
Diagnostic workout of AKI
KDIGO guidelines http://kdigo.org/guidelines/

Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.
https://www.ncbi.nlm.nih.gov/pubmed/26162677
Basic investigation for all AKI
- Renal ultrasound
- Ca
- Biochemistry
- 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.
https://www.ncbi.nlm.nih.gov/pubmed/21669886
Renal biopsy can be diagnostic and can provide information about background histology. 85% of pts develop peri-renal haematoma.

Future – renal biomarkers

Summary

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.
https://www.ncbi.nlm.nih.gov/pubmed/22231034
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.
https://www.ncbi.nlm.nih.gov/pubmed/27209269
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?
https://link.springer.com/content/pdf/10.1007/s00134-017-4948-0
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
https://jamanetwork.com/journals/jama/fullarticle/201386
Intermittent versus continuous renal replacement therapy for acute renal failure in adults: cochrane review
http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003773.pub3/full
Modality on mortality – no strong data to support continuous or intermittent RRT
Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients
http://www.nejm.org/doi/full/10.1056/NEJMoa0902413
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
Target 25ml/kg/hr
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
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773999/