Appendix D: Evaluation and General Management Guidelines for Patients with AKI. Supplementary material is linked to the online version of the paper at http://www.kdigo.org/clinical_practice_guidelines/AKI.php 24 Kidney International Supplements (2012) 2, 19–36 chapter 2.2 Chapter 2.3: Evaluation and general management of patients with and at risk for AKI Given that AKI is associated with significant morbidity and mortality, and because no specific treatment is available to reverse AKI, early recognition and management is paramount. Indeed, recognition of patients at risk for AKI, or with possible AKI but prior to clinical manifestations, is likely to result in better outcomes than treating only established AKI. Chapter 2.2 introduced the approach to risk assessment with further detail provided in Appendix C. This chapter will concern itself with the evaluation and general management of patients with, or even at risk for, AKI. Further detail is provided in Appendix D. We highlight the importance of beginning management at the earliest point in the development of AKI—in patients with suspected AKI or even in those at increased risk who have been exposed to the various factors discussed in Chapters 2.2 and Appendix C. Although much of the remaining chapters in this guideline pertain to management of specific aspects of AKI, there are general management principles that are common to all patients and these will be discussed here and further expounded upon in Appendix D. Treatment goals in patients with AKI include both reducing kidney injury and complications related to decreased kidney function. 2.3.1: Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes. (Not Graded) 2.3.2: Monitor patients with AKI with measurements of SCr and urine output to stage the severity, according to Recommendation 2.1.2. (Not Graded) 2.3.3: Manage patients with AKI according to the stage (see Figure 4) and cause. (Not Graded) 2.3.4: Evaluate patients 3 months after AKI for resolution, new onset, or worsening of pre-existing CKD. (Not Graded) K If patients have CKD, manage these patients as detailed in the KDOQI CKD Guideline (Guidelines 7–15). (Not Graded) K If patients do not have CKD, consider them to be at increased risk for CKD and care for them as detailed in the KDOQI CKD Guideline 3 for patients at increased risk for CKD. (Not Graded) http://www.kidney-international.org chapter 2.3 & 2012 KDIGO Figure 4 | Stage-based management of AKI. Shading of boxes indicates priority of action—solid shading indicates actions that are equally appropriate at all stages whereas graded shading indicates increasing priority as intensity increases. AKI, acute kidney injury; ICU, intensive-care unit. Kidney International Supplements (2012) 2, 19–36 25 RATIONALE As emphasized in Chapter 2.2, AKI is not a disease but rather a clinical syndrome with multiple etiologies. While much of the literature examining epidemiology and clinical consequences of AKI appear to treat this syndrome as a homogeneous disorder, the reality is that AKI is heterogeneous and often is the result of multiple insults. Figure 5 illustrates an approach to evaluation of AKI. Further discussion of evaluation in clinical practice is provided in Appendix D. The clinical evaluation of AKI includes a careful history and physical examination. Drug history should include overthe-counter formulations and herbal remedies or recreational drugs. The social history should include exposure to tropical diseases (e.g., malaria), waterways or sewage systems, and exposure to rodents (e.g., leptospirosis, hantavirus). Physical examination should include evaluation of fluid status, signs for acute and chronic heart failure, infection, and sepsis. Measurement of cardiac output, preload, preload responsiveness, and intra-abdominal pressure should be considered Figure 5 | Evaluation of AKI according to the stage and cause. 26 Kidney International Supplements (2012) 2, 19–36 chapter 2.3 in the appropriate clinical context. Laboratory parameters— including SCr, blood urea nitrogen (BUN), and electrolytes, complete blood count and differential—should be obtained. Urine analysis and microscopic examination as well as urinary chemistries may be helpful in determining the underlying cause of AKI. Imaging tests, especially ultrasound, are important components of the evaluation for patients with AKI. Finally, a number of biomarkers of functional change and cellular damage are under evaluation for early diagnosis, risk assessment for, and prognosis of AKI (see Appendix D for detailed discussion). Individualize frequency and duration of monitoring based on patient risk, exposure and clinical course. Stage is a predictor of the risk for mortality and decreased kidney function (see Chapter 2.4). Dependent on the stage, the intensity of future preventive measures and therapy should be performed. Because the stage of AKI has clearly been shown to correlate with short-term2,5,27,29 and even longer-term outcomes,31 it is advisable to tailor management to AKI stage. Figure 4 lists a set of actions that should be considered for patients with AKI. Note that for patients at increased risk (see Chapters 2.2 and 2.4), these actions actually begin even before AKI is diagnosed. Note that management and diagnostic steps are both included in Figure 4. This is because response to