Xu, J.; Jiang, W.; Shen, B.; Fang, Y.; Teng, J.; Wang, Y.; Ding, X. (Shanghai)
Acute Kidney Injury in Cancer Patients
Gallieni, M.; Cosmai, L. (Milan); Porta, C. (Pavia)
Acute Kidney Injury in the Geriatric Population
Rosner, M.H. (Charlottesville, VA); La Manna, G. (Bologna); Ronco, C. (Vicenza)
This new volume in the series Contributions to Nephrology is fully dedicated to acute kidney injury (AKI). The book has been developed in conjunction with the Shanghai Spring AKI Forum where many of these critical topics will be discussed in a collaborative forum that brings experts from across the world together.
AKI is a complex syndrome that is a significant burden among hospitalized patients. In recent years, there has been an increase in AKI events due to the increased susceptibility of fragile and elderly subjects and the increase in significant and potentially nephrotoxic exposures. The latter include advanced surgery (especially complex cardiovascular surgery, imaging techniques, and nephrotoxic drugs). Recently, a plethora of new chemotherapeutic agents has become important causes of AKI in patients with cancer.
The structure of the book is designed to offer the reader recent advances in the field of AKI in different settings. First, there is a reappraisal of the current definitions and staging classifications for AKI available in the literature. This is followed by a description of new criteria to identify patients at risk and characterize early kidney insult by biomarkers. The use of biomarkers other than urine output and serum creatinine for diagnosis and risk assessment of AKI has the hope of revolutionizing aspects of the care of patients. Other important aspects discussed in this book include the sequelae of AKI (most importantly the development of chronic kidney disease) and AKI in special populations such as children, the elderly and those with cancer (a field termed “onconephrology”).
Finally, AKI is a syndrome with consequences that affect not only patient outcomes but also healthcare expenditures. This volume addresses these critical topics from several perspectives including the use of electronic medical records to link practice patterns and outcomes and the use of precision medicine to target AKI therapies to specific phenotypes and genotypes based upon techniques to define pathogenesis and the financial burden of AKI. In addition, quality measures should be identified and the ratio between cost and benefit of different therapies should be carefully analyzed.
AKI is a complicated field that requires the intervention of different specialists who combine their knowledge to optimize outcomes. For this reason, this book is a perfect tool not only for nephrologists but also for every specialist who wishes to become acquainted with this complex syndrome and aims to participate in the multifaceted endeavor to improve care and outcomes in these patients.
Xiaoqiang Ding, Shanghai
Mitchell H. Rosner, Charlottesville, VA
Claudio Ronco, Vicenza
Ding X, Rosner MH, Ronco C (eds): Acute Kidney Injury – Basic Research and Clinical Practice. Contrib Nephrol. Basel, Karger, 2018, vol 193, pp 1–12 (DOI: 10.1159/000484956)
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Acute Kidney Injury: Diagnosis and Classification in Adults and Children
Zaccaria Riccia · Stefano Romagnolib
aDepartment of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, and bDepartment of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Abstract
Background: The acute reduction of kidney function in critically and noncritically ill patients (regardless of their age) is one of the deadliest clinical conditions ever reported in modern medicine. Acute kidney injury (AKI) symptoms are sneaky and potentially difficult to be identified at the right time at the bedside. One of the greatest efforts of the recent history of critical care nephrology has been to find a common classification for AKI definition and staging with the purpose of allowing a timely diagnosis and push forward epidemiologic research. Summary: AKI is currently defined by the Kidney Disease Improving Global Outcomes (KDIGO) consensus classification that applies conventional serum creatinine and urine output (UO) criteria. According to a recent large epidemiologic study, this classification led to the confirmation that AKI occurs in about half of adult critically ill patients admitted to the intensive care unit and that a stepwise increase in mortality is associated with the severity of AKI along KDIGO stages. Both serum creatinine and UO have inherent limitations in accurately diagnosing abrupt decreases of renal function, but their common and easy application in routine clinical practice is currently considered the standard of care for AKI diagnosis. Pediatric and neonatal AKI have recently been described and specific staging with KDIGO modification has been proposed. Key Messages: AKI is frequent in critically ill patients and significantly affects intensive outcomes independent of other clinical factors. AKI can be diagnosed and its severity accurately staged by the KDIGO classification and its modification for pediatric patients. Serum creatinine and UO criteria are applied in order to diagnose and stage AKI. Despite some significant limitations of these commonly applied biomarkers, their application has made it possible to clearly appraise the importance of accurate AKI identification in clinical practice in several studies for prognostic and therapeutic purposes.
© 2018 S. Karger AG, Basel
Introduction
Acute kidney injury (AKI) is one of the most common diseases among adult and pediatric critically ill patients admitted to the intensive care unit (ICU) and it is associated with severe short- and long-term complications, including increased mortality [1]. AKI is characterized by a rapid decline in kidney function mostly referred to a decrease in glomerular filtration rate (GFR). Since the (re)-establishment and optimization of hemodynamics with adequate intravascular volume, cardiac output and perfusion pressure are the only effective therapeutic interventions in patients with decreased GFR [2], early identification and diagnosis is crucial. This chapter reviews the evolution of diagnostic criteria of AKI, both in adult and pediatric setting, the currently recommended definition, and its major limitations.
AKI Definition and Classification in Adult Patients
The field of critical care nephrology and AKI has been hampered by the long-standing lack of a standardized system to diagnose and classify this syndrome. Over the years, a number of different definitions have been applied without well-defined terms identifying “acute renal failure” or “acute tubular necrosis.” As a demonstration of the confusion that reigned around renal failure in the past, a survey conducted in 2004 during an international meeting on Critical Care Nephrology showed that more than 200 different definitions of AKI were provided by the involved clinicians [3]. The first innovative and revolutionary step in the AKI definition was performed