Acute Kidney Injury: Diagnosis and Management
Am Fam Physician. 2019 Dec 1;100(11):687-694.
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Article Sections
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
SORT: KEY RECOMMENDATIONS FOR PRACTICE
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 |
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