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Chapter 26: Acute Kidney Injury and Renal Replacement Therapy

Saad A. Bhatti; Karen Braich; Vijay Lapsia

INTRODUCTION

The incidence of dialysis-requiring acute kidney injury (AKI-D) has increased in the past decade in the United States. From 2000 to 2009, there were 1.09 million hospitalizations (95% confidence interval [CI], 1.04–1.15 million) with AKI-D in the United States. From 2007 to 2009, the population incidence of AKI-D increased by 11% per year (95% CI, 1.07–1.16; P < 0.001).1 Hospitalized patients with AKI-D were older than their counterparts who did not have AKI-D (63.4 vs 47.6 years), were more likely to be male (57.3% vs 41.1%), to be black (15.6% vs 10.2%), to have sepsis (27.7% vs 2.6%), to have heart failure (6.2% vs 2.7%), and to undergo cardiac catheterization (5.2% vs 4.4%) and mechanical ventilation (29.9% vs 2.4%).1 The temporal trend in the 6 diagnoses—septicemia, hypertension, respiratory failure, coagulation/hemorrhagic disorders, shock, and liver disease—sufficiently and fully accounted for the temporal trend in AKI-D.2 This chapter will discuss the diagnosis of acute kidney injury and types of renal replacement therapy.

DIAGNOSIS OF ACUTE KIDNEY INJURY

Acute kidney injury is considered when there is an abrupt decrease in urine output. Diagnostic criteria have gone through an evolution, from RIFLE (risk, injury, failure, loss of kidney function, and end-stage kidney disease) criteria, AKIN (Acute Kidney Injury Network) criteria, and now KDIGO (Kidney Disease: Improving Global Outcomes) criteria.3-5 This was deemed necessary for research, clinical, and prognostication purposes. See Tables 26-1 and 26-2.

TABLE 26-1RIFLE and AKIN Criteria
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TABLE 26-1RIFLE and AKIN Criteria
RIFLE Category Serum Creatinine Criteria Urine Output Criteria
A. The acute dialysis quality initiative (ADQI) criteria for the definition and classification of AKI (ie, RIFLE criteria)
Risk Increase in serum creatinine ≥ 1.5 × baseline or decrease in GFR ≥ 25% < 0.5 mL/kg/h for ≥ 6 h
Injury Increase in serum creatinine ≥ 2.0 × baseline or decrease in GFR ≥ 50% < 0.5 mL/kg/h for ≥ 12 h
Failure Increase in serum creatinine ≥ 3.0 × baseline or decrease GFR ≥ 75% or an absolute serum creatinine ≥ 354 µmol/L with an acute rise of at least 44 µmol/L < 0.3 mL/kg/h > 24 h or anuria ≥ 12 h
B. The acute kidney injury network (AKIN) criteria for the definition and classification of AKI
Stage 1 Increase in serum creatinine ≥ 26.2 µmol/L or increase to ≥ 150–199% (1.5- to 1.9-fold) from baseline < 0.5 mL/kg/h for ≥ 6 h
Stage 2 Increase in serum creatinine to 200–299% (> 2- to 2.9-fold) from baseline < 0.5 mL/kg/h for ≥ 12 h < 0.5 mL/kg/h for ≥ 12 h
Stage 3 Increase in serum creatinine to ≥ 300% (≥ 3-fold) from baseline or serum creatinine ≥ 354 µmol/L with an acute rise of at least 44 µmol/L or initiation of RRT < 0.3 mL/kg/h ≥ 24 h or anuria ≥ 12 h

AKI = ...

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