Acute Kidney Injury

Acute Kidney Injury
Final Draft (8 March 2011) Read All the Guidelines Download this and previous pdfs
Authors of this guideline were:

Dr Andrew Lewington & Dr Suren Kanagasundaram Please send feedback fro the next edition to Dr Andrew Lewington at Andrew.Lewington@leedsth.nhs.uk and Dr Suren Kanagasundaram at Suren.Kanagasundaram@nuth.nhs.uk
Contents Introduction
Summary of clinical practice guidelines for Acute Kidney Injury
1. Definition epidemiolog! and out"omes #Guidelines 1.1 $ 1.%& '. (lini"al assessment #Guidelines '.1 $ '.'& %. )revention #Guidelines %.1 $ %.*& *. +anagement #Guidelines *.1 $ *.,& ,. -reatment fa"ilities and referral to renal servi"es #Guidelines ,.1 $ ,..& /. (hoi"e of renal repla"ement modalit! #Guideline /.1& .. (hoi"e of dial!ser0haemofilter mem1rane and 1uffer #Guidelines ..1 $ ..%& 2. 3as"ular a""ess for renal repla"ement therap! #RR-& #Guidelines 2.1 $ 2.4& 4. Anti"oagulation for e5tra"orporeal therapies #Guidelines 4.1 $ 4.*& 16. Renal repla"ement therap! pres"ription #Guidelines 16.1 $ 16.,& 11. -iming of initiation of renal repla"ement treatment #Guidelines 11.1 $ 11.,& 1'. 7du"ation #Guideline 1'.1&
Summary of audit measures for Acute Kidney Injury

#Audit measures 1$'*&
Rationale for clinical practice guidelines for Acute Kidney Injury

1. Definition epidemiolog! and out"omes #Guidelines 1.1 $ 1.%& '. (lini"al assessment #Guidelines '.1 $ '.'& %. )revention #Guidelines %.1 $ %.*& *. +anagement #Guidelines *.1 $ *.,& ,. -reatment fa"ilities and referral to renal servi"es #Guidelines ,.1 8 ,..& /. (hoi"e of renal repla"ement modalit! #Guideline /.1& .. (hoi"e of dial!ser0haemofilter mem1rane and 1uffer #Guidelines ..1 $ ..%& 2. 3as"ular a""ess for renal repla"ement therap! #RR-& #Guidelines 2.1 $ 2.4& 4. Anti"oagulation for e5tra"orporeal therapies #Guidelines 4.1 $ 4.*& 16. Renal repla"ement therap! pres"ription #Guidelines 16.1 $ 16.,& 11. -iming of initiation of renal repla"ement treatment #Guidelines 11.1 $ 11.,& 1'. 7du"ation #Guideline 1'.1&
Acknowledgement Introduction
A"ute kidne! in9ur! #AK:& has now repla"ed the term a"ute renal failure and an universal definition and staging s!stem has 1een proposed to allow earlier dete"tion and management of AK:. -he new terminolog! ena1les health"are professionals to "onsider the disease as a spe"trum of in9ur!. -his spe"trum e5tends from less severe forms of in9ur! to more advan"ed in9ur! when a"ute kidne! failure ma! re;uire renal repla"ement therap! #RR-&. (lini"all! AK: is "hara"terised 1! a rapid redu"tion in kidne! fun"tion resulting in a failure to maintain fluid ele"trol!te and a"id$1ase homoeostasis. -here have previousl! 1een man! different definitions of AK: used in the literature whi"h has made it diffi"ult to determine the epidemiolog! and out"omes of AK:. <ver re"ent !ears there has 1een in"reasing re"ognition that relativel! small rises in serum "reatinine in a variet! of "lini"al settings are asso"iated with worse out"omes1. -o address the la"k of an universal definition for AK: a "olla1orative network of international e5perts representing nephrolog! and intensive "are so"ieties esta1lished the A"ute Dial!sis =ualit! :nitiative #AD=:& and devised the R:>L7 definition and staging s!stem for AK:'. Shortl! after this man! of the original mem1ers of the AD=: group "olla1orated to form the A"ute Kidne! :n9ur! ?etwork #AK:?&% *. -he AK:? group modified the R:>L7 staging s!stem to refle"t the "lini"al signifi"an"e of relativel! small rises in serum "reatinine. +ost re"entl! the international guideline group Kidne! Disease@ :mproving Glo1al <ut"omes #KD:G<& has 1rought together international e5perts from man! different spe"ialties to produ"e a definition and staging s!stem that harmonises the previous definitions and staging s!stems proposed 1! 1oth AD=: and AK:?,. :t is anti"ipated that this definition and staging s!stem will
1e adopted glo1all!. -his will ena1le future "omparisons of the in"iden"e out"omes and effi"a"! of therapeuti" interventions for AK:. -o date there is a pau"it! of data on the in"iden"e of AK: whether "ommunit! or hospital$ a";uired. -he reported prevalen"e of AK: from AS data ranges from 1B #"ommunit!$a";uired& up to ..1B #hospital$a";uired& of all hospital admissions/ .. -he population in"iden"e of AK: from AK data ranges from 1.' per million population #pmp& per !ear from earl! data2 up to *2/$/%6 pmp0!ear from more re"ent series4$11 again depending on definition. -he in"iden"e of AK: re;uiring renal repla"ement therap! #RR-& ranges from '' pmp0!ear. to '6% pmp0!ear16. An estimated ,8'6B of "riti"all! ill patients e5perien"e an episode of AK: during the "ourse of their illness and AK: re"eiving RR- has 1een reported in *C4B of all admissions to intensive$"are units #:(A&1'. Data from the :ntensive (are ?ational Audit Resear"h (entre #:(?AR(& suggests that AK: a""ounts for nearl! 16 per"ent of all :(A 1ed da!s1%. A"ute kidne! in9ur! is "ommon in hospitalised patients and also has a poor prognosis with the mortalit! ranging from 16B$26B dependent upon the patient population studied. )atients who present with un"ompli"ated AK: have a mortalit! rate of up to 16B1* 1,. :n "ontrast patients presenting with AK: and multiorgan failure have 1een reported to have mortalit! rates of over ,6B. :f renal repla"ement therap! is re;uired the mortalit! rate rises further to as high as 26B
1/ 1.
A"ute kidne! in9ur! is no longer "onsidered to 1e an inno"ent 1!stander merel! refle"ting "o$ e5istent pathologies. :t has 1een demonstrated to 1e an independent risk fa"tor for mortalit! 12$
'6
. -he "ause of this is un"lear 1ut is possi1l! asso"iated with an in"reased risk of Dnon$renalE
"ompli"ations su"h as 1leeding and sepsis12. An alternative e5planation ma! lie in e5perimental work that has demonstrated the Fdistant effe"tsF of is"haemi" AK: on the other organs. :n these e5perimental models isolated is"haemi" AK: upregulates inflammator! mediators in other organs in"luding the 1rain lungs and heart'1. -he AK ?ational (onfidential 7n;uir! into )atient <ut"ome and Death #?(7)<D& adding insult to in9ur! a"ute kidne! in9ur! report was pu1lished last !ear''. -his report e5amined the "are of patients who died with a diagnosis of AK:. :t identified man! defi"ien"ies in the "are of patients who developed AK: and reported that onl! ,6B of patients re"eived good "are. -here was poor attention to detail inade;uate assessment of risk fa"tors for AK: and an una""epta1le dela! in re"ognising post admission AK:. -he report made a num1er of re"ommendations whi"h in"luded the following
all emergen"! admissions should have a risk assessment for AK:
all emergen"! admissions should have ele"trol!tes "he"ked on admission and appropriatel! thereafter predi"ta1le avoida1le AK: should not o""ur all a"ute admission should re"eive ade;uate senior reviews #"onsultant review within 1' hours& there should 1e suffi"ient "riti"al "are and renal 1eds to allow rapid step up "are undergraduate medi"al training should in"lude the re"ognition of the a"utel! ill patient and the prevention diagnosis and management of AK: postgraduate training in all spe"ialties should in"lude training in the dete"tion prevention and management of AK:.
-he ?(7)<D report was used to support a su""essful proposal made to the ?ational :nstitute for Gealth and (lini"al 75"ellen"e #?:(7& for an AK: guideline. :t is hoped that the guideline will 1e availa1le in the near future. <n"e a patient has developed AK: the therapeuti" options are limited with the mainsta! of treatment 1eing renal repla"ement therap! #RR-&. Gowever there are man! important aspe"ts surrounding the "are of a patient with AK: that must 1e "onsidered whi"h in"lude timel! referral and transfer to renal servi"es if appropriate. -here is a pau"it! of eviden"e to guide the optimal time to initiate RR- and the de"ision remains the "hoi"e of the individual ph!si"ian. :f a patient "ommen"es RR- then there are num1er of pra"ti"al issues to 1e "onsidered in"luding the modalit! the "hoi"e of filter mem1rane the optimal site of vas"ular a""ess anti"oagulation and the intensit! of the treatment. -he purpose of these "lini"al pra"ti"e guidelines is to review the availa1le eviden"e and provide a pragmati" approa"h to the patient with AK:. -here is a pressing need for renal ph!si"ians to engage in undergraduate and postgraduate edu"ational programmes to improve the "urrent management of AK:.
References
1. )raught +L Shlipak +G. Are small "hanges in serum "reatinine an important risk fa"torH (urr <pin ?ephrol G!pertens '66,I 1* '/,$'.6 '. Jellomo R Ron"o ( Kellum KA +ehta RL )alevsk! ) and the AD=: workgroup. A"ute renal failure 8 definition out"ome measures animal models fluid therap! and information te"hnolog! needs. -he se"ond international "onsensus "onferen"e of A"ute Dial!sis =ualit! :nitiative #AD=:& Group. (rit (are '66*I 2@ R'6*$R'1' %. +ehta RL Kellum KA Shah S3 et al. '66.. A"ute Kidne! :n9ur! ?etwork #AK:?&@ report of an initiative to improve out"omes in a"ute kidne! in9ur!. (riti"al "are 11 R %1 *. +olitoris JA Levin A Larno"k D et al. :mproving out"omes of a"ute kidne! in9ur!@ report of an initiative. ?at (lin )ra"t ?ephrol '66.I % #2&@ *%4$**' 5. Kidne! Disease@ :mproving Glo1al <ut"omes. (lini"al pra"ti"e guideline on a"ute kidne! in9ur!. '611. www.kdigo.org
/. ?ash K GafeeM A Gou S. Gospital$a";uired renal insuffi"ien"!. Am K Kidne! Dis '66'I %4@4%684%/ .. Kaufman K Dhakal + )atel J et al. (ommunit!$a";uired a"ute renal failure. Am K Kidne! Dis 1441I 1.@ 141$142 2. >eest -G Round A Gamad S. :n"iden"e of severe a"ute renal failure in adults@ results of a living "ommunit! 1ased stud!. J+K 144%I%6/@ *218*2%. 4. Stevens )7 -amimi ?A Al Gasani +K et al. ?on$spe"ialist management of a"ute renal failure. =K+ '661I 4*@ ,%%8,*6. 16. +et"alfe L Simpson K+ Khan :G et al. A"ute renal failure re;uiring renal repla"ement therap!@ in"iden"e and out"ome. =K+ '66'I 4,@ ,.48,2%. 11. Gegart! K +iddleton R Kre1s + et al. Severe a"ute renal failure. )la"e of "are in"iden"e and out"omes. =K+ '66,I 42@ //1$/// 1'. +etnitM )GG Krenn (G SteltMer G et al. 7ffe"t of a"ute renal failure re;uiring renal repla"ement therap! on out"ome in "riti"all! ill patients. (rit (are +ed '66'I %6@ '6,18'6,2. 13. :ntensive$(are ?ational Audit Resear"h (entre '66, www.i"nar".org 1*. Gou SG Jushinsk! DA Lish KJ (ohen KK Garrington K-. Gospital$a";uired renal insuffi"ien"!@ a prospe"tive stud!. Am K +ed 142%I .*@'*%$2 1,. Shusterman ? Strom JL +urra! -G +orrison G Lest SL +aislin G. Risk fa"tors and out"ome of hospital$a";uired a"ute renal failure. (lini"al epidemiologi" stud!. Am K +ed 142.I 2%@/,$.1 1/. LiaNo > Kun"o 7 )as"ual K +adero R 3erde 7. -he spe"trum of a"ute renal failure in the intensive "are unit "ompared with that seen in other settings. -he +adrid A"ute Renal >ailure Stud! Group. Kidne! :nt 1442I ,%@S1/$'* 1.. (osentino > (haff ( )iedmonte +. Risk fa"tors influen"ing survival in :(A a"ute renal failure. ?ephrol Dial -ransplant 144*I 4@1.4$2' 12. (hertow G+ Lev! 7+ Gammermeister K7 et al. :ndependent asso"iation 1etween a"ute renal failure and mortalit! following "ardia" surger!. Am K +ed 16*@%*%$%*2 1442 14. Lev! 7+ 3is"oli (+ GorwitM R:. -he effe"t of a"ute renal failure on mortalit!@ a "ohort anal!sis. KA+A 144/I '.,@ 1*24$1*4* '6. A"hino S Jellomo R Goldsmith D et al. An assessment of the R:>L7 "riteria for a"ute renal failure in hospitaliMed patients. (rit (are +ed '66/I %*@141%$ 141. '1. Li O Gassoun G- Santora R Ra11 G. <rgan "rosstalk@ the role of the kidne!. (urr <pin (rit (are. '664 De"I1, #/&@*21$. ''. ?ational (onfidential 7n;uir! into )atient <ut"ome and Death Adding :nsult to :n9ur! '664. www.n"epod.org
Summary of Clinical Practice Guideline on Acute Kidney Injury

1. Acute Kidney Injury (AKI) (Guideline AKI 1.1-1.3)
Guideline 1.1 AKI : Definition, Epidemiology and Outcomes
Le re"ommend that the international Kidne! Disease@ :mproving Glo1al <ut"omes #KD:G<& definition of a"ute kidne! in9ur! #AK:& should 1e adopted. #?ot Graded&
A"ute kidne! in9ur! is defined when one of the following "riteria is met Serum "reatinine rises 1! P '/Qmol0L within *2 hours or Serum "reatinine rises P 1., fold from the referen"e value whi"h is known or presumed to have o""urred within one week or urine output is R 6.,ml0kg0hr for S/ "onse"utive hours
-he referen"e serum "reatinine should 1e the lowest "reatinine value re"orded within % months of the event :f a referen"e serum "reatinine value is not availa1le within % months and AK: is suspe"ted

repeat serum "reatinine within '* hours a referen"e serum "reatinine value "an 1e estimated from the nadir serum "reatinine value if patient re"overs from AK:

Le re"ommend that the international Kidne! Disease@ :mproving Glo1al <ut"omes #KD:G<& staging "lassifi"ationT of a"ute kidne! in9ur! #AK:& should 1e adopted. #?ot Graded& Stag Serum creatinine (SCr) criteria e
1 ' % in"rease P '/ Umol0L within *2hrs or in"rease P1., to 1.4 O referen"e S(r in"rease P ' to '.4 O referen"e S(r in"rease P% O referen"e S(r or in"rease %,* Umol0L or "ommen"ed on renal repla"ement therap! #RR-& irrespe"tive of stage
Urine output criteria

R6., mL0kg0hr for S / "onse"utive hrs R6., mL0kg0 hr for S 1' hrs R6.% mL0kg0 hr for S '* hrs or anuria for 1' hrs

Le re"ommend that serum "reatinine and urine output remain the 1est 1iomarkers for AK:. Serum "reatinine should 1e measured using the enM!mati" te"hni;ue. #1J&
2. Acute Kidney Injury (AKI) (Guidelines AKI 2.1 2.2)

Guideline 2.1 AKI : Clinical Assessment; History, Examination
Le re"ommend that all patients presenting with AK: should have a "omprehensive histor! and e5amination performed to help determine the aetiolog! of the AK:. #1A&
Guideline 2.2 AKI : Clinical Assessment; Investigations
Le re"ommend that all patients presenting with AK: should have appropriate 1aseline investigations performed whi"h should in"lude a urinal!sis and a renal tra"t ultrasound within '* hours #if renal tra"t o1stru"tion is suspe"ted&. #1A&

Guideline 3.1 AKI : Prevention; Risk Assessment
Le re"ommend that patients at risk of AK: should 1e identified and appropriate preventative measures should 1e instituted as earl! as possi1le. #1J&
Guideline 3.2 AKI : Prevention; Fluid Therapy

Le re"ommend that pres"ription of appropriate intravenous fluid should 1e "arefull! "onsidered following assessment of the patientVs volume status. -hereafter the patientWs "lini"al response should 1e monitored "losel!. #1J&
Guideline 3.3 AKI : Prevention; Contrast-Induced AKI (CI-AKI)

Le re"ommend that patients identified as 1eing at risk of "ontrast indu"ed$AK: #(:$AK:& should have a "areful assessment of volume status and re"eive pre$pro"edure volume e5pansion with 6.4B sodium "hloride or isotoni" sodium 1i"ar1onate if "lini"all! indi"ated. #1A&
Guideline 3.4 AKI : Prevention; AKI secondary to Rhabdomyolysis

Le re"ommend that patients identified as 1eing at risk of developing AK: se"ondar! to rha1dom!ol!sis should re"eive intravenous volume e5pansion with 6.4B sodium "hloride and sodium 1i"ar1onate. #1J&

Guideline 4.1 AKI : Management; General Management
Le re"ommend that general supportive measures in"lude optimisation of haemod!nami" status 1! appropriate fluid therap! administration of vasopressors and0or inotropes and treatment of an! underl!ing sepsis. ?ephroto5i" medi"ations should 1e stopped. #1A&
Guideline 4.2 AKI : Management; Pharmacological Therapy

Le re"ommend that therapeuti" drug dosing must 1e adapted to altered kineti"s in AK:. #1J&
Le re"ommend that there is no spe"ifi" pharma"ologi"al therap! proven to effe"tivel! treat AK: se"ondar! to h!poperfusion in9ur! and0or sepsis. #1J&
Guideline 4.4 AKI : Management; Nutritional Support

Le re"ommend that patients with AK: re"eiving renal repla"ement therap! #RR-& should 1e referred to a dieti"ian for individual assessment. #1D&
Guideline 4.5 AKI : Management; Nutritional support

Le re"ommend that patients with AK: should re"eive ',$%, k"al0kg0da! and up to a ma5imum of 1..g amino a"ids0kg0da! if h!per"ata1oli" and re"eiving "ontinuous renal repla"ement therap!. -ra"e elements and water solu1le vitamins should 1e supplemented as re;uired. #1(&

Guideline 5.1 AKI : Treatment facilities & referral to renal services
Le re"ommend that renal servi"es should work together with other spe"ialties to develop guidelines for the management of AK:. -hese should in"lude "lear guidelines with respe"t to when to re;uest a renal referral. #1A&

Le re"ommend that spe"ialist renal advi"e should 1e given with "onsultant renal ph!si"ian input. #1J&

Le re"ommend that transfer proto"ols should 1e developed 1ased on lo"al ph!siologi"al earl! warning s"ores to ensure appropriate triage of in$patients with AK: arriving from other hospitals. #1(&

Le re"ommend that ph!siologi"al surveillan"e should 1e performed for all patients with AK: to identif! earl! signs of ph!siologi"al deterioration whi"h ma! re;uire es"alation in the level of "are. #1A&
Le suggest that renal ph!si"ians and intensivists should work together to provide "are for patients with AK: on the intensive "are unit #:(A&. ?ephrolog! trainees should 1e trained to "are for a"utel! ill patients with AK:. #'(&

Le suggest that intensive "are units should "onta"t renal servi"es to dis"uss patients likel! to re;uire ongoing single organ renal support prior to step$down. Advan"e warning of su"h patients will fa"ilitate forward planning and "ontinued follow$up. #'(&

Le re"ommend that AK: survivors with residual renal impairment should 1e managed a""ording to lo"al "hroni" kidne! disease #(KD& guidelines. Dis"harge planning should in"lude plans for (KD management where relevant. #1A&.
6. Acute Kidney Injury (AKI) (Guidelines AKI 6.1)

Guideline 6.1 AKI : Choice of renal replacement therapy modality
Le re"ommend that the "hoi"e of RR- modalit! should 1e guided 1! the individual patientWs "lini"al status medi"al and nursing e5pertise and availa1ilit! of modalit!. #1J&

Guideline 7.1 Choice of dialyser / haemofilter membrane
Le re"ommend that s!ntheti" or modified "ellulosi" mem1ranes should 1e used in preferen"e to unmodified "ellulose mem1ranes. #1J&
Guideline 7.2 Choice of dialysate / replacement fluid

Le re"ommend that 1i"ar1onate should 1e the preferred 1uffer for dial!sate and repla"ement fluid in "ontinuous renal repla"ement therap! #(RR-& te"hni;ues unless regional "itrate anti"oagulation is emplo!ed. #1(&
Guideline 7.3 Microbial standards for fluids

Le re"ommend that mi"ro1ial standards for fluids used for "hroni" haemodial!sis #GD& 0 haemodiafiltration #GD>& should 1e also applied to e5tra"orporeal therap! for AK:. #1A&
Guideline 8.1 AKI : Vascular access for RRT

Le re"ommend that a"ute a""ess for renal repla"ement therap! should 1e veno$venous rather than arterio$venous. #1A&

Le re"ommend that dial!sis "atheters should 1e of an ade;uate length to minimise the risks of a""ess re"ir"ulation. #1(&

Le suggest that the a""ess site and "atheter t!pe should 1e "hosen with regard to the phase of the patientWs illness. #'(&

Le re"ommend that a""ess should 1e pla"ed 1! e5perien"ed or appropriatel! supervised staff. Real$time ultrasound guidan"e should 1e used to aid pla"ement of upper 1od! a""ess. #1A&

Le re"ommend that it is advisa1le that real$time ultrasound guidan"e 1e used for the insertion of femoral a""ess. #1D&

Le re"ommend that su1"lavian a""ess should 1e avoided in patients at risk of progressing to (KD stage * or , due to the risks of "ompromising future permanent vas"ular a""ess. #1D&

Le suggest that non$dominant arm upper lim1 vas"ulature should 1e preserved as a "ontingen"! for future permanent a""ess. #'(&

Le re"ommend that temporar! a""ess should 1e "hanged at appropriate intervals to minimise the risk of infe"tion. #1(&
Le suggest that lo"al poli"ies on prevention of "atheter$related infe"tion should 1e optimised 1! reserving the "atheter for e5tra"orporeal treatment onl!. #1D&

Guideline 9.1 AKI : Anticoagulation for extracorporeal therapies
Le re"ommend that anti"oagulation for RR- should 1e tailored a""ording to patient "hara"teristi"s and the modalit! of RR- "hosen. #1(&

Le re"ommend that regional anti"oagulation with "itrate redu"es risk of haemorrhage "ompared to s!stemi" heparinisation. -he "omple5it! of the te"hni;ue means that this should 1e in routine use on an! unit on whi"h it is emplo!ed in order to allow suffi"ient levels of e5pertise to 1e maintained. #1(&

Le suggest that prosta"!"lin is a suita1le alternative to unfra"tionated heparin in those at in"reased risk of 1leeding 1ut ma! "ause haemod!nami" insta1ilit!. #'(&

Le suggest that a no$anti"oagulation saline flush strateg! "an 1e used in patients re"eiving (RR- and intermittent therapies who are at high risk of 1leeding. Gowever ultrafiltration re;uirements are in"reased effe"tive intermittent GD time is redu"ed and the te"hni;ue runs the risk of mem1rane fi1re rupture. #'(&

Guideline 10.1 AKI : Renal Replacement Therapy prescription
Le re"ommend that the delivered dose of RR- should 1e assessed to ensure the ade;ua"! of the pres"ription. #1A&

Le re"ommend that the pres"ri1ed dose should 1e assessed at ea"h session #for intermittent haemodial!sis& and dail! #for "ontinuous te"hni;ues& to a""ount for an! measured shortfalls in delivered dose. #1A&

Le re"ommend that patients with AK: and multi$organ failure treated 1! "ontinuous renal repla"ement therap! #(RR-& should re"eive treatment doses e;uivalent to post dilution ultrafiltration rates P ', ml0kg0hr. A proportionate upward ad9ustment to the pres"ri1ed ultrafiltration rate should 1e made in pre$dilutional "ontinuous haemofiltration. #1A&

Le re"ommend that patients with AK: and multi$organ failure treated 1! intermittent haemodial!sis should re"eive either alternate da! haemodial!sis with at least the minimum dose "onsidered appropriate for end$stage renal disease #7SRD& urea redu"tion ratio #ARR& S/,B or eKt03S1.' or dail! haemodial!sis. #1J&

Le suggest that renal repla"ement therap! dosing methods that re;uire an assessment of patient weight should use a measured weight rather than an e5trapolated weight from pre$ mor1id readings. #'J&
11. Acute Kidney Injury (AKI) (Guidelines AKI 11 .1 11.5)

Guideline 11.1 AKI : Timing of initiation of renal replacement treatment
Le re"ommend that the de"ision to start RR- in patients with AK: should remain a "lini"al de"ision 1ased on fluid ele"trol!te and meta1oli" status of ea"h individual patient. #1(&

Le re"ommend that RR- should 1e initiated on"e AK: is esta1lished and unavoida1le 1ut 1efore overt "ompli"ations have developed. #1J&

Le re"ommend that the threshold for initiating RR- should 1e lowered when AK: o""urs as part of multi$organ failure. #1(&

Le re"ommend that the initiation of RR- ma! 1e deferred if the underl!ing "lini"al "ondition is improving and there are earl! signs of renal re"over!. #1D&
Guideline 11.5 AKI : Timing of discontinuation of renal replacement treatment

Le re"ommend that an improvement in the patientWs "lini"al "ondition and urine output would 9ustif! temporar! dis"ontinuation of ongoing renal support to see if AK: is re"overing. #1D&

Guideline 12.1- AKI: Education
Le re"ommend that undergraduate and postgraduate medi"al trainees should 1e taught the prin"iples of prevention re"ognition and management of AK:. #1(&
Summary of Audit Measures:

:t is re"ommended that the following audit measures are re"orded for all patients diagnosed with a"ute kidne! in9ur!. Gowever it is re"ogniMed that it ma! onl! 1e possi1le for renal units to re"ord these audit measures for patients that have 1een referred for a renal spe"ialist opinion. -he Renal Asso"iation would en"ourage other spe"ialties to re"ord these audit measures for all patients diagnosed with AK: irrespe"tive of whether or not the! are referred to renal servi"es.
1. :n"iden"e and out"omes of patients diagnosed with

1. "ommunit!$a";uired AK: 2. hospital a";uired AK:
'. :n"iden"e and out"omes of patients with different "auses of AK: %. :n"iden"e of a"ute admissions0patients undergoing ma9or surger! who had
1. the risk of AK: assessed on admission0pre$surger! 2. ele"trol!tes "he"ked on admission0pre$surger! and re"he"ked within
'* hours '. )roportion of patients who had a urinal!sis performed within '* hours of the diagnosis of AK: unless anuri" %. )roportion of patients where there has 1een a dela! of S*2 hours in re"ognising the diagnosis of AK: *. )roportion of patients developing AK: se"ondar! to o1stru"tion who had a renal ultrasound e5amination R '* hrs after a diagnosis of AK: esta1lished ,. )roportion of patients with or at risk of AK: who are pres"ri1ed intravenous fluids without an assessment of volume status /. )roportion of patients with AK: who did not have the appropriate ad9ustment of medi"ation doses
.. )roportion of patients with or at risk of AK: who re"eive nephroto5i" medi"ations 2. )roportion of patients at high risk of "ontrast indu"ed AK: #(:$AK:& who developed AK: and did not
1. re"eive pre$pro"edure volume assessment 2. re"eive appropriate volume e5pansion 3. have appropriate ad9ustments to medi"ations
'. )roportion of patients with severe AK: where there is do"umented eviden"e of patient involvement in de"ision making with respe"t to "ommen"ing renal repla"ement therap! #RR-& %. :n"iden"e of dela!s of transfer of patients with AK: S'* hours following referral to renal servi"es due to a la"k of resour"es on renal unit *. :n"iden"e of patients with single organ AK: admitted to :(A for RR- due to a la"k of resour"es on the renal unit ,. ?um1er of AK: inpatient transfers re;uiring es"alation of "are within '* hours of arrival on renal unit /. :n"iden"e of dial!sis "atheter$related 1a"teraemia and sepsis in patients with AK: .. :n"iden"e of heparin indu"ed throm1o"!topenia 2. )roportion of "riti"all! ill patients with AK: treated with alternate da! haemodial!sis who re"eive Kt03 P 1.' per session 4. )roportion of "riti"all! ill patients with AK: treated with "ontinuous renal repla"ement therap! who re"eive S ', mls0kg0hr post dilution ultrafiltration 16. )roportion of patients with AK: re"eiving renal repla"ement therap! reviewed 1! dieti"ian within '* hours 11. )roportion of patients with AK: re"eiving renal repla"ement therap! pres"ri1ed the re"ommended nutritional support 1'. )roportion of patients with AK: who re"over kidne! fun"tion within 46 da!s of episode as defined 1!
1. return of serum "reatinine to within '6B of 1aseline value #most
re"ent value within % months 1ut a""epting value up to one !ear&

2. dial!sis independen"e #if previousl! re;uiring dial!sis&
'. )roportion of AK: survivors with residual "hroni" kidne! disease with post$ dis"harge (KD planning %. )roportion of AK: survivors who are given information on the "ause of AK: and how this might 1e avoided in the future *. <ut"ome measures for patients developing AK: should in"lude
1. 2. 3. 4.
length of hospital sta! hospital mortalit! 46 da! mortalit! one !ear mortalit!
Rationale for clinical practice guidelines for Acute Kidney Injury


Le re"ommend that the international Kidne! Disease@ :mproving Glo1al <ut"omes #KD:G<& definition of a"ute kidne! in9ur! #AK:& should 1e adopted. #not graded& Audit measures
1. :n"iden"e and out"omes of patients diagnosed with

1. "ommunit!$a";uired AK: 2. hospital a";uired AK:
'. )roportion of patients where there has 1een a dela! of S *2 hours in re"ognising the diagnosis of AK: %. )roportion of patients with AK: who re"over kidne! fun"tion within 46 da!s of episode as defined 1!
1. return of serum "reatinine to within '6B of 1aseline value #most
re"ent value within % months 1ut a""epting up to one !ear&

2. dial!sis independen"e #if previousl! re;uiring dial!sis&
'. <ut"ome measures for patients developing AK: should in"lude

1. 2. 3. 4.
length of hospital sta! hospital mortalit! 46 da! mortalit! one !ear mortalit!
Rationale <ver re"ent !ears it has 1een re"ognised that even small in"reases in serum "reatinine #S(r& are asso"iated with worse patient out"omes1. -o refle"t the importan"e of these "hanges in S(r the term a"ute kidne! in9ur! #AK:& has now repla"ed a"ute renal failure #AR>&. -his allows AK: to 1e "onsidered as a spe"trum of severit! that if not dete"ted or re"ognised in its earl! stages ma! ultimatel! result in a"ute kidne! failure and the need for renal repla"ement therap! #RR-&. -he most re"ent definitions proposed 1! the A"ute Dial!sis =ualit! :nitiative #AD=:& R:>L7 and the A"ute Kidne! :n9ur! ?etwork #AK:?& have 1een 1ased on rises in serum "reatinine or redu"tions in urine output. -hese definitions aimed to promote the earlier dete"tion and re"ognition of AK: triggering appropriate treatment prior to progressive in9ur! and kidne! failure. -he appli"ation of these definitions in more than ,66 666 patients has validated the in"reased risk of mortalit! asso"iated with developing AK:'$*. -hese studies have also indi"ated that the in"iden"e of AK: in hospitalised patients ma! 1e as high as 12B. -hese definitions have
re"entl! 1een harmonised 1! the Kidne! Diseases@ :mproving Glo1al <ut"omes :nternational #KD:G<& guideline group,. :t is important to note that the diagnosis of AK: should 1e made initiall! 1ased on the diagnosti" "riteria 1elow. <n"e the diagnosis of AK: has 1een esta1lished its severit! "an 1e determined using the staging s!stem #shown in -a1le 1 in the rationale for guideline re"ommendation 1.'&. A"ute kidne! in9ur! is diagnosed when one of the following "riteria is met

Serum "reatinine rises 1! P '/Qmol0L from the 1aseline value within *2 hours or Serum "reatinine rises P 1., fold from the 1aseline value whi"h is known or presumed to have o""urred within one week or urine output is R 6.,ml0kg0hr for S/ "onse"utive hours
:f the patient does not have a 1aseline serum "reatinine value within one week of their admission or presentation it is a""epta1le to use
a referen"e serum "reatinine value within % months #a""epta1le up to one !ear&
:f a referen"e serum "reatinine value is not availa1le within % months #a""epta1le up to one !ear& and AK: is suspe"ted

repeat serum "reatinine within '* hours a referen"e serum "reatinine value "an 1e estimated from the nadir serum "reatinine value if patient re"overs from AK:
:t is re"ognised that outside of :(A the a""ura"! of urine output measurements will 1e less relia1le. -he use of urine output "riteria for 1oth the diagnosis and staging of AK: has 1een less well studied. (lini"al 9udgement is ne"essar! in patient assessment and the re"ognition that patients ma! develop oliguri" as well as nonoliguri" AK:.
References
1. )raught +L Shlipak +G. Are small "hanges in serum "reatinine and important risk fa"torH (urrent <pinions in ?ephrolog! and G!pertension '66,I 1* '/,$ '.6 '. Goste 7A (lermont G Kersten A 3enkataraman R Angus D( De Ja";uer D Kellum KA. R:>L7 "riteria for a"ute kidne! in9ur! are asso"iated with hospital mortalit! in "riti"all! ill patients@ a "ohort anal!sis. (rit (are. '66/I16#%&@R.%. 7pu1 '66/ +a! 1'. %. A"hino S Jellomo R Goldsmith D Jates S Ron"o (. An assessment of the R:>L7 "riteria for a"ute renal failure in hospitaliMed patients. (rit (are +ed. '66/ KulI%* #.&@141%$..
*. -hakar (3 (hristianson A >re!1erg R Almenoff ) Render +L. :n"iden"e and out"omes of a"ute kidne! in9ur! in intensive "are units@ a 3eterans Administration stud!. (rit (are +ed. '664 SepI%.#4&@',,'$2. ,. Kidne! Disease@ :mproving Glo1al <ut"omes. (lini"al pra"ti"e guideline on a"ute kidne! in9ur!. '616. www.kdigo.org

Le re"ommend that the international Kidne! Disease@ :mproving Glo1al <ut"omes #KD:G<& staging "lassifi"ation of a"ute kidne! in9ur! #AK:& should 1e adopted. #not graded& Rationale -he appli"ation of 1oth the R:>L7 and AK:? staging s!stems to patient populations have demonstrated that as the stage of AK: in"reases so does the risk of mortalit!1$%. A"ute kidne! in9ur! staging "an 1e performed using serum "reatinine or urine output "riteria #-a1le 1&. )atients should 1e staged a""ording to whi"hever "riteria #serum "reatinine or urine output& gives them the highest stage. -a1le 1@ KD:G< staging s!stem for a"ute kidne! in9ur!
Stag Serum creatinine (SCr) criteria e
1 S(r in"rease P '/ Umol0L or S(r in"rease P1.,$ to '$fold from 1aseline ' % S(r in"rease P ' to %$fold from 1aseline S(r in"rease P%$fold from 1aseline or S(r in"rease %,* Umol0L or (ommen"ed on renal repla"ement therap! #RR-& irrespe"tive of stage R6., mL0kg0 hr for S 1' hrs R6.% mL0kg0 hr for S '* hrs or anuria for 1' hrs R6., mL0kg0hr for S / "onse"utive hrs
Urine output criteria
References
1. Goste 7A (lermont G Kersten A 3enkataraman R Angus D( De Ja";uer D Kellum KA. R:>L7 "riteria for a"ute kidne! in9ur! are asso"iated with hospital mortalit! in "riti"all! ill patients@ a "ohort anal!sis. (rit (are. '66/I16#%&@R.%. 7pu1 '66/ +a! 1'
'. -hakar (3 (hristianson A >re!1erg R Almenoff ) Render +L. :n"iden"e and out"omes of a"ute kidne! in9ur! in intensive "are units@ a 3eterans Administration stud!. (rit (are +ed. '664 SepI%.#4&@',,'$2 %. A"hino S Jellomo R Goldsmith D Jates S Ron"o (. An assessment of the R:>L7 "riteria for a"ute renal failure in hospitaliMed patients. (rit (are +ed. '66/ KulI%* #.&@141%$.

Le re"ommend that serum "reatinine and urine output remain the 1est 1iomarkers for AK:. Serum "reatinine should 1e measured using the enM!mati" te"hni;ue. #1J& Rationale :t is re"ogniMed that serum "reatinine represents a poor 1iomarker. An a"ute de"line in kidne! fun"tion ma! not 1e refle"ted 1! a rise in serum "reatinine for several hours. Routine methods for the measurement of serum "reatinine are 1ased on the Kaffe rea"tion first des"ri1ed in 122/1. Sin"e then the method has 1een refined man! times to tr! and over"ome inherent pro1lems of anal!ti"al interferen"e. :n addition to pro1lems of anal!ti"al interferen"e there is large variation in reported "reatinine "on"entrations using differing methods' that refle"t "ali1ration differen"es. -he re"ent introdu"tion of estimated G>R #eG>R& has emphasised the re;uirement for inter$la1orator! agreement of serum "reatinine results. :n 3itro Diagnosti"s #:3Ds& have largel! adopted "ali1ration of their methods to 1e tra"ea1le to :sotope Dilution +ass Spe"trometr! #:D+S& as re"ommended 1! e5pert professional groups su"h as the la1orator! working group of the ?ational Kidne! Disease 7du"ation )rogram #?KD7)&%. Lhilst this will redu"e inter$la1orator! 1ias it will not resolve pro1lems of anal!ti"al interferen"e and impre"ision. ?umerous endogenous su1stan"es are known to interfere with different Kaffe rea"tion 1ased assa!s. -hese in"lude positive interferents su"h as protein as"or1ate p!uvate glu"ose and "ephalosporins* and negative interferents su"h as 1iliru1in*. 7nM!mati" assa!s utilising the enM!mes "reatininase "reatinase and sar"osine o5idase are mu"h less prone to su"h interferen"e*. Repla"ement of Kaffe rea"tion 1ased serum "reatinine assa!s with the enM!mati" assa! and "ali1ration using :D+S "ali1rators should signifi"antl! improve inter$la1orator! agreement of serum "reatinine assa!s. -here is "learl! a need to find 1etter alternative 1io$markers to serum "reatinine. Serum and0or urinar! 1iomarkers "urrentl! 1eing resear"hed in"lude neutrophil gelatinase$asso"iated lipo"alin #?GAL& Kidne! :n9ur! +ole"ule$1 #K:+$1& interleukin$12 #:L$12& and "!stain ( ,$4. -here have 1een a variet! of pu1li"ations demonstrating their utilit! in dete"ting AK: in different patient
"ohorts. Gowever further work is still re;uired to understand their appli"ation 1efore the! "an 1e re"ommended as superior to serum "reatinine. References
1. Kaffe +. A1er den nieders"hlag wel"hen pikrinsaure in normalen hrn erMgeugt und u1er eine neue rea"tion des kreatinins. X )h!siol (hem 122/I16@%41$*66 '. Lawson ? Lang - Jroughton A )rinsloo ) -urner ( +arenah (. (reatinine assa!s@ time for a"tionH Ann (lin Jio"hem '66'I %4@,448/6' %. Re"ommendations for improving serum "reatinine measurement@ A report from the la1orator! working group of the ?ational Kidne! Disease 7du"ation )reogram. (lin (hem '66/I,'@,$12 *. )eake + Lhiting +. +easurement of serum "reatinine 8 "urrent status and future goals. (lin Jio"hem Rev '66/I'.@1.%$12* ,. Gewitt S+ Dear K Star RA. Dis"over! of protein 1iomarkers for renal diseases. K Am So" ?ephrol. '66*I1,#.&@1/.. $ 1/24 /. 3aid!a 3S RamireM 3 :"himura - Jo1adilla ?A Jonventre K3. Arinar! kidne! in9ur! mole"ule$1@ a sensitive ;uantitative 1iomarker for earl! dete"tion of kidne! tu1ular in9ur!. Am K )h!siol Renal )h!siol '66/I '46#'&@ >,1. $ >,'4 .. )arikh (R +ishra K -hiessen$)hil1rook G Dursun J +a = Kell! ( Dent ( Devara9an ) 7delstein (L. Arinar! :L$12 is an earl! predi"tive 1iomarker of a"ute kidne! in9ur! after "ardia" surger!. Kidne! :nt '66/I .6@ 144$'6% 2. +ishra K +a = )rada A +itsnefes + Xahedi K Yang K Jaras"h K Devara9an ). :dentifi"ation of ?eutrophil Gelatinase$Asso"iated Lipo"alin as a ?ovel 7arl! Arinar! Jiomarker for :s"hemi" Renal :n9ur!. K Am So" ?ephrol '66%I 1*@',%*$',*% 4. Gerget$Rosenthal S +arggraf G Gusing K Goring > )ietru"k > Kanssen < )hilipp - Kri11en A. 7arl! dete"tion of a"ute renal failure 1! serum "!statin (. Kidne! :nt '66*I //@ 111,$11''

Guideline 2.1 AKI : Clinical Assessment; History, Examination
Le re"ommend that all patients presenting with AK: should have a "omprehensive histor! and e5amination performed to help determine the "ause of the AK:. #1A& Audit measure
1. :n"iden"e and out"omes of patients with different "auses of AK:

Rationale A"ute kidne! in9ur! is most fre;uentl! "aused 1! is"haemia sepsis or nephroto5i" insults to the kidne!. :n patients with hospital$a";uired AK: the "ause is fre;uentl! multi$fa"torial in patients
with multiple risk fa"tors. Gowever it is essential to "onsider the underl!ing "ause of AK: as a smaller per"entage of "ases ma! 1e "aused 1! a"ute interstitial nephritis or a"ute glomerulonephritis whi"h will re;uire spe"ifi" therap!1. :t is hoped that earlier dete"tion and re"ognition of AK: ma! provide an earlier opportunit! to provide spe"ifi" therap! to these forms of isoteri" AK:'. (lini"al assessment of the patient with AK: starts with a "omprehensive histor! in"luding a review of@

patient notes AK: risk fa"tors o age S ., !rs o "hroni" kidne! disease #(KD eG>R R /6 mls0min01..%m '& o (ardia" failure o Atheros"leroti" peripheral vas"ular disease o Liver disease o Dia1etes mellitus o ?ephroto5i" medi"ations potential "auses for AK: in"luding o redu"ed fluid intake o in"reased fluid losses o urinar! tra"t s!mptoms o re"ent drug ingestion o sepsis s!stemi" "lini"al features o fever o rash o 9oint pains
(lini"al e5amination must in"lude
general
rash uveitis 9oint swelling assessment of volume status o "ore temperature o peripheral perfusion o heart rate o 1lood pressure o 9ugular venous pressure signs of renovas"ular disease o audi1le 1ruits o impalpa1le peripheral pulses a1dominal e5amination o palpa1le 1ladder
o o o
References
1. LiaNo > )as"ual K and the +adrid A"ute Renal >ailure Stud! Group. 7pidemiolog! of a"ute renal failure@ a prospe"tive multi"enter "ommunit!$ 1ased stud!. Kidne! :nternational 144/I ,6@211$212 '. Lines S Lewington A. A"ute kidne! in9ur!. (lin +ed. '664 KunI4 #%&@'.%$.
Guideline 2.2 AKI : Clinical Assessment; Investigations

Le re"ommend that all patients presenting with AK: should have appropriate 1aseline investigations performed whi"h should in"lude a urinal!sis and a renal tra"t ultrasound within '* hours #if renal tra"t o1stru"tion is suspe"ted&. #1A& Audit measures
1. )roportion of patients who had a urinal!sis performed within '* hours of the diagnosis of AK: unless anuri" '. )roportion of patients developing AK: se"ondar! to o1stru"tion who had a renal ultrasound e5amination R '* hrs after a diagnosis of AK: esta1lished
Rationale (lini"al assessment to esta1lish a working diagnosis re;uires a num1er of investigations to 1e performed. A 1aseline set of la1orator! investigations should 1e sent in"luding@

1io"hemistr!
o Area and ele"trol!tes haematolog! o >J( urinal!sis #Z mi"ros"op!& mi"ro1iolog! o urine "ulture #if infe"tion is suspe"ted& o 1lood "ulture #if infe"tion is suspe"ted&
+ore spe"ifi" renal investigations are dependent upon the "lini"al presentation and ma! in"lude@

renal immunolog! urinar! 1io"hemistr! o ele"trol!tes o osmolalit! 7(G
"hest 5$ra! a1dominal 5$ra! renal tra"t ultrasound #within '*hrs if o1stru"tion suspe"ted or isoteri" "ause suspe"ted re;uiring a kidne! 1iops!& kidne! 1iops!
Arinal!sis "an provide important "lini"al information to patients with AK:. )ositive protein values of %[ and *[ on reagent strip testing of the urine suggest intrinsi" glomerular disease. A reagent strip positive for 1lood suggests the presen"e of red 1lood "ells #S ,0high power field&. Although red "ell morpholog! ma! not 1e parti"ularl! useful1 the o1servation of large num1ers of red "ells in the presen"e of proteinuria suggests a glomerular aetiolog! for AK:. -he suspi"ion is strengthened 1! the finding of red "ell "asts on a freshl! "olle"ted sample of urine #this is rarel! performed in the AK&. Gaematuria ma! also 1e found in "ases of lower urinar! tra"t o1stru"tion often in asso"iation with tumours and less "ommonl! asso"iated with "al"uli infe"tion or severe renal is"haemia due to arterial or venous throm1osis. (hara"teristi"all! m!oglo1inuria will "ause a positive reagent strip rea"tion for haematuria without eviden"e of red "ells on urine mi"ros"op!. :n"reased num1ers of white "ells #S , per high power field& are non$spe"ifi" 1ut are found more "ommonl! with a"ute interstitial nephritis infe"tion and glomerulonephritis. 7osinophiluria is not a ver! spe"ifi" test for interstitial nephritis and has a ver! poor positive predi"tive value. Gowever the value of eosinophiluria in interstitial nephritis is in ruling out the disease the negative predi"tive value for patients with AK: is greater than 46B'. Arine mi"ros"op! "an 1e informative in parti"ular "lini"al s"enarios su"h as suspe"ted poisoning. -he presen"e of "r!stalluria ma! provide vital information and in the "ase of eth!lene gl!"ol poisoning o5alate "r!stals ma! 1e visi1le%. )atients who suffer from tumour l!sis s!ndrome "an produ"e urate "r!stal deposition. A num1er of drugs ma! lead to AK: and "r!stalluria in"luding sulphonamides a"!"lovir triamterene indinavir and "atharti"s high in phosphates. 3arious measures have 1een "laimed to aid in the diagnosis of AK: in"luding urine osmolalit! urine0plasma "reatinine and urea ratios urinar! sodium fra"tional e5"retion of sodium #>7?a& fra"tional e5"retion of urea #>7Area& freewater "learan"e and "reatinine "learan"e. All of these have limitations and their spe"ifi"it! and sensitivit! in "lini"al pra"ti"e often means that a single measurement ma! 1e in"on"lusive e5"ept in e5treme "ir"umstan"es*$/.
:n pre$renal AK: there is in"reased urinar! sodium rea1sorption and in"reased urinar! urea rea1sorption. -his should therefore 1e refle"ted 1! low urine sodium "on"entrations low >7?a and low >7Area and in"reased 1lood urea@"reatinine ratios. Arinar! ele"trol!tes should 1e interpreted with "aution parti"ularl! in the elderl! #who ma! alread! have an impaired "on"entrating a1ilit!& and in patients on diureti"s or with a salt$losing state. :n su"h patients the >7Area ma! possi1l! 1e a more useful inde5/. -he normal >7Area is greater than *,B. Levels of less than %,B are asso"iated with pre$renal AK:. )atients with pre$ renal AK: not on diureti"s have 1oth low >7?a #R1B& and low >7Area. Gowever patients with pre$ renal AK: on diureti"s have levels of >7?a greater than 'B 1ut still have low levels of >7Area. :n "omparison patients with A-? have 1oth high >7?a and high >7Area. <ne "lini"al situation where measurement of urinar! ele"trol!tes ma! have "lini"al utilit! is in the diagnosis of hepatorenal s!ndrome as the "ause of AK: in patients with liver disease. -he diagnosti" "riteria for hepatorenal failure in"lude a urine sodium of less than 16 mmol0L #although not a ma9or diagnosti" "riterion&.. Altrasound is the gold standard test for diagnosis of upper tra"t o1stru"tion through the finding of h!dronephrosis and0or h!droureter. Gowever upper urinar! tra"t o1stru"tion ma! not 1e initiall! dete"ted 1! ultrasound in a patient who is volume depleted. :t is therefore re"ommended to repeat the renal tra"t ultrasound if upper urinar! tra"t o1stru"tion is suspe"ted on"e the patient is ade;uatel! fluid resus"itated. -here are other "ir"umstan"es when ultrasound ma! not 1e diagnosti" su"h as in retroperitoneal fi1rosis or earl! in the "ourse of o1stru"tive disease in whi"h "ase additional imaging studies ma! 1e "onsidered su"h as d!nami" nu"lear medi"ine studies or (-. D!nami" nu"lear medi"ine studies will 1e of little diagnosti" use if the patient has oligo$anuri" AK:. References
1. >avaro S Jonfant L DVAngelo A Gia"omini A ?ormanno + (alo L. :s the red "ell morpholog! reall! useful to dete"t the sour"e of haematuriaH Am K ?ephrol 144.I 1.@1.'$1., '. Rossert K. Drug$indu"ed a"ute interstitial nephritis. Kidne! :nt '661I /6@26*$ 21. %. >ogaMMi GJ. (r!stalluria@ a negle"ted aspe"t of urinar! sediment anal!sis. ?ephrol Dial!sis -ransplant 144/I 11@%.4$%2. *. Kellen + Aronson S RoiMen +> Jarnard K -histed RA. )redi"tive and diagnosti" tests of renal failure@ A review. Anesth Analg 144*I .2@1%*$1*' ,. 7spinel (G Gregor! AL. Differential diagnosis of a"ute renal failure. (lin ?ephrol 1426I 1%@.%$..
/. (arvounis () ?isar S Guro$RaMuman S. Signifi"an"e of the fra"tional e5"retion of urea in the differential diagnosis of a"ute renal failure. Kidne! :nt '66'I /'@'''%$'''4 .. Arro!o 3 Gines ) Ger1es AL et al. Definition and diagnosti" "riteria of refra"tor! as"ites and hepatorenal s!ndrome in "irrhosis. :nternational As"ites (lu1 Gepatolog! 144/I '%@1/*$1./

Guideline 3.1 AKI : Prevention; Risk Assessment
Le re"ommend that patients at risk of AK: should 1e identified and appropriate preventative measures should 1e instituted as earl! as possi1le. #1J& Audit measures
1. :n"iden"e of a"ute admissions0patients undergoing ma9or surger! who had

1. risk of AK: assessed on admission0pre$surger! 2. ele"trol!tes "he"ked on admission0pre$surger! and re"he"ked within
'* hours '. )roportion of patients at risk of AK: who re"eive nephroto5i" medi"ations Rationale )u1lished series of AK: suggest that up to %6B of "ases ma! 1e preventa1le with a further signifi"ant per"entage potentiall! remedia1le through simple interventions su"h as volume repletion dis"ontinuing and0or avoiding "ertain potentiall! nephroto5i" agents and earlier re"ognition of "onditions "ausing rapid progression of AK: .1$% Risk fa"tors for developing AK: in"lude@

age S ., !rs "hroni" kidne! disease #(KD eG>R R /6 mls0min01..%m'& "ardia" failure atheros"leroti" peripheral vas"ular disease liver disease dia1etes mellitus nephroto5i" medi"ation h!povolaemia sepsis
References
1. Stevens )7 -amimi ?A Al Gasani +K et al. ?on$spe"ialist management of a"ute renal failure. =K+ '661I 4*@ ,%%8,*6 '. 3i9a!an A +iller SJ. A"ute renal failure@ prevention and nondial!ti" therap!. Semin ?ephrol 1442I 12@,'%$,%' %. Davidman + <lson ) Kohen K Leither - K9ellstrand (. :atrogeni" renal disease. Ar"h :ntern +ed 1441I 1,1@1264$121'
Guideline 3.2 AKI : Prevention; Fluid Therapy

Le re"ommend that pres"ription of appropriate intravenous fluid should 1e "arefull! "onsidered following assessment of the patientVs volume status. -hereafter the patientVs "lini"al response should 1e monitored "losel!. #1J& Audit measure
1. )roportion of patients at risk of AK: who are pres"ri1ed intravenous fluids without an assessment of volume status
Rationale :n hospital AK: following surger! is an important "ontri1utor to postoperative mor1idit! and mortalit!. -he "auses are multifa"torial and therefore involve the identifi"ation of the high risk patients and institution of preventative measures. Avoidan"e of pre$ and peri$operative h!povolaemia is an essential "omponent of patient management. )res"ription of intravenous fluid should follow a "areful assessment of patient volume status i.e. h!povolaemi" euvolaemi" h!pervolaemi". (onsideration should then 1e made regarding the nature of the fluid lost and therefore the nature of the fluid that needs to 1e repla"ed. -here is no eviden"e 1ase to favour the pres"ription of "r!stalloid or "olloids to prote"t kidne! fun"tion in the peri$operative period although there have onl! 1een a handful of studies looking at this1. >ollowing the sele"tion of the appropriate fluid the rate of fluid repla"ement must 1e guided 1! "lini"al assessment with "onsideration for safet! limits. -he patientVs volume status must 1e "ontinuall! monitored and a de"ision made regarding when to stop intravenous fluids. :t is important to re"ognise that the dail! sodium intake in health is 1etween .6 and 166 mmol0da!. >ollowing surger! the 1od!Vs ph!siologi"al response is to retain sodium and water. -he sele"tion of the t!pe of fluid to 1e pres"ri1ed is important as e5"essive peri$operative fluid therap! with 6.4B sodium "hloride #?a 1,*mmol0l (l 1,*mmol0l& "an potentiall! lead to h!per"hloraemi" a"idosis sodium "hloride and water overload whi"h "ontri1utes to postoperative mor1idit! and mortalit!' whereas e5"essive peri$operative fluid repla"ement with ,B de5trose will in"rease the risk of developing h!ponatraemia.
>luid repla"ement pres"riptions should 1e tailored to the needs of the patient. )otassium "ontaining solutions #GartmannVs and RingerVs La"tate& should 1e used "autiousl! in patients who develop progressive AK: due to the potential risk of e5a"er1ating h!perkalaemia. References
1. Xa"harias + Gilmore :(S Ger1ison G) et al. :nterventions for prote"ting renal fun"tion in the perioperative period #Review&. (o"hrane Data1ase of S!stemati" Reviews '66,I :ssue % (D66%,46 '. Lo1o D? +a"afee DAL Allison S). Gow perioperative fluid 1alan"e influen"es post$operative and out"omes. Jest )ra"ti"e and Resear"h (lini"al Anaesthesiolog! '66/I '6 #%& *%4$*,,
Guideline 3.3 AKI : Prevention; Contrast-Induced AKI (CI-AKI)

Le re"ommend that patients identified at 1eing at risk of "ontrast indu"ed$AK: #(:$AK:& should have a "areful assessment of volume status and re"eive pre$pro"edure volume e5pansion with 6.4B sodium "hloride or isotoni" sodium 1i"ar1onate if "lini"all! indi"ated. #1A& Audit measure
1. )roportion of patients at high risk of "ontrast indu"ed AK: #(:$AK:& who developed AK: and did not

re"eive pre pro"edure volume assessment re"eive appropriate volume e5pansion have appropriate ad9ustments to medi"ations
Rationale (ontrast$:ndu"ed a"ute kidne! in9ur! #(:$AK:&se"ondar! to radiologi"al "ontrast media is un"ommon in the general population. :t "lassi"all! o""urs within .' hours of re"eiving the "ontrast media and usuall! re"overs over the following five da!s. :ts in"iden"e in"reases signifi"antl! in patients with risk fa"tors and is asso"iated with an in"reased short and long$term mortalit!1. -he kidne! in9ur! results from a "om1ination of afferent arteriolar vaso"onstri"tion and dire"t to5i"it! of the "ontrast media to the tu1ule epithelial "ells. )revention is important as there is no spe"ifi" treatment and involves the evaluation of potential risk fa"tors #see guideline %.1& and "lini"al assessment of the patientVs volume status'. :t should also 1e "onsidered whether alternative imaging "ould 1e utilised su"h as magneti" resonan"e angiograph! or whether "ar1on dio5ide "an 1e used to redu"e the amount of "ontrast agent re;uired%. )otentiall! nephroto5i" medi"ations should 1e withheld or avoided.
+etformin is not nephroto5i" 1ut is e5"lusivel! e5"reted via the kidne!s. )atients on metformin who develop AK: are at risk of developing la"ti" a"idosis. -he "urrent advi"e from the Ro!al (ollege of Radiologists is that there is no need to stop metformin after re"eiving "ontrast if the serum "reatinine is within the normal range and0or eG>R S /6 ml0min01..%m'. :f serum "reatinine is a1ove the normal referen"e range or eG>R is R /6 ml0min01..%m' an! de"ision to stop it for *2 hours should 1e made in "onsultation with the referring "lini"ian*. )atients at risk of (:$AK: must re"eive appropriate volume e5pansion prior to the pro"edure with intravenous 6.4B sodium "hloride. :ntravenous 6.4B sodium "hloride at a rate of 1 mL0kg0hour for 1' hours pre$ and post$ pro"edure has 1een shown to 1e more effe"tive than 6.*,B sodium "hloride in redu"ing (:$AK:,. +ore re"entl! it has 1een demonstrated that isotoni" 1i"ar1onate given at a rate of % mL0kg0hour for 1 hour pre$pro"edure and 1 mL0kg0hour for / hours post$ pro"edure in "omparison to 6.4B sodium "hloride under the same "onditions gives superior prote"tion/. Gowever it has not !et 1een esta1lished whether this regimen is superior to 6.4B sodium "hloride given for 1' hours pre$ and post$pro"edure. ?evertheless the shorter sodium 1i"ar1onate regimen has o1vious advantages in avoiding an overnight sta!. Low osmolar agents are asso"iated with a de"reased risk of nephroto5i"it! as "ompared to the high osmolar agents parti"ularl! in those at risk from "ontrast media$asso"iated AK:.. )atients with "hroni" kidne! disease #(KD& should re"eive the iso$osmolar nonioni" "ontrast agent iodi5anol whi"h has 1een shown to redu"e the risk of "ontrast indu"ed nephropath! in this patient group2. -he dose of "ontrast media should 1e minimised and further e5posure to "ontrast media should 1e dela!ed until full re"over! of renal fun"tion unless a1solutel! ne"essar!. Renal fun"tion should 1e "he"ked up to *2$.' hours following the pro"edure if in a high risk group to ensure sta1le renal fun"tion. -here have 1een a num1er of small inade;uatel! powered studies investigating the prote"tive effe"ts ?$a"et!l"!steine whi"h have 1een su19e"t to a num1er of meta$anal!ses. -he most re"ent meta$anal!ses have "ommented on the in"onsisten"! of studies to date making a definitive "on"lusion diffi"ult4 16. (urrentl! there is no "ompelling eviden"e for the routine use of ?$a"et!l"!steine11. A re"ent small stud! indi"ated that intravenous isotoni" sodium 1i"ar1onate "om1ined with 1'66 mg 1d oral ?$a"et!l"!steine was more effe"tive than 6.4B sodium "hloride "om1ined with ?$a"et!l"!steine1'. Anfortunatel! this stud! did not in"lude a "omparative arm for intravenous fluid therap! alone. References
1. Lev! 7+ 3is"oli (+ GorwitM R:. -he effe"t of a"ute renal failure on mortalit!@ a "ohort anal!sis. KA+A 144/I '.,@ 1*24$1*4* '. Sta"ul > Adam A Je"ker (R et al. Strategies to redu"e the risk of "ontrast$ indu"ed nephropath!. Am K (ardiol '66/I 42 ,4K$..K %. Shaw DR Kessel D<. -he "urrent status of the use of "ar1on dio5ide in diagnosti" and interventional angiographi" pro"edures. (ardiovas" :ntervent Radiol '66/I '4@ %'%$%%1 *. +etformin@ updated guidan"e for use in dia1eti"s with renal impairment. London@ -he Ro!al (ollege of Radiologists www.R(R.a".uk '664 ,. +ueller ( Juerkle G Juettner GK et al. )revention of "ontrast media asso"iated nephropath!@ randomised "omparison of ' h!dration regimens in 1/'6 patients undergoing "oronar! angioplast!. Ar"h :ntern +ed '66'I 1/'@ %'4$%%/ /. +erten GK Jurgess L) Gra! L3 et al. )revention of "ontrast indu"ed nephropath! with sodium 1i"ar1onate@ a randomiMed "ontrolled trial. KA+A '66*I '41@ '%'2$'%%* .. Jarrett JK (arlisle 7K. +eta$anal!sis of the relative nephroto5i"it! of high$and low$osmolalit! iodinated "ontrast media. Radiolog! 144%I 122@1.1$1.2 2. +"(ullough )A Jertrand +D Jrinker KA et al. A +eta$anal!sis of the renal safet! of isosmolar iodi5anol "ompared with low$osmolar "ontrast media. K Am (oll (ardiol '66/I *2 #*& /4'$/44 4. Kshirsagar A3 )oole ( +ottl A et al. ?$a"et!ls!steine for the prevention of radio "ontrast indu"ed nephropath!@ a meta$anal!sis of prospe"tive "ontrolled trials. K Am So" ?ephrol '66*I 1,@ ./1$./4 16. ?allamothu JK Sho9ania KG Saint et al. :s ?$a"et!ls!steine effe"tive in preventing "ontrast$related nephropath!H A meta$anal!sis. Am K +ed '66*I 11.@ 4%2$4*. 11. Kellum K LeJlan" + 3enkataraman R. A"ute renal failure. (lini"al 7viden"e '66/I 1, 1$'* 1'. Jriguori ( Airoldi > DWAndrea D JoniMMoni 7 +ori"i ? >o"a""io A +i"hev : +ontorfano + (arlino + (osgrave K Ri""iardelli J (olom1o A. Renal :nsuffi"ien"! >ollowing (ontrast +edia Administration -rial #R7+7D:AL& A RandomiMed (omparison of % )reventive Strategies. (ir"ulation '66.I 11,@1'11$1'1.
Guideline 3.4 AKI : Prevention; AKI secondary to Rhabdomyolysis

Le re"ommend that patients identified as 1eing at risk of developing AK: se"ondar! to rha1dom!ol!sis should re"eive intravenous volume e5pansion with 6.4B sodium "hloride and sodium 1i"ar1onate. #1J& Rationale Rha1dom!ol!sis indu"ed AK: results from skeletal mus"le in9ur! and "ell l!sis with the release of m!oglo1in and other mus"le 1reakdown produ"ts. +!oglo1in is freel! filtered 1! the kidne!s and is dire"tl! to5i" to the tu1ule epithelial "ells parti"ularl! in the setting of h!povolaemia and
a"idosis. -here are a num1er of "auses in"luding trauma 1urns "ompartment s!ndrome and drugs #"o"aine e"stas! statins&. +anagement in"ludes volume assessment and "lose monitoring with aggressive fluid resus"itation and alkalinisation of the urine. >luid resus"itation with 6.4B sodium "hloride is preferred at a rate of 16$1,ml0kg0hr to a"hieve high urinar! flow rates #S166ml0hr& with the "autious addition of sodium 1i"ar1onate 1.*B to maintain urinar! pGS /.,1. -hroughout this pro"ess the patientVs volume status must 1e "arefull! evaluated and on"e the patient has 1een ade;uatel! fluid resus"itated "are must 1e taken not to pre"ipitate pulmonar! oedema. References
1. Sever +S 3anholder R Lameire ?. +anagement of "rush related in9uries after disasters. ? 7ng K +ed '66/I %,*@ 16,'$16/% '. Jrown (3R Rhee ) (han L et al. )reventing renal failure in patients with rha1dom!ol!sis@ do 1i"ar1onate and mannitol make a differen"eH K -rauma '66*I ,/@ 1141$114/

Guideline 4.1 AKI : Management; General Management
Le re"ommend that general supportive measures in"lude optimisation of haemod!nami" status 1! appropriate fluid therap! administration of vasopressors and0or inotropes and treatment of an! underl!ing sepsis. ?ephroto5i" medi"ations should 1e stopped. #1A& Audit measures
1. )roportion of patients with AK: who are pres"ri1ed intravenous fluids without an assessment of volume status '. )roportion of patients with AK: who re"eive nephroto5i" medi"ations %. )roportion of patients with severe AK: where there is do"umented eviden"e of patient involvement in de"ision making with respe"t to "ommen"ing renal repla"ement therap! #RR-& *. )roportion of AK: survivors who are given information on the "ause of AK: and how this might 1e avoided in the future
Rationale :n the ma9orit! of "ases AK: "an 1e effe"tivel! treated and resolved 1! ade;uate volume repla"ement treatment of the underl!ing medi"al "ondition #e.g. sepsis haemorrhage& and
avoidan"e of nephroto5i" medi"ations. Gowever it is important to remem1er that the more isoteri" forms of AK: will re;uire spe"ifi" therap! whi"h is outside of the remit of this guideline. :n the h!povolaemi" patient fluid repla"ement is 1est a"hieved through the rapid infusion of repeated small volumes #',6 ml of "r!stalloid or "olloid& and "lose monitoring using a (3) line and urinar! tra"t "atheter #if "lini"all! indi"ated as its use is asso"iated with an in"reased risk of infe"tion &. La"tate and 1ase e5"ess measurements ma! also 1e helpful in "on9un"tion with "lini"al 9udgment in assessing response to volume loading1. Lith respe"t to the use of "olloids it should 1e a"knowledged that there have 1een earlier reports regarding the use of high mole"ular weight h!dro5! eth!l star"h and an in"reased risk of AK:' %. -he multi$"entre German trial 7ffi"a"! of 3olume Su1stitution and :nsulin -herap! in Severe Sepsis -rial #3:S7)& reported a signifi"antl! higher in"iden"e of AK: in patients re"eiving 16B h!dro5!eth!l star"h "ompared to RingerWs la"tate* ,. :t is therefore pro1a1l! prudent to re"ommend that high mole"ular weight h!dro5!eth!l star"hes 1e used "autiousl! in patients with severe sepsis at risk of developing AK: . -he >ren"h e;uivalent of the AK Jlood -ransfusion servi"e re"ommends an upper limit on the volume of star"h solutions used in resus"itation of patients/. A large well "ontrolled prospe"tive stud! is needed to "on"lusivel! prove the safet! of administering h!dro5!eth!l star"h on a dail! 1asis in this patient group. A de"reasing urine output is a sensitive indi"ator of AK: and oliguri" AK: is asso"iated with a poorer prognosis. Do"umentation of urine volume is part of fluid 1alan"e management in an! a"utel! ill patient. Gowever there are a num1er of "aveats to "onsider. Arine volume ma! not 1e diagnosti" parti"ularl! when diureti"s have alread! 1een administered. :t must also 1e re"ognised that part of the usual stress response to surger! is an in"reased se"retion of antidiureti" hormone #ADG& and an upregulation of the renin$angiotensin$aldosterone s!stem resulting in avid salt and water retention.. As a "onse;uen"e there is de"reased urine output and free water "learan"e in the first 1'$'* hours following surger!2. A "areful evalution of volume status is re;uired and not ne"essaril! the pres"ription of more fluid. :f the patient is not h!povolaemi" there is eviden"e that demonstrates there is no asso"iation 1etween urine output per se and the development of AK:4. :n patients with severe AK: there ma! 1e no other option than to "ommen"e renal repla"ement therap! #RR-&. Su"h de"isions should 1e dis"ussed with the patient if the! have mental "apa"it!. -he ?(7)<D adding insult to in9ur! report dete"ted a "on"erning la"k of su"h dis"ussions with patients or relatives 1eing do"umented in the patientsW notes. -he "ommonl! a""epted indi"ations for "ommen"ing RR- are listed in -a1le % se"tion 11.
:t is important to monitor the patientVs volume status throughout the episode of AK:. -his remains an essential part of patient management in the re"over! phase. )atients ma! develop a pol!uri" phase during whi"h the! are at in"reased risk of developing a negative fluid 1alan"e and ele"trol!te distur1an"e in"luding h!pernatraemia and h!pokalaemia. -here will need to 1e "areful "onsideration a1out when to reintrodu"e medi"ations su"h as antih!pertensives and diureti"s. Anfortunatel! this "an 1e overlooked pla"ing the patient at risk of future readmission. >ollowing an episode of AK: the patient should re"eive information regarding the "ause and how this ma! 1e potentiall! avoided in the future. -his ma! involve edu"ating and empowering the patient with respe"t to their risk fa"tors for developing AK: and advi"e as to when to "onsider "onta"ting their general pra"titioner in the future if the! develop inter"urrent illness in the "ommunit!. References
1. )insk! +R et al >luid and volume monitoring. :nt K Artif <rgans '662I %1@ 111$ 1'/ '. S"hortgen > et al. 7ffe"ts of h!dro5!eth!l star"h and gelatin on renal fun"tion in severe sepsis@ a multi"entre randomised stud!. Lan"et '661I %,.@ 411$41/ %. (ittanova +L et al. 7ffe"ts of h!dro5! eth!l star"h in 1rain$dead kidne! donors on renal fun"tion in a kidne! transplant re"ipients. Lan"et 144/I %*2@ 1/'6$ 1/'' *. Jagshaw S et al. >luid resus"itation and the septi" kidne!. (urrent <pinions in (riti"al (are '66/I 1'@ ,'.$,%6 ,. Jrunkhorst et al. German (ompeten"e ?etwork Sepsis #Sep?et&. :ntensive insulin therap! and pentastar"h resus"itation in severe sepsis.? 7ngl K +ed. '662I %,2@1',$1%4 /. S"hortgen > et al. 7ffe"ts of h!dro5!eth!lstar"h and gelatin on renal fun"tion in severe sepsis@ a multi"entre randomised stud!. Lan"et '661I %,.@411$41/ .. Lo1o D? +a"afee DAL Allison S). Gow perioperative fluid 1alan"e influen"es post$operative and out"omes. Jest )ra"ti"e and Resear"h (lini"al Anaesthesiolog! '66/I '6 #%& *%4$*,, 2. Gann DS Kenne! )R. Spe"ial pro1lems of fluid and ele"trol!te management in surger!. (han K(+ and Gill KR eds Kidne! 7le"trol!te Disorders. (hur"hill Livingstone :n" ASA 1446I %*%$%/' 4. Alpert RA RoiMen +> Gamilton LK et al. :ntraoperative Arinar! <utput Does ?ot )redi"t )ostoperative Renal >un"tion in )atients Andergoing A1dominal Aorti" Revas"ularisation. Surger! 142*I 4, .6.$.11

Le re"ommend that therapeuti" drug dosing must 1e adapted to altered kineti"s in AK:. #1J& Audit measure
1. )roportion of patients with AK: who did not have the appropriate ad9ustment of medi"ation doses Rationale :nappropriate drug dosing of patients with AK: is an important "ause of adverse drug events1. )harma"okineti"s in"luding the volume of distri1ution "learan"e and protein 1inding are altered 1! organ failure in the "riti"all! ill patient. Drug doses need to 1e ad9usted appropriatel! with the "orre"t assessment of kidne! fun"tion to redu"e to5i"it!. -here is an important role for the "lini"al pharma"ist on the :(A. A num1er of pu1li"ations have demonstrated the "lini"al and e"onomi" 1enefits of the "riti"al "are pharma"ist'. References
1. S"hiff GD Klass D )eterson K et al. Linking la1orator! and pharma"!@ opportunities for redu"ing errors and improving "are. Ar"h :ntern +ed '66%I 1/%@ 24%$466 '. Kane SL Le1er RK Dasta K>. -he impa"t of "riti"al "are pharma"ists on enhan"ing patient out"omes. :ntensive (are +ed '66%I '4@ /41$/42

Le re"ommend that there is no spe"ifi" pharma"ologi"al therap! proven to effe"tivel! treat AK: se"ondar! to h!poperfusion in9ur! and0or sepsis. #1J& Rationale -here is "urrentl! no eviden"e to support the use of a spe"ifi" pharma"ologi"al therap! in the treatment of AK:. -he rationale 1ehind the use of loop diureti"s was 1ased on their putative a1ilit! to redu"e the energ! re;uirements of the "ells of the as"ending lim1 of Genle and therefore ameliorate the resultant is"haemi" damage1. Loop diureti"s have also 1een used to "onvert patients with oliguri" AK: to non$oliguri" AK: #re"ognised to have a 1etter prognosis& to fa"ilitate the management of fluid and ele"trol!te distur1an"es and redu"e the re;uirement for renal repla"ement therap! #RR-&. <f "on"ern has 1een the demonstration that the use of loop diureti"s is asso"iated with an in"reased risk of failure to re"over renal fun"tion and mortalit! perhaps related to the resultant dela! in "ommen"ing RR- appropriatel!'. A re"ent meta$ anal!sis of nine randomised "ontrolled trials "on"luded that furosemide is not asso"iated with an! signifi"ant "lini"al 1enefits in the prevention and treatment of AK: in adults%. Gigh doses "an 1e asso"iated with an in"reased risk of ototo5i"it! whi"h is an important "onsideration parti"ularl! in those patients ventilated on the :(A.
Dopamine is a non$sele"tive dopamine re"eptor agonist whi"h at low$dose #6.,$%.6 Qg0kg0min& indu"es a dose$dependent in"rease in renal 1lood flow natriuresis and diuresis in health! humans*. :t has 1een proposed that dopamine ma! potentiall! redu"e is"haemi" "ell in9ur! in patients with AK: 1! improving renal 1lood flow and redu"ing o5!gen "onsumption through inhi1ition of sodium transport. -here have 1een a multitude of studies investigating the use of dopamine in the prevention and treatment of AK: whi"h were most re"entl! reviewed in a meta$ anal!sis that "on"luded that there is no good eviden"e to support an! important "lini"al 1enefits to patients with or at risk of AK:,. A possi1le e5planation as to wh! dopamine is not 1enefi"ial has 1een provided 1! a stud! demonstrating that low$dose dopamine "an worsen renal perfusion in patients with AK:/. Additionall! the use of dopamine is asso"iated with side$effe"ts whi"h in"lude "ardia" arrh!thmias and m!o"ardial and intestinal is"haemia.. >enoldopam in "ontrast to dopamine is a sele"tive dopamine A$1 re"eptor agonist whi"h de"reases s!stemi" vas"ular resistan"e whilst in"reasing renal 1lood flow to 1oth the "orte5 and medullar! regions in the kidne!2. :t has 1een used in patients with h!pertensive emergen"ies4 and has 1een noted to improve renal fun"tion in patients with severe h!pertension16. -he ma9orit! of small "lini"al studies that have 1een performed to date have investigated fenoldopamVs a1ilit! to prevent the development of AK: without providing "on"lusive eviden"e. A 1enefi"ial effe"t of fenoldopam in "riti"all! ill patients with or at risk of AK: has 1een suggested 1! a meta$anal!sis of 1/ randomised studies11. -he meta$anal!sis "on"luded that fenoldopam redu"es the need for renal repla"ement therap! and mortalit! in patients with AK:. Su"h results highlight the need for large multi"entre randomised "ontrolled trials to 1e performed 1efore the use of fenoldopam "an 1e re"ommended.
References
1. Ge!man S? Rosen S 7pstein >G et al. Loop diureti"s redu"e h!po5i" damage to pro5imal tu1ules of the isolated perfused rat kidne!. Kidne! :nt 144*I *,@ 421$42, '. +ehta RL )as"ual +- Soroko S et al. Diureti"s mortalit! and nonre"over! of renal fun"tion in a"ute renal failure. KA+A '66'I '22@ ',*.$',,% %. Go K+ Sheridan DK. +eta$anal!sis of frusemide to prevent or treat a"ute renal failure. J+K '66/I %%% #.,/,&@ *'6$*', *. Denton +D (hertow G+ Jrad! GR. Renal$dose dopamine for the treatment of a"ute renal failure@ s"ientifi" rationale e5perimental studies and "lini"al trials. Kidne! :nt 144/I *4@*$1* ,. >riedri"h K< Adhikari ? Gerridge +S. +eta$anal!sis@ low$dose dopamine in"reases urine output 1ut does not prevent renal d!sfun"tion or death. Ann :ntern +ed '66,I 1*'@ ,16$,'* /. Laus"hke A -ei"hgra1er AK+ >rei A et al. Low$dose dopamine worsens renal perfusion in patients with a"ute renal failure. Kidne! :nt '66/I /4@ 1//4$ 1/.*
.. S"henarts )A Sagraves SG Jard + et al. Low$dose dopamine@ a ph!siologi"all! 1ased review. (urrent Surger! '66/I /% #%&@ '14$'', 2. +athur 3S Swan SK Lam1re"ht LK et al. -he effe"ts of fenoldapam a sele"tive dopamine re"eptor agonist on s!stemi" and renal haemod!nami"s in normotensive su19e"ts. (rit (are +ed 1444I '4@ 12%'$12%. 4. +urph! +J +urra! ( Shorten GD. >enoldapam@ a sele"tive peripheral dopamine re"eptor agonist for the treatment of severe h!pertension. ? 7ngl K +ed '661I %*,@ 1,*2$1,,. 16. S"husterman ?G 7lliott LK Lhite LJ. >enoldapam 1ut not nitroprusside improves renal fun"tion in severel! h!pertensive patients with impaired renal fun"tion. Am K +ed 144%I 4,@ 1/1$1/2 11. Landoni G Jiondi$Xo""ai GGL -umlin KA et al. Jenefi"ial impa"t of fenoldapam in "riti"all! ill patients with or at risk for a"ute renal failure@ a meta$ anal!sis of randomised "lini"al trials. Am K Kidne! Dis '66.I *4 #1&@ ,/$/2
Guideline 4.4 AKI : Management; Nutritional Support

Le re"ommend that patients with AK: re"eiving renal repla"ement therap! should 1e referred to a dieti"ian for individual assessment. #1D&
Guideline 4.5 AKI : Management; Nutritional support

Le re"ommend that patients with AK: should re"eive ',$%, k"al0kg0da! and up to a ma5imum of 1..g amino a"ids0kg0da! if h!per"ata1oli" and re"eiving "ontinuous renal repla"ement therap!. -ra"e elements and water solu1le vitamins should 1e supplemented as re;uired. #1(& Audit measures
1. )roportion of patients with AK: re"eiving renal repla"ement therap! reviewed 1! dieti"ian within '* hours '. )roportion of patients with AK: re"eiving renal repla"ement therap! pres"ri1ed the re"ommended nutritional support
Rationale for ! and !" +alnutrition has 1een identified as a predi"tor of in$hospital mortalit! for patients with AK: independent of "ompli"ations and "o$mor1idities1. AK: is asso"iated with signifi"ant meta1oli" and immunologi" distur1an"es along with the indu"tion of a pro$inflammator! state whi"h is e5a"er1ated 1! malnutrition'. Appropriate nutritional support "ould potentiall! mitigate these distur1an"es and improve out"omes. Gowever ver! few s!stemati" studies have 1een performed assessing the impa"t of nutrition on re"ognised "lini"al endpoints. Re"ommendations are therefore 1ased on e5pert opinion.
AK: results in pertur1ations of fluid ele"trol!te and a"id 1ase meta1olism in asso"iation with spe"ifi" alterations in protein and amino a"id "ar1oh!drate and lipid meta1olism. ?egative nitrogen 1alan"e results from protein "ata1olism and the release of amino a"ids from skeletal mus"le%. G!pergl!"aemia ma! o""ur due to insulin resistan"e* de"reased glu"ose uptake 1! skeletal mus"le and a""elerated hepati" glu"oneogenesis,. :mpaired lipol!sis is the ma9or "ontri1utor to lipid a1normalities in"luding h!pertrigl!"eridaemia/. Another "onse;uen"e of AK: is disruption of vitamin and tra"e element 1alan"e. Levels of water$solu1le vitamins are usuall! low with the e5"eption of vitamin (. :t is therefore important to avoid inappropriate supplementation of vitamin ( due to the risk of developing se"ondar! o5alosis. -he levels of fat solu1le vitamins A and 7 are redu"ed whilst vitamin K levels are normal or even elevated. -he tra"e element selenium has 1een shown to 1e profoundl! de"reased in patients with AK:.. ?utritional support for patients with AK: must take into a""ount not onl! the spe"ifi" meta1oli" distur1an"es asso"iated with the kidne! in9ur! 1ut also the underl!ing disease pro"ess. :t is re"ognised that patients with AK: represent a heterogeneous group rarel! presenting with an isolated disease pro"ess 1ut often in asso"iation with sepsis and multi$organ failure. Renal repla"ement therap! results in loss of 1oth ma"ronutrients and mi"ronutrients whi"h must therefore 1e supplemented. -he impa"t made 1! RR- depends on the method utilised and its intensit!. (ontinuous renal repla"ement therap! #(RR-& results in signifi"ant loss of water$ solu1le small mole"ular weight su1stan"es in"luding nutrients. A total dail! loss of 16$1,g amino a"ids and ,$16g protein has 1een reported along with signifi"ant losses of water$solu1le vitamins2. 7nteral nutrition is the re"ommended form of nutritional support for patients with AK:. -he provision of nutrients via the gut lumen helps maintain gut integrit! de"reases gut atroph! and de"reases 1a"terial and endoto5in translo"ation. :f oral feeding is not possi1le then enteral feeding #tu1e feeding& should 1e initiated within '* hours whi"h has 1een shown to 1e safe and effe"tive4. A nasogastri" tu1e is re"ognised as the standard a""ess for administration of enteral nutrition. Gowever a 9e9unal tu1e ma! 1e indi"ated in the presen"e of impaired gastrointestinal motilit!. -otal parenteral nutrition should 1e "onsidered to supplement the enteral route or in those patients without a fun"tioning gut. Referral to a dieti"ian for individual assessment is re"ommended as nutrient re;uirements for patients will var! "onsidera1l! dependent upon the "ourse of the AK: underl!ing disease and need for RR-16.
Guidelines on enteral nutrition in patients with AK: have 1een developed 1! an interdis"iplinar! e5pert group and pu1lished 1! the 7uropean So"iet! for (lini"al ?utrition and +eta1olism )atients11. ?utritional re;uirements are dependent upon the severit! of the underl!ing disease and the t!pe and intensit! of RR-. As a general rule patients with AK: should re"eive '6$%, k"al0kg0da! and up to a ma5imum of 1..g amino a"ids0kg0da! if h!per"ata1oli" and re"eiving (RR-. 7le"trol!tes must 1e monitored "losel! to avoid h!pokalaemia and0or h!pophosphataemia following the initiation of enteral nutrition. References
1. >ia""adori 7 Lom1ardi + Leonardi S Rotelli (> -ortorella G Jorghetti A. )revalen"e and "lini"al out"ome asso"iated with pre$e5isting malnutrition in a"ute renal failure@ a prospe"tive "ohort stud!. K Am So" ?ephrol 1444I 16@ ,21$,4% '. Druml L. ?utritional management of a"ute renal failure. K Renal ?utrition '66,I 1,@ /%$.6 %. Druml L. )rotein meta1olism in a"ute renal failure. +iner 7le"trol!te +eta1 1442I '*@ *.$,* *. +a! R( (lark AS Goheer +A et al. Spe"ifi" defe"ts in insulin mediated mus"le meta1olism in a"ute uraemia. Kidne! :nt 142,I '2@ *46$*4. ,. (ian"iaruso J JelliMMi 3 ?apoli R et al. Gepati" uptake and release of glu"ose la"tate and amino a"ids in a"utel! uraemi" dogs. +eta1olism 1441I *6@ '/1$'/4 /. Druml L Xe"hner R +agomets"hnigg D et al. )ost heparin lipol!ti" a"tivit! in a"ute renal failure. (lin ?ephrol 142,I '%@ '24$'4% .. +etnitM GG >is"her + Jartens ( et al. :mpa"t of a"ute renal failure on antio5idant status in multiple organ failure. A"ta Anaesthesiol S"and '666I **@ '%/$'*6 2. Jellomo R +artin G )arkin G et al. (ontinuous arteriovenous haemodiafiltration in the "riti"all! ill@ influen"e on ma9or nutrient 1alan"es. :ntensive (are +ed 1441I 1.@ %44$*6' 4. >ia""adori 7 +aggiore A Gia"osa R et al. 7nteral nutrition in patients with a"ute renal failure. Kidne! :nt '66*I /,@ 444$1662 16. Kre!mann KG Jerger ++ DeutM ?7) et al. 7S)7? guidelines on enteral nutrition@ intensive "are. (lin ?utrition '66/I ',@ '16$''% 11. (ano ? >ia""adori 7 -esinsk! ) et al. 7S)7? guidelines on enteral nutrition@ adult renal failure. (lin ?utrition '66/I ',@ '4,$%16

Le re"ommend that renal servi"es should work together with other spe"ialties to develop guidelines for the management of AK:. -hese should in"lude "lear guidelines with respe"t to when to re;uest a renal referral. #1A&

Le re"ommend that spe"ialist renal advi"e should 1e given with "onsultant renal ph!si"ian input. #1J&

Le re"ommend that transfer proto"ols should 1e developed 1ased on lo"al ph!siologi"al earl! warning s"ores to ensure appropriate triage of in$patients with AK: arriving from other hospitals. #1(&

Le re"ommend that ph!siologi"al surveillan"e should 1e performed for all patients with AK: to identif! earl! signs of ph!siologi"al deterioration whi"h ma! re;uire es"alation in the level of "are. #1A&

Le suggest that renal ph!si"ians and intensivists should work together to provide "are for patients with AK: on the intensive "are unit #:(A&. ?ephrolog! trainees should 1e trained to "are for a"utel! ill patients with AK:. #'(&

Le suggest that intensive "are units should "onta"t renal servi"es to dis"uss patients likel! to re;uire ongoing single organ renal support prior to step$down. Advan"e warning of su"h patients will fa"ilitate forward planning and "ontinued follow$up. #'(&

Le re"ommend that AK: survivors with residual renal impairment should 1e managed a""ording to lo"al "hroni" kidne! disease #(KD& guidelines. Dis"harge planning should in"lude plans for (KD management where relevant. #1A&. Audit measures
1. :n"iden"e of dela!s of transfer of patients with AK: S'* hours following referral to renal servi"es due to a la"k of resour"es on renal unit. '. :n"iden"e of patients with single organ AK: admitted to :(A for RR- due to a la"k of resour"es on the renal unit. %. ?um1er of AK: in$patient transfers re;uiring es"alation of "are within '* hours of arrival on renal unit. *. )roportion of AK: survivors with residual "hroni" kidne! disease with post$ dis"harge (KD planning.
Rationale for "!1#"!$ Almost all AK: develops outside of the renal unit and it should 1e possi1le to manage the ma9orit! of patients either in the non$spe"ialist ward or in "riti"al "are areas. -he most appropriate fa"ilit! for "are will depend on the presen"e or a1sen"e of non$renal organ failure the need for renal support and the need for renal spe"ialist input. -he latter will 1e determined in part 1! the likelihood that AK: will 1e transient and self$limiting and 1! the aetiolog! of AK: 8 parti"ularl! if an esoteri" diagnosis is possi1le1. -here are three ke! interfa"es whi"h ma! well 1e geographi"all! remote 1ut whose smooth fun"tion will help determine the most appropriate venue for management. -hese e5ist 1etween the non$spe"ialist ward and "riti"al "are #"riti"al "are outrea"h& 1etween renal servi"es and "riti"al "are #the "riti"al "are0nephrolog! interfa"e& and 1etween renal servi"es and the non$ spe"ialist ward #a"ute renal outrea"h&. <rganisation of these interfa"es will 1e di"tated 1! lo"al geograph! pra"ti"e and resour"e. -he need for "larit! in these intera"tions has 1een highlighted 1! a range of studies that have suggested 1oth "lini"al and organisational defi"ien"ies in management. Shortfalls in the 1asi"s of initial assessment and management on non$spe"ialist wards have 1een well demonstrated in 1oth regional' and national studies%. :n those who might need it referral for a renal spe"ialist opinion ma! 1e dela!ed
%*
or not even undertaken % ,. -hese
defi"ien"ies "oupled with failures in the timel! re"ognition of the a"utel! ill patient and the need to es"alate "are% ma! pla"e unne"essar! pressure on "riti"al "are and renal servi"es from patholog! that might otherwise have 1een mitigated. (are of the AK: patient on non$spe"ialist wards ma! 1e fa"ilitated in two wa!s. -he first is through the use of ph!siologi"al severit! s"ores to aid the re"ognition management and pla"ement of the a"utel! ill patient. -hese should now 1e esta1lished in routine pra"ti"e/. -he se"ond is 1! enhan"ing the initial assessment and treatment of evolving AK: 1 to 1oth optimise the management of those who "ould remain in that non$spe"ialist area and also for those who need it ensure timel! transfer to renal servi"es. Gow this goal might 1e a"hieved is un"lear 1ut
a suggested solution ma! in"lude the development and dissemination of "lear written guidelines. A supplementar! edu"ational pa"kage ma! 1e of 1enefit. Joth non$spe"ialists and renal servi"es should have an understanding of the indi"ations for seeking spe"ialist renal advi"e and of transfer and treatment proto"ols. Renal advi"e should 1e provided with "onsultant input given the eviden"e that this "an 1e poor when offered at a more 9unior level%. +e"hanisms to monitor and assure su""ess have !et to 1e esta1lished 1ut "ould in"lude longitudinal audit of the in"iden"e of severe AK: augmented 1! root "ause anal!sis. +ost AK: managed in "riti"al "are areas is paro"hial in origin. and usuall! asso"iated with other organ d!sfun"tion. ?evertheless vigilan"e needs to 1e maintained for those "auses that ma! 1e esoteri" and re;uire spe"ialist renal input. -his ma! 1e espe"iall! relevant for those :(As who "annot "all upon 1edside nephrologi"al assessment #around one third in a re"ent surve!2&. -he main intera"tion 1etween renal servi"es and "riti"al "are will however 1e the flow of si"k 7SRD patients in one dire"tion \4] and the re"ipro"al step$down of AK: patients still re;uiring single organ renal support. -he latter ma! represent a spe"ifi" 1ottlene"k in patient flow due to renal "apa"it! "onstraints and widening provision of RR- on :(A with *%B having no on$site step$ down fa"ilit! of an! nature on whi"h renal support "an "ontinue2. Although eviden"e for dela!ed step$down from "riti"al "are was found in a short o1servational surve! of severe single$organ AK: in Greater +an"hester* a 1' month surve! of patient flow a"ross the ?orth 7ast and (um1ria (riti"al (are ?etwork showed that su"h dela!s were relativel! short #median ' da!s& and amounted to a relativel! modest num1er of "riti"al "are 1ed da!s "onsumed #11% in that !ear&4. -he stud! found that the period of single organ renal support was signifi"antl! longer on those :(As without a renal unit on site 1ut the results overall did not support the ane"dotal impression of fre;uentl! dela!ed step$down of these patients. :t is re"ommended nevertheless that earl! "onta"t is made with renal servi"es to allow forward planning for those patients likel! to step$down still re;uiring renal support. -he AK Department of Gealth #DG& has re"ommended that patients with single organ failure re;uiring o1servation or intervention should re"eive level ' #high dependen"! unit GDA& "are1%. A failure to do so ma! pla"e undue pressure on level % fa"ilities and furthermore ma! in"rease mortalit!1*. DG re"ommendations would "learl! in"lude AK: 1ut a pragmati" interpretation would limit the s"ope to the more severe #AK:? stage %& "ases. :n addition although man! renal units do "ontain level ' fa"ilities diversion of patients awa! from those that do not is not onl! impra"ti"al 1ut we feel is also disadvantageous when renal not "riti"al "are is re;uired. Su"h units must however maintain ph!siologi"al surveillan"e of AK: patients under their "are and "lear pathwa!s should 1e esta1lished to allow rapid es"alation of "are for those that are deteriorating.
Although timel! renal transfer ma! 1e a ke! goal the arrival of patients on the renal unit with unheralded "riti"al illness is a potential disaster in terms of 1oth safet! and the une5pe"ted 1urden that this might pla"e on lo"al "riti"al "are servi"es. A prospe"tive single "entre o1servational stud! e5amined the utilit! of the S<>A #Se;uential <rgan >ailure Assessment& s"ore as a predi"tor of later es"alation of "are in AK: patients transferring from outside hospitals16. -hose re;uiring es"alation of "are within the first '* hours after transfer had high s"ores. -he tool "ould not determine the most appropriate venue for transfer 1ut might augment su19e"tive assessment of illness severit! 1! the referring team trigger pre$emptive responses 1! the re"eiving team su"h as earl! liaison with "riti"al "are and warn of the need for more fre;uent ph!siologi"al o1servation after arrival on the renal unit. -he lo"al +7LS #+odified 7arl! Larning S!stem& s"ore seems to have similar utilit! to the S<>A s"ore 1ut has the added advantage of harmonising with ph!siologi"al assessment within the re"eiving institution as a whole #unpu1lished data ?.S. Kanagasundaram&. A further "onsideration for AK: survivors is the long term management of persisting renal d!sfun"tion after hospital dis"harge. A re"ent o1servational stud! of survivors of AK: re;uiring renal support found in"omplete re"over! of renal fun"tion to 1e an independent determinant of long term survival11 in keeping with the role of (KD as an independent risk fa"tor for death. A su1se;uent o1servational stud! of survivors of RR-$re;uiring :(A AK: "onfirmed these findings1'I patients with de novo (KD following AK: had poorer long term survival than those with full re"over! of renal fun"tion although the highest post$dis"harge mortalit! was in survivors with (KD that had pre$dated AK:. -en per "ent of these survivors to hospital dis"harge eventuall! rea"hed 7SRD with those with pre$e5isting (KD seeming to 1e at highest risk. -he 1urden of (KD in survivors of AK: and the num1ers progressing to 7SRD ma! 1e under$ appre"iated. )lanning for long term management of persisting (KD ma! 1e parti"ularl! poor for those patients residing on non$renal wards who have 1een dis"harged from follow$up 1! the a"ute renal outrea"h servi"e #unpu1lished data ?.S. Kanagasundaram&. -here is a need for AK: survivors to have a "lear post$dis"harge plan for follow$up and management of residual renal d!sfun"tion if present. References
1. Gussein GK Lewington AK) Kanagasundaram ?S. General management of a"ute kidne! in9ur!. Jritish Kournal of Gospital +edi"ine '664I.6@ +16*$+16. '. Stevens )7 -amimi ?A Al$Gasani +K +ikhail A: Kearne! 7 Lapworth R )rosser D: (armi"hael ). ?on$spe"ialist management of a"ute renal failure. =K+ '661I4*@,%%$,*6 %. Stewart K >indla! G Smith ? Kell! K +ason +. Adding insult to in9ur!@ A review of the "are of patients who died in hospital with a primar! diagnosis of
a"ute kidne! in9ur! #a"ute renal failure&. London ?ational (onfidential 7n;uir! into )atient <ut"ome and Death '664 *. Gegart! K +iddleton RK Kre1s + Gussain G (heung ( Ledson - Gut"hison AK Kalra )A Ra!ner G( Stevens )7 <VDonoghue DK. Severe a"ute renal failure in adults@ )la"e of "are in"iden"e and out"omes. =K+ '66,I42@//1$///. 7pu1 '66, Kul '6'4 ,. >eest -G Round A Gamad S. :n"iden"e of severe a"ute renal failure in adults@ Results of a "ommunit! 1ased stud!. Jr +ed K 144%I%6/@*21$*2% /. Armitage + 7ddleston K Stokes - on 1ehalf of the Guideline Development Group. Re"ognising and responding to a"ute illness in adults in hospital@ Summar! of ?:(7 guidan"e. J+K '66.I%%,@',2$',4 .. Liano > Kun"o 7 )as"ual K +adero R 3erde 7. -he spe"trum of a"ute renal failure in the intensive "are unit "ompared with that seen in other settings. -he madrid a"ute renal failure stud! group. Kidne! :nternational 1442I,%@S1/$'* 2. Lright S7 Jodenham A Short A: -urne! KG. -he provision and pra"ti"e of renal repla"ement therap! on adult intensive "are units in the Anited Kingdom. Anaesthesia '66%I,2@16/%$16/4 4. Lright S7 Jaudouin S3 Kaudeer ? Shrestha S +alone K Jurn L Kanagasundaram ?S. )atient flow from "riti"al "are to renal servi"es@ A !ear$ long surve! in a "riti"al "are network. =K+ '662I161@/*%$/*2 16. Kanagasundaram ?S Kones K7. -ransfer of patients with a"ute kidne! in9ur! to spe"ialist renal servi"es$$ph!siologi"al earl!$warning s!stems applied prior to transfer from outside hospitals "an identif! those at risk of deterioration. =K+ '662I161@'*4$',6 11. S"hiffl G >is"her R. >ive$!ear out"omes of severe a"ute kidne! in9ur! re;uiring renal repla"ement therap!. ?ephrolog! Dial!sis -ransplantation '662I'%@''%,$ ''*1 1'. -riverio )$A +artin )$Y Romand K )ugin K )erneger - Saudan ). Long$term prognosis after a"u te kidne! in9ur! re;uiring renal repla"ement therap!. ?ephrol Dial -ransplant '664I'*@'12/$'124 1%. Anon!mous@ (omprehensive "riti"al "are@ A review of adult servi"es in AK #ed. London Department of Gealth AK '666 1*. L!ons RA Lareham K Gut"hings GA +a9or 7 >erguson J. )opulation re;uirement for adult "riti"al$"are 1eds@ A prospe"tive ;uantitative and ;ualitative stud!. Lan"et '666I%,,@,4,$,42

Guideline 6.1 AKI : Choice of renal replacement therapy modality
Le re"ommend that the "hoi"e of RR- modalit! should 1e guided 1! the individual patientWs "lini"al status medi"al and nursing e5pertise and availa1ilit! of modalit!. #1J& Rationale
Anal!sis of the "urrent literature does not allow eviden"e$1ased guidelines for the sele"tion of RR- modalit! for the treatment of AK:. :n the earl! 1426s the options for RR- therap! were generall! limited to intermittent haemodial!sis #:GD& and peritoneal dial!sis #)D&. -he "urrentl! availa1le therapies in industrialised so"ieties now in"lude various forms of "ontinuous renal repla"ement therap! #(RR-& and newer Dh!1ridE therapies su"h as e5tended duration dial!sis #7DD& sustained low$effi"ien"! dial!sis #SL7D& and the Genius^ s!stem. Despite the in"reasing te"hnologi"al sophisti"ation of RR- ke! "lini"al management issues su"h as the optimal dosing of therap! and whether the sele"tion of treatment modalit! impa"t on patient and renal survival remain to 1e determined. Although it is widel! per"eived that (RR- is superior to :GD in haemod!nami"all! unsta1le "riti"all! ill patients prospe"tive randomised "lini"al trials have failed to "onfirm this supposition. :n man! of the earlier trials there was a 1ias for the more "riti"all! ill patients to re"eive (RR- rather than :GD. >or e5ample SwartM and "olleagues1 retrospe"tivel! "ompared patients treated with (33G or :GD and reported a two$fold greater mortalit! in patients treated with (33G. Gowever after ad9usting for severit! of illness there was no differen"e. Similarl! in a prospe"tive stud! mortalit! was .4B in patients treated with (RR- "ompared to ,4B in the :GD treated group 1ut after ad9ustment for "o$mor1idities the modalit! of RR- was no longer a risk fa"tor for out"ome'. Si5 randomised prospe"tive "ontrolled trials "omparing (RR- and :GD from 7urope and the ASA have 1een pu1lished re"entl!%$2. -he smallest of these trials was designed to "ompare the effe"ts of (33G and :GD on s!stemi" haemod!nami"s and splan"hni" perfusion in patients with septi" sho"k with an overall mortalit! of .6B in 1oth the (33G and :GD groups%. :n a AS multi$ "entre trial of 1// patients with AK: +ehta and "olleagues reported intensive "are unit and hospital mortalit! rates of ,4.,B and /,.,B respe"tivel! in patients randomised to (RR- as "ompared to *1.,B and *../B respe"tivel! in patients randomised to :GD #pR6.6'&. Again after "ovariate ad9ustment there was no differen"e in mortalit! attri1uta1le to modalit! of RR- *. :n addition in this stud! there was a high rate of "rossover 1etween the treatment modalities. A AS single$"entre trial randomised 26 patients to either (33GD or :GD and although greater haemod!nami" sta1ilit! and fluid removal rates were reported with the former there was no differen"e in survival,. Similarl! a Swiss stud! randomising 1', patients to either (33GD> or :GD reported an :(A mortalit! of %*B and %2B respe"tivel! for the two modes of RR- with no differen"e in final hospital mortalit!/. <n"e again the Gemodiafe stud! a multi"enter randomised "ontrolled trial of %,4 patients also reported no differen"e in mortalit! a""ording to mode of RR- used #:GD vs (33GD>&.. -his stud! is noteworth! as :GD was su""essfull! delivered to patients despite marked haemod!nami" insta1ilit! with ver! little "rossover 1etween treatment groups. -he authors deli1eratel! "hose "ooled dial!sate in "om1ination with a ver!
high dial!sate sodium "on"entration to minimiMe "ardiovas"ular insta1ilit! during :GD and "ompared to other studies delivered the highest Kt03 dose in the :GD group. >inall! the SGAR> multi$"entre "olla1oration randomised %1/ AK: patients to re"eive either :GD or (33G and found no impa"t on out"ome. although no anal!sis of the effe"t or e;uivalen"e of delivered dose was provided in this paper. A num1er of meta$anal!ses have 1een performed. 7arl! work was hampered 1! in"lusion of non$randomised trial data4 and 1! limited num1ers of randomised trials availa1le at that time16. -he authors of a more re"ent meta$anal!sis were una1le to draw an! "on"lusions on modalit! "hoi"e noting methodologi"al pro1lems in even the most rigorous studies11. Another re"ent meta$anal!sis rea"hed 1roadl! similar "on"lusions on modalit! and although the! noted (RR-$ treated patients to have higher mean arterial pressures no signifi"ant differen"es were found in other haemod!nami" indi"es1'. ?oting the a1sen"e of out"ome differen"e 1etween modalities some have turned their attention to "ost. Joth a retrospe"tive "ohort stud!1% and a prospe"tive assessment of "ost1* in a randomised trial* have suggested that :GD is "heaper than (RR-. Given the nuan"es of lo"al resour"e availa1ilit! pur"hasing pra"ti"e and "lini"al pra"ti"e this limited data "annot 1e used as a 1asis for modalit! "hoi"e at this stage. Studies "omparing other forms of RR- have 1een limited. -here are a limited num1er of studies "omparing peritoneal dial!sis to (RR- in adults. -he former is "ontraindi"ated in those with a1dominal patholog! and ma! not provide satisfa"tor! "learan"es in those adults with h!per"ata1olism or a high urea distri1ution volume due to fluid overload. -wo studies reported an advantage of (RR- although the dose of dial!sis delivered 1! peritoneal dial!sis was low1, 1/. :n paediatri" pra"ti"e parti"ularl! post "ardia" surger! peritoneal dial!sis remains an effe"tive form of RR- in single organ failure1.. +ost re"entl! a randomised trial from JraMil has suggested 1roadl! e;uivalent patient out"omes and meta1oli" "ontrol when )D at high volume #%/ 8 ** L 0 da!& was "ompared to dail! :GD pres"ri1ed to a spKt03 of 1.'12. (omparative studies of "ontinuous and h!1rid te"hni;ues are limited. A small trial randomised %4 patients to either (33G or 1' hour e5tended dial!sis using a single$pass 1at"h s!stem and found e;uivalent "ardiovas"ular tolera1ilit! and urea "learan"es 1ut faster "orre"tion of a"idosis and lower heparin re;uirements with the latter14. Another small randomised trial "ompared (33GD> to a h!1rid te"hni;ue sustained GD> whi"h was administered dail! for / 8 2 hours'6. -here was no differen"e in survival rate at :(A dis"harge or after %6 da!s 1ut the h!1rid group had higher renal re"over! rates in survivors and a shorter :(A length of sta!. -he
delivered doses in ea"h treatment arm were not "lear as diffusive "omponents of "ontinuous and intermittent te"hni;ues are kineti"all! different'1. :n summar! anal!sis of the "urrentl! pu1lished studies does not allow eviden"e$1ased guidelines for the sele"tion of RR- modalit! for the treatment of AK:. Gowever as with the 3eterans A-? stud! most "lini"ians "hose intermittent haemodial!sis0haemofiltration for "ardiovas"ularl! sta1le patients and "ontinuous or h!1rid therapies for those with "ardiovas"ular "ompromise and multi$organ failure'' '%. -he modalit! "hosen should therefore 1e guided 1! the individual patientWs "lini"al status lo"al medi"al and nursing e5pertise and the availa1ilit! of RR- modalit! #-a1le '&. -a1le '@ Advantages and disadvantages of different RR- modalities in AK:
Modality Use in haemodynamically unstable patients
)eritoneal dial!sis :ntermittent haemodial!sis G!1rid te"hni;ues (33G (33GD (33GD> )ossi1le Yes Yes Yes high moderate0high moderate0high high Good Good Good good )ossi1le without )ossi1le without )ossi1le without )ossi1le without Yes ?o moderate high
Solute clearance Volume control

moderate moderate
Anti-coagulation
?o )ossi1le without
(33G@ "ontinuous veno$venous haemofiltration GD@ haemodial!sis GD>@ haemodiafiltration #see review of nomen"lature and ph!si"al pro"esses '%&
References
1. SwartM RD +essana K+ <rMol S )ort >K. (omparing "ontinuous hemofiltration with hemodial!sis in patients with severe a"ute renal failure. Ameri"an Kournal of Kidne! Diseases 1444I%*@*'*$*%' '. Guerin ( Girard R Selli K+ A!Ma" L. :ntermittent versus "ontinuous renal repla"ement therap! for a"ute renal failure in intensive "are units@ Results from a multi"enter prospe"tive epidemiologi"al surve!. :ntensive (are +edi"ine '66'I'2@1*11$1*12 %. Kohn S Gries1a"h D Jaumgartel + Leihpre"ht G S"hmieder R7 Geiger G. 7ffe"ts of "ontinuous haemofiltration vs intermittent haemodial!sis on s!stemi"
haemod!nami"s and splan"hni" regional perfusion in septi" sho"k patients@ A prospe"tive randomiMed "lini"al trial. ?ephrol Dial -ransplant '661I1/@%'6$%'. *. +ehta RL +"Donald J Ga11ai >J )ahl + )as"ual +- >arkas A Kaplan R+ (olla1orative Group for -reatment of AR>it:(A. A randomiMed "lini"al trial of "ontinuous versus intermittent dial!sis for a"ute renal failure. Kidne! :nt '661I/6@11,*$11/% ,. Augustine KK Sand! D Seifert -G )aganini 7). A randomiMed "ontrolled trial "omparing intermittent with "ontinuous dial!sis in patients with arf. Am K Kidne! Dis '66*I**@1666$166. /. Aehlinger D7 Kako1 S+ >errari ) 7i"hel1erger + Gu!nh$Do A +arti G) +ohaupt +G 3ogt J Rothen GA Regli J -akala K >re! >K. (omparison of "ontinuous and intermittent renal repla"ement therap! for a"ute renal failure. ?ephrol Dial -ransplant '66,I'6@1/%6$1/%.. 7pu1 '66, +a! 1/16 .. 3insonneau ( (amus ( (om1es A (osta de Jeauregard +A Klou"he K Joulain - )allot KL (hi"he KD -aupin ) Landais ) Dhainaut K>. (ontinuous venovenous haemodiafiltration versus intermittent haemodial!sis for a"ute renal failure in patients with multiple$organ d!sfun"tion s!ndrome@ A multi"entre randomised trial. Lan"et '66/I%/2@%.4$%2, 2. Lins RL 7lseviers ++ 3an der ?iepen ) Goste 7 +al1rain +L Damas ) Devriendt K. :ntermittent versus "ontinuous renal repla"ement therap! for a"ute kidne! in9ur! patients admitted to the intensive "are unit@ Results of a randomiMed "lini"al trial. ?ephrol Dial -ransplant '664I'*@,1'$,12 4. Kellum KA Angus D( Kohnson K) Le1lan" + Griffin + Ramakrishnan ? Linde$Xwir1le L-. (ontinuous versus intermittent renal repla"ement therap!@ A meta$anal!sis. :ntensive (are +edi"ine '66'I'2@'4$%. 16. -onelli + +anns J >eller$Kopman D. A"ute renal failure in the intensive "are unit@ A s!stemati" review of the impa"t of dial!ti" modalit! on mortalit! and renal re"over!.\"omment]. Am K Kidne! Dis '66'I*6@2.,$22, 11. Jagshaw S+ Jerthiaume LR Delane! A Jellomo R. (ontinuous versus intermittent renal repla"ement therap! for "riti"all! ill patients with a"ute kidne! in9ur!@ A meta$anal!sis. (riti"al (are +edi"ine '662I%/@/16$/1. 1'. Ra1indranath K Adams K +a"leod A+ +uirhead ?. :ntermittent versus "ontinuous renal repla"ement therap! for a"ute renal failure in adults. (o"hrane Data1ase of S!stemati" Reviews '66.@(D66%..% 1%. +anns J Doig (K Lee G Dean S -onelli + Kohnson D Donaldson (. (ost of a"ute renal failure re;uiring dial!sis in the intensive "are unit@ (lini"al and resour"e impli"ations of renal re"over!. (riti"al (are +edi"ine '66%I%1@**4$ *,, 1*. >arese S Kako1 S+ Kali"ki R >re! >K Aehlinger D7. -reatment of a"ute renal failure in the intensive "are unit@ Lower "osts 1! intermittent dial!sis than "ontinuous venovenous hemodiafiltration. Artifi"ial <rgans '664I%%@/%*$/*6 1,. Gang9i AS Ra11at (G +argetts )K Gang9i AS Ra11at (G +argetts )K. Jenefit of "ontinuous renal repla"ement therap! in su1groups of a"utel! ill patients@ A retrospe"tive anal!sis. (lin ?ephrol '66,I/%@'/.$'., 1/. SwartM RD Justami R- Dale! K+ Gillespie JL )ort >K SwartM RD Justami R- Dale! K+ Gillespie JL )ort >K. 7stimating the impa"t of renal repla"ement therap! "hoi"e on out"ome in severe a"ute renal failure. (lin ?ephrol '66,I/%@%%,$%*,
1.. StraMdins 3 Latson AR Garve! J 7uropean )ediatri" )eritoneal Sial!sis Lorking G StraMdins 3 Latson AR Garve! J 7uropean )ediatri" )eritoneal Dial!sis Lorking Group. Renal repla"ement therap! for a"ute renal failure in "hildren@ 7uropean guidelines. )ediatri" ?ephrolog! '66*I14@144$'6. 12. Ga1riel D) (aramori K- +artim L( Jarretti ) Jal1i AL. Gigh volume peritoneal dial!sis vs dail! hemodial!sis@ A randomiMed "ontrolled trial in patients with a"ute kidne! in9ur!. Kidne! :nt $ Supplement '662@S2.$4%. 14. Kielstein K- Krets"hmer A 7rnst - Gafer ( Jahr +K Galler G >liser D. 7ffi"a"! and "ardiovas"ular tolera1ilit! of e5tended dial!sis in "riti"all! ill patients@ A randomiMed "ontrolled stud!. Am K Kidne! Dis '66*I*%@%*'$%*4 '6. A1e + <kada K SuMuki + ?agura ( :shihara Y >u9ii Y :keda K KaiMu K +atsumoto K. (omparison of sustained hemodiafiltration with "ontinuous venovenous hemodiafiltration for the treatment of "riti"all! ill patients with a"ute kidne! in9ur!. Artifi"ial <rgans '616I%*@%%1$%%2 '1. Kanagasundaram ?S )aganini 7)@ (riti"al "are dial!sis$$a gordian knot #1ut is unt!ing the right approa"hH&. ?ephrol Dial -ransplant 1444I1*@',46$',4* ''. -he 3A ?:G A"ute Renal >ailure -rial ?etwork )alevsk! )+ Xhang KG <V(onnor -X (hertow G+ (rowle! S- (houdhur! D >inkel K Kellum KA )aganini 7 S"hein R+ Smith +L Swanson K+ -hompson J- 3i9a!an A Latni"k S Star RA )eduMMi ). :ntensit! of renal support in "riti"all! ill patients with a"ute kidne! in9ur!. ? 7ngl K +ed '662I%,4@.$'6 '%. Kanagasundaram ?S. Renal repla"ement therap! in a"ute kidne! in9ur!@ An overview. Jritish Kournal of Gospital +edi"ine '66.I/2@'4'$'4.

Guideline 7.1 Choice of dialyser / haemofilter membrane
Le re"ommend that s!ntheti" or modified "ellulosi" mem1ranes should 1e used in preferen"e to unmodified "ellulose mem1ranes. #1J&
Guideline 7.2 Choice of dialysate / replacement fluid

Le re"ommend that 1i"ar1onate should 1e the preferred 1uffer for dial!sate and repla"ement fluid in "ontinuous renal repla"ement therap! #(RR-& te"hni;ues unless regional "itrate anti"oagulation is emplo!ed. #1(&
Guideline 7.3 Microbial standards for fluids

Le re"ommend that mi"ro1ial standards for fluids used for "hroni" haemodial!sis #GD& 0 haemodiafiltration #GD>& should 1e also applied to e5tra"orporeal therap! for AK:. #1A& Rationale for $!1#$!%
La1orator! e5periments have shown that s!ntheti" mem1ranes tend to "ause less a"tivation of "omplement and mononu"lear "ells. Results from "lini"al trials have however 1een "onfli"ting with some suggesting a survival advantage for more 1io"ompati1le mem1ranes1$* and others showing no 1enefit,$2. (omparison of individual studies has 1een "ompromised 1! varia1ilit! in methodolog! definitions of AK: definitions of _1io"ompati1ilit!W and in other aspe"ts of dial!sis provision su"h as timing of initiation and ade;ua"!. ?o stud! was 1linded. +eta$anal!ses have !ielded var!ing results. Su1ramanian et al found worse survival with the use of non$1io"ompati1le mem1ranes although this effe"t ma! have 1een "onfined to unsu1stituted rather than modified "ellulose mem1ranes4. -his meta$anal!sis did however in"lude a large o1servational stud! that ma! have skewed results in favour of 1io"ompati1ilit!. -he most re"ent (o"hrane meta$anal!sis "ontinues to show no out"ome advantage with 1io"ompati1le mem1ranes16. -he definition of non$1io"ompati1ilit! in"luded 1oth unsu1stituted and modified "ellulose mem1ranes. ?either meta$anal!sis "ould demonstrate a differen"e in rates of renal re"over!. ?o re"ommendation "an therefore 1e made a1out the use of s!ntheti" over modified "ellulosi" mem1ranes for treating patients with AK:. Adverse survival found with the use of unsu1stituted "ellulose mem1ranes favours the use of either s!ntheti" or modified "ellulose mem1rane materials. -he main determinants of mem1rane "hoi"e will remain te"hni"al with pres"ription of the dial!ser 0 haemofilter di"tated 1! its intended use. La"tate and a"etate have 1een largel! repla"ed 1! 1i"ar1onate as the primar! 1uffer for dial!sate used in :GD for esta1lished renal failure and this pra"ti"e has propagated 1! default to :GD for AK:. :n a similar fashion 1i"ar1onate has 1e"ome the primar! 1uffer for 1oth repla"ement and dial!sate fluids in (RR-. Driven 1! "on"erns a1out e5a"er1ating e5isting la"ti" a"idosis parti"ularl! in those with liver failure the development of "ommer"iall! availa1le 1i"ar1onate$1ased fluids that "ir"umvent the inherent insta1ilit! of su"h solutions has led to their in"reasing utilisation. 7viden"e of 1enefit over la"tate$1ased solutions is in"onsistent with some studies showing no su1stantive differen"es in meta1oli" parameters pG or haemod!nami" status11 whilst others have shown improved haemod!nami" sta1ilit!1' 1% and more rapid "ontrol of s!stemi" a"idosis1*. Despite these "onfli"ting data the likelihood of 1enefit espe"iall! in the si"kest patients and the read! availa1ilit! of "ommer"iall!$prepared 1i"ar1onate fluid seems to 9ustif! its use in (RR-. Little "omparative data e5ists on the meta1oli" effe"ts of "itrate$ and 1i"ar1onate$1ased solutions. A single$"entre prospe"tive se;uential "ohort stud! suggested e;uivalent a"id$1ase and ele"trol!te "ontrol in patients re"eiving (33G1, 1ut num1ers were small and su1stitution fluid infusion rates differed 1etween the two treatment "ohorts. Given the a1sen"e of high ;ualit! eviden"e no re"ommendation "an 1e made on the optimal "hoi"e for meta1oli" "ontrol 1etween "itrate$ and 1i"ar1onate$1ased solutions.
A final "onsideration in the use of dial!sate 0 repla"ement fluids is their mi"ro1ial integrit!. -he potential for "lini"all! signifi"ant transfer of p!rogen$indu"ing material in dial!sate and su1stitution fluids is well re"ognised in the setting of "hroni" haemodial!sis and haemodiafiltration and has led to the esta1lishment of stri"t standards for mi"ro1iologi"al purit!. :n the a1sen"e of spe"ifi" eviden"e for renal support for AK: it is re"ommended that these same standards should appl!. :ntermittent GD will tend to 1e provided under the auspi"es of a renal unit so the same water ;ualit! standards should alread! 1e in pla"e a"ross 1oth a"ute and "hroni" servi"es. -he need to assure mi"ro1ial integrit! of fluids for (RR-s has not however 1een well re"ognised although eviden"e now e5ists that 1rea"hes ma! well 1e fre;uent1/ 1.. References
1. Gimmelfar1 K -olkoff Ru1in ? (handran ) )arker RA Lingard RL Gakim R. A multi"enter "omparison of dial!sis mem1ranes in the treatment of a"ute renal failure re;uiring dial!sis. K Am So" ?ephrol 1442I4@',.$'// '. Gakim R+ Lingard RL )arker RA. 7ffe"t of the dial!sis mem1rane in the treatment of patients with a"ute renal failure. ? 7ngl K +ed 144*I%%1@1%%2$ 1%*' %. S"hiffl G Lang S+ Konig A Strasser - Gaider +( Geld 7. Jio"ompati1le mem1ranes in a"ute renal failure@ )rospe"tive "ase$"ontrolled stud!. Lan"et 144*I%**@,.6$,.' *. S"hiffl G Sitter - Lang S Konig A Gaider + Geld 7. Jioin"ompati1le mem1ranes pla"e patients with a"ute renal failure at in"reased risk of infe"tion. ASA:< Kournal 144,I*1@+.64$.1' ,. Al1right R( Kr. Smelser K+ +"(arth! K- Gom1urger GA Jergstralh 7K Larson -S. )atient survival and renal re"over! in a"ute renal failure@ RandomiMed "omparison of "ellulose a"etate and pol!sulfone mem1rane dial!Mers. +a!o (lini" )ro"eedings '666I.,@11*1$11*. /. Gastaldello K +elot ( Kahn RK 3anherweghem KL 3in"ent KL -ielemans (. (omparison of "ellulose dia"etate and pol!sulfone mem1ranes in the out"ome of a"ute renal failure. A prospe"tive randomiMed stud!. ?ephrol Dial -ransplant '666I1,@''*$'%6 .. Korres A Gahl G+ Do1is ( )olenakovi" +G (akalaroski K Rutkowski J Kisielni"ka 7 Krieter DG Rumpf KL Guenther ( Gaus L Goegel K. Gaemodial!sis$mem1rane 1io"ompati1ilit! and mortalit! of patients with dial!sis$dependent a"ute renal failure@ A prospe"tive randomised multi"entre trial. :nternational multi"entre stud! group. Lan"et 1444I%,*@1%%.$1%*1 2. Kurtal G von Gerrath D S"haefer K. :s the "hoi"e of mem1rane important for patients with a"ute renal failure re;uiring hemodial!sisH Artifi"ial <rgans 144,I14@%41$%4* 4. Su1ramanian S 3enkataraman R Kellum KA. :nfluen"e of dial!sis mem1ranes on out"omes in a"ute renal failure@ A meta$anal!sis. Kidne! :nt '66'I/'@1214$ 12'% 16. Alonso A Lau K Ka1er JL. Jio"ompati1le hemodial!sis mem1ranes for a"ute renal failure. (o"hrane Data1ase of S!stemati" Reviews '662@(D66,'2%
11. Kierdorf G Leue ( GeintM J Riehl K +elMer G Sie1erth GG. (ontinuous venovenous hemofiltration in a"ute renal failure@ :s a 1i"ar1onate$ or la"tate$ 1uffered su1stitution 1etterH (ontri1utions to ?ephrolog! 144,I11/@%2$*. 1'. -homas A? Gu! K+ Kishen R Geraght! :> Jowles JK 3adgama ). (omparison of la"tate and 1i"ar1onate 1uffered haemofiltration fluids@ Ase in "riti"all! ill patients. ?ephrol Dial -ransplant 144.I1'@1'1'$1'1. 1%. Jaren1ro"k + Gaus1erg + +atMkies > de la +otte S S"haefer R+. 7ffe"ts of 1i"ar1onate$ and la"tate$1uffered repla"ement fluids on "ardiovas"ular out"ome in (33G patients. Kidne! :nt '666I,2@1.,1$1.,. 1*. +"Lean AG Davenport A (o5 D Swen! ). 7ffe"ts of la"tate$1uffered and la"tate$free dial!sate in (A3GD patients with and without liver d!sfun"tion. Kidne! :nt '666I,2@1./,$1..' 1,. Aman K ?urmohamed SA 3ervloet +G Groeneveld AJ@ +eta1oli" effe"ts of "itrate$ vs 1i"ar1onate$1ased su1stitution fluid in "ontinuous venovenous hemofiltration@ A prospe"tive se;uential "ohort stud!. Kournal of (riti"al (are '616I',@1'6$1'. 1/. Kanagasundaram ?S Larive AJ )aganini 7). A preliminar! surve! of 1a"terial "ontamination of the dial!sate "ir"uit in "ontinuous veno$venous hemodial!sis. (lin ?ephrol '66%I,4@*.$,, 1.. +oore : Jhat R Goeni"h ?A Kilner AK )ra1hu + <rr K7 Kanagasundaram ?S. A mi"ro1iologi"al surve! of 1i"ar1onate$1ased repla"ement "ir"uits in "ontinuous veno$venous hemofiltration. (riti"al (are +edi"ine '664I%.@*4/$ ,66

Le re"ommend that a"ute a""ess for renal repla"ement therap! should 1e veno$venous rather than arterio$venous. #1A&

Le re"ommend that dial!sis "atheters should 1e of an ade;uate length to minimise the risks of a""ess re"ir"ulation. #1(&

Le suggest that the a""ess site and "atheter t!pe should 1e "hosen with regard to the phase of the patientWs illness. #'(&

Le re"ommend that a""ess should 1e pla"ed 1! e5perien"ed or appropriatel! supervised staff. Real$time ultrasound guidan"e should 1e used to aid pla"ement of upper 1od! a""ess. #1A&

Le re"ommend that it is advisa1le that real$time ultrasound guidan"e 1e used for the insertion of femoral a""ess. #1D&

Le re"ommend that su1"lavian a""ess should 1e avoided in patients at risk of progressing to (KD stage * or , due to the risks of "ompromising future permanent vas"ular a""ess. #1D&

Le suggest that non$dominant arm upper lim1 vas"ulature should 1e preserved as a "ontingen"! for future permanent a""ess. #'(&

Le re"ommend that temporar! a""ess should 1e "hanged at appropriate intervals to minimise the risk of infe"tion. #1(&

Le suggest that lo"al poli"ies on prevention of "atheter$related infe"tion should 1e optimised 1! reserving the "atheter for e5tra"orporeal treatment onl!. #1D&
Audit measure
1. :n"iden"e of dial!sis "atheter$related 1a"teraemia and sepsis in patients with AK:
Rationale for 8!1#8!& :n industrialised so"ieties the vast ma9orit! of "ontinuous therap! is now provided using pumped veno$venous methods1. ?ot onl! does this te"hni;ue support the re;uirement for ade;uate 1lood flow rates to a"hieve the higher ultrafiltration0 dial!sate flow rates used in modern (RR- 1ut it also avoids the potential haMards of the a"ute arterio$venous a""ess used histori"all!'. -he ade;ua"! of intermittent te"hni;ues is mu"h more dependent on delivered e5tra"orporeal 1lood flow. (atheter failure is a fre;uent "ause of under$deliver! of the pres"ri1ed :GD dose% and should 1e 1orne in mind as a "ause of an! pres"ription$deliver! shortfall. -emporar! vas"ular a""ess used in a"ute dial!sis ma! lead to levels of a""ess re"ir"ulation of nearl! *6B depending on the site and length of a""ess 1lood flow and reversal of the lines*.
Several venous "atheters are availa1le with the dual$lumen design 1eing the most popular 1e"ause of ease of insertion and good flow "hara"teristi"s,. Su"h "atheters usuall! have a dou1le$D "ross$se"tional profile and are amena1le to guide wire "hanges/. (atheters made of semi$rigid pol!urethane or softer sili"one are regarded as the 1est in terms of throm1ogeni"it!1. -he former are a reasona1le short$term option #R % weeks& while the latter might 1e 1est utilised for longer term dial!sis 1e"ause of the lower propensit! to "ause endovas"ular trauma1. Su"h "atheters used with su1"utaneous tunnelling are highl! desira1le if RR- is likel! to 1e prolonged #S % weeks&.. A small single$"entre randomised "ontrol trial "ompared the performan"e of tunnelled to non$tunnelled femoral "atheters inserted in AK: patients prior to initiation of renal support2. -unnelled a""ess was found to give 1etter flow "hara"teristi"s fewer post$insertion "ompli"ations greater longevit! and less likelihood of a pres"ription$deliver! shortfall. -here were however more insertion failures in this group and su""essful "atheter pla"ements took signifi"antl! longer. <f note all "atheters insertions were performed 1! a single operator. -he appli"a1ilit! of these findings to routine pra"ti"e is un"lear. Ase of real$time ultrasound guidan"e for "atheter pla"ement at upper 1od! sites has 1een demonstrated to 1e asso"iated with greater su""ess and fewer "ompli"ations4. :t is advisa1le that similar guidan"e 1e used for femoral "atheter insertion. A num1er of fa"tors should 1e taken into "onsideration in "hoosing a site for insertion and appropriate "atheter length. >emoral "atheters shorter than '6 "m from hu1 to tip are asso"iated with higher degrees of a""ess re"ir"ulation* 16. >emoral "atheters of at least '* "m in length ma! produ"e improved flow rates/. Je"ause of the risks of infe"tion and femoral vein throm1osis it is re"ommended that femoral "atheters 1e removed and repla"ed on at least a weekl! 1asis/ 11. :t is advisa1le that femoral "atheters 1e repla"ed 1! upper 1od! a""ess on"e the patient starts to mo1ilise. -he su1"lavian approa"h "arries with it the long$term risk of venous stenosis that ma! "ompromise future ipsilateral permanent upper lim1 arteriovenous a""ess. Su1"lavian a""ess is thus 1est avoided in those with a likelihood of progressing to (KD stage * or ,. -he internal 9ugular approa"h ma! 1e asso"iated with a lower in"iden"e of 1oth a""idental pneumothora5/ and long$term venous stenosis1' in "omparison with su1"lavian a""ess and is the preferred upper 1od! a""ess. :nfe"tion ma! 1e somewhat more "ommon than at the su1"lavian site however espe"iall! in patients with tra"heostomies1'. >or the average adult internal 9ugular vein "atheters should 1e around '6 "m in length on the right and '* "m on the left1' to ensure safe positioning of the "atheter tip in the lower superior vena "ava. Lith appropriate infe"tion "ontrol and "atheter "are upper 1od! a""ess ma! onl!
need repla"ement ever! ' 8 % weeks1' 1%. Lo"al guidelines ma! suggest a more fre;uent s"hedule of repla"ement and should 1e adhered to. (atheter$related 1a"teraemia and e5it site infe"tion are signifi"ant risks of temporar! a""ess for a"ute RR-1*. >astidious insertion te"hni;ue 1! e5perien"ed or appropriatel! supervised staff and rigorous "atheter "are "an redu"e this risk1,. :t is advisa1le that dial!sis "atheters 1e reserved solel! for the purpose of RR- as repeated manipulations for non$RR- related reasons ma! in"rease the risk of "ontamination. Guidewire$e5"hange of "atheters for non$infe"tion related reasons ma! not in"rease 1a"teraemia rates11 1ut "annot 1e re"ommended in the presen"e of "atheter$related 1a"teraemia or e5it$site infe"tion. Jetween periods of RR"atheters ma! 1e lo"ked with heparin 1666 units0ml to lumen volumes unless there is a "lear "ontraindi"ation. :t is re"ommended that higher "on"entrations 1e avoided due to the risks asso"iated with over$dosing and leakage of the lo"k into the s!stemi" "ir"ulation. Alternatives to heparin to redu"e infe"tion risks in"lude heparin and anti1ioti" "om1inations "itralo"k and taurolo"k although no high ;ualit! data "urrentl! e5ists that would support their routine use. Re"entl! antimi"ro1ial "atheters have 1een introdu"ed for vas"ular a""ess either impregnated with silver or anti1ioti" "oated. )reliminar! trials have suggested a redu"tion in the in"iden"e of "atheter asso"iated 1a"teraemia 1ut larger trials will 1e re;uired 1efore the use of these "atheters "an 1e re"ommended as standard pra"ti"e. :n patients who are likel! to progress to stage * or , (KD upper lim1 vas"ulature should 1e preserved as a "ontingen"! for future permanent vas"ular a""ess.. References
1. (anaud J Lera!$+oragues G Le1lan" + Klou"he K 3ela ( Jeraud KK. -emporar! vas"ular a""ess for e5tra"orporeal renal repla"ement therapies in a"ute renal failure patients. Kidne! :nt 1442I,%@S1*'$1,6 '. Stor"k + Gartl LG Ximmerer 7 :nthorn D. (omparison of pump$driven and spontaneous "ontinuous haemofiltration in postoperative a"ute renal failure. Lan"et 1441I%%.@*,'$*,, %. Kanagasundaram ?S Greene - Larive AJ Daugirdas K- Depner -A Gar"ia + )aganini 7). )res"ri1ing an e;uili1rated intermittent hemodial!sis dose in intensive "are unit a"ute renal failure. Kidne! :nt '66%I/*@''42$'%16 *. Kel1er K DelmeM KA Lindus DL. >a"tors affe"ting deliver! of high$effi"ien"! dial!sis using temporar! vas"ular a""ess. Am K Kidne! Dis 144%I''@'*$'4 ,. -apson KS Goeni"h ?A Lilkinson R Lard +K. Dual lumen su1"lavian "atheters for haemodial!sis. :nternational Kournal of Artifi"ial <rgans 142,I2@14,$'66 /. Aldall R. 3as"ular a""ess for "ontinuous renal repla"ement therap!. Seminars in Dial!sis 144/I4@4%$4.
.. (anaud J Desmeules S Klou"he K Lera!$+oragues G Jeraud KK (anaud J Desmeules S Klou"he K Lera!$+oragues G Jeraud K$K. 3as"ular a""ess for dial!sis in the intensive "are unit. Jest )ra"ti"e & Resear"h (lini"al Anaesthesiolog! '66*I12@1,4$1.* 2. Klou"he K Amigues L DeleuMe S Jeraud KK (anaud J. (ompli"ations effe"ts on dial!sis dose and survival of tunneled femoral dial!sis "atheters in a"ute renal failure. Am K Kidne! Dis '66.I*4@44$162 4. Anon!mous@ ?:(7 te"hnolog! appraisal guidan"e no. *4 $ guidan"e on the use of ultrasound lo"ating devi"es for pla"ing "entral venous "atheters ?ational :nstitute for (lini"al 75"ellen"e '66' 16. Le1lan" + >edak S +okris G )aganini 7). Jlood re"ir"ulation in temporar! "entral "atheters for a"ute hemodial!sis. (lin ?ephrol 144/I*,@%1,$%14 11. <liver +K (aller! S+ -horpe K7 S"hwa1 SK (hur"hill D?. Risk of 1a"teremia from temporar! hemodial!sis "atheters 1! site of insertion and duration of use@ A prospe"tive stud!. Kidne! :nt '666I,2@',*%$',*, 1'. (imo"howski G7 Lorle! 7 Rutherford L7 Sartain K Jlondin K Garter G. Superiorit! of the internal 9ugular over the su1"lavian a""ess for temporar! dial!sis. ?ephron 1446I,*@1,*$1/1. 1%. Lei9mer +( 3ervloet +G ter Lee )+. (ompared to tunnelled "uffed haemodial!sis "atheters temporar! untunnelled "atheters are asso"iated with more "ompli"ations alread! within ' weeks of use. ?ephrol Dial -ransplant '66*I14@/.6$/.. 1*. Kairaitis LK Gottlie1 -. <ut"ome and "ompli"ations of temporar! haemodial!sis "atheters. ?ephrol Dial -ransplant 1444I1*@1.16$1.1* 1,. Deshpande KS Gatem ( Alri"h GL (urrie J) Aldri"h -K Jr!an$Jrown (L Kvetan 3. -he in"iden"e of infe"tious "ompli"ations of "entral venous "atheters at the su1"lavian internal 9ugular and femoral sites in an intensive "are unit population. (rit (are +ed '66,I%%@1%$'6I dis"ussion '%*$'%,

Le re"ommend that anti"oagulation for RR- should 1e tailored a""ording to patient "hara"teristi"s and the modalit! of RR- "hosen. #1(&

Le re"ommend that regional anti"oagulation with "itrate redu"es risk of haemorrhage "ompared to s!stemi" heparinisation. -he "omple5it! of the te"hni;ue means that this should 1e in routine use on an! unit on whi"h it is emplo!ed in order to allow suffi"ient levels of e5pertise to 1e maintained. #1(&
Le suggest that prosta"!"lin is a suita1le alternative to unfra"tionated heparin in those at in"reased risk of 1leeding 1ut ma! "ause haemod!nami" insta1ilit!. #'(&

Le suggest that a no$anti"oagulation saline flush strateg! "an 1e used in patients re"eiving (RR- and intermittent therapies who are at high risk of 1leeding. Gowever ultrafiltration re;uirements are in"reased effe"tive intermittent GD time is redu"ed and the te"hni;ue runs the risk of mem1rane fi1re rupture. #'(& Audit measure
1. :n"iden"e of heparin indu"ed throm1o"!topenia

Rationale for &!1#&! (lotting of the e5tra"orporeal "ir"uit is a signifi"ant sour"e of under$deliver! of the pres"ri1ed dose of RR- and is the most fre;uent "ause of therap! interruption in (RR-. -he h!per"oagua1le state of the "riti"all!$ill patient with AK:1 "ompounds various te"hni"al fa"tors su"h as non$laminar flow within 1oth the vas"ular a""ess and "ir"uit 1lood$mem1rane intera"tions the air$1lood interfa"e in the venous 1u11le trap and the haemo"on"entration indu"ed 1! high ultrafiltration volumes used in (33G0(33GD>. -he most widel! used anti"oagulant for RR- in patients with AK: is unfra"tionated heparin #A>G&' %. Although an effe"tive anti"oagulant for :GD in patients with (KD A>G ma! 1e less effe"tive in AK: as man! "riti"all! ill patients have redu"ed levels of antithrom1in espe"iall! when used for patients treated with (RR-. :n addition s!stemi" heparinisation is asso"iated with a risk of 1leeding and also with the development of heparin$indu"ed throm1o"!topenia #G:-&* ,. Low mole"ular weight heparins have generall! not 1een shown to 1e superior over A>G and have an e5tended half life in AK: and re;uire monitoring with anti$Oa a"tivit!%. Regional heparin proto"ols with reversal of heparin 1! infusion of protamine into the return line have 1een developed to prevent s!stemi" anti"oagulation and minimiMe 1leeding risk. Anfortunatel! these proto"ols are "um1ersome ma! 1e asso"iated with parado5i"al in"reased risk of 1leeding if e5"ess protamine is infused and do not alter the risk of G:-. <ther anti"oagulants that "an 1e used as alternatives for anti"oagulation of the e5tra"orporeal "ir"uit in patients with a histor! of G:- in"lude prosta"!"lin #prostaglandin :' 8 whi"h is used in non$G:patients who are at high risk of 1leeding&/$4 hirudin nafamostat and argatro1an%. -he s!ntheti" heparinoids danaparoid and fondiparinu5 ma! also 1e used although "ross rea"tivit! with the G:- anti1odies has o""asionall! 1een reported. :f these agents are used and the peripheral
platelet "ount does not in"rease within .' hours "ross rea"tivit! should 1e e5"luded Argatro1an is "urrentl! not li"ensed in the AK and has to 1e given 1! "ontinuous infusion. Danaparoid fondiparinu5 hirudin are all renall! e5"reted and therefore have e5tended half lives in AK:. -he s!ntheti" heparinoids re;uire monitoring of anti$Oa a"tivit! and hirudin 1! either its plasma "on"entration or the e"arin "lotting time. Girudin is partiall! "leared 1! high flu5 mem1ranes 1ut the ma9orit! of patients given hirudin for (RR- develop anti1odies to hirudin whi"h redu"e its "learan"e and e5tend its half life so in"reasing the risk of haemorrhage. :n "ases of e5"ess anti"oagulation asso"iated with 1leeding there are no spe"ifi" antidotes for these agents unlike protamine for unfra"tionated heparin. Although a"tivated fa"tor 3:: has 1een shown to 1e effe"tive and hirudin "an 1e "leared 1! high flu5 dial!sis0(RR- plasma e5"hange is re;uired in "ases of hirudin anti1odies%. <ver the last de"ade "itrate has emerged as a ver! effe"tive regional anti"oagulant for use in (RR-16$1*. (itrate is infused into the pre$filter line and works 1! "helating "al"ium. (al"ium is then re$infused separatel! or into the return line to maintain normal s!stemi" ioniMed "al"ium "on"entrations. (ommer"iall! availa1le "itrate s!stems have not 1een availa1le until re"entl! so individual units developed their own proto"ols for "itrate anti"oagulation. (itrate "omes as a sodium salt and ea"h mole"ule is indire"tl! "onverted to three 1i"ar1onates so there "an potentiall! 1e "hanges in sodium 1alan"e and a"id$1ase status depending upon the "itrate load and the a1ilit! of the patient to ade;uatel! meta1oliMe "itrate. -here have 1een few prospe"tive "omparative studies of A>G and "itrate anti"oagulation. :n two (RR- studies the median "ir"uit survival time was signifi"antl! prolonged with "itrate #.6 hrs v *6 hr and 1'* v %2 hr& and there was redu"ed 1lood transfusion re;uirements and0or haemorrhage in the "itrate groups16 11. Gowever patients that "annot ade;uatel! meta1olise "itrate to 1i"ar1onate su"h as those with a"ute liver failure ma! develop a D"al"ium gapE due to the a""umulation of "al"ium "itrate "omple5. -he D"al"ium gapE is the "al"ium "omple5ed with "itrate and is the differen"e 1etween the total "al"ium measured and that due to ionised "al"ium and plasma protein 1ound "al"ium. As these patients "annot ade;uatel! meta1olise "itrate the! will develop a meta1oli" a"idosis with h!per"itrataemia. <n the other hand over administration of "itrate to patients who "an meta1olise the "itrate load will result in a s!stemi" alkalosis. :n Kapan nafamostat is used as a regional anti"oagulant and appears to have similar effi"a"! and safet! profile to "itrate. Although A>G remains the most "ommonl! emplo!ed e5tra"orporeal anti"oagulant for RR- in patients with AK: there is emerging data to support the safet! and potential superiorit! of regional "itrate anti"oagulation for (RR-. ?ow that "itrate 1ased anti"oagulation s!stems have
1een developed for (RR- 1! the ma9or "ommer"ial "ompanies the proportion of patients with AK: treated 1! "itrate s!stems ma! in"rease. -he short duration of intermittent te"hni;ues ma! allow a _minimalW heparin #e.g. ,66 :A0hour& or even no heparin strateg!. Regular saline flushes used to sustain the latter ma! however redu"e the effe"tive dial!sis time. ?o heparin use in (RR- is possi1le and "an a"hieve ade;uate solute "learan"es 1ut its disadvantages in"lude the need for in"reased ultrafiltration the potential risk of dial!ser fi1re rupture and additional nursing workload1, 1/. >inall! pre$dilutional fluid repla"ement during "ontinuous haemofiltration "an help minimise the haemo"on"entration indu"ed 1! large ultrafiltration volumes 1ut "omes at the pri"e of the ineffi"ien"! of ultrafiltering a mi5ture of 9ust$infused repla"ement fluid and plasma 8 the proportions of whi"h are important "onsiderations in the (RR- pres"ription. References
1. Davenport A. -he "oagulation s!stem in the "riti"all! ill patient with a"ute renal failure and the effe"t of an e5tra"orporeal "ir"uit. Am K Kidne! Dis 144.I %6@S'6$'. '. Davenport A +ehta S. -he A"ute Dial!sis =ualit! :nitiative$$part 3:@ a""ess and anti"oagulation in (RR-. Adv Ren Repla"e -her. '66'I4@'.%$'21 %. <udemans$van$Straaten G+ Lester K)K )ont A(K+ de S"hetM +R(. Anti"oagulation strategies in "ontinuous renal repla"ement therap!@ "an the "hoi"e 1e eviden"e 1asedH :ntensive (are +ed '66/I %'@ 122$'6' *. +ehta RL. Anti"oagulation strategies for "ontinuous renal repla"ement therapies@ what worksH Am K Kidne! Dis '2@S2$S1* 144/ ,. Davenport A. +anagement of heparin$indu"ed throm1o"!topenia during "ontinuous renal repla"ement therap!. Am K Kidne! Dis 1442I %'@7% /. )onikvar R Kandus A Juturovi" K Kveder R. Ase of prosta"!"lin as the onl! anti"oagulant during "ontinuous venovenous hemofiltration. (ontri1utions to ?ephrolog! 1441I 4%@'12$''6 .. Kournois D (hanu D )ouard ) +auriat ) Safran D. Assessment of standardiMed ultrafiltrate produ"tion rate using prosta"!"lin in "ontinuous venovenous hemofiltration. (ontri1utions to ?ephrolog! 1441I 4%@'6'$'6* 2. Davenport A Lill 7K Davison A+. (omparison of the use of standard heparin and prosta"!"lin anti"oagulation in spontaneous and pump$driven e5tra"orporeal "ir"uits in patients with "om1ined a"ute renal and hepati" failure. ?ephron 144*I //@*%1$*%. 4. Langene"ker SA >elfernig + Ler1a A +ueller (+ (hiari A Ximpfer +. Anti"oagulation with prosta"!"lin and heparin during "ontinuous venovenous hemofiltration. (rit (are +ed 144*I ''@1..*$1.21 16. +on"hi + Jerghmans D Ledou5 D et al. (itrate vs. heparin for anti"oagulation in "ontinuous venovenous hemofiltration@ a prospe"tive randomiMed stud!. :ntensive (are +ed. '66*I %6@'/6$'/,
11. Kutsogiannis DK Gi1ne! R- Stoller! D Gao K. Regional "itrate versus s!stemi" heparin anti"oagulation for "ontinuous renal repla"ement in "riti"all! ill patients. Kidne! :nt. '66,I /.@'%/1$'%/. 1'. )alsson R ?iles KL. Regional "itrate anti"oagulation in "ontinuous venovenous hemofiltration in "riti"all! ill patients with a high risk of 1leeding. Kidne! :nt 1444I ,,@1441$144. 1%. +ehta RL +"Donald JR Aguilar ++ Lard D+. Regional "itrate anti"oagulation for "ontinuous arteriovenous hemodial!sis in "riti"all! ill patients. Kidne! :nt 1446I %2@4./$421 1*. Kirs"h1aum J Galishoff + Reines GD@ La"ti" a"idosis treated with "ontinuous hemodiafiltration and regional "itrate anti"oagulation. (rit (are +ed 144'I '6@%*4$%,% 1,. Smith D )aganini 7) SuhoMa K 7isele G Swann S ?akamoto S. ?on$ heparin "ontinuous renal repla"ement therap! is possi1le in )rogress in Artifi"ial <rgans - 1985 edited 1! ?ose Y K9ellstrand ( :vanovi"h ) (leveland :SA< )ress 142/ pp ''/$'%6 1/. Ramesh )rasad G3 )alevsk! )+ Jurr R Lesko K+ Gupta J Green1erg A. >a"tors affe"ting s!stem "lotting in "ontinuous renal repla"ement therap!@ results of a randomiMed "ontrolled trial. (lin ?ephrol ,%@,,$/6 '666

Le re"ommend that the delivered dose of RR- should 1e assessed to ensure the ade;ua"! of the pres"ription. #1A&

Le re"ommend that the pres"ri1ed dose should 1e assessed at ea"h session #for intermittent haemodial!sis& and dail! #for "ontinuous te"hni;ues& to a""ount for an! measured shortfalls in delivered dose. #1A&

Le re"ommend that patients with AK: and multi$organ failure treated 1! "ontinuous renal repla"ement therap! #(RR-& should re"eive treatment doses e;uivalent to post dilution ultrafiltration rates P ', ml0kg0hr. A proportionate upward ad9ustment to the pres"ri1ed ultrafiltration rate should 1e made in pre$dilutional "ontinuous haemofiltration. #1A&

Le re"ommend that patients with AK: and multi$organ failure treated 1! intermittent haemodial!sis should re"eive either alternate da! haemodial!sis with at least the minimum dose
"onsidered appropriate for end$stage renal disease #7SRD& urea redu"tion ratio #ARR& S/,B or eKt03S1.' or dail! haemodial!sis. #1J&

Le suggest that renal repla"ement therap! dosing methods that re;uire an assessment of patient weight should use a measured weight rather than an e5trapolated weight from pre$ mor1id readings. #'J& Audit measures
1. )roportion of "riti"all! ill patients treated 1! alternate da! haemodial!sis who re"eive Kt03 P1.' per session '. )roportion of "riti"all! ill patients with AK: treated with "ontinuous renal repla"ement therap! who re"eive S ', mls0kg0hr post$dilution ultrafiltration
Rationale for 10!1 ' 10!" -raditionall! in studies in patients with AK: the dose #or intensit!& of treatment has 1een assessed 1! urea "learan"e in dial!sis 1ased modalities and 1! ultrafiltration volume #a surrogate of urea "learan"e& in the "onve"tive therapies. Area is relativel! non$to5i" and regarded as a surrogate for other low mole"ular weight uraemi" to5ins. :t is re"ogniMed that using urea as a marker of intensit! or dose of RR- has a num1er of limitations parti"ularl! in "riti"all! ill patients. Area generation rates will differ 1etween patients due to patient spe"ifi" fa"tors #age se5 and ra"e et"& due to disease spe"ifi" fa"tors #the "ata1oli" rate the presen"e of mus"le in9ur! and0or 1reakdown sepsis and liver disease& and due to medi"al therap! su"h as nutritional support and steroid treatment. Gowever given the "urrent a1sen"e of an! other more suita1le marker urea "learan"e is a""epted as the 1est wa! to "ompare intensit! or dose of RR-. -he urea "learan"e a"hieved during (RR- is appro5imatel! e;ual to the effluent flow rate #dial!sis and ultrafiltration flow rate "om1ined&. -he dose of RR- delivered to patients not onl! in"ludes small solute "learan"es 1ut also larger DmiddleE mole"ules. -he amount of these other mole"ules removed will depend on the modalit! used and is greater for "onve"tive #haemofiltration& than diffusion #dial!sis& 1ased te"hni;ues. +iddle mole"ule "learan"e 1! intermittent therapies is also affe"ted 1! 1oth fre;uen"! and duration of therap!. :n addition to solute "learan"es the pres"ription and deliver! of renal support to patients with AK: also in"ludes other ke! aspe"ts of medi"al management in"luding sodium and water 1alan"e #patients are often grossl! salt$and volume$loaded 1! the time the! rea"h the need for RR-I drug "arriage solutions and "olloids will "ompound this even when the period of Va"tiveV renal re$perfusion has "eased& and "orre"tion of a"id$1ase im1alan"e. -here
are fundamental differen"es in provision of RR- to patients with esta1lished renal failure "ompared to those with AK: in"luding the wide intra$ and inter$individual varia1ilit! in ke! "lini"al and dial!ti" fa"tors su"h as total 1od! water and the "ata1oli" rate1. -hus the pres"ription of a dose of RR- and assessment of its deliver! will need to 1e undertaken dail! #for (RR-& and at ea"h session #for :RR-&. -here is a pau"it! of data regarding Dade;uateE treatment doses of intermittent haemodial!sis #:GD& to 1e delivered in AK:. Anal!sis of a prospe"tivel! "olle"ted data1ase has shown that higher doses of intermittent haemodial!sis defined as a urea redu"tion ratio #ARR& S ,2B improved survival'. :t should 1e noted that this "ut$off dose e;uivalent to a Kt03 of around 1 is lower than that re"ommended for :GD for esta1lished renal failure. :n this stud! dial!sis dose had no impa"t on patient survival in patients at the e5tremes of illness severit!. Lhereas for those patients with intermediate severit! of illness the deliver! of dial!sis dose in e5"ess of the ,6th per"entile #Kt03 ` 1& was asso"iated with lower mortalit! risk than lower doses%. Due to the la"k of prospe"tive studies addressing the minimum dose of RR- re;uired in AK: a "onsensus panel "onvened 1! the multinational A"ute Dial!sis =ualit! :nitiative #AD=:& re"ommended that patients with AK: re"eive at least the minimum dose that is "onsidered appropriate for patients with esta1lished renal failure*. Re"entl! the 3eterans trial reported that there was no signifi"ant improvement in patient out"omes provided a Kt03 of 1.'$1.* per session was delivered,. Due to the diffi"ult! in assessing the volume of distri1ution of urea in patients with AK: several studies have shown that the delivered dose of :GD "an 1e markedl! lower than that pres"ri1ed/$. and is not routinel! measured in "lini"al pra"ti"e. Gowever it must 1e stressed that weight$1ased RR- dosing is important and should 1e performed. -o a"hieve a ARR a1ove /,B or eKt03 a1ove 1.' "onsistentl! in the vast ma9orit! of the haemodial!sis population "lini"ians should aim for a minimum target ARR of .6B or minimum eKt03 of 1.* in individual patients. <nl! one stud! has evaluated the effe"t of dail! and alternate da! :GD on the out"ome among patients with AK:2. -his reported 1oth lower mortalit! #'2B v. */B pa6.61& and shorter duration of AK: #4Z' v. 1/Z/ da!s pa6.661& in the dail! :GD group. Gowever the dose of haemodial!sis delivered to the alternate da! group was low #mean delivered Kt03 of 6.4*Z6.11&. -his pro1a1l! a""ounted for the markedl! in"reased time$averaged urea "on"entration and the high in"iden"e of "ompli"ations in"luding gastrointestinal 1leeding mental status alteration and infe"tion reported in this group. Several studies have looked at dose in (RR-, 4$1'. :n a large single "entre randomiMed "ontrolled trial the *%, enrolled patients were randomised to one of three "ontinuous venovenous haemofiltration #(33G& doses #post dilution&. -he doses were defined 1! a"hieved
dail! ultrafiltration rates of '6 ml0kg0hr %, ml0kg0hr and *, ml0kg0hr4. +ortalit! was markedl! lower in the intermediate and high dose arms #*%B and *'B respe"tivel!& "ompared to the low dose arm #,4B pR6.661&. Su1se;uentl! there have 1een three further studies "omparing the dose of (RR-. -wo smaller studies failed to show an! survival 1enefit11 1'. Gowever survival 1enefit was demonstrated in a stud! that added an additional dose of dial!sis to haemofiltration providing an e;uivalent dose of %, ml0kg0hr1'. An important te"hni"al "onsideration is that the slow dial!sate flow rates emplo!ed in "ontinuous venovenous haemodial!sis #(33GD& and haemodiafiltration #GD>& ensures that the effluent fluid will 1e full! e;uili1rated with plasma with respe"t to small solutes 1! the time it leaves the dial!ser1%. Altrafiltration rates in "onve"tive treatments #haemofiltration& "an thus 1e used inter"hangea1l! with dial!sate flow rates for the (RR-s when "onsidering urea "learan"es1*. -wo large multi"entre randomised "ontrolled studies have 1een pu1lished re"entl! to provide mu"h needed guidan"e on the optimal dose of (RR- in "riti"all! ill patients. -he 3eteran Affairs0?ational :nstitute of Gealth A"ute Renal >ailure -rial ?etwork #A-?& stud! was performed in :(As a"ross the ASA whilst the Randomised 7valuation of ?ormal 3ersus Augmented Level Renal Repla"ement -herap! #R7?AL& was "ondu"ted in :(As in Australia and ?ew Xealand1,. -he A-? stud! showed no additional 1enefi"ial patient out"ome with a delivered (33GD> dose #pre$dilution& of %, ml0kg0h "ompared to '6 ml0kg0h although there was a non signifi"ant trend for 1etter out"ome in the more "riti"all! ill patients with the higher dose of RR-,. -he R7?AL trial failed to demonstrate an! survival 1enefit from re"eiving post dilution (33GD> at a dose of *6 ml0kg0hr versus ', ml0kg0hr. -hese studies have now provided eviden"e that there is no survival 1enefit in "riti"all! ill patients re"eiving ultrafiltration doses S ', ml0kg0hr. -his suggests that a minimum delivered dose of ', ml0kg0h is re;uired and to allow for "ir"uit "lotting a higher dose should 1e pres"ri1ed parti"ularl! for the "riti"all! ill patient. -here is little data on dose "omparisons in "riti"all! ill patients re"eiving peritoneal dial!sis #)D&. A more re"ent stud! (RR- was reported to 1e superior to )D in treating patients with malaria indu"ed AK:1, and this ma! have well have 1een due to the dose of )D delivered as the rate of "reatinine "learan"e and "orre"tion of a"idosis were mu"h inferior during )D therap!. )eritoneal dial!sis has 1een shown to 1e an effe"tive therap! in "hildren post "ardia" surger!1/ when a )D dose in e5"ess of a weekl! Kt03 urea of '.1 was delivered with a median "reatinine "learan"e of .*.% L0wk01..%m'. Automated peritoneal dial!sis ma"hines are the preferred method for delivering individualised peritoneal dial!sis dose and a""uratel! measuring ultrafiltration.
Kust as there are no studies looking at the dose of peritoneal dial!sis re;uired for patients with single organ and multiple organ failure there is a similar pau"it! of data on patient out"omes with the re"entl! introdu"ed Dh!1ridE treatments #su"h as Genius^. e5tended dail! dial!sis #7DD& and slowl! lower effi"ien"! dial!sis #SL7D&&. <nl! a relativel! small num1er of patients were treated 1! h!1rid therapies in the 3eterans stud! 1ut there was no o1vious improvement in patient out"omes with more intensive therap! a1ove alternate da! sessions delivering a Kt03 of P1.%,. Gowever it must 1e remem1ered that if intermittent haemodial!sis 7DD and0or SL7D te"hni;ues are used in the intensive "are unit unless there is a dedi"ated water treatment plant availa1le the simple treatment of domesti" water with a single reverse osmosis unit and ultrafilters ma! not provide the ;ualit! of water re;uired for haemodiafiltration unless 1at"h dial!sate s!stems #Genius^& are used.. -he A-? stud! did not show an! ma9or 1enefit for either intensive haemodial!sis h!1rid therapies or (33GD>, 1ut the amount of intermittent haemodial!sis and0or h!1rid therap! delivered per session was greater than in earlier studies. References
1. Kanagasundaram ?S )aganini ). A"ute renal failure on the intensive "are unit. (lin +ed. ,@*%,$**6. '66, '. Kanagasundaram ?S Greene - Larive AJ Daugirdas K- Depner -A Gar"ia + )aganini 7). )res"ri1ing an e;uili1rated intermittent hemodial!sis dose in intensive "are unit a"ute renal failure. Kidne! :nt '66%I /*@''42$'%16 %. )aganini 7) -apol!ai + Goormasti" + Galsten1erg L KoMlowski L Le1lan" + Lee K( +oreno L Sakai K. 7sta1lishing a dial!sis therap! 0 patient out"ome link in intensive "are unit a"ute dial!sis for patients with a"ute renal failure. Am K Kidne! Dis 144/I '2@S21$S24 *. Kellum KA +ehta RL Angus D( )alevsk! ) Ron"o (. -he first international "onsensus "onferen"e on "ontinuous renal repla"ement therap!. Kidne! :nt . '66'I/'@12,,$12/% ,. -he 3A0?:G a"ute renal failure trial network. :ntensit! of renal support in "riti"all! ill patients with a"ute kidne! in9ur!. ? 7ngl K +ed '662I %,4@ /. Kanagasundaram ?S Greene - Larive AJ et al. )res"ri1ing an e;uili1rated intermittent hemodial!sis dose in intensive "are unit a"ute renal failure. Kidne! :nt '66%I /*@ ''42$'%16 .. 7vanson KA Gimmelfar1 K Lingard R et al. )res"ri1ed versus delivered dial!sis in a"ute renal failure patients. Am K Kidne! Dis. 1442I %'@.%1$.%2 2. S"hiffl G Lang S+ >is"her R. Dail! hemodial!sis and the out"ome of a"ute renal failure. ? 7ngl K +ed. '66'I%*/@%6,$%16 4. Ron"o ( Jellomo R Gomel ) et al. 7ffe"ts of different doses in "ontinuous veno$venous haemofiltration on out"omes of a"ute renal failure@ a prospe"tive randomised trial. Lan"et. '666I%,/@'/$%6 16. Jouman (S <udemans$3an Straaten G+ -i9ssen KG et al. 7ffe"ts of earl! high$volume "ontinuous venovenous hemofiltration on survival and re"over! of renal fun"tion in intensive "are patients with a"ute renal failure@ a prospe"tive randomiMed trial. (rit (are +ed. '66'I %6@''6,$''11
11. -olwani AK (amp1ell R( Stofan JS et al. Standard versus high dose (33GD> for intensive "are unit related a"ute renal failure. K Am So" ?ephrol '662 7pu1 )+:D 12%%.*26 1'. Saudan ) ?ieder1erger + De Seigneu5 S Romand K )ugin K )erneger +artin )Y. Adding a dial!sis dose to "ontinuous haemofiltration in"reases survival in patients with a"ute renal failure. Kidne! :nt '66/I .6@ 1%1'$1%1. 1%. Jellomo R. Do we know the optimal dose for renal repla"ement therap! in the intensive "are unitH Kidne! :nt '66/I .6@ 1'6'$1'6* 1*. Sigler +G. -ransport "hara"teristi"s of the slow therapies@ impli"ations for a"hieving ade;ua"! of dial!sis in a"ute renal failure. Advan"es in Renal Repla"ement -herap! 144.I *@/2$26 1,. R7?AL Repla"ement -herap! Stud! :nvestigators. :ntensit! of "ontinuous renal repla"ement therap! in "riti"all! ill patients. ? 7ngl K +ed. '664I %/1@ 1/'.$1/%2 1/. )hu ?G Gien -- +ai ?- et al. Gemofiltration and peritoneal dial!sis in infe"tion$asso"iated a"ute renal failure in 3ietnam. ? 7ngl K +ed. '66'I %*.@24,$46' 1.. +"?ei"e KL 7llis 77 Drummond$Le11 KK >ontenot 77 <VGrad! (+ JlasMak R-. Ade;ua"! of peritoneal dial!sis in patients following "ardiopulmonar! 1!pass surger!. )ediatr ?ephrol '66,I '6@4.'$4./
11.
Acute Kidney Injury (AKI) (Guidelines AKI 11 .1 11.5)

Le re"ommend that the de"ision to start RR- in patients with AK: should remain a "lini"al de"ision 1ased on fluid ele"trol!te and meta1oli" status of ea"h individual patient. #1(&

Le re"ommend that RR- should 1e initiated on"e AK: is esta1lished and unavoida1le 1ut 1efore overt "ompli"ations have developed. #1J&

Le re"ommend that the threshold for initiating RR- should 1e lowered when AK: o""urs as part of multi$organ failure. #1(&

Le re"ommend that the initiation of RR- ma! 1e deferred if the underl!ing "lini"al "ondition is improving and there are earl! signs of renal re"over!. #1D&
Guideline 11.5 AKI : Timing of discontinuation of renal replacement treatment
Le re"ommend that an improvement in the patientWs "lini"al "ondition and urine output would 9ustif! temporar! dis"ontinuation of ongoing renal support to see if AK: is re"overing. #1D& Rationale for 11!1 ' 11!" Gistori" data suggests that Dearl!E initiation of RR- in AK: is asso"iated with improved survival 1ut the eviden"e 1ase is not suffi"ientl! ro1ust to allow a spe"ifi" re"ommendation and the de"ision to initiate RR- should remain a "lini"al de"ision #-a1le %&. Lhereas the de"ision to initiate RR- is straightforward in those patients with refra"tor! h!perkalaemia meta1oli" a"idosis and volume overload and0or overt uraemi" s!mptoms in the a1sen"e of these overt manifestations there is de1ate as to the optimal time to initiate renal support. 7arl! introdu"tion of RR- as soon as a patient enters AK: stage % ma! 1e of 1enefit so that the patient is not e5posed to the potential deleterious effe"ts of meta1oli" a1normalities and0or volume overload. Gowever earl! initiation of RR- will result in some patients suffering the adverse "onse;uen"es of treatment su"h as venous throm1osis and "atheter$related 1a"teraemia haemorrhage from anti"oagulants and other treatment related "ompli"ations. :n addition some patients with AK: espe"iall! those with single organ failure ma! re"over renal fun"tion without ever developing an Da1soluteE indi"ation for RR-. >inall! animal work has suggested that RR- might dela! renal re"over!1 although it is not "lear whether more modern te"hni;ues of renal support also might 1e impli"ated. :nitial reports some dating 1a"k ,6 !ears suggested a "lini"al 1enefit of earl! initiation of RR-. -hese and other studies'$2 formed the 1asis for the standard "lini"al pra"ti"e that dial!ti" support should 1e instituted when the serum urea rea"hed '2 mmol0l. :n re"ent !ears several retrospe"tive studies have reported improved "lini"al out"omes with earl! institution of (RR- for post$traumati" AK: at urea levels R '1., mmol0l4 or initiation of (RR- in post "ardia" surger! patients with a urine output of R 166 mL02hr16 11. A re"ent o1servational stud! from the AS multi$ "entre ):(ARD group reported that starting RR- at urea values S '. mmol0L was asso"iated with a two$fold in"reased risk of mortalit!1'. Gowever a prospe"tive randomised stud! of 1oth dose and timing of initiation of (33G did not show an! survival advantage of earl! therap!1%. An earl! start was defined as initiation within 1' hours of meeting the following "riteria@ a urine output R %6 ml0hr for S / hours despite attempts at optimisation and a measured urinar! "reatinine "learan"e R '6 ml0min. -herap! was "ommen"ed in the late start group when a "onventional indi"ation was met #severe pulmonar! oedema urea S *6 mmol0l K[ S /., mmol0l&. -he stud! was however underpowered. A re"ent s!stemati" review of the literature identified '% studies in"luding onl! * R(-s and 1 ;uasi$R(-1*. +ost of the other studies were "omparative "ohort studies and mainl! retrospe"tive. -he primar! meta$anal!sis of the R(-s onl! suggested a %/B mortalit! risk
redu"tion although this was non$signifi"ant. +eta$anal!sis of "ohort studies indi"ated a statisti"all! signifi"ant mortalit! risk redu"tion. Joth anal!ses were hampered 1! var!ing definitions of earl! and late starts and 1! the fa"t that studies en"ompassed at least * de"ades of e5perien"e and widel! different populations. >urther prospe"tive o1servational studies pu1lished su1se;uent to this meta$anal!sis have !ielded "onfli"ting results1, 1/. >inall! the eviden"e 1ase for dis"ontinuation of renal support with re"overing renal fun"tion is even less "lear than that for its initiation. A post ho" anal!sis from an international multi$"entre stud! found that urine output at the time of first stopping (RR- was the most important predi"tor of sustained dis"ontinuation espe"iall! if not enhan"ed 1! diureti"s. -hose who returned to RR- within . da!s had a higher mortalit! than those who did not although this "ould have 1een due to an inter"urrent deterioration in the patientWs overall "ondition rather than earl! "essation of renal support1.. -hus the "urrent "onsensus from retrospe"tive and o1servational studies suggests that Dearl!E initiation of RR- in AK: is asso"iated with improved patient survival although this remains to 1e "onfirmed 1! ade;uatel! powered prospe"tive randomiMed trials. :n ever! da! "lini"al pra"ti"e "lini"ians t!pi"all! start RR- earlier in patients with multiple organ failure than in those with AK: alone. -a1le %@ :ndi"ations generall! used to start renal repla"ement therap! in standard "lini"al pra"ti"e in patients with AK:
Jio"hemi"al indi"ations Refra"tor! h!perkalaemia S /., mmol0l Serum urea S '. mmol0l Refra"tor! meta1oli" a"idosis pG R ..1, Refra"tor! ele"trol!te a1normalities@ G!ponatraemia h!pernatraemia or h!per"al"aemia -umour l!sis s!ndrome with h!peruri"aemia and h!perphosphataemia Area "!"le defe"ts and organi" a"idurias resulting in h!perammonaemia meth!maloni"
a"idaemia (lini"al indi"ations Arine output R 6.% ml0kg for '* h or a1solute anuria for 1' h AK: with multiple organ failure Refra"tor! volume overload 7nd organ involvement@ peri"arditis en"ephalopath! neuropath! m!opath! uraemi" 1leeding (reation of intravas"ular spa"e for plasma and other 1lood produ"t infusions and nutrition Severe poisoning or drug overdose Severe h!pothermia or h!perthermia
References 1. (onger KD. Does hemodial!sis dela! re"over! from a"ute renal failureH Seminars in Dial!sis 1446I%@1*/$1*2 '. -es"han )7 Ja5ter (R <VJrien -> >re!hof K? Gall LG. )roph!la"ti" hemodial!sis in the treatment of a"ute renal failure. Annals of internal medi"ine ,%@44'$161/ 14/6 \"lassi"al arti"le]. K Am So" ?ephrol 1442I4@'%2*$'%4. %. 7asterling R7 >orland +. A five !ear e5perien"e with proph!la"ti" dial!sis for a"ute renal failure. -ransa"tions $ Ameri"an So"iet! for Artifi"ial :nternal <rgans 14/*I16@'66$'62 *. >is"her R) Griffen L< Kr. Reiser + (lark DS. 7arl! dial!sis in the treatment of a"ute renal failure. Surger! G!ne"olog! & <1stetri"s 14//I1'%@1614$16'% ,. )arsons >+ Go1son S+ Jlagg (R +"(ra"ken JG. <ptimum time for dial!sis in a"ute reversi1le renal failure. Des"ription and value of an improved dial!ser with large surfa"e area. Lan"et 14/1I1@1'4$1%* /. Kleinkne"ht D Kungers ) (hanard K Jar1anel ( Ganeval D. Aremi" and non$ uremi" "ompli"ations in a"ute renal failure@ 7valuation of earl! and fre;uent dial!sis on prognosis. Kidne! :nt 14.'I1@146$14/ .. (onger KD. A "ontrolled evaluation of proph!la"ti" dial!sis in post$traumati" a"ute renal failure. Kournal of -rauma$:n9ur! :nfe"tion & (riti"al (are 14.,I1,@16,/$16/%
2. Gillum D+ Di5on JS Yanover +K Kelleher S) Shapiro +D Jenedetti RG Dillingham +A )aller +S Gold1erg K) -omford R(. -he role of intensive dial!sis in a"ute renal failure. (lin ?ephrol 142/I',@'*4$',, 4. Gettings LG Re!nolds G? S"alea -. <ut"ome in post$traumati" a"ute renal failure when "ontinuous renal repla"ement therap! is applied earl! vs. Late. :ntensive (are +edi"ine 1444I',@26,$21% 16. Demirkili" A Kurala! 7 Yeni"esu + (aglar K <M JS (ingoM > Guna! ( Yildirim 3 (e!lan S Arslan + 3ural A -atar G. -iming of repla"ement therap! for a"ute renal failure after "ardia" surger!. K (ard Surg '66*I14@1.$'6 11. 7lahi ++ Lim +Y Koseph R? Dhannapuneni RR Sp!t -K. 7arl! hemofiltration improves survival in post$"ardiotom! patients with a"ute renal failure. 7ur K (ardiothora" Surg '66*I'/@16'.$16%1 1'. Liu KD Gimmelfar1 K )aganini 7 :kiMler -A Soroko SG +ehta RL (hertow G+. -iming of initiation of dial!sis in "riti"all! ill patients with a"ute kidne! in9ur! (lin K Am So" ?ephrol '66/I1@41,$414 1%. Jouman (S <udemans$3an Straaten G+ -i9ssen KG Xandstra D> Kese"ioglu K. 7ffe"ts of earl! high$volume "ontinuous venovenous hemofiltration on survival and re"over! of renal fun"tion in intensive "are patients with a"ute renal failure@ A prospe"tive randomiMed trial. (rit (are +ed '66'I%6@''6,$''11 1*. Sea1ra 3> Jalk 7+ Liangos < Sosa +A (endoroglo + Ka1er JL. -iming of renal repla"ement therap! initiation in a"ute renal failure@ A meta$anal!sis. Am K Kidne! Dis '662I,'@'.'$'2* 1,. Jagshaw S+ A"hino S Jellomo R +orimatsu G +orgera S S"hetM + -an : Jouman ( +a"edo 7 Gi1ne! ? -olwani A <udemans$van Straaten G+ Ron"o ( Kellum KA. Jeginning and 7nding Supportive -herap! for the Kidne! :@ -iming of renal repla"ement therap! and "lini"al out"omes in "riti"all! ill patients with severe a"ute kidne! in9ur!. Kournal of (riti"al (are '664I'*@1'4$ 1*6 1/. Shiao (( Lu 3( Li LY Lin Y> Gu >( Young GG Kuo (( Kao -L Guang D+ (hen Y+ -sai )R Lin SL (hou ?K Lin -G Yeh Y( Lang (G (hou A Ko LK Lu KD ?ational -aiwan Aniversit! Surgi"al :ntensive (are Anit$ Asso"iated Renal >ailure Stud! G. Late initiation of renal repla"ement therap! is asso"iated with worse out"omes in a"ute kidne! in9ur! after ma9or a1dominal surger!. (riti"al (are #London 7ngland& '664I1%@R1.1 1.. A"hino S Jellomo R +orimatsu G +orgera S S"hetM + -an : Jouman ( +a"edo 7 Gi1ne! ? -olwani A Straaten G< Ron"o ( Kellum KA. Dis"ontinuation of "ontinuous renal repla"ement therap!@ A post ho" anal!sis of a prospe"tive multi"enter o1servational stud!. (rit (are +ed '664I%.@',./$ ',2'
1'. A"ute Kidne! :n9ur! #AK:& #Guidelines AK: 1'.1&
Guideline 12.1 AKI : Education

Le re"ommend that undergraduate and postgraduate medi"al trainees should 1e taught the prin"iples of prevention and treatment of AK:. #1(&
Rationale A"ute kidne! in9ur! ma! 1e en"ountered in all 1ran"hes of medi"ine and the opportunit! to tea"h trainees should 1e em1ra"ed 1! nephrologists. -he ?(7)<D adding insult to in9ur! AK: stud! re"ommended that 1oth undergraduate and postgraduate medi"al training for all spe"ialties should in"lude the re"ognition of the a"utel! ill patients and the prevention diagnosis and management of AK:1. -here is other supportive eviden"e that "urrentl! medi"al trainees do not re"eive ade;uate training in the management of AK:'. -he importan"e of the asso"iation 1etween small rises in serum "reatinine and adverse patient out"omes should 1e highlighted. +edi"al students and trainees should 1e taught the prin"iples of volume assessment and fluid pres"ri1ing. -here should 1e a "onsolidation of inter$spe"ialt! training and an emphasis on the development of AK: in the a"utel! ill patient. References
1. ?ational (onfidential 7n;uir! into )atient <ut"ome and Death Adding :nsult to :n9ur! '664. www.n"epod.org '. Ali + Lewington AK). Do medi"al trainees re"eive ade;uate training in the management of a"ute kidne! in9ur!. A1stra"t. Ameri"an So"iet! of ?ephrolog! '616
Acknowledgements
-his guideline has 1een endorsed 1! the So"iet! for A"ute +edi"ine and the :ntensive (are So"iet!. Dr Andrew Lewington and Dr Suren Kanagasundarum have no "onfli"ts of interest to de"lare.
Downloads
1. A"ute Kidne! :n9ur! $ >inal Draft #62 Kanuar! '611& !(df file #,'*.14 KJ& Download '. A"ute Kidne! :n9ur! $ Draft 3ersion #12 Septem1er '616& !(df file #*4'.11 KJ& Download %. , $ A"ute Kidne! :n9ur! $ (urrent version $ 62 April '662 #>:?AL& !(df file #,22.1, KJ& Download *. , $ A"ute Kidne! :n9ur! $ (urrent version $ '4 Kanuar! '662 #DRA>-& !(df file #///.2/ KJ& , $ A"ute Kidne! :n9ur!@ (urrent version $ '4061062 #DRA>-& Download
In this section

Guidelines )eritoneal Dial!sis )eritoneal A""ess Assessment of the )otential Kidne! -ransplant Re"ipient A"ute Kidne! :n9ur! Jlood Jorne 3irus :nfe"tion Renal Repla"ement -herap! Gaemodial!sis 3as"ular A""ess for Gaemodial!sis ?utrition in (KD Anaemia in (KD (ardiovas"ular Disease in (KD (KD $ +ineral and Jone Disorders Dete"tion +onitoring and (are of )atients with (KD )ost$operative (are of the Kidne! -ransplant Re"ipient
Latest news

Reminder - Nominations open for 3 Executive Committee Positions Reminder for expressions of interest for the position of Chair of the Clinical Practice Guidelines Committee Latest Kidney Care Updates Green Nephrology Update Amgen Bursary 2011
+ore news...
What we do
+eetings A1stra"ts )u1li"ations Koint A"tivities
Calendar & News

?ews 7vent listings e?ews
Information and Resources

Renal Anits
eG>R (al"ulator -he AK e(KD Guide :nformati"s Links Resour"es :nformation for )atients )ro"edures >or )atients
Clinical Affairs
(lini"al Affairs Joard (lini"al Servi"e Guidelines <ther Guidelines >uture (lini"al )ra"ti"e Guidelines Renal Registr!
Academic Affairs
A"ademi" affairs 1oard :nternational (ommittee Resear"h Renal S"ientists -he AK (al"iph!la5is Registr! -rials G?$D?A (olle"tion
Education & Training

-he -raining and 7du"ation (ommittee -raining >le5i1le -rainees (urri"ulum resour"es (ourses Advan"ed ?ephrolog! (ourse Le"tures
UK Nephrology
?ephrolog! in the AK
>rom the -sar >rom S"otland >rom Lales >rom ?orthern :reland
About the Association

-he Renal Asso"iation (onta"ts (ommittees 75e"utive (ommittee +em1ership (orporate +em1ers Koin the Renal Asso"iation Awards and )riMes Gistor! of the Renal Asso"iation +emorandum Arti"les & Rules :nterests De"laration A1out the we1site
A1out the Renal Asso"iation (onta"t us

Acute Kidney Injury

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Acute Kidney Injury

Hochgeladen von

Copyright:

Verfügbare Formate

Acute Kidney Injury

Authors of this guideline were:

Summary of audit measures for Acute Kidney Injury

Rationale for clinical practice guidelines for Acute Kidney Injury

all emergen"! admissions should have a risk assessment for AK:

Summary of Clinical Practice Guideline on Acute Kidney Injury

Guideline 1.2 AKI : Definition, Epidemiology and Outcomes

Urine output criteria

Guideline 1.3 AKI : Definition, Epidemiology and Outcomes

2. Acute Kidney Injury (AKI) (Guidelines AKI 2.1 2.2)

Guideline 2.2 AKI : Clinical Assessment; Investigations

3. Acute Kidney Injury (AKI) (Guidelines AKI 3.1 3.4)

Guideline 3.2 AKI : Prevention; Fluid Therapy

Guideline 3.3 AKI : Prevention; Contrast-Induced AKI (CI-AKI)

Guideline 3.4 AKI : Prevention; AKI secondary to Rhabdomyolysis

4. Acute Kidney Injury (AKI) (Guidelines AKI 4.1 4.5)

Guideline 4.2 AKI : Management; Pharmacological Therapy

Guideline 4.3 AKI : Management; Pharmacological Therapy

Guideline 4.4 AKI : Management; Nutritional Support

Guideline 4.5 AKI : Management; Nutritional support

5. Acute Kidney Injury (AKI) (Guidelines AKI 5.1 5.7)

Guideline 5.2 AKI : Treatment facilities & referral to renal services

Guideline 5.3 AKI : Treatment facilities & referral to renal services

Guideline 5.4 AKI : Treatment facilities & referral to renal services

Guideline 5.5 AKI : Treatment facilities & referral to renal services

Guideline 5.6 AKI : Treatment facilities & referral to renal services

Guideline 5.7 AKI : Treatment facilities & referral to renal services

6. Acute Kidney Injury (AKI) (Guidelines AKI 6.1)

7. Acute Kidney Injury (AKI) (Guidelines AKI 7.1 7.3)

Guideline 7.2 Choice of dialysate / replacement fluid

Guideline 7.3 Microbial standards for fluids

8. Acute Kidney Injury (AKI) (Guidelines AKI 8.1 8.9)

Guideline 8.1 AKI : Vascular access for RRT

Guideline 8.2 AKI : Vascular access for RRT

Guideline 8.3 AKI : Vascular access for RRT

Guideline 8.4 AKI : Vascular access for RRT

Guideline 8.5 AKI : Vascular access for RRT

Guideline 8.6 AKI : Vascular access for RRT

Guideline 8.7 AKI : Vascular access for RRT

Guideline 8.8 AKI : Vascular access for RRT

Guideline 8.9 AKI : Vascular access for RRT

9. Acute Kidney Injury (AKI) (Guidelines AKI 9.1 9.4)

Guideline 9.2 AKI : Anticoagulation for extracorporeal therapies

Guideline 9.3 AKI : Anticoagulation for extracorporeal therapies

Guideline 9.4 AKI : Anticoagulation for extracorporeal therapies

10. Acute Kidney Injury (AKI) (Guidelines AKI 10.1 10.5)

Guideline 10.2 AKI : Renal Replacement Therapy prescription

Guideline 10.3 AKI : Renal Replacement Therapy prescription

Guideline 10.4 AKI : Renal Replacement Therapy prescription

Guideline 10.5 AKI : Renal Replacement Therapy prescription

11. Acute Kidney Injury (AKI) (Guidelines AKI 11 .1 11.5)

Guideline 11.2 AKI : Timing of initiation of renal replacement treatment

Guideline 11.3 AKI : Timing of initiation of renal replacement treatment

Guideline 11.4 AKI : Timing of initiation of renal replacement treatment

Guideline 11.5 AKI : Timing of discontinuation of renal replacement treatment

12. Acute Kidney Injury (AKI) (Guidelines AKI 12.1)

Summary of Audit Measures:

1. :n"iden"e and out"omes of patients diagnosed with

re"ent value within % months 1ut a""epting value up to one !ear&

Rationale for clinical practice guidelines for Acute Kidney Injury

Guideline 1.1 AKI : Definition, Epidemiology and Outcomes

1. :n"iden"e and out"omes of patients diagnosed with

re"ent value within % months 1ut a""epting up to one !ear&

'. <ut"ome measures for patients developing AK: should in"lude