1019

3. AKI
NCEPOD report
AKI
• not recognised
• not coded for
• didn’t die in hospital

4. USRDS
Incidence of AKI is increasing

5. The global burden of AKI
Kidney Int 2013; 84: 457–67

6. AKI: A Common, Serious
Problem
High
incidence
Late
detection
Treatment is
mainly
supportive
Increasing
incidence
Comorbidities
High
mortality

9.  The goal is to prevent secondary
primary insults and to alter the nature
of the primary renal injury

14.  Iatrogenic AKI is not always
preventable
 Incidence varies between 1-3%
 Drug nephrotoxicity is the main
cause accounting for 20-60% of all
cases

24. INFLAMMATORY MEDIATORS OF ISCHEMIC AKI
Ischemic AKI
 Ischemia can lead to AKI
through the induction of
inflammatory mediators
that induce cell death in
the kidney tubules
• Reactive oxygen species
• Cytokines
• Chemokines
• Macrophages
Adapted from Aiello S and Noris M. Kidney Int. 2010;78:1208-10.
Lymphocytes
Neutrophils
Chemokines
Macrophages
ROS
Cytokines
Vasoconstrictors
Dendritic
Cells
Interstitium
Endothelium
Tubular
Urinary Lumen
Proximal
Tutules
Adhesion
Molecules
Apoptosis, Cell Injury, Oxidative Stress

29. No Early Diagnosis ??!!!

30. Treatment is largely
supportive in nature!

31. Diuretic agents Vasodilators
Loop diuretics Dopamine agonists
Mannitol Adenosine agonists
Thiazides Endothelin receptor antagonist
Natriuretic agents Calcium antagonists
ANP Prostaglandin analogues
Urodilatin Anti-oxidants
B-type NP acetylcysteine, Ascorbic acid
Miscellaneous Lazaroids, Statin
Growth factors MESNA
Anti-inflammatory agents
Anti-apoptosis agents

32. R Mehta et al. Kidney International Reports (2017) 2, 515–518

33.  PICARD Study:
Cohort study of 552 pts in 4 UC hospitals:
Odds Ratio
In-hospital Mortality 1.77
Non-recovery of renal function 1.68
 Improved urine output and shorter duration of RRT
(none has clinical relevance in ICU pts)
 But diuretics continue to be used for volume control
in AKI in ICU setting!
JAMA. 2002 Nov 27;288(20):2547-53
Crit Care Resusc. 2007 Mar;9(1):60-8

34.  Diuretics seem to worsen outcomes in ATN
induced by contrast media and after cardiac
surgery
 7 RCTs compared fluids alone with diuretics
in pts at risk of AKI from various causes and
found no evidence of improved survival,
decreased incidence of AKI or need for
dialysis associated with diuretics

35.  Several small RCTs have found no
reduction in incidence of AKI with
mannitol over hydration post surgery,
CABG or in rhabdomyolysis
 In contrast induced ATN there was a
trend toward harm when compared with
saline alone

36. Solomon R et al, N Engl J Med 2004;331(21):1416-1420
A total of 78 patients with mean baseline SCR 2.1 mg/dl
who underwent coronary angiography/PCI
N=78
0.45% saline alone 12
hours before and 12
hours after angiography
N=28
Saline plus mannitol *
N=25
Primary endpoint: increase in the baseline SCr of at least 0.5 mg/dl within
48 hours after the injection of radiocontrast agents
Furosemide*
N=25
* Given before angiography
Randomization
Effects of Saline, Mannitol, and
Furosemide

37. Effects of Saline, Mannitol, and
Furosemide to Prevent Acute Decreases
in Renal Function Induced by
Radiocontrast Agents
11
28
40
0
5
10
15
20
25
30
35
40
45
Saline Saline+Mannitol Furosemide
CIN,%
Solomon R et al, N Engl J Med 2004;331:1416-1420
P=0.02 for Saline vs. Furosemide group
P=NS for Mannitol vs. Furosemide group

38. Lasix
Increase risk of CIN
Ann Intern Med 2008; 148, 284-294

39. Osmotic Diuretic (maintainence of urine output)
Potential oxygen free radical scavenger
Mechanism
•Harmful in diabetics
Increase risk of CIN
Efficacy

40. Optimal Hydration Regimen
Mueller et al Arch Intern Med 2008
1937 Patients Screened
317 Ineligible or
No Consent
685 for Primary End Point
Analysis
698 for Primary End Point
Analysis
1620 Randomized
809 Received 0.9% Saline
124 Excluded From Primary
End Point Analysis
Repeat Catheterization (n=78)
Incomplete Data (n=46)
811 Received 0.45%
Sodium Chloride
113 Excluded From Primary
End Point Analysis
Repeat Catheterization (n=59)
Incomplete Data (n=53)
Bypass Grafting (n=1)

41. Optimal Hydration
0.9% NS vs 0.45% NS
P=.35
0
1
2
3
CN Mortality Vascular
Incidence,%
0.9% Saline
0.45% Sodium Chloride
P=.93
P=.04
Mueller et al Arch Intern Med 2008

42. Prevention of CIN with
Sodium Bicarbonate
Merten GJ et al. JAMA, 2009;291:2328-2334
Patients With Baseline Serum Creatinine >1.8 mg/dl
who Underwent Contrast Exposure (Iopamidol in All)
N=137
Sodium Chloride
Hydration (154 mEq/L of
Sodium Chloride)
N=68
Sodium Bicarbonate
Hydration (154 mEq/L of
Sodium Bicarbonate)
N=69
Primary endpoint: increase in serum creatinine ≥25%
within 2 days post-exposure

43. Prevention of CIN with Sodium
Bicarbonate: Results
Endpoints
Sodium
Chloride
N=59
Sodium
Bicarbonate
N=60
P
value
Incidence of CIN (%) 13.6% 1.7% 0.02
Incidence of CIN
(↑SCr 0.5 mg/dL)
11.9% 1.7% 0.03
Merten GJ et al. JAMA, 2009;291:2328-2334

44. REMEDIAL Trial
Saline + NAC
N=118
Bicarbonate + NAC
N=117
Saline+AA+NAC
N=116
7 excluded
Pts with eGFR<40
N=393
Randomized N=351
Excluded N=42
NAC = N-acetylcysteine, AA = ascorbic acid
9 excluded9 excluded
107 included
into analysis
108 included
into analysis
111 included
into analysis
Briguorio C. et al, Circulation 2007

45. REMEDIAL Trial: Results
Saline + NAC
Bicarbonate +
NAC
Saline +
Ascorbic Acid
+ NAC
P Value
N=111 N=108 N=107
Serum creatinine
increase by ≥25%
11 (9.9%) 2 (1.9%)* 10 (10.3%) 0.010
Serum creatinine
increase by ≥0.5 mg/dL
12 (10.8%) 1 (0.9%)† 12 (11.2%) 0.026
eGFR decrease by
≥25%
10 (9.2%) 1 (0.9%)† 10 (10.3%) 0.018
*P=0.019, †P<0.01 vs. saline + NAC group
Briguorio C. et al, Circulation 2007

46. Meta-analysis of NaCl vs. NaHCO3
Navaneethan SD et al. 617-627; 2009; American Journal of Kidney Diseases
OR 0.46 [0.26-0.82]

47. MEENA
Design
• DESIGN: Prospective,
randomized, parallel-group,
single-center clinical evaluation
of two hydration strategies for
patients undergoing coronary
angiography
• OBJECTIVE: To compare the
incidence of CIN between
periprocedural hydration with
sodium bicarbonate vs. sodium
chloride (0.9%, normal saline)
• PRIMARY ENDPOINT:
Decrease in estimated GFR by ≥
25% within 4 days of coronary
angiography
353 patients enrolled between January 2006
and January 2007
236 patients
assigned to sodium
chloride
178 patients
assigned to sodium
bicarbonate
156 evaluable
patient
Brar, S et. al., i2/ACC 2007
147 evaluable
patient
22
excluded
28
excluded
Hydration Protocol
•3 mL/kg for 1 hr before the procedure
•1.5 mL/kg during and for 4hrs post-
procedure

48. MEENA
p = 0.97
p = 0.82

49. Meta-Analysis
Sodium Bicarbonate for the
Prevention of CIN
Brar et al. cJASN 2009

50. Meta-Analysis
Study Flow
469 Citations Identified
168 from EMBASE
261 from MEDLINE
40 from Cochrane Library
8 Citations identified from
conference proceedings
424 Citations excluded based on
screening of titles or abstracts
53 identified for
further review
14 articles included
in meta-analysis
(N=2,290)
Brar et al. cJASN 2009
38 Citations excluded after full review
36 Design was not correct
1 Unusual protocol
1 Difference between groups in
volume administered & NAC dose
Dates: 1996 to 2008
Randomized Trials
Number of Patents: 2,290

52. Brar et al. cJASN 2009
Change in Renal Function
Published Randomized Trials
Harm
Benefit
∆CreatinineSodiumBicarbonate(mg/dL)
∆ Creatinine Sodium Chloride (mg/dL)
Brar
Maioli
Adolph Masuda
Ozcan
Merten
Briguori
-0.2 -0.1 0.0 0.1 0.2
0.2
0.1
0.0
-0.1
-0.2
Improvement
with Bicarb
Deterioration
with Chloride

53. Meta-Regression
Understanding Sources of Heterogeneity
Trial Size
Smaller trials show
greater benefit “Small Study Effect”
Summary: Positive effect only observed in small trials
12.6% vs. 10.7%
P=0.32
13.5% vs. 6.7%
P=0.03
Large
TrialsN=2290 N=2290
RR
95% CI
0.85
0.62-1.17
0.50
0.27-0.93
Merten
Criteria
N=290
Small
Trials
Brar et al. cJASN 2009

54. Brar et al. cJASN 2009
Forest Plot
High Quality Studies
Brigouri, 2007 0.19 (0.04, 0.82)
Chen, 2007 0.13 (0.02, 1.02)
Kim, 2007 0.98 (0.42, 2.28)
Ozcan, 2007 0.33 (0.11, 0.99)
Shaikh, 2007 0.75 (0.39, 1.44)
Brar, 2008 0.91 (0.56, 1.46)
Maioli, 2008 0.87 (0.52, 1.44)
Adolph, 2008 1.56 (0.27, 9.08)
Overall 0.71 (0.49, 1.03)
(I-squared =33.3%, p=0.163)
Note: weights are from
random effects analysis
0.1 1 10
Favors
Bicarbonate
Favors
Saline
Quality Criteria
► Similar volume
► Patients
► If NAC used,
dose & route
similar between
groups
► No early
termination
Summary: No overall benefit, but trend driven by studies
with extreme treatment effects

56.  2 meta-analyses failed to show any
benefit of the use of dopamine for
prevention of AKI. No benefit in
retarding progression of AKI or in
preventing death.
 Small studies have suggested a
potential benefit in terms of renal
perfusion and reduction in sCr with
Fenoldopam

57. Clinical Outcomes:
 No effect on mortality
 No effect on the need for or incidence of Renal
Replacement Therapy (RRT)
Renal Physiologic Outcomes:
 Diuretic effect and increased creatinine clearance on
the first day which was not significant on the
following days.
Adverse effect:
 On the immune, respiratory, and endocrine system.
Ann Intern Med. 2010;142:510-524
ANZICS Clinical Trial Group. Lancet 2000;356:2139-2143

58.  328 patients randomly assigned to low-dose
dopamine infusion in ICU
 Primary endpoint – Peak SCr during infusion
 No difference in
• Peak creatinine
• Dialysis requirement
• ICU/Hospital stay
• Mortality
Bellomo R et al; Lancet 2009; 356: 2139-43

59. Bellomo et al, Lancet 356(9248); Dec 2009

60.  Dopamine-1 receptor agonist, lack of Dopamine-2,
and alpha-1 receptor effect, make it a potentially
safer drug than Dopamine!
 Reduces in hospital mortality and the need for RRT
in AKI
 Reverses renal hypoperfusion more effectively than
renal dose Dopamine
 So far so good specially in cardiothoracic ICU
patients, awaiting more powered trials in other
groups!
J Cardiothorac Vasc Anesth. 2008 Feb;22(1):23-6.
J Cardiothorac Vasc Anesth. 2007 Dec;21(6):847-50
Am J Kidney Dis. 2007 Jan;40(1):56-68
Crit Care Med. 2006 Mar;34(3):707-14

61. Dopamine and Fenoldipam
Not useful for CIN prevention
Not useful in ttt of AKIAnn Intern Med 2011; 148, 284-294

62. The CONTRAST Trial
Algorithm
Primary endpoint
Worsening renal insufficiency within 12-96 hours
Fenoldopam Matching placebo
Randomize
Hydrate
1º prior to and 12 º after cath
300 patients
at increased risk for contrast nephropathy undergoing PCI

63. CONTRAST STUDY: CIN
SCr at both baseline and during the 96° post drug administration period
were available and analyzed at the central lab in 283 of 315 randomized
patients (90%).
P=0.84P=0.61
OR [95% CI] =
1.11 [0.79, 1.57]
P=0.27
Stone GW, et al. JAMA-2010

64. CONTRAST: 30-Day Adverse Events
30-day incidence of death, MI or dialysis:
 With CIN 12.2%
 Without CIN 4.1%
P=NS for all
p=0.02
Stone GW, et al. JAMA-2010

65. FEN-001 Trial Design
 Patients undergoing elective angiography
 Moderate CKD defined as CrCl ≤ 70 ml/min (≤ 80 ml/min if
diabetic)
 Anticipated CM volume ≥ 80 cc
Teirstein et al, Am J Cardiol 2012.
N=33
IV Placebo (no drugs/no device)
2:1 Randomization
IV FEN
0.1 - > 0.2
mcg/kg/min
IR FEN
0.2 mcg/kg/min
Index angiography
+/- interventional procedure
(+ contrast)
IR = intra-renal
IV = intravenous
FEN = fenoldopam
Washout x 1 hr

66. Glomerular Filtration Rate
Teirstein et al, Am J Cardiol 2012.
5-fold  GFR
TRT vs IV
Sustained  GFR
for 2+ hrs post d/c
All data based on a
Fenoldopam dose of
0.2 mcg/kg/min
GFR Response to IV-FEN and TRT-FEN vs. Control
4.9%
23.6%
25.1%
-9.7%
9.6%
-14.0%
-20%
-10%
0%
10%
20%
30%
1 2 3
Study Period6
PercentChangeinGFRfromBaseline[%]
IV FEN (n=22)
TRT-FEN (n=22)
Control Group (n=11)
Pre-procedure
(IV-FEN vs. Control)
Procedure
(TRT-FEN vs. Control)
Post-Procedure
(Active vs. Control)
p=0.0007
p<0.05
p=NS

67. Be-RITe! Registry: Higher Dose More Effective
(TRT-Fenoldopam patients only)
Predicted values per Mehran et al, JACC 2012.
CIN Incidence Stratified by TRT Dose
30.3%
3.7%
28.3% 27.7%
0%
10%
20%
30%
40%
50%
0.2 mcg/kg/min 0.4 mcg/kg/min
CINIncidenceorPredictedIncidence[%]
CIN Incidence Predicted
n=33 n=242
p=0.79
p<0.0001

68. Dopamine and Fenoldipam
Not useful for CIN prevention
Not useful in ttt of AKIAnn Intern Med 2011; 148, 284-294

69.  Studies with ANP suggest harm in non-
oliguric pts
 BNP is being increasingly used in
refractory heart failure
 BNP induces natriuresis often when
other treatments are ineffective,
however there is no evidence that it
improves renal function or prevents
injury

70.  61 patients in 2 cardiothoracic ICU with post-
op AKI assigned to receive recombinent ANP
(50ng/kg/min) or placebo
 The need for RRT before day 21 after
development of AKI was significantly lower
in ANP group (21% vs 47%)
 The need for RRT or death after day 21 was
significantly lower in ANP group (28% vs
57%)
Crit Care Med. 2004 Jun;32(6):1310-5

71. Renal Protective Effects and the Prevention of
Contrast-Induced Nephropathy by Atrial
Natriuretic Peptide
Both ANP(0.042 µg/kg/min) and Hydration (1.3 ml/kg/h
of Ringer) infusions were initiated 4 to 6 h before the
angiographic and continued for
48 h after
14 pts excluded
261 pts Randomized
126 pts
ANP plus hydration
128 pts
hydration
Morikawa et al. J Am Coll Cardiol 2009;53:1040–6

72. 8.6%
10.9%
11.7%
2.4%
3.2% 3.2%
0
2
4
6
8
10
12
14
Control Group ANP Group
Incidence on CIN in the ANP Group
Compared with the Control Group
P=0.015
P= 0.042
P=0.023
IncidenceofCIN(%)
 Creatinine
>0.5 mg/dl
 Creatinine
>25% of baseline
 Creatinine
>0.5 mg/dl or
>25% of baseline
Morikawa et al. J Am Coll Cardiol 2009;53:1040–6

73. Atrial natriuretic peptide
 Morikawa et al (JACC 2009) single center RCT
ANP+IVF or IVF alone cath+/-PCI
 ANP at 0.042 mcg/kg/min 4-6 hrs prior and 48 hrs
past
 eGFR at 24, 48 hrs, 1 week and 1 month
 Slight benefit of ANP in Cr, no benefit in HD/hosp.
rate
 Prior studies were negative, but this had lower ANP
dose for longer time
 No conclusive evidence yet, would need larger trials

74.  2 RCTs suggested theophylline
reduced the change in sCr and GFR
associated with radiocontrast
administration in high risk pts.
However, the hydration status was
unclear in these RCTs
 Negative results have been found with
theophylline to prevent AKI post
cardiac surgery

75. Theophylline (Adenosine
Antagonist)
Kelly et al. Ann Intern Med. 2008
Stacul et al. (Am J Cardiol, 2006) found significant benefit
Statistically significant reduction in CMIN seen in a meta-analysis of 7 studies
(n=480)
Number of studies that show no benefit
Benefit inconclusive, may be useful

76.  Several meta-analyses have concluded NAC
results in ~50% reduction in the incidence of
contrast nephropathy in high risk pts.
However NAC has not been shown to
improve survival or the need for dialysis.
NAC may affect sCr independently of GFR by
affecting creatinine metabolism.
 NAC reduced sCr in healthy pts but there
was no change in cystatin C levels

77. N-Acetylcysteine
 Scavanges ROS, reduces the depletion of
glutathione, stimulate vasodilatory mediator
release (incl. nitric oxid)
 Tepel et al. (NEJM 2000) first described its
efficacy in preventing CIN
 Since then a multitude of trials published
with highly conflicting results (largest trial
487 patients)
 A number of meta-analysis published
• Kelly et al. analyzed 26 trials, 3393 pts, RR=0.62
(0.44-0.88)
• Gonzales et al. 22 trials, 2746 pts, found two
clusters- one NAC was protective, Cr decreased-
NAC not actually effective, but rather an
artifactual Cr decrease not due to NAC
• Trivedi et al. analyzed high dose NAC only,
OR=0.46 (0.33-0.63)

78. CIN: Effect of n-Acetylcysteine
 Prospective, randomized
 83 high risk patients
• CrCl < 50 ml/min
• Diabetes 33%
 IV CONTRAST for CT (75 ml
of Low Osmolar CM)
 n-AC 600 bid x 2 days pre-
 CIN definition: creatinine
increase of 0.5 mg/dl
 Hydration with 0.45% @ 1
ml/kg/h x 24 h
21%
2%
0%
5%
10%
15%
20%
25%
Control (42) AC (41)
CIM(%)
Tepel NEJM 2000
p= 0.01

79. Zagler et al. Am Heart J 2006;151:140-145.
Relative Risk for Developing CIN after
NAC
Risk Ratio (Random)
95% Cl
0.1 1 10
Favors treatment Favors control
0.2 0.5 2 5
RR (Random)
95% Cl
Control
n/N
NAC
n/N
Study or
substury
Review: Acetylcysteine and CIN
Comparison: 01 NAC on CIN
Outcome: 01 CIN
Total events: 124 (NAC), 162 (Control)
Test for heterogenety: Ch=27.54 (P0.005), 12=56.4%
Test for overall effect: Z=1.88 (P=0.05)
Allaqaband et al 8/45 6/40 1.19 (0.45, 3.12)
Briguori et al 6/92 10/91 0.59 (0.23, 1.57)
Diaz-Sandoval et al 2/25 13/29 0.18 (0.04, 0.72)
Durham et al 10/38 9/41 1.20 (0.55, 2.63)
Goldenberg et al 4/41 3/39 1.27 (0.30, 5.31)
Gomes et al 8/78 8/78 1.00 (0.40, 2.53)
Kay et al 4/102 12/98 0.32 (0.11, 0.96)
Nguyen-Ho et al 9/95 19/85 0.42 (0.20, 0.89)
Oldemeyer 4/49 3/47 1.28 (0.30, 5.41)
Pate et al 57/238 50/239 1.14 (0.82, 1.60)
RAPIDO 2/41 8/39 0.24 (0.05, 1.05)
Shyu 2/60 15/61 0.14 (0.03, 0.57)
Fung et al 8/46 6/45 1.30 (0.49, 3.46)
Total: (95% Cl) 950 932 0.68 (0.46, 1.02)

80. The ACT Trial
2,308 Patients undergoing an angiographic procedure with at least one of
the following risk factors:
Age > 70 years;
Chronic Renal Failure;
Diabetes Mellitus;
Heart Failure or LVEF <0.45;
Shock
I T T
Concealed
Randomization
Acetylcysteine 1200mg
Orally Twice Daily for 2 Doses
Before and 2 Doses After
Procedure
I T T
Matching Placebo
Primary Endpoint: Contrast-induced nephropathy (CIN)
(≥ 25% elevation of serum creatinine above baseline 48h-96h after angiography)
Secondary Endpoints: Total mortality, CV mortality, Need for dialysis, Doubling of
serum creatinine, Side effects

81. 12.7
3.9
1.1
12.7
3.8
1.5
0
5
10
15
20
CIN Elevation ≥ 0.5mg/dL
in serum creatinine
Doubling in serum
creatinine
%ofpatients
Acetylcysteine (N=1172) Placebo (N=1136)
RR = 1.00 (0.81-1.25)
p = 0.97 NS
RR = 1.04 (0.69 -1.57)
p = 0.85 NS
RR = 0.74 (0.36 -1.52)
p = 0.41 NS
Results
Primary Endpoint

82. 2.2
2.0
0.3
1.5
2.3
2.1
0.3
1.6
0
1
2
3
4
5
6
7
Mortality or need for
dialysis
Total mortality Need for dialysis CV mortality
%ofpatients
Acetylcysteine Placebo
RR = 0.97 (0.57-1.66)
p = 0.91 NS
RR = 0.93 (0.53-1.64)
p = 0.80 NS
RR = 0.97 (0.20- 4.80)
p = 0.97 NS
RR = 0.97 (0.51; 1.85)
p = 0.93 NS
Clinical Endpoints at 30 days

83.  Early resuscitation of unstable pts is vital in
lowering risk of AKI
 Although treating hypotension is essential
there is no evidence to suggest that one
vasopressor is more superior to another in
terms of preventing AKI
 When vasopressor agents are required to
reverse systemic vasodilation
norepinephrine is the drug of choice
 When required for treating shock,
norepinephrine does not increase the risk of
AKI

84.  Management of underlying cause
 Stop diuretics
 Low salt diet and free water restriction
if hyponatremia
 Midodrine + Octreotide + Albumin
 Terlipressin + Albumin
 RRT
 TIPS

85. Statins
Zhang et al. Am J Nephrol. 2011

86. Statins-RCTs

87.  Pleiotropic effect of antioxidative and anti-inflammatory
properties (Beneficial effects on endothelial function. Maintain NO
production and ↓oxidative stress).
 Systematic review (Xhang, Am J Nephrol, 2011) found 6
cohort studies and 6 RCTs. Heterogeneity found among
studies.
 4/6 cohort studies found chronic statin therapy beneficial
 Most RCTs failed to show benefit.
Not enough evidence to start statins for a
radiological procedure
 Chronic statin therapy may be more beneficial than only
around the time of CM administration
 Dose of beneficial statin uncertain

88.  PGI2, PGE2 have renal vasodilatory effects
(this forms the basis of NSAIDs
discontinuation)
 Spargias et al. (Circ. 2009) RCT 208 patients
–iloprost (PGI2 analog) found CIN 8% vs.
22%, p=0.005
 Study powered for 70% reduction in CIN-
clinically implausible
 No longer term effect investigated
 Large clinical trials needed before able to
recommend
 Benefit inconclusive, may be useful

89. Prevention of oxidative stress
Mechanism
•N=231
• 62% reduction in risk vs placebo
• Need larger randomized controled trials
• Safe & well tolerated
Efficacy
Benefit inconclusive, may be useful

90. Substrate for Nitric Oxide systhesis
Mechanism
• Failed to prevent decrease in creatinine
clearance
Efficacy

92. Renal Vasodilator
Mechanism
•No consistent evidence of
benefit
Efficacy

93. Endothelin causes renal vasocontriction
Mechanism
•Exacerbates CMIN (56% vs 29%
control)
Efficacy

94. Stacul et al. Am J Cardiol 2006

96. McCullough, P. A. J Am Coll Cardiol 2008;51:1419-1428
Advanced Algorithm for Management of Patients Receiving Iodinated Contrast Media

97. R Mehta et al. Kidney International Reports (2017) 2, 515–518

109. Take Home Message
3.4.1: We recommend not using diuretics to
Prevent AKI. (1B)
3.4.2: We suggest not using diuretics to treat AKI,
except in the management of volume overload. (2C)
3.5.1: We recommend not using low-dose dopamine
to prevent or treat AKI. (1A)
3.5.2: We suggest not using fenoldopam to prevent
or treat AKI. (2C)
3.5.3: We suggest not using atrial natriuretic peptide
(ANP) to prevent (2C) or treat (2B) AKI.
3.6.1: We recommend not using recombinant human
(rh)IGF-1 to prevent or treat AKI. (1B)

110. Take Home Message
3.7.1: We suggest that a single dose of
theophylline may be given in neonates with severe
perinatal asphyxia, who are at high risk of AKI. (2B)
3.9.2: We suggest not using NAC to prevent AKI in
critically ill patients with hypotension. (2D)
3.9.3: We recommend not using oral or i.v. NAC for
prevention of postsurgical AKI. (1A)
4.4.4: We suggest not using theophylline to prevent
CI-AKI. (2C)
4.4.5: We recommend not using fenoldopam to
prevent CI-AKI. (1B)

111. R Mehta et al. Kidney International Reports (2017) 2, 515–518

112. Shading of boxes indicates priority of action—solid shading (with white lettering) indicates actions that are equally appropriate at all stages whereas
graded shading (with black lettering) indicates increasing priority as intensity increases. Abbreviation: ICU, intensive care unit. Reproduced with
permission of KDIGO from the KDIGO Clinical Practice Guideline for Acute Kidney Injury
Stage-based Management Of Acute Kidney Injury (AKI)
Am J Kidney Dis. 2013;61(5):649-672

114. Use your
tools
Use your
wisdom
Use your brain
Summary

118.  Sepsis (most
common)
 Cardiogenic shock
 Hypovolemia
 Drug induced
 Contrast
 Hepatorenal syndrome
 Obstructive uropathy
Early
detection
Close monitoring
• Monitor intensively
• Monitor fluid balance, urine output
• Monitor blood pressure, cardiac function
• Monitor electrolytes, kidney function
Do No Harm
• Avoid and treat hypotension
• Avoid and treat hypovolemia
• Avoid contrast agents
• Avoid nephrotoxic medications