Acute kidney injury—an overview of diagnostic methods and clinical management

Abstract

Acute kidney injury (AKI) is a common condition in multiple clinical settings. Patients with AKI are at an increased risk of death, over both the short and long term, and of accelerated renal impairment. As the condition has become more recognized and definitions more unified, there has been a rapid increase in studies examining AKI across many different clinical settings. This review focuses on the classification, diagnostic methods and clinical management that are available, or promising, for patients with AKI. Furthermore, preventive measures with fluids, acetylcysteine, statins and remote ischemic preconditioning, as well as when dialysis should be initiated in AKI patients are discussed. The classification of AKI includes both changes in serum creatinine concentrations and urine output. Currently, no kidney injury biomarkers are included in the classification of AKI, but proposals have been made to include them as independent diagnostic markers. Treatment of AKI is aimed at addressing the underlying causes of AKI, and at limiting damage and preventing progression. The key principles are: to treat the underlying disease, to optimize fluid balance and optimize hemodynamics, to treat electrolyte disturbances, to discontinue or dose-adjust nephrotoxic drugs and to dose-adjust drugs with renal elimination.

Real-Time and Non-invasive Monitoring of the Activation of the IRE1α-XBP1 Pathway in Individuals with Hemodynamic Impairment

“…Our ER stress monitoring studies converge toward the concept that adaptive cellular responses that are engaged very early after an ischemic insult are required to protect against tissue damage (notably, cell death and tissue remodeling), and individuals who, for as yet unknown reasons, are not able to mount a robust adaptive response are less protected against AKI and have a worse renal prognosis. This concept is consistent with the “preconditioning” hypothesis in which repeated small insults (including those that promote ER stress ( Inagi et al, 2008 , Liu et al, 2016 , Usuki et al, 2013 )) prior to a major injury may afford protection to the target tissue, in part because adaptive responses are already engaged ( Hertzberg et al, 2017 , Stokfisz et al, 2017 ). An understanding of the ability to activate these early responses is critical to correctly identify individuals at risk, which is likely due to complex interactions between intrinsic factors (e.g., genetic and epigenetic factors), acquired structural lesions (e.g., CKD), and environmental triggers (the nature, intensity and duration of the stressor).…”

Acute kidney injury is associated with severe infection and fatality in patients with COVID-19: A systematic review and meta-analysis of 40 studies and 24,527 patients

“…Therefore, antiviral drugs and immunomodulatory drugs are the primary modes of management for AKI in COVID-19 [ 72 ]. However, several older drugs, such as diuretics, acetylcysteine and sodium bicarbonate, are used to treat AKI in COVID-19 [ 73 ]. Alternatively, traditional Chinese medications (Bailing Granules) and Chinese herbal medicine are also used to treat AKI in COVID-19 [ 74 ].…”

Early initiation of renal replacement therapy improves survival in patients with acute kidney injury

“…Although drugs are tested for prevention and/or treatment of AKI, RRT appears to be our only efficacious option at the time. Thus, management of AKI is largely limited to preventing further deterioration and loss of function with the use of temporizing actions in severe cases until RRT is established (4). Interaction of RRT and the outcome of RRT, along with mechanical ventilation, vasoactive therapy and nutritional support, is one of the defined life-sustaining technologies in the current treatment of the critically ill. A recent trend suggests an increasing use of RRT in critically ill patients with AKI (5).…”