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Acute kidney injury (AKI) is a common syndrome that is independently associated with increased mortality. A standardized definition is important to facilitate clinical care and research. The definition of AKI has evolved rapidly since 2004, with the introduction of the Risk, Injury, Failure, Loss, and End-stage renal disease (RIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) classifications. RIFLE was modified for pediatric use (pRIFLE). They were developed using both evidence and consensus. Small rises in serum creatinine are independently associated with increased mortality, and hence are incorporated into the current definition of AKI. The recent definition from the international KDIGO guideline merged RIFLE and AKIN. Systematic review has found that these definitions do not differ significantly in their performance. Health-care staff caring for children or adults should use standard criteria for AKI, such as the pRIFLE or KDIGO definitions, respectively. These efforts to standardize AKI definition are a substantial advance, although areas of uncertainty remain. The new definitions have enabled the use of electronic alerts to warn clinicians of possible AKI. Novel biomarkers may further refine the definition of AKI, but their use will need to produce tangible improvements in outcomes and cost effectiveness. Further developments in AKI definitions should be informed by research into their practical application across health-care providers. This review will discuss the definition of AKI and its use in practice for clinicians and laboratory scientists.

Worldwide, acute kidney injury (AKI) is associated with poor patient outcomes. Over the last few years, collaborative efforts, enabled by a common definition of AKI, have provided a description of the epidemiology, natural history and outcomes of this disease and improved our understanding of the pathophysiology. There is increased recognition that AKI is encountered in multiple settings and in all age groups, and that its course and outcomes are influenced by the severity and duration of the event. The effect of AKI on an individual patient and the resulting societal burden that ensues from the long term effects of the disease, including development of chronic kidney disease (CKD) and end stage renal disease (ESRD), is attracting increasing scrutiny. There is evidence of marked variation in the management of AKI which is, to a large extent, due to a lack of awareness and an absence of standards for prevention, early recognition and intervention. These emerging data point to an urgent need for a global effort to highlight that AKI is preventable, its course modifiable, and its treatment can improve outcomes. In this article, we provide a framework of reference and propose specific strategies to raise awareness of AKI globally, with the goal to ultimately improve outcomes from this devastating disease.

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Due to the risk of inducing hyperchloraemic acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions, eg Ringer' s lactate/acetate or Hartmann' s solution should replace 0.9% saline, except in cases of hypochloraemia, eg from vomiting or gastric drainage. Evidence level 1b * Recommendation 2Solutions such as 4% dextrose/0.18% saline and 5% dextrose are important sources of free water for maintenance, but should be used with caution as excessive amounts may cause dangerous hyponatraemia, especially in children and the elderly. These solutions are not appropriate for resuscitation or replacement therapy except in conditions of significant free water deficit, eg diabetes insipidus. Evidence level 1b * Recommendation 3To meet maintenance requirements, adult patients should receive sodium 50-100 mmol/day, and potassium 40-80 mmol/day in 1.5-2.5 litres of water by the oral, enteral or parenteral route (or a combination of routes). Additional amounts should only be given to correct deficit or continuing losses. Careful monitoring should be undertaken using clinical examination, fluid balance charts, and regular weighing when possible. Evidence level 5 * Preoperative fluid management Recommendation 4In patients without disorders of gastric emptying undergoing elective surgery, clear non-particulate oral fluids should not be withheld for more than two hours prior to the induction of anaesthesia. Evidence level 1a * Recommendation 5In the absence of disorders of gastric emptying or diabetes, preoperative administration of carbohydrate-rich beverages 2-3 h before induction of anaesthesia may improve patient well being and facilitate recovery from surgery. It should be considered in the routine preoperative preparation for elective surgery. Evidence level 2a * Recommendation 6Routine use of preoperative mechanical bowel preparation is not beneficial and may complicate intra-and post-operative management of fluid and electrolyte balance. Its use should therefore be avoided whenever possible. Evidence level 1a* Recommendation 7Where mechanical bowel preparation is used, fluid and electrolyte derangements commonly occur and should be corrected by simultaneous intravenous fluid therapy with Hartmann' s or Ringer-lactate/acetate type solutions. Evidence level 5 * Recommendation 8Excessive losses from gastric aspiration/vomiting should be treated preoperatively with an appropriate crystalloid solution which includes an appropriate potassium supplement. Hypochloraemia is an indication for the use of 0.9% saline,