Diagnostic workout of AKI
KDIGO guidelines http://kdigo.org/guidelines/
Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.
Basic investigation for all AKI
- Renal ultrasound
- Urinalysis – microscopy and electrolytes
The subsequent tests are guided by the clinical picture and history
A prospective evaluation of urine microscopy in septic and non-septic acute kidney injury.
Renal biopsy can be diagnostic and can provide information about background histology. 85% of pts develop peri-renal haematoma.
Future – renal biomarkers
When to start and when to stop RRT
Does this patient with AKI need RRT? https://www.ncbi.nlm.nih.gov/pubmed/26690077
Strategies for the optimal timing to start renal replacement therapy in critically ill patients with acute kidney injury. https://www.ncbi.nlm.nih.gov/pubmed/28222898
Renal replacement therapy in critically ill patients with acute kidney injury–when to start.
The optimal time of initiation of renal replacement therapy in acute kidney injury: A meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620297/
Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial.
Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit http://www.nejm.org/doi/full/10.1056/NEJMoa1603017
When to stop –
- Has the original precipitant for the AKI resolved?
- Is there evidence of some degree of recovery of kidney function?
- Has any fluid overload been resolved?
Can this patient be safely weaned from RRT?
The terms ‘early’ and ‘late’ RRT should be replaced with TIMELY RRT
Furosemide stress test/challenge test – 0.5-1mg/kg.
How to select mode of RRT
Depends on resources, where you work
Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study
Intermittent versus continuous renal replacement therapy for acute renal failure in adults: cochrane review
Modality on mortality – no strong data to support continuous or intermittent RRT
Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients
Nice comparison of IHD vs CRRT vs SLED https://lifeinthefastlane.com/ccc/ihd-vs-crrt-vs-sled/
The dose of RRT
No benefits to higher intensity RRT
Drug dosing during RRT
Does anyone adjust drug dosing when pt is on SLEDD? If so, how? Even the pharmacist disagree on what to do – Survey of pharmacists’ antibiotic dosing recommendations for sustained low-efficiency dialysis. https://www.ncbi.nlm.nih.gov/pubmed/26499505
SaMpling Antibiotics in Renal Replacement Therapy (SMARRT): an observational pharmacokinetic study in critically ill patients