GFR Criteria Urine output criteria

1 Increased creatinine x1.5-

1.9 from baseline or

≥ 0.3 mg/dl

UO <0.5ml/kg/hr for 6-

12hr

2 Increased creatinine x2.0-

2.9 from baseline

UO <0.5ml/kg/hr ≥ 12h

3 Increased creatinine x3

from baseline OR SCr ≥

4.0mg/dl OR RRT

UO < 0.3 ml/kg/hr for

≥ 24h

or anuria ≥ 12h

Diagnostic criteria for AKI:

•SCr increase ≥0.3mg/dl within 48h OR

•SCr increase ≥1.5 times baseline, which is known or

presumed to have occurred within the last 7 days OR

•Urine volume < 0.5 ml/kg for 6h

OB Considerations

• CKD affects an estimated 3% of pregnant women

• Physiologic changes in pregnancy make defining and measuring

AKI challenging

• Anesthetic considerations should be tailored to physiologic

changes in kidney disease: increased risks of bleeding, aspiration

pneumonitis, and difficult airway

15,16

• Avoidance of nephrotoxic drugs

Cardiac Considerations

• 25-50% of patients develop AKI after cardiac surgery

17,18,19,20

• Cardiopulmonary bypass introduces insults to kidneys: non-

pulsatile blood flow, hemodilution, hemolysis releases of free

hemoglobin & iron, hypothermia

.21

• Assess patient risk factors

, maintain glucose (<180mg/dL)

23-

, hold ACE and ARBs

28-29

, avoid hypotension using

vasopressors and balanced crystalloids

21,30

, monitor serum

creatinine and urine output postoperatively to recognize

AKI.

Pediatric Considerations

• It is difficult to determine rates of AKI incidence among children and

neonates due to the lack of a standardized AKI definition.

31-32

• Avoid Nephrotoxic drugs such as antimicrobials, contrast and NSAIDs

in patients at increased risk for AKI.

• 86% of children with congenital heart disease undergoing cardiac

surgery have postoperative AKI

• Maintain normovolemic state during surgery to reduce incidence of

postoperative AKI: Overtransfusion of blood products is predictive of

developing AKI. Hypovolemia causing decreased perfusion to kidneys

causes renal ischemic damage.

Perioperative

Acute Kidney

Injury Prevention

•Patient risk factors

•Procedural risk factors

•Intraoperative risk

•Antimicrobials, contrast,

NSAIDs

3,4,5

•Contributing factors:

hypovolemia,

venodilation from

anesthetics, PPV,

inflammation

•<180mg/dL

•KDIGO Criteria

Patient Risk Factors

2,9,10,11

Preexisting kidney disease • Chronic vascular disease

• Cardiac failure/decompensation • Diabetes •

Mechanical ventilation • Major surgery • HTN • PVD

• CHF • Sepsis • Ascites • Cerebrovascular disease •

Renal insufficiency • Age >65 • CKD • COPD • BMI

Intraoperative Risk Factors

10,11,12

•Hemodilution, HGB level, transfusion,

inadequate O2 delivery, diruetics,

vasopressors and inotropes, selective renal

ischemia reperfusion injury, intraoperative

hypertension

Other Procedural Factors

10,11,12

•Duration of surgery, intraperitoneal surgery,

transplantation of solid nonrenal organs,

hemodilution, use of intraaortic balloon pump,

intraabdominal hypertension, emergency surgery,

bleeding complications

KDIGO

For more information, see complete

Avoiding Kidney Injury Toolkit at

https://mpog.org/quality/toolkits/

References

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3. Zhang, Xinyu, Peter T. Donnan, Samira Bell, and Bruce Guthrie. 2017. “Non-Steroidal Anti-Inflammatory Drug Induced Acute Kidney Injury in the Community Dwelling General Population and People with Chronic Kidney Disease: Systematic Review and Meta-Analysis.” BMC

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