Rubin: AKI in the ICU, an Updated Look

Today we are joined by Dr. Mario Rubin, Associate Professor of Medicine in the Nephrology Department and the acting Director of the Nephrology fellowship here at the University of Maryland. Dr. Rubin is a recent transplant from Boston where he served as director of nephrology education and director of the Transplant Nephrology Fellowship at Massachusetts General Hospital. We stole him for a single hour and received one the best talks EVER on AKI. This talk is so good and contains SO MANY pearls that a written summary cannot even scratch the surface of the information discussed in this talk. Do yourself a favor and just watch this video!!

Clinical Pearls (thanks to Dr. Donald Slack)

  1. Definition:
    • Currently use the Amsterdam Criteria (established in 2005)
      • 3 Stages, with Stage I defined by a rising SCr by 0.3, or a 1.5x rise above baseline
  2. Data on the benefits of balanced solutions is varied, for now continue to monitor and treat with best fluid, i.e.: whatever is available fastest for your patient
  3. Morbidity and Mortality Data
    • Mortality in AKI requiring hemodialysis approaches 50% 
    • Fluid overload in AKI (especially by > 10%) is associated with a statistically significant increase in hospital mortality
      • Yet diuretic use in the setting of ATN is associated with worse outcomes
      • We do not have an effective and proven pharmacologic treatment for AKI
        • The only FDA approved treatment is dialysis
  4. Common Indications:
    • Volume overload, metabolic acidosis, hyperkalemia, uremia or azotemia unresponsive to other medical management
      • Difficult to define what constitutes “uremia”
    • Certain toxic ingestions
  5. Timing of Dialysis
    • Several historical papers and meta-analysis suggest “early” dialysis (definitive differs per paper) is associated with better survival and renal recovery versus “late” dialysis
      • More recent data (even from this past month) may suggest otherwise
    • In AKI, there is inconclusive data regarding the timing of initiation of renal replacement therapy
  6. CRRT v IHD
    • Cost:  CRRT is, by many analyses, considered to be roughly 3x more costly
    • Outcomes:
      • Several large papers from 2001 and 2004, and meta-analyses since then, suggest no benefit of CRRT over IHD in renal recovery or patient mortality, even in critically ill patients.
    • Expert Opinion:
      • In certain populations (hepatic failure, cerebral edema or acute brain injury), CRRT is probably beneficial over IHD due to fewer fluctuations in hydrostatic and osmotic pressures.
      • Otherwise, there is little benefit for one over the other

Suggested Reading

  1. Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstädt H, Boanta A, Gerß J, Meersch M. Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial. JAMA. 2016 May 24-31;315(20):2190-9. [PubMed link]
  2. Koyner JL, Davison DL, Brasha-Mitchell E, Chalikonda DM, Arthur JM, Shaw AD, Tumlin JA, Trevino SA, Bennett MR, Kimmel PL, Seneff MG, Chawla LS. Furosemide Stress Test and Biomarkers for the Prediction of AKI Severity. J Am Soc Nephrol. 2015 Aug;26(8):2023-31. [PubMed Link]
  3. Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, de Prost N, Lautrette A, Bretagnol A, Mayaux J, Nseir S, Megarbane B, Thirion M, Forel JM, Maizel J, Yonis H, Markowicz P, Thiery G, Tubach F, Ricard JD, Dreyfuss D; AKIKI Study Group. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med. 2016 May 15. [NEJM Link]
  4. Liu KD, Himmelfarb J, Paganini E, Ikizler TA, Soroko SH, Mehta RL, Chertow GM. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol. 2006 Sep;1(5):915-9. [PubMed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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