Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM.
BACKGROUND
Acute renal failure on the intensive care unit is associated with significant mortality and morbidity.


OBJECTIVE
To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques.


METHODS
A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system.


CONCLUSIONS
Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest specific vasodilators [corrected] under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention.


BACKGROUND
The online version of this article (doi:10.1007/s00134-009-1678-y) contains supplementary material, which is available to authorized users.
Joannidis
Michael
M
Medical Intensive Care Unit, Department of Internal Medicine I, Medical University Innsbruck, Anichstasse 31, 6020 Innsbruck, Austria. michael.joannidis@i-med.ac.at
Druml
Wilfred
W
Forni
Lui G
LG
Groeneveld
A B Johan
AB
Honore
Patrick
P
Oudemans-van Straaten
Heleen M
HM
Ronco
Claudio
C
Schetz
Marie R C
MR
Woittiez
Arend Jan
AJ
D058186:Acute Kidney Injury / Q000188:drug therapy / Q000378:metabolism / Q000503:physiopathology / Q000517:prevention & control*; D002316:Cardiotonic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D032921:Consensus; D005112:Extracorporeal Circulation; D005440:Fluid Therapy; D006801:Humans; D007362:Intensive Care Units; D018046:Protein C Inhibitor / Q000008:administration & dosage / Q000627:therapeutic use; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000627:therapeutic use; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000627:therapeutic use
D002316:Cardiotonic Agents; D018046:Protein C Inhibitor; D049994:Sodium Potassium Chloride Symporter Inhibitors; D014665:Vasodilator Agents