KDIGO

GUIDELINES FOR
ACUTE KIDNEY INJURY
A Quick Reference Guide
About The Quick Reference
The 2012 Kidney Disease: Improving Global Outcomes (KDIGO)
Clinical Practice Guideline for acute kidney injury (AKI)1 aims to
assist practitioners caring for adults and children at risk for or
with AKI. Guideline development followed an explicit process of
evidence review and appraisal.

Guideline recommendations are based on systematic reviews of

relevant trials. Appraisal of the quality of the evidence and the
strength of recommendations followed the GRADE approach.

This Quick Reference Guide contains a number of important

recommendations that have been extracted directly from the
published KDIGO Guidelines. For the full version of the KDIGO
Guidelines, please visit www.kdigo.com.
Guideline Rating Nomenclature
Within each recommendation, the strength of recommendation is
indicated as Level 1, Level 2, or Not Graded, and the quality of the
supporting evidence is shown as A, B, C, or D. The implications of the
recommendation for clinicians and the meaning of the assigned quality of
evidence are as follows*:

Grade** Clinicians
Level 1 Most patients should receive the recommended course
‘‘We recommend’’ of action.
Level 2 Different choices will be appropriate for different patients.
‘‘We suggest’’ Each patient needs help to arrive at a management
decision consistent with her or his values and
preferences.
 Grade Quality of evidence Meaning
A High We are confident that the true effect lies
close to that of the estimate of the effect.
B Moderate The true effect is likely to be close to
the estimate of the effect, but there is a
possibility that it is substantially different.
C Low The true effect may be substantially different
from the estimate of the effect.
D Very low The estimate of effect is very uncertain, and
often will be far from the truth.
*Please refer to the Guideline for the implications of the recommendation for patients and for policy

**The additional category ‘‘Not Graded’’ was used, typically, to provide guidance based on common sense or where
the topic does not allow adequate application of evidence. The most common examples include recommendations
regarding monitoring intervals, counseling, and referral to other clinical specialists. The ungraded recommendations
are generally written as simple declarative statements, but are not meant to be interpreted as being stronger
recommendations than Level 1 or 2 recommendations.
Definitions
CRRT - Continuous Renal Replacement Therapy
RRT - Renal Replacement Therapy

AKI Definitions
2.1.1: AKI is defined as any of the following
(Not Graded):
• Increase in SCr by ≥ 0.3 mg/dl
(≥ 26.5 μmol/l) within 48 hours; OR
• Increase in SCr to ≥ 1.5 times baseline,

which is known or presumed to have
occurred
within prior 7 days; OR

• Urine volume <0.5 ml/kg/h for 6 hours
Staging
2.1.2: A
 KI is staged for severity according to the following criteria (below).
(Not Graded)
Staging of AKI
Stage Serum Creatinine Urine Output

1 1.5-1.9 times baseline OR <0.5 ml/kg/h for 6-12 hours

≥0.3 mg/dl (≥ 26.5 μmol/l) increase

2 2.0-2.9 times baseline <0.5 ml/kg/h for ≥12 hours

3 3.0 times baseline OR increase <0.3 ml/kg/h for ≥ 24 hours

in serum creatinine to ≥4.0 mg/dl OR Anuria for ≥ 12 hours
(≥353.6 μmol/l) OR initiation of renal
replacement therapy OR, in patients
<18 years, decrease in eGFR to <35
ml/min per 1.73 m2
AKI Stage: High Risk 1
Stage-based Discontinue all nephrotoxic agents when possible
management of AKI Ensure volume status and perfusion pressure
Shading of boxes Consider functional hemodynamic monitoring
indicates priority of
action—solid shading Monitor Serum creatinine and urine output
indicates actions that Avoid hyperglycemia
are equally appropriate Consider alternatives to radiocontrast procedures
at all stages whereas Non-invasive diagnostic
graded shading
Consider invasive diagn
indicates increasing
priority as intensity
increases.
 2 3

c workup
nostic workup
Check for changes in drug dosing
Consider Renal Replacement Therapy
Consider ICU admission
Avoid subclavian catheters if possible
RRT Use
5.1.1: Initiate RRT emergently when life-threatening changes in fluid,
electrolyte, and acid-base balance exist. (Not Graded)

5.1.2: C
 onsider the broader clinical context, the presence of conditions
that can be modified with RRT, and trends of laboratory tests—rather
than single BUN and creatinine thresholds alone—when making the
decision to start RRT. (Not Graded)

5.2.1: D
 iscontinue RRT when it is no longer required, either because intrinsic
kidney function has recovered to the point that it is adequate to meet
patient needs, or because RRT is no longer consistent with the goals of
care. (Not Graded)

5.2.2: W
 e suggest not using diuretics to enhance kidney function
recovery, or to reduce the duration or frequency of RRT. (2B)
RRT Anticoagulation
5.3.1: In a patient with AKI requiring RRT, base the decision to use
anticoagulation for RRT on assessment of the patient’s potential
risks and benefits from anticoagulation (see flow chart on next page).
(Not Graded)

5.3.1.1: W
 e recommend using anticoagulation during RRT in AKI
if a patient does not have an increased bleeding risk or
impaired coagulation and is not already receiving systemic
anticoagulation. (1B)

Some of the uses of the products described in the KDIGO guidelines have not been
approved or cleared by the FDA. For example, citrate has not been approved for
use as an anticoagulant for CRRT in the United States.
5.3.2: F
 or patients without an increased bleeding risk or impaired
coagulation and not already receiving effective systemic
anticoagulation, we suggest the following:

5.3.2.1: F
 or anticoagulation in intermittent RRT, we recommend using
either unfractionated or low-molecular-weight heparin, rather
than other anticoagulants. (1C)

5.3.2.2: F
 or anticoagulation in CRRT, we suggest using regional citrate
anticoagulation rather than heparin in patients who do not
have contraindications for citrate. (2B)

5.3.2.3: F
 or anticoagulation during CRRT in patients who have
contraindications for citrate, we suggest using either
unfractionated or low-molecular-weight heparin, rather than
other anticoagulants. (2C)
5.3.3: F
 or patients with increased bleeding risk who are not receiving
anticoagulation, we suggest the following for anticoagulation during
RRT:

5.3.3.1: W
 e suggest using regional citrate anticoagulation, rather
than no anticoagulation, during CRRT in a patient without
contraindications for citrate. (2C)

5.3.3.2: W
 e suggest avoiding regional heparinization during CRRT in
a patient with increased risk of bleeding. (2C)
Flow-chart summary
of recommendations
regarding RRT
anticoagulation.
Heparin includes low-
molecular-weight or Rec. 5.3.1.1
unfractionated heparin.
NO Underlying condition NO
Impaired requires systemic
coagulation? anticoagulation?
YES
YES

Proceed without
anticoagulation Use anticoagulation
adapted to this
condition
 Rec. 5.3.2.1 NO
Heparin
Increased
Intermittent RRT
bleeding risk?
Proceed without
YES anticoagulation

Choose RRT
Modality
Rec. 5.3.2.2 & 5.3.3.1 Rec. 5.3.2.3 Rec. 5.3.3.2
YES YES
CRRT Contraindications Increased Proceed without
for citrate? bleeding risk? anticoagulation

NO NO

Regional citrate Heparin

anticoagulation
Vascular Access
5.4.1: W
 e suggest initiating RRT in patients with A C
AKI via an uncuffed nontunneled dialysis
D
catheter, rather than a tunneled catheter. (2D)

5.4.2: W
 hen choosing a vein for insertion of a
dialysis catheter in patients with AKI,
consider these preferences (Not Graded):
A. First choice: right jugular vein;
B. Second choice: femoral vein;
C. Third choice: left jugular vein;
B
D. Last choice: subclavian vein with
preference for the dominant side.
RRT Modality
5.6.1: U
 se continuous and intermittent RRT as complementary therapies
in AKI patients. (Not Graded)

5.6.2: W
 e suggest using CRRT, rather than standard intermittent RRT, for
hemodynamically unstable patients. (2B)

5.6.3: W
 e suggest using CRRT, rather than intermittent RRT, for AKI
patients with acute brain injury or other causes of increased
intracranial pressure or generalized brain edema. (2B)
RRT Solutions
5.7.1: W
 e suggest using bicarbonate, rather than lactate, as a buffer in
dialysate and replacement fluid for RRT in patients with AKI. (2C)

5.7.2: W
 e recommend using bicarbonate, rather than lactate, as a buffer
in dialysate and replacement fluid for RRT in patients with AKI and
circulatory shock. (1B)

5.7.3: W
 e suggest using bicarbonate, rather than lactate, as a buffer in
dialysate and replacement fluid for RRT in patients with AKI and liver
failure and/or lactic acidemia. (2B)
RRT Dosing
5.8.1: T
 he dose of RRT to be delivered should be prescribed before
starting each session of RRT. (Not Graded) We recommend
frequent assessment of the actual delivered dose in order to
adjust the prescription. (1B)

5.8.2: P
 rovide RRT to achieve the goals of electrolyte, acid-base, solute,
and fluid balance that will meet the patient’s needs. (Not Graded)

5.8.3: W
 e recommend delivering a Kt/V of 3.9 per week when using
intermittent or extended RRT in AKI. (1A)

5.8.4: W
 e recommend delivering an effluent volume of 20–25 ml/kg/h for
CRRT in AKI (1A). This will usually require a higher prescription of
effluent volume. (Not Graded)
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