Clinical Practice Guidelines

Kidney Disease: Improving Global Outcomes Clinical Practice Guidelines on Acute Kidney Injury

RATIONALE
The acute deterioration of kidney function is a worldwide health problem, with increasing incidence, prevalence, high costs and poor outcomes. Whereas the concept of “acute renal failure” introduced in the 1950s and its subsequent treatment with dialysis was the focus of attention for most of the second half of the past century, the term “acute kidney injury” has recently been introduced to encompass the entire spectrum of the disease, from its early onset as injury, to its progressive loss of kidney function of increasing severity, and ultimately kidney failure requiring renal replacement therapy. In reviewing the incidence of acute kidney failure requiring dialysis in intensive care settings, critical care experts were first to identify the final stage of kidney failure as representing the tip of an iceberg. It was this realization that led to the formation of the Acute Dialysis Quality Initiative (ADQI) and subsequently the establishment of a broader inter-organizational group, the Acute Kidney Injury Network (AKIN). The work of these two groups has been instrumental in defining the spectrum, establishing the risks, and addressing the clinical challenges posed by AKI.

AKI occurs outside hospitals and is common on medical, surgical, pediatric, and oncology wards where it is a predictor of immediate and long-term poor outcomes of the underlying disease processes. AKI is more prevalent in and a significant risk factor for patients with chronic kidney disease (CKD). Individuals with CKD are especially susceptible to AKI, which in turn acts as a promoter of progression of the underlying CKD.

The burden of AKI is most significant in developing countries with limited resources for the care of these patients once the disease progresses to kidney failure necessitating renal replacement therapy. Addressing the unique circumstances and needs of developing countries, especially in the detection of AKI in its early and potentially reversible stages is of paramount importance.

Research over the past decade has identified a plethora of preventable risk factors for AKI and the potential for improving their management and outcomes. Unfortunately, these are not widely known and are variably practiced worldwide resulting in lost opportunities to improve the care and outcomes of patients with AKI. Importantly, there is no unifying approach to the diagnosis and care of these patients. There is a worldwide need to recognize, detect, intervene and circumvent the need for dialysis and to improve outcomes of AKI. Evidence-based clinical practice guidelines for the diagnosis, evaluation, classification, prevention, and management of AKI within the complex clinical settings in which it occurs can lead to improved outcomes and identify research questions to better understand, prevent and manage the disease.

At its meeting in December 2006, the KDIGO Board determined that AKI meets the criteria for developing clinical practice guidelines.

It is prevalent.
It is amenable to early detection and potential prevention.
It imposes a heavy burden of illness (morbidity and mortality).
The cost per person of managing the disease is high.
There is considerable clinical practice variability in preventing, diagnosing, treating, and achieving outcomes.
Clinical practice guidelines have the potential to reduce variations, improve outcomes, and reduce costs.

GUIDING PRINCIPLES AND PROCESS

Scientific and methodological rigor using an evidence-based approach
Interdisciplinary approach. Work Group members will be chosen for their leadership in their respective fields and commitment to quality of care and expertise in clinical practice
Independence of Work Groups.The workgroup will have independence and final responsibility in the formulation of recommendations. This will assure an unbiased approach to guideline development, without influence of organizations or industry
Openness of the guideline development process. Following their initial review by KDIGO Executive Committee and Board, the draft guidelines will be subjected to a public review process that invites comment from groups and professionals whom the guidelines will affect. Comments submitted at each phase of review will be carefully considered by the Work Group prior to publication of final guidelines.

KDIGO will convene a Work Group, with its first meeting to take place in June 2008. The Work Group will be charged with developing clinical practice guidelines for the diagnosis, evaluation, classification, prevention and management of AKI.

SCOPE

Definition, Evaluation and Classification

Definition of AKI

Classification of AKI (RIFLE, others)
Diagnostic tools (urinary abnormalities, blood tests, biomarkers, imaging techniques)
Clinical settings to consider (community, in-hospital, ICU, developing countries)
Limitations (age, adults > 18 yrs, specific infectious and/or nephrotoxic insults)
Post–transplant AKI (delayed graft failure) should also be excluded

Prevention

Susceptible groups and risk factors (genetic, clinical, age, baseline eGFR)
General measures (volume status, hemodynamic monitoring, urine flow, renal perfusion)
Pharmacologic interventions (diuretics, vasopressors, vasodilators, acetylcysteine)
Measures to consider in the use of drugs and procedures associated with AKI

Treatment

Non-dialytic (volume, anti-sepsis, ventilation, metabolic control, euglycemia)
Dialytic (type, dose, initiation, discontinuation, anticoagulants, access)

Prognosis

Scoring systems (recovery, mortality)
The interrelationship between AKI and CKD
Factors that determine general and renal recovery and outcome

RESEARCH RECOMMENDATIONS
The evidence review process and the expertise of the Work Group will be utilized to identify gaps in knowledge regarding the diagnosis, evaluation, classification, prevention and management of AKI and make research recommendations for implementation subsequent to the release of the guidelines.