Evidence-based guideline for AKI staging, prevention, conservative management, renal replacement therapy modalities, CRRT prescription, and special populations in the critically ill.
A comprehensive, evidence-based clinical guideline for the definition, staging, prevention, conservative management, and renal replacement therapy of acute kidney injury in critically ill adults. This resource synthesizes recommendations from the major international nephrology and critical care professional societies, expert consensus panels, and landmark randomized controlled trials into a single integrated reference for intensivists, nephrologists, hospitalists, ICU nurses, and advanced practice providers managing patients with AKI in the intensive care unit.1 2 3 4 5 6 7
Acute kidney injury affects approximately 50-60% of critically ill patients and is independently associated with increased morbidity, mortality, length of stay, and long-term risk of chronic kidney disease. AKI requiring renal replacement therapy occurs in approximately 5-10% of ICU admissions and carries a hospital mortality exceeding 40-50%. Early recognition using standardized staging criteria, prevention through nephrotoxin avoidance and hemodynamic optimization, appropriate conservative management of complications, and evidence-based initiation and prescription of renal replacement therapy are the cornerstones of AKI management in critical care.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Definition, Staging & Epidemiology | KDIGO AKI definition and staging criteria (complete table); RIFLE and AKIN criteria with historical comparison; novel biomarkers (NGAL, KIM-1, TIMP-2-IGFBP7/NephroCheck); subclinical AKI concept; ICU epidemiology; outcomes by stage; long-term renal outcomes |
| Part 2 | Etiology, Diagnostic Workup & Prevention | Pre-renal, intrinsic, and post-renal causes; pathophysiology of ischemic and nephrotoxic ATN; diagnostic workup (urinalysis, microscopy, FENa, FEUrea, renal ultrasound); differential diagnosis; prevention strategies (volume optimization, nephrotoxin avoidance, contrast-associated AKI evidence, hemodynamic targets, glycemic control); drug dose adjustment table |
| Part 3 | Conservative Management of AKI Complications | Fluid management and volume assessment; hyperkalemia emergency management algorithm (calcium, insulin/dextrose, albuterol, sodium zirconium cyclosilicate/patiromer dosing); metabolic acidosis; hyponatremia; diuretic therapy and furosemide stress test; drug dosing in AKI; nutritional considerations |
| Part 4 | Renal Replacement Therapy: Modalities, Timing & Prescription | RRT modalities comparison (IHD, CRRT, SLED/PIRRT); indications and timing (STARRT-AKI, AKIKI, IDEAL-ICU, ELAIN trial results); CRRT prescription (dose, dialysate, blood flow, filter selection); anticoagulation protocols (citrate, heparin); vascular access; CRRT troubleshooting; IHD prescription; RRT discontinuation criteria |
| Part 5 | Special Populations & Long-Term Outcomes | Sepsis-associated AKI; cardiac surgery-associated AKI; contrast-associated AKI; hepatorenal syndrome (terlipressin, albumin); rhabdomyolysis-induced AKI; tumor lysis syndrome; AKI in pregnancy; long-term outcomes and CKD progression; nephrology referral criteria; quality metrics |
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. “KDIGO Clinical Practice Guideline for Acute Kidney Injury.” Kidney Int Suppl. 2012;2(1):1-138. DOI: 10.1038/kisup.2012.1 ↩︎
Ostermann M, Bellomo R, Burdmann EA, et al. “Controversies in Acute Kidney Injury: Conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference.” Kidney Int. 2020;98(2):294-309. DOI: 10.1016/j.kint.2020.04.020 ↩︎
Bagshaw SM, Wald R, Adhikari NKJ, et al. “Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury (STARRT-AKI).” N Engl J Med. 2020;383(3):240-251. DOI: 10.1056/NEJMoa2000741 ↩︎
Gaudry S, Hajage D, Schortgen F, et al. “Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit (AKIKI).” N Engl J Med. 2016;375(2):122-133. DOI: 10.1056/NEJMoa1603017 ↩︎
Kellum JA, Lameire N; KDIGO AKI Guideline Work Group. “Diagnosis, Evaluation, and Management of Acute Kidney Injury: A KDIGO Summary (Part 1).” Crit Care. 2013;17(1):204. DOI: 10.1186/cc11454 ↩︎
Barbar SD, Clere-Jehl R, Bourredjem A, et al. “Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis (IDEAL-ICU).” N Engl J Med. 2018;379(15):1431-1442. DOI: 10.1056/NEJMoa1803213 ↩︎
Zarbock A, Kellum JA, Schmidt C, et al. “Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial.” JAMA. 2016;315(20):2190-2199. DOI: 10.1001/jama.2016.5828 ↩︎
Sepsis-associated AKI, cardiac surgery-associated AKI, contrast-associated AKI, hepatorenal syndrome, rhabdomyolysis, tumor lysis syndrome, AKI in pregnancy, long-term outcomes, CKD progression, nephrology referral criteria, and quality metrics.
RRT modalities comparison (IHD, CRRT, SLED/PIRRT), timing evidence (STARRT-AKI, AKIKI, IDEAL-ICU, ELAIN), CRRT prescription and dose, citrate and heparin anticoagulation protocols, vascular access, troubleshooting, and discontinuation criteria.
Fluid management, hyperkalemia emergency algorithm, electrolyte and acid-base management, diuretic therapy including furosemide stress test, drug dosing in AKI, and nutritional considerations.
Pre-renal, intrinsic, and post-renal AKI causes; diagnostic workup including urinalysis, FENa, FEUrea, and imaging; prevention strategies; nephrotoxin avoidance; contrast-associated AKI evidence; drug dose adjustment table.
KDIGO AKI definition and staging criteria, RIFLE and AKIN historical comparison, novel biomarkers (NGAL, KIM-1, NephroCheck), subclinical AKI, ICU epidemiology, and outcomes by stage.