Acute Kidney Injury: Pearls and Pitfalls

Patients meeting the KDIGO definition for AKI typically require admission to the hospital (if etiology is identified/addressed and close follow-up established then reliable patients can be discharged – shared decision-making). Since there are various causes of AKI, simultaneous attempts should be made to treat the direct and indirect causes of AKI. As such, for all pre-renal causes of AKI, IV fluid resuscitation should not be delayed.

 CRACKCast E097 – Renal Failure

This chapter covers an approach to acute and chronic kidney injuries, including causes, complications and treatments.

EMCrit Project

AKI is a powerful predictor of mortality.

Acute Kidney Injury – A Simple Emergency Approach to AKI

The 2012 Kidney Disease – Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury (AKI) [1] defines AKI by any of the following: Increase in serum creatinine by ≥0.3 mg/dL (>26.5 μmol/L) within 48 hours; or Increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within prior 7 days; or Urine volume <0.5 mL/kg/h for 6 hours.

Acute Renal Failure Management

Contrary to “popular belief”, troponin elevation in patients with renal failure is NOT due to reduced troponin clearance.

Acute-on-chronic kidney disease: prevention, diagnosis, management and referral in primary care

Acute kidney injury (in a community setting) occurs most commonly in people with existing chronic kidney disease.

AKI (for nephrologists)

This section covers general management of acute renal failure only.

Contrast-Induced Nephropathy: Confounding Causation

The history of the study of CIN is just another example of evidence-based medicine successfully applied to the debunking of a common belief in a clinical syndrome. As ED physicians are faced with the challenge of rapidly diagnosing life-threatening conditions (i.e. aortic dissection/aneurysmal rupture, pulmonary embolism, occlusion or aneurysmal rupture of cerebral vessels, traumatic vascular injury), we should not delay emergent contrast-enhanced CT scans waiting for SCr.

Effect of No Prehydration vs Sodium Bicarbonate Prehydration Prior to Contrast-Enhanced Computed Tomography in the Prevention of Postcontrast Acute Kidney Injury in Adults With Chronic Kidney Disease: The Kompas Randomized Clinical Trial

Among patients with stage 3 CKD undergoing contrast-enhanced computed tomography, withholding prehydration did not compromise patient safety. The findings of this study support the option of not giving prehydration as a safe and cost-efficient measure.

EM@3AM – Acute Kidney Injury

Urine microscopic examination often facilitates diagnosis in patients with an AKI secondary to intrinsic renal pathology: granular casts = ATN, red blood cell casts = glomerulonephritis, white blood cell casts = AIN.

Evaluation and Management of Acute Kidney Injury Emergencies

The presentation and severity of AKI is variable. AKI, with severe life-threatening laboratory abnormalities, may present with multi-organ failure or with vague/minimal clinical findings.

IV Contrast, Unleashed

“The putative risk of administering modern intravenous iodinated contrast media in patients with reduced kidney function has been overstated.”

There's just been AKI. So what do we do with the ACEi/ARB?

However, in recent years there has been growing concern about their potential for ‘nephrotoxicity’. They are widely believed to be associated with AKI, particularly in patients who are hypovolaemic or septic.