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editorial
. 2020 Apr 13;9(4):1104. doi: 10.3390/jcm9041104

Table 7.

AKI prevention measures.

General Measures
Identify patients at risk
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    Personal risks: older age, history of CKD, diabetes, dementia, coronary artery disease.

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    Related to clinical scenario: reason for admission, severity of illness, ICU stay, and recurrent hospitalizations.
Use of Clinical decision support systems (CDSS)
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    Electronic-based alert systems in the hospitals have shown to improve the detection of AKI.
Maintain euvolemia
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    Use intravenous fluids if hypovolemia is anticipated in clinical settings such as poor oral intake, vomiting, diarrhea, polyuria, etc.

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    Avoid starches for volume resuscitation

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    Avoid volume overload by discontinuing fluids when appropriate.
Avoid nephrotoxic medications.
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    Discontinue medications such as NSAIDs

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    Avoid ACE/ARB inhibitors (controversial) which affect the hemodynamics of the kidneys.

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    Avoid nephrotoxic antibiotics such as aminoglycosides, amphotericin and vancomycin. If their use is necessary, monitor levels if appropriate.

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    Utilize minimal dose and for the shortest time possible.
Judicious use of contrasted studies
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    Outweigh risks vs. benefits of contrasted studies. Intra-arterial pose a higher risk than intravenous contrasted studies.
Avoid hypotension
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    Decrease in renal blood flow is a known risk factor for AKI. It is therefore imperative to keep MAP >65 (target 65–70 mmHg), and a higher target (80–85 mmHg) in chronically hypertensive patients.

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    If vasopressors are too be used in the ICU, norepinephrine should be the first-choice to protect kidney function.
Renal function monitoring
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    Monitor SCr as often as necessary, depending on the risk factors and clinical scenario.

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    Monitor fluid input and urinary output.
Specific Clinical Scenarios
Patients undergoing a procedure needing IV contrast use
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    Discontinue nephrotoxic medications

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    IV hydration with intravenous isotonic saline at a rate of 1 to 1.5 mL per kilogram per hour for 12 h before and up to 24 h after the procedure. A shorter protocol for patients undergoing urgent procedures comprises an intravenous infusion of isotonic saline for 1 to 3 h before and 6 h after the procedure.

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    Recent data does not support the use of IV bicarbonate or N-acetyl cysteine.

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    Utilize low-osmolar or iso-osmolar contrast media.

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    Minimize contrast volume (<350 mL or <4 mL per kilogram)
Traumatic and non-traumatic rhabdomyolysis
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    Early and aggressive volume expansion with isotonic solutions aimed at increasing urine flow (about 200–300 mL/h).

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    Use of bicarbonate is not evidence based and might precipitate metastatic tissue calcification and ionized hypocalcemia

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    Use of diuretics is not generally recommended.
Patients undergoing cardiac surgery Preoperative:
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    Perform pre-operative AKI stratification.

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    Delay elective surgeries if current AKI and delay 24–72 h after contrast use.

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    Discontinue ACE/ARB (controversial)

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    Discontinue NSAIDs.

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    Limited use of blood transfusions.

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    Correcting hypoalbuminemia with exogenous albumin preoperatively may play a role in preventing AKI.

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    Use of balanced crystalloid solutions guided by measures of fluid responsiveness.

Intraoperative
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    Cold perfusion of the kidneys during aortic aneurysm repair

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    Avoidance of hyperthermia.

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    Pulsatile Cardiopulmonary bypass.

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    Avoidance of hemodilution.

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    Use of volatile anesthetics.

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    Minimization of aortic manipulation.

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    Techniques to prevent procedure-related atheroembolism.

Postoperative
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    Low tidal volume strategy.

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    General measures mentioned above.

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    Glucose control (target 127–179 mg/dL).

AKI; acute kidney injury; CKD, chronic kidney disease; ICU, intensive care unit; NSAIDs, nonsteroidal anti-inflammatory drugs; SCr, serum creatinine; ACE, angiotensin converting enzyme; ARB, angiotensin-receptor blocker; MAP, mean arterial pressure; IV, intravenous.