From the Guidelines
Acute on chronic kidney disease (AKD on CKD) is a serious condition that requires prompt recognition and intervention to prevent progression to end-stage kidney disease, cardiovascular events, and mortality. The key features of AKD on CKD include a rapid increase in serum creatinine, decreased urine output, fluid overload, electrolyte abnormalities, metabolic acidosis, and uremic symptoms 1. Management of AKD on CKD involves identifying and treating the precipitating cause, discontinuing nephrotoxic medications, adjusting medication dosages, maintaining euvolemia, and monitoring electrolytes closely 1. Some of the key considerations in managing AKD on CKD include:
- Identifying the underlying cause of the acute kidney injury, such as dehydration, infection, or medication toxicity 1
- Temporarily discontinuing nephrotoxic medications, including NSAIDs and certain antibiotics 1
- Adjusting medication dosages based on reduced kidney function 1
- Maintaining euvolemia with careful fluid management 1
- Monitoring electrolytes closely to prevent complications such as hyperkalemia and hypocalcemia 1 The condition carries worse outcomes than either acute kidney injury in previously normal kidneys or stable CKD, with higher risks of progression to end-stage kidney disease, cardiovascular events, and mortality 1. Therefore, prompt recognition and intervention are essential to improve outcomes in patients with AKD on CKD. It is also important to note that the definition of recovery from AKI or AKD is not standardized, and further work is warranted to delineate the epidemiology of AKD, including differences in the predictors, course, and outcomes relative to AKI 1. In clinical practice, the focus should be on preventing progression to end-stage kidney disease and reducing the risk of cardiovascular events and mortality. This can be achieved by providing timely and appropriate management, including identifying and treating the underlying cause, discontinuing nephrotoxic medications, adjusting medication dosages, maintaining euvolemia, and monitoring electrolytes closely 1.
From the Research
Acute on CKD Features
- Acute on chronic kidney disease (CKD) refers to the sudden worsening of renal function in patients with pre-existing CKD, which can lead to long-term kidney dysfunction and potentially end-stage kidney disease (ESKD) 2.
- The development of acute-on-chronic kidney dysfunction is often caused by systemic illness or toxic exposure, and determining the underlying cause is critical for management 3.
- Patients with CKD are at high risk for developing critical illness and requiring admission to intensive care units (ICU), where they may require acute renal replacement therapy 2.
Clinical Presentations and Management
- Acute kidney injury (AKI) is characterized by an abrupt decrease in renal function, and its severity is determined by the degree of serum creatinine increase or decrease in urine output 3.
- The management of AKI includes controlling the underlying cause, achieving and maintaining euvolemia, nutritional optimization, blood glucose control, and pharmacotherapy 3.
- The furosemide stress test (FST) can be used to predict the progression of AKI in critically ill patients, with a urinary flow rate of less than 200mls in the first 2 hours after the test being predictive of progression to stage III AKI 4.
Treatment Options
- Hyperkalemia is a life-threatening emergency that requires immediate treatment, and options include restriction and binding of dietary potassium, correction of metabolic acidosis, and increasing urinary excretion with furosemide 5.
- Salbutamol has been shown to be an effective agent in treating hyperkalemia by inducing a shift of potassium into the intracellular compartment 5.
- Small doses of furosemide can be used in chronic kidney disease patients with residual renal function undergoing hemodialysis to increase urinary volume and sodium excretion 6.