Recommended and translated by Bin Du (Peking Union Medical College Hospital)
KDIGO’s Clinical Guidelines for AKI Qiu Zhanjun, Department of Emergency Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine Kidney International 2012; 2(Suppl): 1
Strength of recommendation
Grading
Significance
Patients
Clinicians
Policy
Level 1 “We recommend”
The majority of patients in your hospital should receive the recommended treatment measures, only a minority of patients do not
The majority of patients should receive the recommended treatment measures
Recommendations can be used as a reference for policy development or behavior evaluation
Level 2 “We recommend”
Most patients in your hospital should receive the recommended treatment, but many do not
Different patients should have different treatment options. Each patient needs help to make decisions that are consistent with his or her values and wishes
Recommendations will likely need to be discussed extensively and involve stakeholders before policy is developed
Quality of supporting evidence
Grading
Quality of evidence
Significance
A
High
We believe the true efficacy is very close to the efficacy assessment results
B
Medium
The true efficacy is likely to be close to the efficacy assessment, but there may be significant differences between the two
C
Low
True efficacy is likely to be significantly different from the efficacy assessment
D
Very low
The efficacy assessment is very uncertain and often far from the true picture
Summary of Recommendations
Recommendation
Recommendation level
2. AKI definition
2.1
Definition and grading of AKI
2.1.1
AKI is defined as any of the following – Increase in SCr ≥ 0.3 mg/dl (≥ 26.5 μmol/l) within 48 hours; or – Known or presumed increase in SCr to ≥ 1.5 times the basal value within the last 7 days; or – Urine output < 0.5 ml/kg/h x 6 hrs
Not graded
2.1.2
The severity of AKI is graded according to the following criteria (Table 2) Table 2 Grading of AKI
Grading
Serum creatinine
Urine volume
1
1.5 C 1.9 times the basal value or an increase of ≥ 0.3 mg/dl (≥ 26.5 μmol/l)
< 0.5 ml/kg/hr x 6 C 12 hrs
2
2.0 C 2.9 times the basal value
< 0.5 ml/kg/hr x ≥ 12 hrs
3
3.0 times the basal value or creatinine elevated to ≥ 4.0 mg/dl (≥ 353.6 μmol/l) or initiation of renal replacement therapy or age < 18 years with eGFR decreased to < 35 ml/min/1.73 m2
< 0.3 ml/kg/hr x ≥ 24 hrs or absence of urine ≥ 12 hrs
Unclassified
2.1.3
The cause of AKI should be determined whenever possible
Unclassified
2.2
Risk assessment
2.2.1
We recommend grading the risk of AKI according to the patient’s susceptibility and exposure
1B
2.2.2
Treat patients according to their susceptibility and exposure to reduce the risk of AKI (see relevant guidelines section)
Not graded
2.2.3
Identify patients at high risk of AKI by measuring SCr and urine volume to detect AKI
Not graded
2.3
Evaluation and general treatment of patients at high risk of AKI
2.3.1
Rapidly evaluate patients with AKI to determine the cause, with particular attention to reversible factors
Unclassified
2.3.2
Monitor patients with AKI by measuring SCr and urine output, and grade the severity of AKI according to the recommendations in 2.1.2
Not graded
2.3.3
Treatment of patients with AKI according to grading and etiology (Figure 4)
Not graded
2.3.4
Assess recovery, new disease or exacerbation of previous CKD 3 months after AKI – If the patient has CKD, treat according to the details of the KDOQI CKD guidelines – Even if the patient does not have CKD, treat as a high-risk patient for CKD and treat according to the KDOQI CKD guidelines3 for patients at high risk of CKD should be treated according to the recommended treatment
Not graded
2.4
Clinical application
2.3
Diagnosis of functional and structural changes in the kidney
3. Prevention and treatment of AKI
3.1
Hemodynamic monitoring and supportive therapy to prevent and treat AKI
3.1.1
In the absence of hemorrhagic shock, we recommend the use of isotonic crystalloids rather than colloidal fluids (albumin or starch) as an initial option for volume expansion therapy in patients at high risk of AKI or AKI
2B
3.1.2
In patients with vasodilatory shock combined with AKI or at high risk for AKI, we recommend a combination of boosting agents and fluid therapy
1C
3.1.3
For patients at high risk of perioperative or infectious shock, we recommend correcting hemodynamic and oxygenation indices according to the treatment plan to prevent AKI from occurring or causing AKI to worsen
2C
3.2
General supportive care for patients with AKI, including management of complications
3.3
Blood glucose control and nutritional support
3.3.1
For critically ill patients, we recommend insulin therapy to maintain blood glucose 110 C 149 mg/dl (6.1 C 8.3 mmol/l)
2C
3.3.2
For patients with any stage of AKI, we recommend a total caloric intake of 20 C 30 kcal/kg/d
2C
3.3.3
We recommend not to restrict protein intake to prevent or delay RRT
2C
3.3.4
We recommend protein supplementation of 0.8 C 1.0 g/kg/d for non-catabolic AKI patients who do not require dialysis treatment and 1.0 C 1.5 g/kg/d for AKI patients on RRT; for patients on continuous renal replacement therapy (CRRT) or who are highly catabolic, this should not exceed 1.7 g/kg/d
2D
3.3.5
We recommend that patients with AKI have a preference for enteral for nutritional support
2C
3.4
Clinical applications
3.4.1
We recommend not using diuretics for AKI prevention
1B
3.4.2
We recommend against the use of diuretics for AKI, except in cases of excessive volume loading
2C
3.5
Vasodilator drug therapy: dopamine, fenoldopa and natriuretic peptides
3.5.1
We do not recommend the use of small doses of dopamine for the prevention or treatment of AKI
1A
3.5.2
We do not recommend the use of fenoldopam for the prevention or treatment of AKI
2C
3.5.3
We recommend no use of atrial natriuretic peptide (ANP) to prevent (2C) or treat (2B) AKI
3.6
Growth hormone therapy
3.6.1
We recommend against the use of recombinant human (rh) IGF-1 for the prevention or treatment of AKI
1B
3.7
Adenosine receptor antagonists
3.7.1
For neonates at high risk of AKI with severe perinatal asphyxia, we recommend administration of a single dose of theophylline
2B
3.8
Prevention of aminoglycoside and amphotericin-related AKI
3.8.1
We recommend against the use of aminoglycosides for the treatment of infections unless there is no other more appropriate and less nephrotoxic therapeutic drug option
2A
3.8.2
For patients with normal and stable renal function, we recommend that aminoglycosides be administered once daily rather than multiple times daily
2B
3.8.3
When aminoglycosides are administered in a multiple daily regimen and the duration of therapy exceeds 24 hours, we recommend monitoring drug concentrations
1A
3.8.4
When aminoglycosides are administered in a once-daily regimen for more than 48 hours, we recommend monitoring drug concentrations
2C
3.8.5
We recommend topical application (e.g., respiratory nebulized inhalation, instilled antibiotic beads) rather than intravenous application of aminoglycosides when appropriate and feasible
2B
3.8.6
We recommend the use of liposomal amphotericin B rather than regular amphotericin B
2A
3.8.7
For the treatment of systemic fungal or parasitic infections, we recommend the use of azole antifungals and/or echinocandins over regular amphotericin B if the efficacy is comparable
1A
3.9
Prevention of aminoglycoside and amphotericin-related AKI
3.9.1
We recommend against non-stop coronary artery bypass grafting solely for the purpose of reducing perioperative AKI or the need for RRT
2C
3.9.2
For critically ill patients with combined hypotension, we recommend against the use of NAC for AKI prevention
2D
3.9.3
We recommend not using oral or intravenous NAC for the prevention of AKI after surgery
1A
4. Contrast-induced AKI
4.1
Contrast-induced AKI: Definition, epidemiology and prognosis After intravascular use of contrast, AKI should be defined and graded according to recommendation 2.1.1 C 2.1.2
Unclassified
4.1.1
In patients with altered renal function after intravascular contrast use, CI-AKI and other possible causes of AKI should be evaluated
Not graded
4.2
Assessment of people at risk for CI-AKI
4.2.1
All patients requiring intravascular (intravenous or arterial) iodine contrast should be evaluated for risk of CI-AKI, especially screening for previous abnormal renal function
Unclassified
4.2.2
For patients at high risk of CI-AKI, other imaging methods should be considered
Unclassified
4.3
Non-pharmacological interventions for CI-AKI
4.3.1
For patients at high risk of CI-AKI, a minimal dose of contrast should be used
Unclassified
4.3.2
For patients at high risk of CI-AKI, we recommend isotonic or hypotonic iodine contrast agents over hypertonic iodine contrast agents
1B
4.4
Blood glucose control and nutritional support
4.4.1
For patients at high risk of CI-AKI, we recommend intravenous volume expansion with isotonic sodium chloride or sodium bicarbonate solution
1A
4.4.2
For patients at high risk of CI-AKI, we recommend not using oral rehydration solution alone
1C
4.4.3
For patients at high risk of CI-AKI, we recommend oral NAC in combination with intravenous isotonic crystalloids
2D
4.4.4
We recommend not using theophylline for CI-AKI prevention
2C
4.4.5
We recommend against the use of fenoldopa for the prevention of CI-AKI
1B
4.5
Role of hemodialysis or hemofiltration
4.5.1
For patients at high risk of CI-AKI, we recommend against prophylactic use of intermittent hemodialysis (IHD) or hemofiltration (HF) for removal of contrast agents
2C
5. Dialysis for AKI
5.1
Timing of renal replacement therapy for AKI
5.1.1
RRT should be started urgently in the presence of life-threatening volume, electrolyte and acid-base balance changes
Not graded
5.1.2
The decision to initiate RRT should be made with full consideration of the clinical situation, the presence of conditions that can be corrected by RRT, and trends in laboratory findings, and should not be based solely on BUN and creatinine levels
Unclassified
5.2
Criteria for discontinuation of renal replacement therapy for AKI
5.2.1
RRT should be discontinued when it is no longer needed (renal function is restored to a level sufficient to meet the patient’s needs, or RRT no longer meets the therapeutic goals)
Not graded
5.2.2
We recommend not using diuretics to promote recovery of renal function or shortening the course of RRT or frequency of treatment
2B
5.3
Anticoagulation
5.3.1
For patients at high risk of CI-AKI, the smallest dose of contrast agent should be used
Unclassified
5.3.1.1
We recommend anticoagulation during RRT if the patient with AKI is not at significant risk of bleeding or coagulopathy and is not receiving systemic anticoagulation
1B
5.3.2
For patients who are not at high risk of bleeding or coagulation dysfunction and are not receiving effective systemic anticoagulation, we have the following recommendations.
5.3.2.1
For anticoagulation during intermittent RRT, we recommend the use of plain heparin or low-molecular-weight heparin, and no other anticoagulation should be used
1C
5.3.2.2
For anticoagulation in CRRT, we recommend the use of topical citrate anticoagulation rather than heparin if the patient has no contraindications to citrate anticoagulation
2B
5.3.2.3
For anticoagulation during CRRT in patients with contraindications to citrate anticoagulation, we recommend the use of plain heparin or low molecular weight heparin and no other anticoagulation should be used
2C
5.3.3
For patients at high risk of bleeding who are not on anticoagulation, we recommend the following anticoagulation measures during CRRT.
5.3.3.1
For patients without contraindications to citrate, we recommend topical citrate anticoagulation during CRRT and no other anticoagulant measures should be used
2C
5.3.3.2
For patients at high risk of bleeding, we recommend avoiding topical heparinization during CRRT
2C
5.3.4
For patients who develop heparin-induced platelet deficiency (HIT), all heparin should be discontinued and we recommend the use of direct inhibitors of thrombin (e.g., argatroban [argatroban]) or factor Xa inhibitors (e.g., danaparin [danaparoid] or dalteparin sodium [fondaparinux]) during RRT, and no other anticoagulant measures should be used
1A
5.3.4.1
In patients with HIT without severe liver failure, we recommend the use of argatroban rather than other thrombin or factor Xa inhibitors during RRT
2C
5.4
Blood glucose control and nutritional support
5.4.1
For patients with AKI, we recommend using a non-capsulated, non-tunneled dialysis catheter for RRT, rather than a tunneled catheter
2D
5.4.2
The following considerations should be taken into account when selecting a dialysis catheter for venous placement in AKI patients: – First choice: right internal jugular vein – Second choice: femoral vein – Third choice: left internal jugular vein – Last choice: subclavian vein (preference for dominant limb side)
Unclassified
5.4.3
We recommend ultrasound-guided placement of dialysis catheters
1A
5.4.4
We recommend that after placement of an internal jugular or subclavian vein dialysis catheter, a chest radiograph should be taken before the first use
1B
5.4.5
For ICU patients with AKI requiring RRT, we recommend that topical antibiotics not be applied to the skin at the non-tunnel dialysis catheter placement site
2C
5.4.6
For patients with AKI requiring RRT, we recommend not using antibiotic locks to prevent catheter-related infections in non-tunneled dialysis catheters
2C
5.5
Filter membranes for AKI renal replacement therapy
5.5.1
For patients with AKI, we recommend the use of dialyzers with biocompatible membrane materials for IHD or CRRT
2C
5.6
Modalities of renal replacement therapy in AKI patients
5.6.1
Patients with AKI should use continuous and intermittent RRT as a complement to each other
Not graded
5.6.2
For hemodynamically unstable patients, we recommend the use of CRRT rather than standard intermittent RRT
2B
5.6.3
For patients with acute brain injury or AKI with other conditions causing intracranial hypertension or diffuse cerebral edema, we recommend CRRT rather than intermittent RRT
2B
5.7
Buffer solution selection for renal replacement therapy in AKI patients
5.7.1
When RRT is performed in AKI patients, we recommend the use of carbonate rather than lactate buffer as dialysate and replacement solution
2C
5.7.2
For RRT in AKI patients with combined shock, we recommend using carbonate rather than lactate as dialysate and replacement solution
1B
5.7.3
For RRT in AKI patients with combined liver failure and/or lactic acidosis, we recommend carbonate rather than lactate
2B
5.7.4
We recommend that dialysis and replacement fluids used in patients with AKI should meet at least the American Association of Medical Devices (AAMI) standards related to bacterial and endotoxin contamination
1B
5.8
Dosing of AKI renal replacement therapy
5.8.1
The dose of RRT should be determined prior to initiation of each RRT
Not graded
We recommend frequent assessment of the actual treatment dose for adjustment
1B
5.8.2
Electrolyte, acid-base, solute and fluid balance goals should be met during RRT
Not graded
5.8.3
When intermittent or extended RRT is used in AKI patients, we recommend that Kt/V 3.9/week should be achieved
1A
5.8.4
When CRRT is performed in AKI patients, we recommend an outflow fluid volume of 20 C 25 ml/kg/hr
1A
This usually requires a higher prescribed dose of outflow fluid
Unclassified