What are the guideline sources, guidelines and references for Acute kidney injury ?
Guideline sources The following summarized guidelines for the evaluation and management of acute kidney injury (AKD) are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2023; 2021), the American Society for Extracorporeal Technology (AmSECT/STS/SCA 2022), the Canadian Association of Radiologists (CAR 2022), the European Society of Cardiology (ESC 2021), the National Institutes of Health (NIH 2021), the Acute Disease Quality Initiative (ADQI 2020; 2017), the United Kingdom Kidney Association (UKKA 2019), the Japanese Society of Blood Purification in Critical Care (JSBPCC/JSPN/JSDT/JSICM/JSN 2018), the European Society for Vascular Surgery (ESVS 2017), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2012), the European Renal Best Practice Foundation (ERBP 2012), the European Society of Intensive Care Medicine (ESICM 2010), and the American Society for Parenteral and Enteral Nutrition (ASPEN 2010). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 17 18 18 19 20 21 Definition https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 1/19 6/23/23, 1:57 AM Acute kidney injury Pathway AKD is a sudden decrease in kidney function resulting from structural or functional injury that is characterized by decreased GFR, increased serum creatinine, and oliguria. 18 Epidemiology AKD has multiple possible causes, including renal hypoperfusion, intrinsic renal dysfunction (glomerulonephritis, vasculitis, tubular necrosis, interstitial nephritis), or obstruction to the emptying of the kidneys (post-renal AKD). 20 Pathophysiology The incidence of AKD in the United States is estimated at 179-317 cases per 100,000 person-years. 19 Disease course Hypoperfusion of the kidneys with resultant ischemic injury represents the most important group of etiologies, mediating AKD through cellular injury caused by a mismatch between oxygen and nutrient delivery to the nephrons. 18 Prognosis and risk of recurrence Approximately 40% of patients with AKD do not recover renal function by hospital discharge. In this group of patients, AKD is associated with 1-year age-adjusted mortality of approximately 60%, compared to approximately 10% in patients who recovered renal function within 7 days. 21 Calculator Calculator Calculator AKIN classification for acute kid Diagnostic criteria for acute kidn Licurse sc Guidelines 1. Screening and diagnosis Diagnostic criteria: As per ERBP 2012 guidelines, diagnose and stage the severity of AKI as follows (meeting any of the criteria): Situation Guidance Serum creatinine increase 1.5-1.9 times baseline Stage 1 https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 2/19 6/23/23, 1:57 AM Acute kidney injury Pathway Serum creatinine increase > 0.3 mg/dL (26.5 mcmol/L) Urinary output < 0.5 mL/kg/hour during a 6 hour block Serum creatinine increase 2.0-2.9 times baseline Stage 2 Urinary output < 0.5 mL/kg/hour during two 6 hour block Serum creatinine increase > 3 times baseline Stage 3 Serum creatinine increase > 4.0 mg/dL (353 mcmol/L) Initiation of RRT Urinary output < 0.3 mL/kg/hour during > 24 hours Anuria for > 12 hours. As per KDIGO 2012 guidelines, diagnose AKI in patients meeting any of the following criteria: increase in serum creatinine by 0.3 mg/dL (26.5 mcmol/L) within 48 hours increase in serum creatinine to 1.5 times baseline, known or presumed to have occurred within the prior 7 days urine volume of 0.5 mL/kg/hour for 6 hours. Definitions: As per ADQI 2017 guidelines, define persistent AKI as an AKI (by serum creatinine or urine output criteria) lasting > 48 hours from onset. B Show 4 more As per ERBP 2012 guidelines, use a uniform definition of AKI based on urinary output and on changes in serum creatinine level. B Differential diagnosis: suspect RPGN when a patient with no obvious cause of progressive or non-resolving AKI has urine dipstick results showing hematuria and proteinuria, without UTI or trauma due to catheterization. B 2. Classification and risk stratification Risk assessment: As per ADQI 2020 guidelines, avoid using biomarkers of acute damage before a kidney injury for the assessment of AKI risk. D Show 6 more https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 3/19 6/23/23, 1:57 AM Acute kidney injury Pathway As per UKKA 2019 guidelines, identify patients at risk of AKI by the most appropriate risk factor profile for that population or, where no specific risk factor profile exists, through clinical judgment and recognition of generic risk factors for AKI. B As per JSN 2018 guidelines, consider involving the urine output whenever possible for AKI staging for better reflection of the survival outcomes and the renal outcomes. C Show 4 more As per ERBP 2012 guidelines, stratify patients for risk of AKI according to their susceptibilities, especially preexisting proteinuria and CKD, and exposures to nephrotoxic medication or interventions. B 3. Diagnostic investigations Baseline renal function testing: As per JSN 2018 guidelines, assess the baseline renal function using multiple methods whenever possible. B As per ERBP 2012 guidelines: Use the first documented serum creatinine value of the episode as 'baseline' rather than historical creatinine values or a calculated value based on a presumed GFR of 75 mL/min. B Consider using 'shift-based' calculation of the urinary output criteria, especially in patients without a bladder catheter. C Use the ideal weight rather than the true weight in calculating the diuresis in mL/min/kg. As per KDIGO 2012 guidelines, test patients at increased risk for AKI with serum creatinine measurements and urine output to detect AKI. Urinalysis: obtain urine dipstick testing for blood, protein, leukocytes, nitrites, and glucose in all patients as soon as AKI is suspected or detected unless already obtained. Document the results and take appropriate measures if abnormal. B Renal ultrasound: As per ACR 2021 guidelines, obtain renal ultrasound as initial imaging of unspecified AKI to detect hydronephrosis and evaluate renal size and morphology. B As per UKKA 2019 guidelines, obtain a renal tract ultrasound in all patients with AKI within 24 hours (unless a clear cause of AKI is apparent or AKI is improving) or within 6 hours if pyonephrosis is suspected or there is a high index of suspicion for urinary tract obstruction. B Novel biomarkers: As per ADQI 2020 guidelines, consider obtaining a combination of damage and functional biomarkers along with clinical information to improve the diagnostic accuracy of AKI, recognize the different pathophysiological processes, discriminate AKI etiology, and assess AKI severity. C As per JSN 2018 guidelines: https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 4/19 6/23/23, 1:57 AM Acute kidney injury Pathway Consider obtaining urinary neutrophil gelatinase-associated lipocalin and liver-type fatty acid- binding protein for early diagnosis of AKI. C Consider obtaining urinary neutrophil gelatinase-associated lipocalin for the differentiation of pre-renal AKI from renal AKI. C Evaluation for etiology: As per UKKA 2019 guidelines: Elicit appropriate history and perform a physical examination to help determine the cause of the episode of acute injury. B Determine and document the cause or presumed causes of AKI wherever possible. B As per JSN 2018 guidelines: Obtain evaluation to determine the cause of AKI and eliminate the reversible factors. B Assess the potential presence of CKD and other comorbidities. B As per ADQI 2017 guidelines, evaluate patients with AKI for the underlying etiology. Consider obtaining a nephrology consultation if the etiology is not clear or subspecialty care is required. B As per ERBP 2012 guidelines, determine the cause of AKI whenever possible. Assess the presence of hypovolemia, post-renal causes, low cardiac output, use of nephrotoxic agents, acute glomerulonephritis, and renal microangiopathy as underlying contributors to AKI. As per KDIGO 2012 guidelines, evaluate all patients with AKI promptly to determine the cause, with special attention to reversible causes. Show 2 more 4. Medical management General principles: As per UKKA 2019 guidelines, obtain relevant assessment in patients at risk of AKI exposed to a significant renal insult, to ensure that exposure is limited and further insults are avoided or minimized. B Show 3 more As per ADQI 2017 guidelines, guide selection of drugs, dosing, and monitoring in patients with acute kidney disease by the functional phase, trajectory, and stage of acute kidney disease with the aim to personalize clinical decision-making. Individualize the decision to discontinue, introduce and/or reintroduce medications in patients with acute kidney disease. B Show 2 more Fluid resuscitation: consider administering isotonic crystalloids rather than colloids for expansion of intravascular volume in patients with AKI in the absence of hemorrhagic shock. C Vasopressors: administer vasopressors in conjunction with uids in patients with vasomotor shock with, or at risk for, AKI. B https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 5/19 6/23/23, 1:57 AM Acute kidney injury Pathway Management of hyperglycemia: consider administering insulin therapy targeting plasma glucose 6.1-8.3 mmol/L (110-149 mg/dL) in critically ill patients. C Therapies with no evidence for benefit: As per JSN 2018 guidelines: Avoid using loop diuretics for the treatment of AKI except to correct fluid overload. D Do not use low-dose dopamine for the treatment of AKI. D As per KDIGO 2012 guidelines, do not use low-dose dopamine D or recombinant human IGF- 1 for the treatment of AKI. D Show 2 more 5. Inpatient care Renal function monitoring, patients at risk for AKI: As per UKKA 2019 guidelines, obtain close monitoring for AKI in adult inpatients deemed at high risk of AKI, particularly if there has been a new exposure. Monitor urine output and measure serum creatinine daily until at least 48 hours after the period of increased risk has elapsed. B Show 2 more As per ERBP 2012 guidelines, obtain serial measurements of serum creatinine and urine output at frequencies and duration based on the patient's risk and clinical course, to detect AKI at an early stage in patients at increased risk for AKI. Renal function monitoring, patients with AKI: As per UKKA 2019 guidelines, obtain urea and electrolytes monitoring in adult hospital inpatients with newly diagnosed AKI, at a minimum frequency of once daily (unless more frequent testing is indicated, such for hyperkalemia management) until renal function has returned to baseline or has stabilized, and then regularly, thereafter, in order to detect progressive or recurrent AKI in a timely fashion. B Show 2 more As per ADQI 2017 guidelines: Obtain timed urine CrCl assessment to estimate the renal function in patients with persistent AKI in a stable condition. B Recognize that equations to estimate GFR are not accurate for the assessment of renal function in patients with persistent AKI in the setting of CKD. B As per KDIGO 2012 guidelines: Monitor patients with AKI with measurements of serum creatinine and urine output to stage the severity. Individualize the frequency and duration of monitoring based on patient risk and clinical course. Hemodynamic monitoring: https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 6/19 6/23/23, 1:57 AM Acute kidney injury Pathway As per UKKA 2019 guidelines, assess the physiological status of the patient promptly after identification of AKI or recognition of high risk for it. A Show 3 more As per ADQI 2017 guidelines, obtain additional monitoring in patients with persistent AKI to reevaluate hemodynamic and volume status, adequacy of kidney perfusion, and to identify complications of AKI, such as fluid overload, acidosis, and hyperkalemia, as these could indicate a need for RRT. B As per KDIGO 2012 guidelines, consider providing protocol-based management of hemodynamic and oxygenation parameters to prevent the development or worsening of AKI in high-risk patients in the perioperative setting or in patients with septic shock. C 6. Nonpharmacologic interventions Nutritional support: As per UKKA 2019 guidelines, refer patients with AKI receiving RRT to a dietitian for individual assessment. B As per JSN 2018 guidelines, consider tailoring nutritional support (calories, protein) in patients with AKI to the severity and the underlying disease. C Show 2 more As per KDIGO 2012 guidelines, consider aiming for a total energy intake of 20-30 kcal/kg/day in patients with any stage of AKI. C Show 3 more As per ASPEN 2010 guidelines, obtain formal nutritional assessment, including evaluation of inflammation, and develop a nutrition care plan in patients with renal disease. B Show 5 more 7. Therapeutic procedures Renal replacement therapy, indications: As per UKKA 2019 guidelines, consider initiating acute RRT in patients with progressive or severe AKI unless a decision has been made not to escalate therapy. B Show 4 more Updated evidence: STARRT-AKI In critically ill patients with severe AKI, an accelerated strategy was not superior to a standard strategy with respect to death from any cause at 90 days. STARRT-AKI Investigators et al. N Engl J Med. 2020 Jul 16. https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 7/19 6/23/23, 1:57 AM Acute kidney injury Pathway As per JSPN/JSBPCC/JSDT/JSICM/JSN 2018 guidelines: Decide on the timing of initiation of blood purification based on the clinical symptoms and disease conditions. B Consider using improvements in clinical condition and urine output to determine the timing of discontinuation of blood purification. C Landmark trials: IDEAL-ICU In patients with early-stage septic shock who had severe AKI at the failure stage of the risk, injury, failure, loss, and end-stage kidney disease classification system but without life- threatening complications related to AKI, an early strategy was not superior to a delayed strategy with respect to death at 90 days. Saber D Barbar et al. N Engl J Med. 2018 Oct 11. As per KDIGO 2012 guidelines, initiate RRT emergently when life-threatening changes in uid, electrolyte, and acid-base balance are present. Show 2 more Landmark trials: ATN In critically ill patients with AKI and failure of at least one nonrenal organ or sepsis, intensive RRT was not superior to less-intensive RRT with respect to death at 60 days. VA/NIH Acute Renal Failure Trial Network et al. N Engl J Med. 2008 Jul 3. Renal replacement therapy, choice of modality: As per UKKA 2019 guidelines, decide on the choice of modality based on the condition of the patient as a whole, the severity of the underlying disease, the degree of fluid overload and its impact on other organs, rather than on isolated creatinine or urea values. B Show 2 more As per JSPN/JSBPCC/JSDT/JSICM/JSN 2018 guidelines, consider performing blood purification either continuously or intermittently in hemodynamically stable patients. C Prefer continuous blood purification in hemodynamically unstable patients. C Landmark trials: Atan In patients in the ICU with AKI who were vasopressor-dependent, continuous venovenous hemofiltration-high cutoff was not superior to continuous venovenous hemofiltration-standard with respect to a norepinephrine-free time over 7 days. Rafidah Atan et al. Crit Care Med. 2018 Oct. https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 8/19 6/23/23, 1:57 AM Acute kidney injury Pathway As per KDIGO 2012 guidelines: Use continuous and intermittent replacement therapy as complementary therapies in patients with AKI. Consider using continuous RRT rather than standard intermittent RRT in hemodynamically unstable patients, in patients with acute brain injury or other causes of increased ICP or generalized brain edema. C Renal replacement therapy, dosing: As per UKKA 2019 guidelines, prescribe and adjust the dose of acute extracorporeal RRT at each session (for intermittent hemodialysis or hybrid therapies such as sustained low-efficiency dialysis) and daily (for continuous RRT) taking into account the patient's current and predicted metabolic and fluid needs and any measured shortfalls in delivered dose. A Show 4 more As per KDIGO 2012 guidelines, ensure that the dose of RRT to be delivered is before starting each session. Show 4 more Renal replacement therapy, insertion of dialysis catheter: As per UKKA 2019 guidelines, use venovenous access for acute RRT. A Show 4 more As per KDIGO 2012 guidelines, consider using an uncuffed non-tunneled dialysis catheter over a tunneled catheter for RRT in patients with AKI. C Show 5 more Renal replacement therapy, periprocedural anticoagulation: As per UKKA 2019 guidelines, tailor anticoagulation for RRT to the patient's characteristics and the chosen modality of RRT. B Show 3 more As per JSPN/JSBPCC/JSDT/JSICM/JSN 2018 guidelines: Consider administering nafamostat mesylate in patients with a high risk of bleeding. C Consider performing blood purification without the use of anticoagulants in patients with active bleeding. C As per KDIGO 2012 guidelines, individualize the decision to administer anticoagulation for RRT based on the assessment of the patient's potential risks and bene ts from anticoagulation. Show 7 more Renal replacement therapy, technical considerations: As per UKKA 2019 guidelines, ensure that fluids used for continuous or intermittent hemodialysis, hemofiltration, or hemodiafiltration in patients with AKI meet the microbial standards for fluids used for chronic hemodialysis. A As per KDIGO 2012 guidelines, consider using bicarbonate rather than lactate as a buffer in dialysate and replacement uid, C including in patients with liver failure and/or lactic acidemia. https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 9/19 6/23/23, 1:57 AM Acute kidney injury Pathway C Use bicarbonate rather than lactate as a buffer in dialysate and replacement uid in patients with circulatory shock. C Show 2 more Renal replacement therapy (evaluation of fistula malfunction): consider obtaining fluoroscopy fistulography or duplex ultrasound of the hemodialysis access in patients with suspected dysfunction of the upper or lower extremity hemodialysis access (arteriovenous fistula or graft), suggested by an abnormal clinical indicator or hemodynamic indicator (reduction in dialysis vascular access blood flow rate or kinetics). C Show 5 more Renal replacement therapy (management of fistula malfunction): guide interventional radiologic therapy by imaging. B Show 6 more 8. Specific circumstances Pediatric patients (diagnosis and evaluation): consider using the KDIGO diagnostic criteria for AKI to predict the survival outcomes in pediatric patients 3 months of age. C Show 3 more Pediatric patients (renal replacement therapy): Discuss the indications for RRT taking into account the patient's current status and survival prognosis. Explain the advantages and disadvantages of different treatment modalities to the patient's family, and consult with them about suitable therapeutic strategies. B Consider using an appropriate modality tailored to the patient's constitution and disease condition in pediatric patients with AKI requiring blood purification. C Pediatric patients (monitoring): obtain close monitoring for AKI in pediatric inpatients deemed at high risk of AKI, particularly if there has been a new exposure. Monitor urine output and measure serum creatinine regularly (reflecting the potential burden of venipuncture) until at least 48 hours after the period of increased risk has elapsed. B Show 3 more Patients with COVID-19-associated AKI (evaluation): stratify patients for risk of AKI based on their comorbidities and demographics. B Show 4 more Patients with COVID-19-associated AKI (general principles of management): follow published evidence-based guidelines on AKI for risk- and stage-based prevention and management of COVID-19-associated AKI. Show 2 more Patients with COVID-19-associated AKI (hemodynamic support): individualize fluid and hemodynamic management based on a dynamic assessment of cardiovascular status in critically ill patients with COVID-19. B Show 2 more https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 10/19 6/23/23, 1:57 AM Acute kidney injury Pathway Patients with COVID-19-associated AKI, renal replacement therapy: As per NIH 2021 guidelines: Use continuous RRT, if available, in critically ill patients with AKI developing indications for RRT. B Use prolonged intermittent RRT rather than intermittent hemodialysis if continuous RRT is not available or not possible due to limited resources. B As per ADQI 2020 guidelines, decide on the timing of RRT initiation, vascular access site, and modality of acute RRT based on patient needs, local expertise, and the availability of personnel and equipment. Show 7 more 9. Preventative measures Prevention of AKI in the ICU (fluid therapy): initiate controlled fluid resuscitation in true or suspected volume depletion. B Show 2 more Prevention of AKI in the ICU (vasopressors and inotropes): maintain mean arterial pressure 60-65 mmHg B attempting to individualize the target pressure where possible, especially if knowledge of the premorbid BP is available. Show 2 more Prevention of AKI in the ICU (vasodilators): consider administering vasodilators for renal protection when volume status is corrected and the patient is closely hemodynamically monitored with particular regard to the development of hypotension. C Show 2 more Prevention of AKI in the ICU (nutritional support): provide adequate nutritional support, preferably via the enteral route, in all patients at risk of AKI. B Prevention of AKI in the ICU (other measures): do not implement tight glycemic control routinely in the general ICU. population. D Consider implementing 'normal-for-age' glycemic control with IV insulin therapy to prevent AKI in surgical ICU patients. D Show 4 more Prevention of contrast-induced nephropathy, risk assessment: As per CAR 2022 guidelines, use a simple screening questionnaire to detect stable outpatients without a current (3-6 months depending on institutional preference) estimated GFR on file and without a provided history of CKD on the requisition to identify patients with AKI or severe CKD. E Show 4 more As per ERBP 2012 guidelines, obtain a baseline serum creatinine before an intervention encompassing a risk for contrast-induced nephropathy. As per KDIGO 2012 guidelines, assess the risk for contrast-induced AKI and, in particular, screen for preexisting impairment of kidney function in all patients being considered for a https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 11/19 6/23/23, 1:57 AM Acute kidney injury Pathway procedure requiring intravascular administration of iodinated contrast medium. Prevention of contrast-induced nephropathy, restriction of contrast medium use: As per CAR 2022 guidelines, assess the overall risk of worsening AKI with contrast versus the benefit of improved diagnostic capability and therapeutic intervention for the use of IV or intra- arterial contrast in the setting of preexisting AKI. E Show 6 more As per ESC 2021 guidelines, use low- or iso-osmolar contrast media (at the lowest possible volume) for invasive strategies in patients with CKD presenting with myocardial infarction. A As per ERBP 2012 guidelines: Balance the risk for contrast-induced nephropathy against the benefit of administering contrast. Consider obtaining alternative imaging modalities not requiring contrast administration in patients at increased risk for contrast-induced nephropathy, if those carry the same diagnostic accuracy. As per KDIGO 2012 guidelines: Consider obtaining alternative imaging methods in patients at increased risk for contrast- induced AKI. Administer the lowest possible dose of contrast medium in patients at risk for contrast-induced AKI. Administer either iso-osmolar or low-osmolar iodinated contrast media, rather than high- osmolar iodinated contrast media, in patients at increased risk of contrast-induced AKI. B Prevention of contrast-induced nephropathy (discontinuation of medications): do not discontinue metformin before contrast administration and/or re-test kidney function afterward in patients with an estimated GFR > 30 mL/min/1.73 m . D Show 2 more Prevention of contrast-induced nephropathy, IV and oral fluids: As per CAR 2022 guidelines, do not initiate oral or IV hydration in patients with an estimated GFR > 30 mL/min/1.73 m receiving IV or intra-arterial iodinated contrast media. D Show 2 more As per ESC 2021 guidelines, consider offering pre- and post-hydration with isotonic saline if the expected contrast volume is > 100 mL in invasive strategies in patients with CKD and myocardial infarction. C Consider using tailored hydration regimens as an alternative to the pre- and post-hydration regimen. C As per ESVS 2017 guidelines, consider administering isotonic sodium chloride or sodium bicarbonate solutions for volume expansion before contrast administration in patients at increased risk of contrast-induced nephropathy. C As per ERBP 2012 guidelines: Administer either isotonic sodium chloride or sodium bicarbonate solutions for volume expansion in patients at increased risk for contrast-induced nephropathy. B Consider using the oral route for hydration if adequate intake of fluid and salt is assured. C https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 12/19 6/23/23, 1:57 AM Acute kidney injury Pathway As per KDIGO 2012 guidelines: Administer IV isotonic sodium chloride or sodium bicarbonate solution for volume expansion in patients at increased risk for contrast-induced AKI. B Do not use oral uids alone in patients at increased risk of contrast-induced AKI. D As per ESICM 2010 guidelines, administer isotonic crystalloids for prophylactic volume expansion in patients at risk of contrast-induced nephropathy. B Consider administering isotonic sodium bicarbonate solution, especially for emergency procedures. B Prevention of contrast-induced nephropathy, N-acetylcysteine: As per CAR 2022 guidelines, do not use N-acetylcysteine for the prophylaxis of contrast- associated AKI. D As per ERBP 2012 guidelines, consider administering oral N-acetylcysteine only in patients receiving appropriate fluid and salt loading. C Do not use oral N-acetylcysteine as the only method for the prevention of contrast-induced nephropathy. C As per KDIGO 2012 guidelines, consider offering oral N-acetylcysteine together with IV isotonic crystalloids in patients at increased risk of contrast-induced AKI. C As per ESICM 2010 guidelines, avoid using N-acetylcysteine as prophylaxis against contrast- induced nephropathy in critically ill patients. D Updated evidence: ACT In patients undergoing an intravascular angiographic procedure with at least 1 risk factor for contrast-induced AKI (age > 70 years, renal failure, diabetes mellitus, HF, or hypotension), acetylcysteine was not superior to placebo with respect to a contrast-induced AKI. ACT Investigators. Circulation. 2011 Sep 13. Prevention of contrast-induced nephropathy, other agents: As per CAR 2022 guidelines, do not use other pharmacological agents, such as statins, theophylline, prostaglandin E1, nicorandil, ascorbic acid, allopurinol, alpha-tocopherol, fenoldopam, natriuretic peptides, or trimetazidine, for the prevention of contrast-induced AKI. D As per ERBP 2012 guidelines: Avoid using theophylline for the prevention of contrast-induced nephropathy. D Do not use fenoldopam for the prevention of contrast-induced nephropathy. D As per KDIGO 2012 guidelines: Avoid using theophylline for the prevention of contrast-induced AKI. D Do not use fenoldopam for the prevention of contrast-induced AKI. D As per ESICM 2010 guidelines: Do not use fenoldopam for prophylaxis of contrast-induced nephropathy. D https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 13/19 6/23/23, 1:57 AM Acute kidney injury Pathway Consider administering theophylline to minimize the risk of contrast-induced nephropathy, especially in acute interventions when hydration is not feasible. C Prevention of contrast-induced nephropathy, renal replacement therapy: As per CAR 2022 guidelines, do not use any form of post-iodinated contrast media administration RRT, either dialysis or continuous RRT, to reduce the risk of contrast-associated AKI. D As per ERBP 2012 guidelines, do not use prophylactic intermittent hemodialysis or hemofiltration for the sole purpose of preventing contrast-induced nephropathy. D As per KDIGO 2012 guidelines, avoid using prophylactic intermittent hemodialysis or hemo ltration for contrast-media removal in patients at increased risk for contrast-induced AKI. D As per ESICM 2010 guidelines, consider performing periprocedural continuous venovenous hemofiltration in an ICU environment to limit contrast-induced nephropathy after coronary interventions in high-risk patients with advanced chronic renal insufficiency. C Prevention of contrast-induced nephropathy, serial creatinine assessment: As per CAR 2022 guidelines: Obtain a follow-up serum creatinine measurement 48-72 hours after intra-arterial iodinated contrast media administration in all patients with an estimated GFR 30 mL/min/1.73m . Do not obtain routine serum creatinine measurement in the remainder of patients as the risk of AKI is extremely low. Instruct any at-risk patient to seek medical attention and kidney function testing if they develop increased shortness of breath, peripheral edema, or note a marked decline in urine output in the days following the imaging test. E As per ERBP 2012 guidelines, consider obtaining a repeat serum creatinine 12-72 hours after contrast media administration in high-risk patients. C Prevention of postoperative AKI: Avoid performing off-pump CABG surgery solely for the purpose of reducing perioperative AKI or the need for RRT. D Do not use oral or IV N-acetylcysteine for the prevention of postoperative AKI. D Prevention of rhabdomyolysis-induced AKI: administer IV fluids promptly for volume expansion, if not already volume overloaded, in order to achieve a high urinary flow rate and protect against AKI in adult and pediatric patients with rhabdomyolysis. B Prevention of amphotericin B-induced nephrotoxicity: Consider preferring lipid formulations of amphotericin B over conventional formulations of amphotericin B. C Prefer azoles and/or echinocandins over conventional amphotericin B, if equal therapeutic ef cacy can be assumed, in the treatment of systemic mycoses or parasitic infections. B Prevention of aminoglycoside-induced nephrotoxicity: avoid using aminoglycosides for the treatment of infections unless no suitable, less nephrotoxic, alternatives are available. D https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 14/19 6/23/23, 1:57 AM Acute kidney injury Pathway Show 3 more Prevention of cardiac surgery-associated AKI (prevention, pharmacologic strategies): consider administering prophylactic human atrial natriuretic peptide via continuous infusion of 0.02 g/kg/min, started before surgery and continuing for 12 hours into the postoperative period, to prevent cardiac surgery-associated AKI and dialysis in adult patients undergoing cardiac surgery. C Show 3 more Prevention of cardiac surgery-associated AKI (prevention, cardiopulmonary bypass strategies): avoid administering hyperthermic perfusion (> 37 C) to reduce the risk of cardiac surgery-associated AKI in adult patients undergoing cardiac surgery with cardiopulmonary bypass. D Show 2 more Prevention of cardiac surgery-associated AKI (prevention, minimally invasive extracorporeal circulation): consider using minimally invasive extracorporeal circulation techniques to minimize the risk of cardiac surgery-associated AKI in adult patients undergoing cardiac surgery with cardiopulmonary bypass. C Measures with no evidence for benefit: As per JSN 2018 guidelines: Do not use loop diuretics D or low-dose dopamine for the prevention of AKI. D Insufficient evidence to support the use of low-dose atrial natriuretic peptide for the prevention of AKI. I Do not use diuretics, D low-dose dopamine, D or recombinant human IGF-1 for the prevention of AKI. D Show 2 more Landmark trials: Low-dose dopamine in patients with early renal dysfunction In critically ill patients at risk of renal failure, low-dose dopamine was not superior to placebo with respect to peak serum creatinine concentration. Bellomo R et al. Lancet. 2000 Dec 23-30. 10. Follow-up and surveillance Discharge from hospital: include a record in the discharge summary regarding AKI detected whilst in hospital, its maximum stage, etiology, the need for renal support (temporary/ongoing), and discharge renal function, if dialysis-independent. B Show 2 more Follow-up: As per UKKA 2019 guidelines: https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 15/19 6/23/23, 1:57 AM Acute kidney injury Pathway Obtain serum creatinine and potassium measurement 1-2 weeks after restarting potential culprit drugs after an episode of AKI and after any subsequent dose titration. B Arrange a formal post-discharge nephrology visit as follows: Situation Guidance Residual CKD stage G4 at hospital discharge Within 90 days Within 30 days Residual CKD stage G5 (non-dialysis- requiring) at hospital discharge Within 30 days. B Ongoing dialysis requirements at the time of hospital discharge As per JSN 2018 guidelines, consider confirming the patient's condition approximately 3 months later and obtaining long-term follow-up in accordance with their condition. C As per ERBP 2012 guidelines, assess patients 2 months after AKI to evaluate the completeness of resolution, and to detect new-onset CKD or worsening of preexisting CKD. B As per KDIGO 2012 guidelines, evaluate patients 3 months after AKI for resolution, new onset, or worsening of preexisting CKD. References 1. Arif Khwaja. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120 4):c179 84. Open 2. Michael Joannidis, Wilfred Druml, Lui G Forni et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM. Intensive Care Med. 2010 Mar;36 3 392 411. Open 3. Suren Kanagasundaram, Caroline Ashley, Sheetal Bhojani et al. 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The Japanese clinical practice guideline for acute kidney injury 2016. Clin Exp Nephrol. 2018 Oct;22 5 985 1045. Open https://web.pathway.md/diseases/recRY6zuQyeq4bFgI 16/19 6/23/23, 1:57 AM Acute kidney injury Pathway 8. Jean-Philippe Collet, Holger Thiele, Emanuele Barbato et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42 14 1289 1367. Open 9. National Institutes of Health. Coronavirus Disease 2019 COVID 19 Treatment Guidelines. National Institutes of Health. 2021 Oct. Open 10. Mitra K Nadim, Lui G Forni, Ravindra L Mehta et al. COVID 19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative ADQI Workgroup. Nat Rev Nephrol. 2020 Dec;16 12 747 764. Open 11. Lakhmir S Chawla, Rinaldo Bellomo, Azra Bihorac et al. Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative ADQI 16 Workgroup. 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