKI, defined by any RIFLE category, was associated with an increase in hospital mortality (OR 3.29, 95% CI 3.19-3.41, P 36% with AKI on the day of admission. For successive increases in severity of RIFLE category, there were increases in hospital mortality. The RIFLE criteria represent a simple tool for the detection and classification of AKI and for correlation with clinical outcomes.

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Author and article information

Journal

Journal ID (publisher-id): BPU

Journal ID (nlm-ta): Blood Purif

Journal ID (doi): 10.1159/issn.0253-5068

Title: Blood Purification

Publisher: S. Karger AG

ISBN: 978-3-8055-9031-0

ISBN: 978-3-8055-9032-7

ISSN (Print): 0253-5068

ISSN (Electronic): 1421-9735

Publication date Subscription-year: 2009

Publication date (Print): January 2009

Publication date (Electronic): 23 January 2009

Volume: 27

Issue: 1

Pages: 127-134

Affiliations

^aDepartment of Pediatric Cardiosurgery, Bambino Gesù Hospital, Rome, and ^bDepartment of Nephrology, Dialysis and Transplantation, S. Bortolo Hospital, Vicenza, Italy

Article

Publisher ID: 167019 Other ID: Blood Purif 2009;27:127–134

DOI: 10.1159/000167019

PubMed ID: 19169028

SO-VID: fa0c2e3d-dbc1-4641-a1dc-0e706aef47fd

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

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Today’s Approach to the Critically Ill Patient with Acute Kidney Injury

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Karger: Nephrology

Most cited references 36

The RIFLE criteria and mortality in acute kidney injury: A systematic review.

Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial.

A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients.

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