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Acute kidney injury

2012; Elsevier BV; Volume: 380; Issue: 9857 Linguagem: Inglês

10.1016/s0140-6736(12)62104-7

1474-547X

Athanasios Chalkias, Theodoros Xanthos,

Acute Kidney Injury Research

The Seminar on acute kidney injury (AKI) by Rinaldo Bellomo and colleagues (Aug 25, p 756)1Bellomo R Kellum JA Ronco C Acute kidney injury.Lancet. 2012; 380: 756-766Summary Full Text Full Text PDF PubMed Scopus (1032) Google Scholar is excellent. AKI is typically diagnosed by the accumulation of end products of nitrogen metabolism, decreased urine output, or both.2Bellomo R Ronco C Kellum JA Mehta RL Palevsky P Acute Dialysis Quality Initiative workgroupAcute renal failure–definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the Acute Dialysis Quality Initiative Group.Crit Care. 2004; 8: R204-R212Crossref PubMed Google Scholar In the presence of decreased urine output, however, the diagnosis of AKI should be established only in the absence of increased intra-abdominal pressure.Intra-abdominal hypertension and abdominal compartment syndrome are severe complications present in about 30–50% of mechanically ventilated patients in intensive-care units.3Hedenstierna G Larsson A Influence of abdominal pressure on respiratory and abdominal organ function.Curr Opin Crit Care. 2012; 18: 80-85Crossref PubMed Scopus (37) Google Scholar Patients with high intra-abdominal pressure can present with oliguria or anuria owing to direct mechanical pressure and increased renal venous pressure, which could be incorrectly interpreted as AKI. The term AKI implies that a continuum of kidney injury exists that begins long before loss of excretory kidney function can be measured with standard laboratory tests.Furthermore, in patients with left-ventricular failure and increased intra-abdominal pressure, the elevated haemodynamic variables, together with oliguria, could be incorrectly interpreted as fluid overload, resulting in increased use of diuretics, decreased renal arterial blood flow, and, ultimately, AKI or further deterioration of the already compromised renal function. Additionally, in normovolaemic patients with increased gut permeability and intra-abdominal pressure, oliguria could be attributed to decreased endovascular volume, which might be treated with additional fluids, exacerbating visceral oedema and perhaps leading to decreased glomerular blood flow.4Malbrain ML Chiumello D Pelosi P et al.Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study.Crit Care Med. 2005; 33: 315-322Crossref PubMed Scopus (552) Google Scholar, 5Ball CG Kirkpatrick AW McBeth P The secondary abdominal compartment syndrome: not just another post-traumatic complication.Can J Surg. 2008; 51: 399-405PubMed Google ScholarIntra-abdominal hypertension must be taken into account during any exploration of the cause of oliguria and should always be excluded before the diagnosis of AKI.We declare that we have no conflicts of interest. The Seminar on acute kidney injury (AKI) by Rinaldo Bellomo and colleagues (Aug 25, p 756)1Bellomo R Kellum JA Ronco C Acute kidney injury.Lancet. 2012; 380: 756-766Summary Full Text Full Text PDF PubMed Scopus (1032) Google Scholar is excellent. AKI is typically diagnosed by the accumulation of end products of nitrogen metabolism, decreased urine output, or both.2Bellomo R Ronco C Kellum JA Mehta RL Palevsky P Acute Dialysis Quality Initiative workgroupAcute renal failure–definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the Acute Dialysis Quality Initiative Group.Crit Care. 2004; 8: R204-R212Crossref PubMed Google Scholar In the presence of decreased urine output, however, the diagnosis of AKI should be established only in the absence of increased intra-abdominal pressure. Intra-abdominal hypertension and abdominal compartment syndrome are severe complications present in about 30–50% of mechanically ventilated patients in intensive-care units.3Hedenstierna G Larsson A Influence of abdominal pressure on respiratory and abdominal organ function.Curr Opin Crit Care. 2012; 18: 80-85Crossref PubMed Scopus (37) Google Scholar Patients with high intra-abdominal pressure can present with oliguria or anuria owing to direct mechanical pressure and increased renal venous pressure, which could be incorrectly interpreted as AKI. The term AKI implies that a continuum of kidney injury exists that begins long before loss of excretory kidney function can be measured with standard laboratory tests. Furthermore, in patients with left-ventricular failure and increased intra-abdominal pressure, the elevated haemodynamic variables, together with oliguria, could be incorrectly interpreted as fluid overload, resulting in increased use of diuretics, decreased renal arterial blood flow, and, ultimately, AKI or further deterioration of the already compromised renal function. Additionally, in normovolaemic patients with increased gut permeability and intra-abdominal pressure, oliguria could be attributed to decreased endovascular volume, which might be treated with additional fluids, exacerbating visceral oedema and perhaps leading to decreased glomerular blood flow.4Malbrain ML Chiumello D Pelosi P et al.Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study.Crit Care Med. 2005; 33: 315-322Crossref PubMed Scopus (552) Google Scholar, 5Ball CG Kirkpatrick AW McBeth P The secondary abdominal compartment syndrome: not just another post-traumatic complication.Can J Surg. 2008; 51: 399-405PubMed Google Scholar Intra-abdominal hypertension must be taken into account during any exploration of the cause of oliguria and should always be excluded before the diagnosis of AKI. We declare that we have no conflicts of interest. Acute kidney injuryAcute kidney injury (formerly known as acute renal failure) is a syndrome characterised by the rapid loss of the kidney's excretory function and is typically diagnosed by the accumulation of end products of nitrogen metabolism (urea and creatinine) or decreased urine output, or both. It is the clinical manifestation of several disorders that affect the kidney acutely. Acute kidney injury is common in hospital patients and very common in critically ill patients. In these patients, it is most often secondary to extrarenal events. Full-Text PDF Acute kidney injury – Authors' replyWe appreciate the concerns expressed by Athanasios Chalkias and Theodoros Xanthos about the role of increased intra-abdominal pressure in the pathogenesis of acute kidney injury (AKI), and indeed mention this possibility in our Seminar.1 However, as shown in a prospective investigation,2 although increased intra-abdominal pressure is common in patients in intensive care, its clinical meaning and renal consequences remain unclear in the absence of a full abdominal compartment syndrome. Therefore, we argue that routine measurement of intra-abdominal pressure is not justified unless intra-abdominal compartment syndrome seems clinically likely and renal function is being rapidly lost. Full-Text PDF