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Implementing the Kidney Disease: Improving Global Outcomes/acute kidney injury guidelines in ICU patients

Eric A J Hoste, Wouter De Corte
Current Opinion in Critical Care 2013, 19 (6): 544-53
24240820

PURPOSE OF REVIEW: Acute kidney injury (AKI) is a frequent finding in critically ill patients and is associated with adverse outcomes. With the purpose of improving outcome of AKI, the Kidney Disease: Improving Global Outcomes (KDIGO) group, a group of experts in critical care nephrology, has presented a set of guidelines in 2012, based on the evidence gathered until mid 2011. This review will update these guidelines with recent evidence.

RECENT FINDINGS: Early application of a set of therapeutic measures - a bundle - is advised for the prevention and therapy of AKI. Hemodynamic optimization remains the cornerstone of prevention and treatment of AKI. Fluid resuscitation should be with isotonic crystalloids. Recent evidence demonstrated a higher risk for renal replacement therapy (RRT) and mortality in hydroxyethyl starch-exposed patients. Further, blood pressure should be maintained by the use of vasopressors in vasomotor shock. Nephrotoxic drugs should be avoided or stopped when possible. Contrast-associated AKI should be prevented by prehydration with either NaCl 0.9% or a bicarbonate solution. Other therapies, including intravenous N-acetylcysteine and hemofiltration are not recommended. Optimal timing of RRT remains controversial. Fluid overload remains an important determinant for the initiation of RRT. Continuous therapies are preferred in hemodynamically unstable patients; otherwise, choice of modality does not impact on outcomes.

SUMMARY: The KDIGO guidelines as presented in 2012 provide guidelines on the domain of definition of AKI, prevention and treatment, contrast-induced AKI and dialysis interventions for AKI. Especially, early application of a set of measures, the AKI bundle, may prevent AKI and improve outcome.

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