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Renal Replacement Therapy Initiation in Acute Kidney Injury - Adult - Inpatient

Renal Replacement Therapy Initiation in Acute Kidney Injury - Adult - Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Urology and Nephrology


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Renal Replacement Therapy Initiation in
Acute Kidney Injury – Adult – Inpatient
Clinical Practice Guideline


Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 3
METHODOLOGY ..................................................................................................................................................... 4
DEFINITIONS .......................................................................................................................................................... 4
INTRODUCTION ..................................................................................................................................................... 4
RECOMMENDATIONS ............................................................................................................................................ 5
ACUTE KIDNEY INJURY DIAGNOSIS AND CLASSIFICATION CRITERIA ............................................................................................ 5
Table 1. Acute Kidney Injury Diagnosis and Staging Criteria................................................................................ 5
STAGE 1 OR 2 ACUTE KIDNEY INJURY PATIENTS .................................................................................................................... 5
STAGE 3 ACUTE KIDNEY INJURY PATIENTS ........................................................................................................................... 5
Table 2. Indications for Renal Replacement Therapy in Stage 3 AKI Patients ...................................................... 6
Table 3. Relative Contraindications for Renal Replacement Therapy ................................................................... 6
UW HEALTH IMPLEMENTATION ............................................................................................................................. 6
APPENDIX A. EVIDENCE GRADING SCHEME(S) ....................................................................................................... 8
RENAL REPLACEMENT THERAPY INITIATION IN ACUTE KIDNEY INJURY ALGORITHM ............................................. 9
REFERENCES ......................................................................................................................................................... 10







2


Contact for Content:
Name: Tripti Singh, MD - Nephrology
Phone Number: (608) 270-5674
Email Address: tsingh@medicine.wisc.edu

Name: Sana Waheed, MD - Nephrology
Phone Number: (608) 265-4565
Email Address: swaheed@medicine.wisc.edu

Contact for Changes:
Name: Katherine Le, PharmD – Center for Clinical Knowledge Management
Phone Number: (608) 890-5898
Email Address: kle@uwhealth.org


Coordinating Team Members:
Paula Cynkar, PA – Hospital Medicine
Ravi Dhingra, MD – Cardiology
Eliza Harrold, PA – Nephrology
Pierre Kory, MD – Pulmonary
Anne O’Connor, MD – Cardiology
Ann O’Rourke, MD – Trauma and Acute Care Surgery
John Rice, MD – Hepatology

Reviewers:
Margaret Murray, RN, DNP- Cardiac Surgery & Heart/Lung Transplant

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (08/24/17)


Release Date: August 2017 | Next Review Date: May 2019




















3


Executive Summary
Guideline Overview
This guideline has been developed to help identify when patients with acute kidney injury should
be initiated on renal replacement therapy.

Key Practice Recommendations
1. When diagnosis and staging acute kidney injury, it is recommended to use the Kidney
Disease: Improving Global Outcomes (KDIGO) workgroup criteria.
2. For stage 1 or 2 AKI patients, it is recommended to discontinue nephrotoxic agents when
possible, and obtain relevant labs, imaging and test to investigate cause of AKI.
3. It is not recommended to initiate renal replacement therapy in patients with stage 1 or 2 AKI
without indication.
4. It is recommended to consider initiating renal replacement therapy in a stage 3 AKI patient if
the patient has one or more indications for renal replacement therapy:
a. Refractory hyperkalemia (e.g., K+>6.5 mmol/l, rapidly increasing, or cardiac
toxicity)
b. Refractory acidemia and metabolic acidosis (e.g., pH≤7.2 despite normal or low
arterial pCO2)
c. Fluid overload (e.g., secondary respiratory distress, diuretic resistant,
continued/refractory evidence of high filling pressures, increase in weight by 10-
15% from baseline)
d. Uremia (e.g., bleeding, asterixis, encephalopathy, pericarditis)
5. For stage 3 AKI patients initiated on RRT, it is recommended to document the cause for
AKI.
6. It is not recommended to initiate renal replacement therapy in any stage 3 AKI patient who
has one or more of the following relative contraindications for RRT:
a. Futile prognosis
b. Receiving hospice care
c. High likelihood renal function will not recover in patient who is not a candidate for
long-term dialysis
d. Hepatorenal syndrome (HRS), high MELD score and is not a liver transplant
candidate
Scope
Disease/Condition(s): Acute Kidney Injury, Renal Replacement Therapy

Clinical Specialty: Hospital Medicine, Nephrology, Cardiology, Surgery, Critical Care,
Hepatology

Intended Users: Physicians, Advanced Practice Providers, Nurses

Objective(s):To assist in determining when to initiate renal replacement therapy in acute kidney
injury patients

Target Population: Adult patient diagnosed with acute kidney injury patients with native
kidney(s)

Interventions and Practices Considered:
• Continuous Veno-Venous Hemofiltration (CVVH)
• Intermittent hemodialysis (IHD)

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Major Outcomes Considered:
• Overall survival
• Long-term kidney dialysis
• Quality of Life
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: None identified.
Definitions
Acute Kidney Injury is defined by:
1

• A rise in serum creatinine by 0.3mg/dL in 48 hours or less, or
• A ≥50% rise in serum creatinine from baseline in 7 days, or
• A urine output of <0.5 mL/kg/h for >6 hours.
Introduction
Acute kidney injury (AKI) is a common and potentially fatal complication of many illnesses
among 1% of the community-based population, 8-15% of hospitalized patients and up to 50% of
patients in the intensive care unit. Renal replacement therapy (RRT) remains the primary
supportive therapy for patients with severe kidney injury and despite improvement in
technology, the optimal timing as to when to initiate RRT can be unclear.
2
A delay in initiating
RRT can result in serious preventable complications whereas early initiating carries the risk of
starting an invasive procedure in a patient who may recover renal function without RRT.
3
This
guideline is meant to help address uncertainties in the AKI patients who may require RRT by
prompting clinicians with relevant criteria for RRT initiation and contraindications to RRT.

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Recommendations
Acute Kidney Injury Diagnosis and Classification Criteria
1. When diagnosis and staging acute kidney injury, it is recommended to use the Kidney
Disease: Improving Global Outcomes (KDIGO) workgroup criteria outlined in Table 1.
1

(UW Health High quality of evidence, strong recommendation.)

Table 1. Acute Kidney Injury Diagnosis and Staging Criteria
1

Acute Kidney Injury is defined by:
• A rise in serum creatinine by 0.3mg/dL in 48 hours or less, or
• A >50% rise in serum creatinine from baseline in 7 days, or
• A urine output of <0.5 mL/kg/h for >6 hours.

Stage Serum creatinine Urine output
1 1.5-1.9 times baseline, or ≥0.3 mg/dl increase, or
GFR decrease ≥25%
< 0.5 mL/kg/h for 6-12 hours
2 2.0-2.9 times baseline OR GFR decrease ≥50% < 0.5 mL/kg/h for ≥ 6-12 hours
3 3.0 times baseline, or
Increase in serum creatinine to 4.0 mg/dl, or GFR
decrease ≥75%
< 0.3 mL/kg/h for ≥ 24 hours OR
Anuria for ≥ 12 hours
Stage 1 or 2 Acute Kidney Injury Patients
1. For stage 1 or 2 AKI patients, it is recommended to discontinue nephrotoxic agents
when possible and obtain relevant labs, imaging and test to investigate cause of AKI.
(UW Health Moderate quality of evidence, strong recommendation.)
a. It is recommended to consider obtaining the following labs when investigating
AKI:
4-6

i. Urinalysis
ii. Basic metabolic panel, phosphorus, and magnesium
iii. Urine sodium, urine urea, and urine creatinine
iv. Urine protein to creatinine ratio
v. Urine microscopy and culture
b. It is recommended to consider obtaining an ultrasound of the kidney and urinary
tract if the cause of AKI is unknown or obstruction is suspected.
5

2. It is recommended to correct hypovolemia/hypotension (i.e., administer fluids as
necessary) in a patient with stage 1 or 2 AKI and treat any complications from AKI such
as hyperkalemia or pulmonary edema as necessary.
5
(UW Health High quality of evidence,
strong recommendation.)
3. It is not recommended to initiate renal replacement therapy in patients with stage 1 or 2
AKI.
7,8
(UW Health Low quality of evidence, strong recommendation.)
4. If there is no resolution of renal insufficiency following appropriate interventions, it is
recommended to consider initiating renal replacement therapy if indicated. (UW Health
Low quality of evidence, strong recommendation.)
Stage 3 Acute Kidney Injury Patients
1. It is recommended to consider initiating renal replacement therapy in a stage 3 AKI
patient if the patient has one or more indications for renal replacement therapy as
outlined in Table 2.
5,7
(UW Health Low quality of evidence, strong recommendation.)




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Table 2. Indications for Renal Replacement Therapy in Stage 3 AKI Patients
3
• Refractory hyperkalemia (e.g., K+>6.5 mmol/l, rapidly increasing, or cardiac toxicity)
• Refractory acidemia and metabolic acidosis (e.g., pH≤7.2 despite normal or low arterial
pCO2)
• Fluid overload (e.g., secondary respiratory distress, diuretic resistant, increase in weight
by 10-15% from baseline)
• Uremia (e.g., bleeding, asterixis, encephalopathy, pericarditis)


2. If renal replacement therapy is indicated, it is recommended to consult Nephrology
regarding which RRT modality is best to initiate in a patient given trials data shows there
is no significant difference in terms of patient survival rates between the two modalities.
8

(UW Health Low quality of evidence, strong recommendation.)
3. If a patient is has stage 3 AKI and does not have an immediate indication for RRT, it is
recommended to continue evaluating the patient’s AKI as appropriate (e.g., discontinue
nephrotoxic agents, correct hypovolemia/hypotension, etc.) (UW Health Low quality of
evidence, weak/conditional recommendation.)
4. For stage 3 AKI patients initiated on RRT, it is recommended to document the cause for
AKI. (UW Health Very low quality of evidence, strong recommendation.)
5. It is not recommended to initiate renal replacement therapy in any stage 3 AKI patient
who has one or more of the following relative contraindications for RRT as outlined in
Table 3.
5,7
(UW Health Low quality of evidence, strong recommendation.)

Table 3. Relative Contraindications for Renal Replacement Therapy
5,7
• Futile prognosis
• Receiving hospice care
• High likelihood renal function will not recover in patient who is not a candidate for long-
term dialysis
• Hepatorenal syndrome (HRS) with cirrhosis, high MELD score and is not a liver
transplant candidate


UW Health Implementation
Potential Benefits:
• Decrease in practice variation amongst providers
• Reduced

Potential Harms:
• Decrease in practice variation amongst providers
• Reduced

Companion Documents
1. Renal Replacement Therapy Initiation in Acute Kidney Injury algorithm

Pertinent UW Health Policies & Procedures
1. UW Health Nursing Policy 3.11AP – Continuous Renal Replacement Therapy (CRRT) Using
the NxStage System One Machine (Adult and Pediatric)
2. UW Health Nursing Policy 1.28AP – Care of Hemodialysis/Apheresis Catheters (Adult &
Pediatric)

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Guideline Metrics
1. Number of Stage 3 AKI patients initiated on renal replacement therapy with appropriate
indication
2. Number of Stage 1 or Stage 2 AKI patients initiated on renal replacement therapy
3. Number of patients initiated on continuous renal replacement therapy versus intermittent
hemodialysis

Implementation Plan/Clinical Tools
Include an education plan, methods of communication, and identification of related tools. Guideline
content is expected to have some integration into the Health Link documentation system.
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Delegation Protocols
Continuous Renal Replacement (CRRT)-Based Dose Adjustment – Adult – Inpatient [5]

Order Sets & Smart Sets
IP- CRRT WITH Citrate- Adult- Continuous Renal Replacement Therapy WITH Citrate
Anticoagulation – Procedure [4382]
IP- CRRT WITHOUT Citrate- Adult- Continuous Renal Replacement Therapy WITHOUT Citrate
Anticoagulation – Procedure [5445]
IP-Peritoneal Dialysis- Adult-Supplemental [4883]
IP - Hemodialysis - Adult - Procedure [5138]
IP – Electrolyte Supplementation – Adult – ICU/IMC Supplemental [3439]


Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.


8


Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.



Patient with
Acute Kidney Injury
Stage 1 or 2
AKI?
Discontinue
nephrotoxic agents
when possible
YES
Does
patient have
≥ 1 indication
for renal
replacement
therapy?
NO
Acute Kidney Injury defined as:
Increase in SCr by ≥0.3 mg/dL within 48 hours; or
Increase in SCr to ≥1.5 times baseline, which is known or presumed to
have occurred within the prior 7 days; or
Urine volume < 0.5mL/kg/h for 6 hrs
Stage Serum creatinine Urine output
1 1.5-1.9 times baseline OR
≥0.3 mg/dl increase OR GFR
decrease ≥25%
< 0.5 mL/kg/h for 6-12 hours
2 2.0-2.9 times baseline OR
GFR decrease ≥50%
< 0.5 mL/kg/h for ≥ 12 hours
3 3.0 times baseline OR
Increase in serum creatinine to
4.0 mg/dl OR GFR decrease
≥75%
< 0.3 mL/kg/h for ≥ 24 hours
OR Anuria for ≥ 12 hours

Indications for renal replacement therapy
Refractory hyperkalemia (e.g., K+> 6.5 mmol/l, rapidly increasing, or
cardiac toxicity)
Refractory acidemia and metabolic acidosis (e.g, pH ≤7.2 despite normal
or low arterial pCO2)
Fluid overload (e.g., secondary respiratory distress, diuretic resistant,
increase in weight by 10-15% from baseline)
Uremia (e.g., bleeding, asterixis, encephalopathy, pericarditis)
Note: Renal replacement therapy may be initiated as continuous veno-venous
hemofiltration (CVVH) or intermittent hemodialysis (IHD). Trials data shows
that there is no significant difference in terms of patient survival rates.
It is recommended to consult Nephrology regarding which RRT modality is
best to initiate.
Does pt have
relative
contraindication
to RRT?
Treat as indicatedYES
Relative contraindications for
RRT:
Futile prognosis
Patient receiving hospice
care
High likelihood renal
function will not recover in
patient who is not candidate
for long-term dialysis
Patient with hepatorenal
syndrome (HRS) with
cirrhosis, high MELD score
and is not a liver transplant
candidate
Obtain relevant labs,
imaging and tests to
investigate cause of AKI
Tests and imaging to consider when investigating AKI:
Labs
Urinalysis
Basic metabolic panel , magnesium, phosphorus
Urine sodium, urine urea and urine creatinine
Urine protein to creatinine ratio
Urine microscopy and culture
Ultrasound of kidney and urinary tract if cause of AKI is unknown or
obstruction suspected
Correct hypovolemia/
hypotension
(i.e., administer fluids
as necessary)
Treat complications of
AKI
(e.g., hyperkalemia,
pulmonary edema)
Resolution
of renal
insufficiency?
NO
NO
Treat as clinically
indicated
YES
Consider initiating renal
replacement therapy if
patient has indication for
RRT
NO
Renal Replacement Therapy Initiation in Acute Kidney Injury
Document
cause for
Stage 3 AKI
YES
Initiate renal
replacement
therapy
Exclusion criteria: Patients with non-native kidneys
Last reviewed/revised 08/2017

10


References
1. Palevsky PM, Liu KD, Brophy PD, et al. KDOQI US commentary on the 2012 KDIGO
clinical practice guideline for acute kidney injury. Am J Kidney Dis. 2013;61(5):649-672.
2. Lai TS, Shiao CC, Wang JJ, et al. Earlier versus later initiation of renal replacement
therapy among critically ill patients with acute kidney injury: a systematic review and
meta-analysis of randomized controlled trials. Ann Intensive Care. 2017;7(1):38.
3. Mendu ML, Ciociolo GR, Jr., McLaughlin SR, et al. A Decision-Making Algorithm for
Initiation and Discontinuation of RRT in Severe AKI. Clin J Am Soc Nephrol.
2017;12(2):228-236.
4. Rahman M, Shad F, Smith MC. Acute kidney injury: a guide to diagnosis and
management. Am Fam Physician. 2012;86(7):631-639.
5. Ostermann M, Sprigings D. Acute kidney injury. In: Acute Medicine - A Practical Guide to
the Management of Medical Emergencies, 5th Edition. John Wiley & Sons, Ltd;
2017:160-169.
6. Goldsmith D, Jayawardene S, Ackland P. ABC of Kidney Disease. Hoboken,
UNKNOWN: John Wiley & Sons, Incorporated; 2013.
7. Bagshaw SM, Wald R. Strategies for the optimal timing to start renal replacement
therapy in critically ill patients with acute kidney injury. Kidney Int. 2017;91(5):1022-
1032.
8. Ronco C, Ricci Z, De Backer D, et al. Renal replacement therapy in acute kidney injury:
controversy and consensus. Crit Care. 2015;19:146.