Acute Kidney Injury in Adults: An Underdiagnosed Condition

Kristy Washinger; MSN; FNP-BC

Disclosures

Journal for Nurse Practitioners. 2017;13(10):667-674. 

In This Article

RRT

When supportive care is unsuccessful, RRT may be necessary. Serious preventable complications can be caused by delaying the initiation of RRT. A risk with early initiation of RRT is that the patient could recover kidney function without it.[20] Common reasons to start RRT include hyperkalemia, metabolic acidosis, volume overload, and overt uremic symptoms (anorexia, nausea, vomiting, somnolence, restless legs, neuropathy, and encephalopathy). The mainstays for RRT in AKI are intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT).

IHD is performed for a few hours at a time over spaced intervals. It achieves the fastest removal of small solutes. CRRT is delivered continuously and uses slower blood flow rates that result in slower fluid and solute removal. CRRT is often used for hemodynamically unstable patients, whereas IHD is used for patients who are stable hemodynamically. A trial of withholding IHD and CRRT should be considered when the kidney function starts to improve as noted by improvements in urine output, fluid status, and electrolytes. It can be discontinued when the kidney function has improved to a point that fluid status and electrolytes are stable without it.[5]

The KDIGO recommends an uncuffed nontunneled dialysis catheter in the jugular or femoral vein.[5] The subclavian vein should be avoided because it may lead to central vein stenosis. If RRT will be needed for more than 1 to 3 weeks, a tunneled dialysis catheter is indicated to prevent infection and maintain stability of the catheter.[5]

Palliative Care

Palliative care should be considered in the patient with multiple comorbidities who is not responding to supportive care and/or RRT. For adequate decision making, the patient and family need to be counseled on the probability of kidney recovery, survival prediction, and quality of life. The medical team, patient, and family need to agree on realistic treatment goals of care.[21]

Prognosis

Patients with AKI are at increased risk of developing CKD, end-stage renal disease, and premature death. An estimated 2 million people worldwide die from AKI every year.[22] Patient outcomes progressively worsen with a higher severity of AKI. For these reasons, a patient with 1 episode of AKI should be closely monitored for the development or worsening of CKD after discharge.

Outpatient Follow-up

The severity of the AKI episode often assists the provider in determining the frequency of follow-up care.[22] The KDIGO recommends evaluating patients 3 months after the episode for resolution, new onset, or worsening CKD.[5] Nephrology follow-up should be considered for patients with a severe AKI episode, new-onset CKD, or worsening CKD.[22] Nephrotoxic medications should be avoided, and renal dosing is appropriate for patients with CKD.

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