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Content Update

May 15, 2018

Impact of Electronic Alerts on Detection and Course of Acute Kidney Injury: A single-center Korean quality improvement study evaluated the effect of an electronic medical record (EMR) acute kidney injury (AKI) alert system with automated recommendations for nephrologist consultation on the detection, course, and outcome of AKI events. Compared to historical controls, patients evaluated when the alert system was in place were less likely to receive no nephrology consult, and consults were more likely to occur early. Patients were also more likely to have AKI detected, have less severe AKI, and have better overall recovery at 30 days. The alert system had no effect on 30-day mortality. Although the study had important limitations, an EMR alert system with automated recommendation for nephrology consults shows promise for improved detection and management of AKI.


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



  • image 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 AKI is a common complication in critically ill patients and is associated with high morbidity and mortality.

  • image 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 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 The most effective prevention strategies for AKI include limiting exposure to nephrotoxic medications and maintaining adequate hydration with isotonic fluids.

  • image 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 For patients with prolonged or severe AKI, RRT is the cornerstone of support along with aggressive fluid and electrolyte management.

  • image 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 Diuretic resistance is a common phenomenon in the AKI patient ...

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