Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017

Abstract

BackgroundAcute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity.ObjectivesTo determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles.MethodA systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system.ResultsWe formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65–70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely.ConclusionThe results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-017-4832-y) contains supplementary material, which is available to authorized users.

Preoperative right heart hemodynamics predict postoperative acute kidney injury after heart transplantation

“…Recognition of post-HTx CRS may provide possibilities of prevention and treatment strategies in the settings of HTx. Importantly, early prediction of postoperative AKI based on preoperative RAP and PAPi could help to timely and more proactively intervene in the patients who are at high risk, in terms of giving more attention to the perioperative volume overload, postponing the introduction of nephrotoxic CNI, prolonging the support of the right ventricle with inotropes, no ventilation, and early introduction of pulmonary vasodilators (e.g., sildenafil) [11, 27, 30–33]. Furthermore, these patients could possibly benefit from functional kidney stress tests to assess the renal functional reserve and identify patients who will progress to AKI post-HTx [34, 35].…”

Clinical examination findings as predictors of acute kidney injury in critically ill patients

“…Early detection and possible prevention of further kidney injury is of utmost importance to limit its consequences as still no treatment for AKI exists . Clinical examination consists of readily available signs, can be performed by anyone after training and could assist in early detection of AKI.…”

Lunge-Nieren-Interaktionen bei kritisch Kranken

“…Hinweisend sind unter anderem ein erhöhter zentralvenöser Druck (ZVD) sowie bilaterale pulmonale Infiltrate erkennbar in der Röntgenuntersuchung der Lungen [13,29]. Eine Flüssigkeitsüberladung, insbesondere bei Patienten mit AKI, muss deshalb vermieden werden [6,32] [13,29].…”

“…den, dass unter mechanischen Beatmung, sowohl invasiv als auch nichtinvasiv, in der klinischen Routine ohnehin auf ein möglichst lungenprotektives Vorgehen geachtet werden soll. In Bezug auf das Volumenmanagement sei nochmal darauf hingewiesen, dass insbesondere bei ARDS-Patienten eine Überwässerung zu vermeiden ist[6,49]. Open access funding provided by University of Innsbruck and Medical University of Innsbruck.…”