Contrast-induced acute kidney injury and renal support for acute kidney injury: a KDIGO summary (Part 2)

Abstract

Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever international multidisciplinary clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. Two topics, contrast-induced AKI and management of renal replacement therapy, deserve special attention because of the frequency in which they are encountered and the availability of evidence. Recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided. This review is an abridged version of the guideline and provides additional rationale and commentary for those recommendation statements that most directly impact the practice of critical care.

Serum creatinine role in predicting outcome after cardiac surgery beyond acute kidney injury

“…However, avoidance of AKI by preventive measures remains the mainstay of management in high risk patients. Contrast induced AKI is probably an exception in that it is preventable and manageable by hydration, N-acetyl cysteine and bicarbonate [148] . Renoprotective measures include preventive simple maneuvers such as avoidance of nephrotoxic drugs, hydration, glycemic control, maintenance of renal perfusion and goal directed therapy (GDT), as well as more advanced pharmacological interventions [1,2,70,71] (Table 3).…”

“…Most studies have found lower mortality with the earlier initiation of RRT [163,186,187] . In addition, recent guidelines suggest that using continuous RRT is superior to standard intermittent RRT in hemodynamically unstable patients [148] . It is clinically indicated and applicable, although reviews to date have not found differences in survival between the two modes [188] .…”

Estudio epidemiológico prospectivo sobre la nefropatía por contraste en pacientes críticos

“…Aunque hay diversos estudios publicados, con resultados dispares, basándose en la evidencia de los meta-análisis más recientes, que comparan la incidencia de NAC tras la administración de contraste iso-osmolar versus hipo-osmolar, el grupo KDIGO (Kidney Disease: Improving Global Outcomes) recomienda utilizar en pacientes con riesgo alto de desarrollar NAC, tanto el contraste iso como el hipo-osmolar, en contra del hiperosmolar (46) .…”

“…Tabla 3. Estrategias evaluadas para disminuir el riesgo de NAC (28) En las guías KDIGO (46) se establece que el riesgo de NAC es clínicamente importante cuando la creatinina plasmática basal es ≥ 1,3 mg/dl en varones, y ≥ 1,0 mg/dl en mujeres, equivalente a un filtrado glomerular estimado de < 60 ml/minuto por 1.73 m 2 (82) . Aunque otros autores (83) mostraron que la incidencia de Insuficiencia renal aguda era significativa sólo cuando la concentración de creatinina basal era > 1.8 mg/dl, se recomienda realizar medidas preventivas cuando el FG estimado sea < 60 ml/min por 1.73 m 2 .…”

“…La gran mayoría de las series publicadas en la literatura que estudian esta entidad, son series que incluyen un perfil único de paciente, sobre todo pacientes cardiacos (22,26,28,(46)(47)(48)(49)(50)(66)(67)(68)(114)(115)(116) , donde la administración de contraste se realiza para intervencionismo coronario percutáneo. Al analizar estudios llevados a cabo con pacientes críticos, la regla general suele ser también focalizar sobre un único perfil de paciente, médicos (80) o quirúrgicos (73) , en los que la exploración con contraste analizada es el TAC.…”