Acute kidney injury: An intensivist's perspective

Annals of intensive care, 2017

The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18-19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: "Acute Renal Failure in the ICU: from injury to recovery." The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools,

Basic Nephrology and Acute Kidney Injury, 2012

Acute kidney injury (AKI), impairment of kidney function requires special attention in intensive care unit's (ICU), because if multiorgan failure affect the kidney, it carries a greater risk for worse outcome and furthermore survivors have higher risk then normal population for chronic renal failure. It was reported that they also have higher mortality and morbidity rates compared to normal population (Kellum, 2008 & Shiffle, 2006). Acute tubular necrosis (ATN) is the primary causes of AKI in hospital and ICU and sepsis, ischemic or toxic insults were reported as the most common reason for ATN. The rates of AKI have been reported in hospitalized patients to be between 3.2%-20% and in ICUs this rate rises up to 22% and even to 67% depending on the population studied and the definition used (Murugan 2011). Based on the administrative data, the incidence of severe AKI (defined requiring dialysis) from 1988 to2002 has increased from 4 to 27 per 100000 population. But fortunately in hospital mortality, has decreased from 41.3 to28 % (p<0.001) (Waikar, 2008). Likewise a progressive 2.8% annual increase in incidence of AKI and progressive 3.8% annual decrease in AKI associated mortality(95%CI:-4.7 to-2.12:p<0.001) was observed from 1996-2005 in a large database in Australia and New Zealand (Pisoni, 2008&Bagshaw, 2007). Despite the fact that mortality might be decreasing in ICU patients with AKI, it is still high and reported to be up to 43-88%. Mortality rate becomes even higher when patients require renal replacement therapy (Kellum, 2008). Interestingly, it was reported that irreversible AKI requiring chronic dialysis therapy increased from 3.7% in 1984 to 18.2% in 1995 in surviving patients. Even higher number of patients (33-68%) at discharge whose kidney failed to recover and who needed long term dialysis. This changing renal outcome in the survivors of ICU acquired AKI cases might be related to increasing number of older patients, several co morbid conditions, more severe AKI cases than before and in addition, complication of the more aggressive renal replacement therapies currently used (Shiffle, 2006). Since AKI in critical ill patients have high mortality rate and even if patients survive, they are at risk for End Stage Renal Disease (ESRD) and higher mortality than the normal population, it is important to recognize the clinical picture of AKI and to institute prevention as early as possible. Thus, physician should be alarmed and be ready for early intervention in this particular group of patients. With the introduction of the RIFLE

Nature Reviews Nephrology, 2010

| Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI). However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in whom fluid challenges are frequent and excretion is impaired. In this Review article, we discuss how interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to ongoing organ dysfunction. Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used. However, hypovolemia and renal hypoperfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy. Thus, accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury. Similar randomized, controlled studies in patients with AKI now seem justified.

Kidney International, 2009

Demographics, past medical history, severity of illness scores, and clinical and laboratory values stratified by the presence or absence of fluid overload are included in . APACHE III scores and the number of failed organ systems, sepsis, and ventilator requirements were significantly higher in patients with fluid overload than in those without. o r i g i n a l a r t i c l e

sarb.be

Anesthesiology, 2013

A cute kidney injury (AKI) is associated with poor outcome both in critically ill patients and after major surgery. 1 The occurrence of AKI has been associated with poor short-term and long-term outcome, increased risk of chronic renal failure, and increased risk of death. 2 Several risk factors of postoperative AKI have been identified, and may help identifying patients with the highest risk of AKI. However, recognizing contributors to AKI (e.g., systemic inflammation, systemic hemodynamics alterations, nephrotoxic agents, and others) remains a challenge for anesthesiologists and intensivists because these factors are often associated and AKI multifactorial. The early diagnosis of AKI remains another issue. Interest in the development and validation of AKI biomarkers has increased among the medical community. In this article, we analyze the risk factors of and contributors to AKI after major surgery, and specifically discuss the strategy of fluid management and potential negative outcome associated with inappropriate fluid administration, with a case scenario intended to illustrate the current knowledge of perioperative AKI. We emphasize hemodynamic management for the prevention and correction of acute renal failure.

Anaesthesia and Intensive Care, 2012

Indian Journal of Medical Sciences, 2017

Background: Acute kidney injury (AKI) in the intensive care unit (ICU) is associated with high mortality. A thorough understanding of the clinical spectrum of the disease is needed in order to device methods to improve the final outcome due to this problem. Aims and Objectives: The aim of present study was to analyze the clinical spectrum, causes, risk and prognostic factors and final outcome of AKI in the setting of ICU. Materials and Methods: This prospective study involved patients admitted to ICU during the period between June 09 to June 10. Patients who developed AKI during the ICU stay were included in the study. The clinical and laboratory data were collected at admission and then on daily basis. Data recorded includes patients demographic profile, underlying clinical illness responsible for ICU admission, dialysis requirement, need for ventilation, total duration of ICU stay, acute physiology and chronic health evaluation (APACHE)-IV score and final outcome and these data were analyzed for predicting survival using univariate and multivariate analysis. Results: 574 patients were admitted to ICU from June 09 to June 10 and (n = 124; 21.6%) patients developed AKI after admission to ICU. Mean age 44.87 ± 15.14 years and (n = 71; 57.1%) were males and (n = 53; 42.9%) were females. Out of 124 patients (50.80%; n = 63) had medical, (33.87% n = 42) had surgical and (15.32%; n = 19) had obstetric cause of admission in ICU. Of the 574 patients (12.02%; n = 69) had associated co morbidities, hypertension is the most common associated morbidities (4.7%; n = 27), others were diabetes mellitus (3.6%; n = 21), coronary artery disease (3.0%; n = 17), cerebrovascular disease (0.3%; n = 2), chronic obstructive pulmonary disease (0.3%; n = 2;). The etiology of AKI was multi-factorial, sepsis were the most common cause observed in (69.64%; n = 39), hypotension (67.84%; n = 38), volume depletion (19.64%; n = 11), nephrotoxic drugs (64.28%; n = 36) patients. Multi organ system failure (MOSF) was noted in (29.03%; n = 36) patients. MOSF and sepsis were found to be significant adverse prognostic factors when multiple logistic regression analysis was done. Conclusion: AKI was seen in 21.6% of cases in our ICU and associated with poor prognosis. Presence of sepsis, MOSF, higher APACHE IV scores and ventilation requirement were correlated with higher mortality in AKI patients in ICU. Early recognisition and intervention improves the outcome.

Critical Care, 2010

Introduction: Serum creatinine concentration (sCr) is the marker used for diagnosing and staging acute kidney injury (AKI) in the RIFLE and AKIN classification systems, but is influenced by several factors including its volume of distribution. We evaluated the effect of fluid accumulation on sCr to estimate severity of AKI.

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2010

Purpose This review provides a focused and comprehensive update on emerging evidence related to acute kidney injury (AKI).