Acute kidney injury

მიმოხილვა 
თეორია 
დიაგნოზი 
მართვა 
მეთვალყურეობა 
წყაროები 

მიაქციეთ ყურადღება, რომ ფორმულა/შეყვანის გზა და დოზა შეიძლება განსხვავებული იყოს მედიკამენტების დასახელების და ბრენდის, ფორმულარის ან გეოგრაფიული ადგილმდებარეობის მიხედვით. მკურნალობის შესახებ რეკომენდაციები სპეციფიკურია პაციენტის ჯგუფების მიხედვით: იხილეთ გაფრთხილება

მწვავე

prerenal azotemia

1-ლი რიგის – treatment of underlying condition

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1-ლი რიგის –

treatment of underlying condition

Prerenal azotemia is managed with techniques to improve the hemodynamic status of the patient. The underlying cause must be identified and treated, along with restoring euvolemia and hemodynamic stability.

Patients may have a history of excessive fluid loss from hemorrhage, the gastrointestinal (GI) tract, or sweating. There may be a history of sepsis, burns, major surgery, pancreatitis, or congestive heart failure.[90][93]

In practice, a fluid challenge can be both diagnostic and therapeutic in suspected hypovolemic prerenal azotemia. The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]

Electrolyte and acid-base balance should be monitored and optimized. For management of hyperkalemia, see Hyperkalemia in adults.

Management is often difficult if prerenal azotemia results from impaired cardiac function due to poor left or right ventricular systolic function, when volume overload/venous congestion may occur concurrently with renal hypoperfusion.[118]

It requires optimization of cardiac output and volume status as indicated by the clinical scenario, along with close monitoring of renal function and urine production during therapy.[5][113]

плюс – review drugs and stop nephrotoxins

with hypovolemia

плюс – volume expansion

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плюс –

volume expansion

Лечение рекомендовано ВСЕМ пациентам выбранной группы

Crystalloid (normal saline or balanced solutions, such as Ringer lactate [Hartmann solution]) is sufficient in most cases for volume expansion.[5][113] Colloid might be used if there is significant hypoalbuminemia.

In the US, the Food and Drug Administration (FDA) issued safety labeling changes in July 2021 for solutions containing hydroxyethyl starch (HES) stating that HES products should not be used unless adequate alternative treatment is unavailable.[114] Solutions containing HES are associated with adverse outcomes including kidney injury and death, particularly in critically ill patients and those with sepsis.[115][116] In view of the serious risks posed to these patient populations, the Pharmacovigilance Risk Assessment Committee of the European Medicines Agency in February 2022 recommended suspending HES solutions for infusion in Europe.[117]

The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]

Hemorrhage requires blood product replacement.

Рассмотреть – vasopressor

with volume overload

Consider – diuretic

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Consider –

diuretic

Additional treatment recommended for SOME patients in selected patient group

The use of diuretics may be helpful to manage volume in patients with ineffective circulating volume and prerenal AKI. Diuretic-unresponsive volume overload is an indication to proceed to renal replacement therapy by means of dialysis or filtration.

Impaired urine production and volume expansion are commonly seen in cases of AKI.

Loop diuretics (e.g., furosemide) and metolazone may be effective in promoting diuresis, although diuretic resistance is often seen.[118]

Patients may also require sodium restriction.[119]

Primary options

furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response

Secondary options

torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day

bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day

metolazone: 5-20 mg orally once daily

with uremia, severe metabolic acidosis, hyperkalemia refractory to medical management, or volume overload unresponsive to diuretics

考虑 – renal replacement therapy

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考虑 –

renal replacement therapy

针对特定患者群中部分患者治疗的附加建议

Nephrologist consultation is required.

Conventional hemodialysis for 4 to 6 hours is used in hemodynamically stable patients.

Other modes of renal replacement include sustained low-efficiency dialysis (SLED), extended daily dialysis (EDD), or continuous renal replacement therapy (CRRT).[124] Major commonly used modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF).

CRRT is mostly used in hemodynamically unstable patients (e.g., patients with sepsis, or with severe congestive heart failure) or those in whom aggressive ultrafiltration within the conventional 4- to 6-hour treatment of hemodialysis would not be tolerated.

Studies have shown that intensive dialysis in critically ill patients with AKI confers no increased benefit.[124][125][126][127][139]

Early dialysis appeared to reduce mortality compared with a delayed strategy in one small single-center randomized trial of critically ill patients with AKI.[128] However, a larger study and meta-analysis found no benefit associated with early initiation of renal replacement therapy.[129][140]

intrinsic renal failure

一线治疗 – treatment of underlying condition

加 – review drugs and stop nephrotoxins

with volume overload

Consider – diuretic

Back

Consider –

diuretic

Treatment recommended for SOME patients in selected patient group

The use of diuretics in the management of AKI is primarily for volume control.[1] Diuretic-unresponsive volume overload is an indication to proceed to renal replacement therapy by means of dialysis or filtration.

Impaired urine production and volume expansion are commonly seen in cases of AKI.

Loop diuretics (e.g., furosemide) and metolazone may be effective in promoting diuresis, although diuretic resistance is often seen.

Patients may also require sodium restriction.[119]

Opções primárias

furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response

Opções secundárias

torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day

bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day

metolazone: 5-20 mg orally once daily

with preexisting prerenal azotemia

Considerar – volume expansion

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Considerar –

volume expansion

Tratamento adicional recomendado para ALGUNS pacientes no grupo de pacientes selecionado

The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]

with uremia, severe metabolic acidosis, hyperkalemia refractory to medical management, or volume overload unresponsive to diuretics

Consider – renal replacement therapy

Back

Consider –

renal replacement therapy

Treatment recommended for SOME patients in selected patient group

Nephrologist consultation recommended.

Conventional hemodialysis is used in hemodynamically stable patients.

Other modes of renal replacement include sustained low-efficiency dialysis (SLED), extended daily dialysis (EDD), rapid-start peritoneal dialysis, or continuous renal replacement therapy (CRRT).[122][123] Major commonly used modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF).

CRRT is mostly used in hemodynamically unstable patients (e.g., patients with sepsis or severe congestive heart failure) or those in whom aggressive ultrafiltration within the conventional 4-to 6-hour treatment of hemodialysis would not be tolerated.

Studies have shown that intensive dialysis in critically ill patients with AKI confers no increased benefit.[124][125][126][127][139]

Early dialysis appeared to reduce mortality compared with a delayed strategy in one small single-center randomized trial of critically ill patients with AKI, but subsequent meta-analyses found no clear benefit associated with early initiation of renal replacement therapy.[71][128][129][130][131]

obstructive renal failure

1st line – bladder catheterization

Plus – review drugs and stop nephrotoxins

2nd line – relief of obstruction above bladder neck

with hypovolemia

Consider – volume expansion

Back

Consider –

volume expansion

Treatment recommended for SOME patients in selected patient group

The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]

with volume overload

Considerar – diuretic

with uremia, severe metabolic acidosis, or hyperkalemia refractory to medical management, or volume overload unresponsive to diuretics

Considerar – renal replacement therapy

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Acute kidney injury

მკურნალობის ალგორითმი

prerenal azotemia

treatment of underlying condition

review drugs and stop nephrotoxins

volume expansion

vasopressor

diuretic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

第一选择

第二选择

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

第一选择

第二选择

renal replacement therapy

intrinsic renal failure

treatment of underlying condition

review drugs and stop nephrotoxins

diuretic

Opções primárias

Opções secundárias

These drug options and doses relate to a patient with no comorbidities.

Opções primárias

Opções secundárias

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Opções primárias

Opções secundárias

volume expansion

renal replacement therapy

obstructive renal failure

bladder catheterization

review drugs and stop nephrotoxins

relief of obstruction above bladder neck

volume expansion

diuretic

Opções primárias

Opções secundárias

These drug options and doses relate to a patient with no comorbidities.

Opções primárias

Opções secundárias

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Opções primárias

Opções secundárias

renal replacement therapy

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