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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

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For the chapters in the Wells Handbook, please go to Chapter 73. Acute Kidney Injury and Chapter 75. Electrolyte Homeostasis.

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KEY CONCEPTS

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KEY CONCEPTS

  • Image not available. Three classification systems exist for staging severity of acute kidney injury (AKI): (a) Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease (RIFLE), (b) Acute Kidney Injury Network (AKIN), and (c) Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines. All three classification systems are based on separate criteria for serum creatinine (Scr) and urine output.

  • Image not available. AKI is a common complication in critically ill patients and is associated with high morbidity and mortality.

  • Image not available. AKI has traditionally been categorized based on three types of injury: (a) prerenal—decreased renal blood flow, (b) intrinsic—structural damage within the kidney, and (c) postrenal—an obstruction within the urine collection system. However, recent advances in early detection of AKI with the availability of novel biomarkers has challenged this traditional classification and instead suggested distinguishing AKI in terms of functional change versus kidney damage.

  • Image not available. Conventional formulas used to estimate glomerular filtration rate (eGFR) and creatinine clearance should not be used to estimate kidney function and adjust medication regimens in AKI patients.

  • Image not available. The most effective prevention strategies for AKI include limiting exposure to nephrotoxic medications and maintaining adequate hydration with isotonic fluids.

  • Image not available. Supportive management remains the primary approach to prevent or reduce complications associated with AKI or comorbid conditions. Supportive therapies include renal replacement therapy (RRT), nutritional support, avoidance of nephrotoxins, and blood pressure and fluid management.

  • Image not available. For patients with prolonged or severe AKI, RRT is the cornerstone of support along with aggressive fluid and electrolyte management.

  • Image not available. Drug dosing for AKI patients receiving continuous renal replacement therapy (CRRT) or sustained low-efficiency dialysis (SLED) is poorly characterized. Dosing requirements of agents primarily eliminated by the kidney may require individualization and require adjustment as renal function declines, and then subsequently increase as AKI resolves. Therapeutic drug monitoring should be utilized whenever possible for any agent with a narrow therapeutic index.

  • Image not available. Diuretic resistance is a common phenomenon in the AKI patient and can be addressed with sodium restriction, combination diuretic therapy, or a continuous infusion of a loop diuretic.

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Acute kidney injury (AKI) is a clinical syndrome generally defined by an abrupt reduction in kidney function as evidenced by changes in, serum creatinine (Scr), blood urea nitrogen (BUN), and urine output. The consequences of AKI can be serious, especially in hospitalized patients. Early recognition along with supportive therapy is the focus of management for those with established AKI, as there is no therapy that directly reverses the injury. Individuals at risk, such as those with history of chronic kidney disease (CKD), need to have their hemodynamic status carefully monitored and their exposure to nephrotoxins minimized. A thorough patient assessment including medical and surgical history, medication use, physical examination, and multiple laboratory tests is essential. Management goals include maintenance ...

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