Issues of Acute Kidney Injury Staging and Management in Sepsis and Critical Illness: A Narrative Review

Abstract

Acute kidney injury (AKI) has a high incidence on intensive care units around the world and is a major complication in critically ill patients suffering from sepsis or septic shock. The short- and long-term complications are thereby devastating and impair the quality of life. Especially in terms of AKI staging, the determination of kidney function and the timing of dialytic AKI management outside of life-threatening indications are ongoing matters of debate. Despite several studies, a major problem remains in distinguishing between beneficial and unnecessary "early" or even harmful renal replacement therapy (RRT). The latter might prolong disease course and renal recovery. AKI scores, however, provide an insufficient outcome-predicting ability and the related estimation of kidney function via serum creatinine or blood urea nitrogen (BUN)/urea is not reliable in AKI and critical illness. Kidney independent alterations of creatinine- and BUN/urea-levels further complicate the situation. This review critically assesses the current AKI staging, issues and pitfalls of the determination of kidney function and RRT timing, as well as the potential harm reflected by unnecessary RRT. A better understanding is mandatory to improve future study designs and avoid unnecessary RRT for higher patient safety and lower health care costs.

Keywords: acute kidney injury; biomarkers; disease staging; glomerular filtration rate; renal replacement therapy; timing.

Figure 1

Algorithm for the initiation of renal replacement therapy (“Heidelberg Standard”) [74,75]. AKI, Acute kidney injury; BUN, Blood urea nitrogen; FO, Fluid overload; FiO₂, Fractional inspired oxygen; K⁺, Potassium; O₂, Oxygen; RRT, Renal replacement therapy. ^a Unexplained decline in mental status, nausea, vomiting, bleedings due to thrombocytophatia, pericarditis, pruritus. ^b RRT might be beneficial despite unstable hemodynamics, especially in cardiac decompensation or critical O₂ demand. An individual risk-benefit analysis is mandatory.