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"Kidneys" Том 8, №4, 2019

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The Renal Association Clinical Practice Guideline Acute Kidney Injury (AKI), August 2019

Authors: Suren Kanagasundaram (chair)(1), Caroline Ashley(2), Sheetal Bhojani(3), Alma Caldwell(4), Timothy Ellam(5), Amrit Kaur(6), David Milford(7), Chris Mulgrew(8), Marlies Ostermann(9)
(1) — Consultant Nephrologist, Newcastle upon Tyne Hospitals NHS Foundation Trust Honorary Clinical Senior Lecturer, Institute of Cellular Medicine, Newcastle University
(2) — Renal Pharmacist, Royal Free Hospital
(3) — Consultant Paediatrician with Special Interest in Nephrology, University Hospital Wishaw, NHS Lanarkshire
(4) — Patient representative
(5) — Consultant Nephrologist, Newcastle upon Tyne Hospitals NHS Foundation Trust
(6) — Consultant Paediatric Nephrologist, Royal Manchester Children’s Hospital
(7) — Consultant Paediatric Nephrologist, Birmingham Children’s Hospital
(8) — Consultant Nephrologist, Royal Devon and Exeter NHS Foundation Trust
(9) — Consultant in Critical Care and Nephrology, Guy’s and St. Thomas’ NHS Foundation Trust

Categories: Nephrology

Sections: Medical forums

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https://renal.org/wp-content/uploads/2017/07/FINAL-AKI-Guideline.pdf

Summary of clinical practice guidelines

1. Definition, Epidemiology and Outcomes

Guideline 1.1 — Adults and Paediatrics

We recommend that the Kidney Disease: Improving Global Outcomes (KDIGO) system for the diagnosis and staging of AKI should be adopted; serum creatinine-based criteria should be applied according to the current NHS England biochemical detection algorithm. (1B)

We suggest that, when the true, reference serum creatinine (SCr) is uncertain, the presence of an active episode of AKI occurring in secondary care can be inferred from frequent SCr testing (e.g. at 12 and 24 hours after the index value). (2D)

2. Recognition of the patient at risk of AKI

Guideline 2.1 — Adults and Paediatrics (unless otherwise stated)

We recommend that:

— patients at risk of AKI should be identified by the most appropriate risk factor profile for that population or, where no specific risk factor profile exists, through clinical judgement and recognition of generic risk factors for AKI; in this way, appropriate preventative measures may be instituted as early as possible (1C)

— in-patients deemed at high risk of AKI should be closely monitored for AKI, particularly if there has been a new exposure. Urine output should be monitored and serum creatinine tested daily (for adults) or regularly (for paediatric patients, reflecting the potential burden of venepuncture) until at least 48 hours after the period of increased risk has elapsed (1D)

— out-patients deemed at high risk of AKI should be closely monitored for AKI if there has been a new exposure. This should include regular monitoring of the serum creatinine until at least 48 hours after the period of increased risk has elapsed. For paediatric patients, monitoring should be undertaken by secondary care but may be in an out-patient or in-patient setting depending on clinical circumstances (1D)

3. Clinical Assessment

History, Examination

Guideline 3.1 — Adults and Paediatrics (unless otherwise stated)

We recommend that:

— all patients with AKI have an appropriate history and examination performed to help determine the cause of the episode of AKI (1D)

adults only: all patients with progressive AKI should be re-assessed, particularly if the course is atypical (1D)

paediatrics only: all patients with progressive AKI should be re-assessed by a consultant, or in conjunction with one, within 4 hours of the creatinine result, particularly if the course is atypical (1D)

— a diagnosis of a rapidly progressive glomerulonephritis should be considered when a patient with no obvious cause of progressive or non-resolving acute kidney injury has urine dipstick results showing haematuria and proteinuria, without urinary tract infection or trauma due to catheterisation — adult patients should be referred to renal services whilst paediatric patients with AKI should already be receiving nephrology input (1D)

— patients at risk of AKI and who have suffered a significant exposure to a renal insult should undergo a relevant assessment to ensure that exposure is limited and further insults are avoided or minimised (1D)

— urine dipstick testing for blood, protein, leucocytes, nitrites and glucose is performed in all patients as soon as acute kidney injury is suspected or detected unless this has already been done. The results should be documented and it should be ensured that appropriate action is taken when results are abnormal (1D)

— when AKI is diagnosed, its cause or presumed causes should be documented and, wherever possible, determined (1D)

Investigations

Guideline 3.2 — Adults and Paediatrics (unless otherwise stated)

We recommend that:

— all patients with AKI should have appropriate baseline investigations performed. These should include urinalysis and a renal tract ultrasound within 24 hours (unless a clear cause of AKI is apparent or AKI is improving), and within 6 hours if pyonephrosis is suspected or there is a high index of suspicion for urinary tract obstruction (1D)

adults only: hospital in-patients with newly diagnosed AKI should have their urea and electrolytes monitored at a minimum frequency of once daily (unless more frequent testing is indicated; e.g. for hyperkalaemia management) until renal function has returned to baseline or has stabilised, and then regularly, thereafter, in order that progressive or recurrent AKI may be detected in a timely fashion (1D)

paediatrics only: when AKI is detected, serum creatinine should be checked, regularly, until completion of the AKI episode and, depending on remaining risk factors for AKI, thereafter, to allow timely detection of progressive or recurrent disease — the frequency of monitoring will rely on clinical judgement and the balance between optimal monitoring and the burden of over-frequent venepuncture (1D)

— adults only: patients with newly diagnosed AKI who are managed in the community should have their urea and electrolytes monitored regularly until renal function has returned to baseline or has stabilised in order to detect progressive or recurrent AKI in a timely fashion (1D)

4. Management of the patient with AKI and at increased risk of it

Guideline 4.1 — Adults and Paediatrics

These recommendations apply to patients at high risk of AKI as well as those who have developed it.

We recommend:

— that an assessment of the physiological status of the patient with AKI be made promptly following identification of AKI or recognition of a high risk for it (following NICE CG50) (1A)

— prompt identification and treatment of sepsis where appropriate (1A)

— optimisation of haemodynamic status using appropriate fluid therapy (supported by NICE CG176) and administration of vasopressors and/or inotropes as appropriate (1B)

— careful clinical assessment when administering fluid therapy in order to avoid adverse outcomes as a consequence of fluid overload (1B)

— that, at present, there is no specific pharmacological therapy proven to treat AKI secondary to hypoperfusion injury and/or sepsis (1A)

5. Medicines Management in AKI

Guideline 5.1 — Adults and Paediatrics

We recommend that:

— a documented review is undertaken of all medications in those at risk of or with identified AKI, in order to withhold medications which may adversely affect renal function (1D)

— therapeutic drug dosing must be adapted to altered kinetics in AKI (1B)

— regular re-evaluation of drug dosing is undertaken as renal function changes and as renal support is initiated, altered or discontinued (1D)

— individual acute hospital Trusts either sign-post to external guidance on drug use in AKI, for example, for the prescribing of antibiotics, analgesia, contrast media, and chemotherapy, or develop their own, in-house evidence-based recommendations (1D)

— all patients re-starting potential culprit drugs after an episode of AKI should have their serum creatinine and potassium re-measured 1–2 weeks after this and after any subsequent dose titration (1D)

6. Rhabdomyolysis

Guideline 6.1 — Adults and Paediatrics

We recommend that adult and paediatric patients identified as being at risk of developing AKI due to rhabdomyolysis, and who are not volume overloaded, should receive prompt intravenous volume expansion in order to achieve a high urinary flow rate. (1B)

7. Nutritional support

Guideline 7.1 — Adults and Paediatrics

We recommend that patients with AKI receiving renal replacement therapy should be referred to a dietitian for individual assessment. (1D)

8. Treatment facilities and transfer to renal services

Guideline 8.1 — Adults

We recommend that:

— when specialist renal advice on patients with AKI is sought, this should be given with consultant renal physician involvement; senior input is intended to ensure that high quality advice has been offered and so may include retrospective but timely discussion of cases referred to non-consultant members of the renal team (1D)

— transfer protocols should be developed based on the National Early Warning Score (NEWS) to ensure appropriate triage of in-patients with AKI arriving from other hospitals (1C)

— renal services should work with other specialties and local primary and secondary care providers to develop guidelines on indications and local processes for renal referral for the management of AKI; these should harmonise with national guidance, where available (1C)

We suggest that:

— intensive care units should make early contact renal services to discuss patients likely to require ongoing single organ renal support prior to step-down. Advance warning of such patients will facilitate forward planning and continued follow-up (2D)

Guideline 8.2 — Paediatrics

We recommend that:

— paediatric renal services should work in collaboration with tertiary specialities within the same centre as well as local hospitals to develop regional guidelines and transfer protocols for the early detection, management and treatment of AKI in children and young people (1D)

— paediatric intensive care units should liaise early with renal services to discuss children or young people who may require ongoing renal replacement therapy following discharge from intensive care. This should be undertaken with consultant paediatric nephrologist input. Early referral facilitates forward planning and helps establish relationships with children and their families (1D)

— urgent secondary care assessment should be arranged for all possible cases of AKI, developing in the community. This should be undertaken with consultant paediatric nephrologist input (1D)

9. Renal Support

Adults and Paediatrics (unless otherwise stated)

Guideline 9.1 — Choice of renal replacement therapy

We recommend that:

— acute renal replacement therapy (RRT) should be considered for patients with progressive or severe AKI, unless a decision has been made not to escalate therapy (1B)

— the decision to initiate RRT and choice of modality should be based on the condition of the patient as a whole, severity of the underlying disease, degree of fluid overload and its impact on other organs but not on an isolated creatinine or urea values (1B)

— intermittent and continuous extracorporeal modalities should be considered as complementary treatments for AKI. The choice of renal replacement therapy should be guided by the clinical status of the individual patient, the medical and nursing expertise, and the availability of machines. Peritoneal dialysis may be considered as an alternative to extracorporeal treatments in paediatric patients (1B)

— the decision whether to start continuous or intermittent RRT should be based on the condition of the patient. Continuous RRT should preferably be offered to patients who are haemodynamically unstable or have acute brain injury or cerebral oedema (2B)

Guideline 9.2 — Choice of membrane and fluids

We recommend that:

— dialysers with a biocompatible membrane should be used for IHD and CRRT (1C)

— bicarbonate should be the preferred buffer for dialysate and replacement fluid in continuous renal replacement therapy (CRRT) techniques (1C)

— fluids used for continuous or intermittent haemodialysis, haemofiltration or haemodiafiltration in patients with AKI meet the microbial standards for fluids used for chronic haemodialysis (1A)

Guideline 9.3 — Vascular access for RRT

We recommend that:

— veno-venous access is used for acute renal replacement therapy (1A)

— dialysis catheters should be of an adequate length to minimise the risk of premature filter clotting and access recirculation (1C)

— access should be placed by experienced or appropriately supervised staff. Real-time ultrasound guidance should be used to aid placement (1A)

— subclavian vein access should be avoided if possible in patients at risk of progressing to CKD stage 4 or 5 due to the potential risk of compromise of future, ipsilateral arterio-venous dialysis access (1D)

— temporary access should be changed at appropriate intervals as per local infection control policies (1C)

— dialysis catheters should be reserved for extracorporeal treatment, only, to reduce the risk of catheter-related infections (1D)

— antimicrobial locking solutions should be used routinely to reduce the risk of catheter related bloodstream infections in adults (1C)

We suggest that:

— antimicrobial locking solutions should be used routinely to reduce the risk of catheter related bloodstream infections in children and young people (2D)

— non-dominant arm upper limb vasculature should be preserved in patients with AKI on the background of CKD as a contingency for future permanent arterio-venous dialysis access (2C)

Guideline 9.4 — Anticoagulation for extracorporeal therapies

We recommend that:

— anticoagulation for RRT should be tailored to the patient’s characteristics and the chosen modality of RRT (1B)

— for anticoagulation in CRRT, regional citrate anticoagulation should be the first line choice. When citrate is contraindicated or not available, unfractionated heparin or epoprostenol should be considered (1B)

— for anticoagulation in acute intermittent RRT, unfractionated heparin or low molecular weight heparin should be used as the first line anticoagulant (1C)

We suggest that:

— in case of contraindications to citrate, heparin or epoprostenol, a no-anticoagulation or saline flush strategy may be considered in patients receiving continuous or intermittent RRT (2C)

Guideline 9.5 — Renal replacement therapy prescription

We recommend that:

— the dose of acute extracorporeal RRT should be prescribed and adjusted at each session (for intermittent haemodialysis or hybrid therapies such as SLED — sustained low efficiency dialysis) and daily (for continuous RRT). The prescription should take into account the patient’s current and predicted metabolic and fluid needs and any measured shortfalls in delivered dose (1A)

— patients with AKI treated by CRRT should receive treatment doses equivalent to post dilution ultrafiltration rates of 25 ml/kg/hr. (1A) A proportionate upward adjustment to the prescribed ultrafiltration rate should be made when pre-dilutional haemofiltration is employed

— patients with AKI treated by intermittent RTT (intermittent haemodialysis or a hybrid therapy) should receive treatment with at least the minimum dose considered appropriate for end-stage renal disease, assuming a thrice weekly schedule: urea reduction ratio (URR) ≥ 65 % or single pool (sp)Kt/V ≥ 1.2 per session. (1B) In practice, this will require targeting a higher dose (URR ≥ 70 % or spKt/V ≥ 1.3 per session) to accommodate prescription-delivery shortfalls

— consideration should be given to the risk of dialysis disequilibrium syndrome in patients initiating intermittent haemodialysis with a high serum urea and that a lower intensity first dialysis should be prescribed for patients at risk. (1B) We suggest that a urea > 30 mmol/L would be a reasonable threshold to consider these measures (2C)

We suggest that:

— renal replacement therapy dosing methods that require an assessment of patient weight should use a measured weight rather than an extrapolated weight from pre-morbid readings (2B)

Guideline 9.6 — Timing of initiation of renal replacement therapy

We recommend that:

— the decision to start RRT in patients with AKI should be based on fluid, electrolyte and metabolic status of each individual patient. It should be started before the onset of life threatening complications of AKI unless a decision has been made that escalation of therapy is not appropriate (1C)

— initiation of RRT may be deferred if the underlying clinical condition is improving, there are early signs of renal recovery and the metabolic and fluid demands of the patient are met (1D)

— an improvement in the patient’s clinical condition and urine output and correction of the fluid state would justify temporary discontinuation of ongoing renal support to explore if AKI is recovering (1D)

10. Discharge planning

Guideline 10.1 — Adults and Paediatrics

We recommend that:

— the discharge summary should include a record of AKI detected whilst in hospital, its maximum stage, aetiology, the need for renal support (temporary/ongoing), and discharge renal function, if dialysis-independent (1D)

— the discharge summary should include specific recommendations on the need for immediate, post-discharge monitoring of renal function, advice on drug therapy that may have been implicated in the episode (e.g. avoidance, scope for re-introduction, future sick day guidance), and information offered to the patient, relatives and/or carers (1D)

— the discharge summary should link to relevant local guidelines, advise on the need for documentation of the AKI in the primary care record and note the need for registration on the primary care CKD register if residual CKD exists at the time of discharge (1D);

— formal post-discharge nephrology review should be arranged (1C):

- within 90 days for those with residual CKD stage G4 at hospital discharge

- within 30 days for those with residual CKD stage G5 (non-dialysis-requiring) at hospital discharge

- within 30 days for those with ongoing dialysis requirements at the time of hospital discharge.

Переклад: проф. Д. Іванов, І. Кучма

Науковий редактор перекладу: акад. НАМН України проф. Л.А. Пиріг



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