Document Detail

Acute kidney injury: quoi de neuf?
MedLine Citation:
PMID:  25249802     Owner:  NLM     Status:  PubMed-not-MEDLINE    
BACKGROUND: Acute kidney injury (AKI) is frequently encountered in the nephrology practice. Serum creatinine, with its many shortcomings, is still the main biomarker used to detect AKI.
METHODS: This review focuses on recent advances in definition, diagnosis, risk factors, and molecular mechanisms of AKI. In addition, specific AKI syndromes such as contrast-induced AKI, hepatorenal syndrome, and acute decompensated heart failure are discussed. The connection between AKI and subsequent chronic kidney disease and recent developments in renal replacement therapy are also covered.
RESULTS: Novel biomarkers such as cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) are being investigated to replace serum creatinine in the detection of AKI. Recent studies suggest that intravenous (IV) fluid use is beneficial for the prevention of contrast-induced AKI, while N-acetylcysteine use is not as well established. Diuretics are clearly beneficial in the treatment of acute decompensated heart failure. Ultrafiltration is less promising and can lead to adverse side effects. Although terlipressin use in hepatorenal syndrome is associated with reduced mortality, it is not available in the United States; combination therapy with midodrine, octreotide, and albumin provides an alternative. Fluid resuscitation is frequently used in critically ill patients with AKI; however, overly aggressive fluid resuscitation is frequently associated with an increased risk of mortality. A 3-step approach that combines guided fluid resuscitation, establishment of an even fluid balance, and an appropriate rate of fluid removal may be beneficial. If fluid resuscitation is needed, crystalloid solutions are preferred over hetastarch solutions. Renal replacement therapy is the last resort in AKI treatment, and timing, modality, and dosing are discussed. Research suggests that AKI leads to an increased incidence of subsequent chronic kidney disease. However, this relationship has not been fully established and additional studies are needed for clarification.
CONCLUSION: Despite major advances in AKI research, serum creatinine remains the major biomarker for the detection of AKI. The following interventions have shown to be beneficial: IV fluids for contrast-induced AKI; diuretics for acute decompensated heart failure/cardiorenal syndrome; and combination therapy with midodrine, octreotide, and albumin for hepatorenal syndrome. Fluid resuscitation in a patient with AKI should be used with caution because too liberal use of fluids can be associated with increased mortality. AKI appears to be related to increased rates of subsequent chronic kidney disease, and patients with AKI should therefore be monitored closely. Recent studies on renal replacement therapy have neither revealed an optimal timing for initiation of dialysis nor a clear advantage for a specific dialysis modality.
Ronald R Reichel
Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  The Ochsner journal     Volume:  14     ISSN:  1524-5012     ISO Abbreviation:  Ochsner J     Publication Date:  2014  
Date Detail:
Created Date:  2014-09-24     Completed Date:  2014-09-24     Revised Date:  2014-09-26    
Medline Journal Info:
Nlm Unique ID:  101125795     Medline TA:  Ochsner J     Country:  United States    
Other Details:
Languages:  eng     Pagination:  359-68     Citation Subset:  -    
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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