Prevention of acute kidney injury and protection of renal function in the intensive care unit: Expert opinion of the working group for nephrology, ESICM

• Published in: Intensive care medicine 2010-03, Vol.36 (3), p.392-411
• Main Authors: Joannidis, Michael, Druml, Wilfred, Forni, Lui G., Groeneveld, A. B. Johan, Honore, Patrick, Oudemans-van Straaten, Heleen M., Ronco, Claudio, Schetz, Marie R. C., Woittiez, Arend Jan
• Format: Article
• Language: English
• Subjects: Acute Kidney Injury - drug therapy; Acute Kidney Injury - metabolism; Acute Kidney Injury - physiopathology; Acute Kidney Injury - prevention & control; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthesiology; Biological and medical sciences; Cardiotonic Agents - administration & dosage; Cardiotonic Agents - therapeutic use; Clinical death. Palliative care. Organ gift and preservation; Clinical medicine; Clinical Trials as Topic; Combined Modality Therapy; Consensus; Creatinine; Critical Care Medicine; Diuretics; Emergency Medicine; Emergency procedures; Expert Panel; Extracorporeal Circulation; Fluid Therapy; Hemodynamics; Hospitals; Humans; Hypertension; Illnesses; Intensive; Intensive care; Intensive care medicine; Intensive Care Units; Internal medicine; Intervention; Kidneys; Medical sciences; Medicine; Medicine & Public Health; Mortality; Nephrology; Nutrition; Pain Medicine; Patients; Pediatrics; Pneumology/Respiratory System; Prevention; Protein C Inhibitor - administration & dosage; Protein C Inhibitor - therapeutic use; Renal replacement therapy; Sepsis; Sodium Potassium Chloride Symporter Inhibitors - therapeutic use; Surgery; Vasodilator Agents - administration & dosage; Vasodilator Agents - therapeutic use; Working groups
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-009-1678-y

Background Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. Objectives To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. Method A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system Conclusions and recommendations Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest using vasopressors in vasodilatory hypotension, specific vasodilators under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention.