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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Assess a patient's kidney function based on clinical presentation, laboratory results, and urinary indices.

  2. Identify pharmacotherapeutic outcomes and endpoints of therapy in a patient with acute kidney injury (AKI).

  3. Apply knowledge of the pathophysiology of AKI to the development of a treatment plan.

  4. Design a diuretic regimen based on the pharmacokinetic and pharmacodynamic characteristics of the drug.

  5. Select pharmacotherapy to treat complications associated with AKI.

  6. Develop strategies to minimize the occurrence of AKI.

  7. Monitor and evaluate the safety and efficacy of the therapeutic plan.

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KEY CONCEPTS

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  • Equations to estimate creatinine clearance (CrCl) that incorporate a single serum creatinine concentration (e.g., Cockcroft-Gault) typically overestimate kidney function.

  • There is currently no drug therapy that hastens patient recovery in AKI, decreases length of hospitalization, or improves survival.

  • Loop diuretics are the diuretics of choice for the management of volume overload in AKI.

  • There is no indication for the use of low-dose dopamine in the treatment of AKI.

  • Identifying patients at risk for development of AKI and implementing preventive methods to decrease its occurrence or severity is critical.

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A cute kidney injury (AKI) is a potentially life–threatening clinical syndrome that occurs primarily in hospitalized patients and frequently complicates the course of the critically ill. It is characterized by a rapid decrease in glomerular filtration rate (GFR) and the resultant accumulation of nitrogenous waste products (e.g., creatinine and urea nitrogen), with or without a decrease in urine output. The term acute renal failure (ARF) has largely been replaced by AKI in recent years because AKI more completely encompasses the entire spectrum of acute injury to the kidney, from mild changes in kidney function to end-stage kidney disease requiring renal replacement therapy (RRT). Furthermore, the definition of ARF has been inconsistent in the literature, and a recent survey showed more than 30 different definitions in the literature.1 Efforts to standardize the definition of ARF has led to a change in terminology to AKI as well as the development of a consensus definition and severity staging for AKI.2

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The first consensus definition/classification for AKI was the RIFLE classification system, which categorizes patients into groups based on their change in serum creatinine or GFR from baseline, or decreased urine output.3 The categories of kidney dysfunction in the RIFLE classification include patients at risk (R), those with kidney injury (I), and those with kidney failure (F). Two additional categories of clinical outcomes are sustained loss (L), which requires RRT for at least 4 weeks; and end stage (E), which necessitates RRT for at least 3 months. Patients are assigned a class based on their indicator with the greatest severity. The complete schematic for the RIFLE classification system is depicted in Figure 25–1.

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FIGURE 25–1.

Algorithm for classification of acute kidney injury. The classification system includes separate criteria for ...

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