Sepsis-Associated Acute Kidney Injury

The BMJ provides a comprehensive article on Sepsis-associated acute kidney injury (AKI). It discusses risk factors such as advanced age, chronic kidney disease, cardiovascular disease, diabetes, and liver disease. Review of sepsis definitions and kidney injury scores like RIFLE, AKIN and KDIGO are discussed. Markers beyond creatinine are surveyed, like albuminuria, urine microscopy for casts, NGAL etc.

As well as early detection, early resuscitation is important, with balanced electrolyte solutions rather than 0.9% Saline; controversy exists as to the Surviving Sepsis recommendations of 20mL or more per kg fluid, and the potential negative effects of excess fluid are highlighted.

Vasopressor choices to maintain mean arterial pressure include Norepinephrine and Vasopressin. Dopamine and Phenylephrine have not achieved comparable results or safety. Angiotensin II may have promise in future studies.

Mechanical ventilation, although unavoidable often, may increase AKI risk from multiple mechanisms like changes in intrathoracic pressure, reducing venous return, cardiac output, and renal perfusion, as well as neurohormonal and inflammatory pathways.

Pharmacological treatments for AKI are largely preliminary. Renal Replacememt therapy should not begin too early from recent trials, optimal dose being 20-25mL/kg/hour. Removal of toxins via hemoperfusion has not been proven effective. Nephrotoxic agents should be avoided (NSAIDS, contrast, Hydroxyethyl Starch).

BMJ link

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