How to improve the care of patients with acute kidney injury
Intensive Care Med
How to improve the care of patients with acute kidney injury
Rinaldo Bellomo 2
Suvi T. Vaara 0 1
John A. Kellum 3
0 Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital , Helsinki , Finland
1 Department of Intensive Care, Austin Hospital , Melbourne , Australia
2 Department of Intensive Care and Department of Medicine, Austin Hospital , Studley Rd, Heidelberg, VIC 3084 , Australia
3 Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh , Pittsburgh, PA , USA
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Introduction
Almost all patients treated in adult general intensive
care units (ICUs) carry an increased risk for acute
kidney injury (AKI). This syndrome of abruptly decreased
glomerular filtration rate was diagnosed in over 50% of
critically ill patients in a multinational cohort study and
is associated with a variety of adverse short-term [1] and
long-term outcomes [2, 3]. Therefore, being aware of
AKI and staying up-to-date regarding the implications
of latest clinical research are relevant to all intensivists.
This issue of Intensive Care Medicine provides a
comprehensive collection of the latest advances in the field
of AKI research as well as expert opinions and reviews
covering topics about AKI in specific populations [4, 5]
as well as key elements of AKI management [6, 7]. This
set of papers combines state-of-the-art knowledge and
new ideas to improve current clinical practice and
represents “required reading” for practicing intensivists with
all major aspects of this syndrome being analyzed and
reviewed in depth.
The unified definition of AKI [8], although not
without challenges [9], has resulted in better understanding
of epidemiology and promoted standardization of trial
endpoints [10]. Moreover, significant effort has been
invested in the search for predictive biomarkers of AKI.
Although initial results were disappointing [11], failures
in the biomarker field have increased our understanding
of this syndrome and, more recently, cell cycle arrest
biomarkers seem to hold greater promise for better patient
care [12]. At the same time, animal research has revealed
the potentially different pathophysiology behind septic
AKI. Such understanding may allow advances in drug
*Correspondence:
1 Department of Intensive Care and Department of Medicine, Austin
Hospital, Studley Rd, Heidelberg, VIC 3084, Australia
Full author information is available at the end of the article
development and some promising agents are currently
being tested in septic AKI [4].
Adequate identification of patients with an increased
risk for AKI is a key element in the chain of prevention of
AKI. Flechet et al. report encouraging results from their
analysis in the EPaNIC database showing that models
comprising routinely collected data outperformed
neutrophil gelatinase-associated lipocalin in predicting AKI
[13]. Furthermore, a challenge for any predictive tool is to
improve care. Meersch et al. have recently used cell cycle
arrest biomarkers in cardiac surgical patients to define
subjects with high risk and randomized them either to a
treatment bundle aiming at avoiding further nephrotoxic
insults and optimization of the hemodynamic status or
to standard care. This approach resulted in a lower rate
of developing AKI, but the study was underpowered to
examine renal recovery or mortality rates [12]. This
single-center trial turns a new page in biomarker research to
biomarker-directed management protocols for AKI
prevention and treatment and should hopefully prompt
others to study interventions using enrichment strategies.
Management of AKI
Fluid therapy is administered to all ICU patients. Patients
with oliguric AKI are at especially high risk of
developing fluid overload that associates with increased
mortality. Therefore, understanding when additional fluids can
be beneficial in oliguria and when they can cause harm is
a key element in the management of these patients [14].
Strategies that deliver more fluids are clearly not superior
to strategies that deliver less fluid either for prevention or
resolution of AKI in the setting of septic shock. In
addition, knowledge of different fluid types and their
potential harm has greatly increased, and the review by Perner
et al. provides comprehensive insights into these issues
[7].
About one-fifth of patients with AKI commence renal
replacement therapy (RRT) [1]. The optimal time to start
RRT in the absence of emergency indications remains
uncertain, but the STARRT-AKI trial (NCT02568722) is
now well underway and is likely to bring high-level
evidence to the field along with other recent trials that are
discussed in the review summarizing the state-of-the-art
for management of RRT by Bagshaw et al. [6]. The issue
of optimal timing for the discontinuation of RRT also
lacks definitive evidence, but Forni et al. provide
practical insights into the topic in (...truncated)