Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference

Abstract

In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.

Keywords: acute kidney disease; acute kidney injury; fluid management; nephrotoxicity; renal replacement therapy; risk stratification.

Figure 1 |. Schematic for acute kidney injury/acute kidney diseases and disorders (AKI/AKD) follow-up.

The figure displays a potential paradigm for the care of patients who experience AKI/AKD. The degree of nephrology-based follow-up increases as the duration and severity of AKI/AKD increases. The timing and nature of follow-up are suggestions, as there are limited data to inform this process. Future research efforts should work to clarify the timing of AKI/AKD follow-up and which specific healthcare providers should provide it. The items in each bucket follow the “OR” rule; therefore, each patient should follow the most-severe bucket even if they meet only 1 criterion in that bucket. For example, a patient with CKD G4, regardless of severity of AKI, should be followed by a nephrologist in 1 week. AKI stage 3D, AKI stage 3 treated by dialysis; CKD, chronic kidney disease; CV, cardiovascular; dx, diagnosis; KAMPS, kidney function–advocacy–medications–pressure–sick day protocol; SCr, serum creatinine; UA, urine analysis; WATCH-ME, weight assessment–access–teaching–clearance–hypotension–medications. Reproduced with permission under a Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0) from Acute Dialysis Quality Initiative. Quality improvement goals for acute kidney injury; ADQI XXII. Available at: https://www.adqi.org/Images_Charts-Call.htm. Accessed June 14, 2020.

Figure 2 |. Classifying drugs that potentially cause acute kidney injury.

Iterative classification of agents that have potential to cause kidney dysfunction or kidney injury or both. Functional and injury biomarkers have a role in distinguishing among the different pathophysiological processes. Examples of deleterious risk modifiers are duration of therapy, drug burden, hypotension, and pharmacokinetic/pharmacodynamic interactions. Examples of interventions to mitigate risk are daily dynamic prescribing, kidney monitoring, and patient and provider education. Susceptibility factors include those listed in the 2012 Kidney Disease: Improving Global Outcomes Acute Kidney Injury guideline: dehydration or volume depletion; advanced age; female gender; black race; chronic kidney disease; chronic diseases of the heart, lung, or liver; diabetes mellitus; cancer; and anemia. Any final impact depends on underlying susceptibility, associated risk factors, clinical context, drug management, and modifying factors. Examples of drugs that correspond to the relevant categories above include trimethoprim, cimetidine (neither dysfunction nor injury); angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers (dysfunction without injury); aminoglycoside, acyclovir, vascular endothelial growth factor antagonists (injury without dysfunction); and nonsteroidal anti-inflammatory drugs (dysfunction and injury).

Figure 3 |

Schematic diagram of renal replacement therapy (RRT) decisions in acute kidney injury (AKI).