Acute Kidney Injury: Diagnosis and Management

Michael G. Mercado; Dustin K. Smith; Esther Guard

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Dec 1, 2019 Issue

Acute Kidney Injury: Diagnosis and Management

MICHAEL G. MERCADO, MD, Naval Hospital Bremerton, Bremerton, Washington

DUSTIN K. SMITH, DO, Branch Health Clinic, Diego Garcia, British Indian Ocean Territory

ESTHER L. GUARD, DO, Eglin Family Medicine Residency, Eglin Air Force Base, Florida

Am Fam Physician. 2019 Dec 1;100(11):687-694.

Author disclosure: No relevant financial affiliations.

Acute kidney injury is a clinical syndrome characterized by a rapid decline in glomerular filtration rate and resultant accumulation of metabolic waste products. Acute kidney injury is associated with an increased risk of mortality, cardiovascular events, and progression to chronic kidney disease. Severity of acute kidney injury is classified according to urine output and elevations in creatinine level. Etiologies of acute kidney injury are categorized as prerenal, intrinsic renal, and postrenal. Accurate diagnosis of the underlying cause is key to successful management and includes a focused history and physical examination, serum and urine electrolyte measurements, and renal ultrasonography when risk factors for a postrenal cause are present (e.g., older male with prostatic hypertrophy). General management principles for acute kidney injury include determination of volume status, fluid resuscitation with isotonic crystalloid, treatment of volume overload with diuretics, discontinuation of nephrotoxic medications, and adjustment of prescribed drugs according to renal function. Additional supportive care measures may include optimizing nutritional status and glycemic control. Pharmacist-led quality-improvement programs reduce nephrotoxic exposures and rates of acute kidney injury in the hospital setting. Acute kidney injury care bundles are associated with improved in-hospital mortality rates and reduced risk of progression. Nephrology consultation should be considered when there is inadequate response to supportive treatment and for acute kidney injury without a clear cause, stage 3 or higher acute kidney injury, preexisting stage 4 or higher chronic kidney disease, renal replacement therapy, and other situations requiring subspecialist expertise.

Acute kidney injury is defined as the sudden loss of kidney function over hours to days resulting in the inability to maintain electrolyte, acid-base, and water balance. Because of an aging population and increasing prevalence of hypertension and diabetes mellitus, from 2005 to 2014, the number of hospitalizations with a principal diagnosis of acute kidney injury increased from 281,500 to 504,600, and the number of hospitalizations with a secondary diagnosis of acute kidney injury increased from 1 million to 2.3 million.1 Patients with acute kidney injury requiring renal dialysis and other forms of renal replacement therapy are 50 times more likely to progress to chronic kidney disease than those not requiring renal replacement therapy.2 Risk factors for acute kidney injury are listed in Table 1.3–6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Isotonic crystalloids are preferred over colloids when fluid resuscitation is indicated in patients with acute kidney injury.^7,27,28	C	Consistent evidence from RCTs showing no clear renal or mortality benefit of colloids over isotonic crystalloids
Balanced crystalloids are preferred over 0.9% sodium chloride for fluid resuscitation in critically ill and non–critically ill patients.^30–32	B	Evidence from cohort studies and a limited number of RCTs showing improved mortality and decreased need for renal replacement therapy
Pharmacist-led quality improvement initiatives, multimodal educational programs delivered to clinicians, and care bundles may improve acute kidney injury care.^34,41,42	B	Evidence from a limited number of cohort studies showing improvements in hospital mortality and acute kidney injury progression
There is no difference in 90-day mortality between early initiation of renal replacement therapy and delayed initiation.³⁸	B	Evidence from a limited number of RCTs
High-dose statins lower the risk of contrast media–induced acute kidney injury in patients undergoing coronary angiography or percutaneous intervention compared with low-dose statins.⁵¹	A	Consistent evidence from multiple RCTs and meta-analysis

RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Isotonic crystalloids are preferred over colloids when fluid resuscitation is indicated in patients with acute kidney injury.^7,27,28	C	Consistent evidence from RCTs showing no clear renal or mortality benefit of colloids over isotonic crystalloids
Balanced crystalloids are preferred over 0.9% sodium chloride for fluid resuscitation in critically ill and non–critically ill patients.^30–32	B	Evidence from cohort studies and a limited number of RCTs showing improved mortality and decreased need for renal replacement therapy
Pharmacist-led quality improvement initiatives,

The Authors

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MICHAEL G. MERCADO, MD, FAAFP, is director of medical services at the Naval Hospital in Bremerton, Wash., and is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

DUSTIN K. SMITH, DO, FAAFP, is senior medical officer for the U.S. Naval Hospital in Yokosuka, Japan, stationed at Branch Health Clinic, Diego Garcia, British Indian Ocean Territory. He is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

ESTHER L. GUARD, DO, FAAFP, is a faculty member at the Eglin Family Medicine Residency, Eglin Air Force Base, Fla., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Michael G. Mercado, MD, FAAFP, Naval Hospital Bremerton, 1 Boone Rd., Bremerton, WA 98312 (email: michael.mercado.md@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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