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Acute kidney injury

Nature Reviews Disease Primers volume 7, Article number: 52 (2021) Cite this article

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Abstract

Acute kidney injury (AKI) is defined by a sudden loss of excretory kidney function. AKI is part of a range of conditions summarized as acute kidney diseases and disorders (AKD), in which slow deterioration of kidney function or persistent kidney dysfunction is associated with an irreversible loss of kidney cells and nephrons, which can lead to chronic kidney disease (CKD). New biomarkers to identify injury before function loss await clinical implementation. AKI and AKD are a global concern. In low-income and middle-income countries, infections and hypovolaemic shock are the predominant causes of AKI. In high-income countries, AKI mostly occurs in elderly patients who are in hospital, and is related to sepsis, drugs or invasive procedures. Infection and trauma-related AKI and AKD are frequent in all regions. The large spectrum of AKI implies diverse pathophysiological mechanisms. AKI management in critical care settings is challenging, including appropriate volume control, nephrotoxic drug management, and the timing and type of kidney support. Fluid and electrolyte management are essential. As AKI can be lethal, kidney replacement therapy is frequently required. AKI has a poor prognosis in critically ill patients. Long-term consequences of AKI and AKD include CKD and cardiovascular morbidity. Thus, prevention and early detection of AKI are essential.

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Fig. 1: Relationship between AKI, AKD, CKD and NKD.
Fig. 2: Consequences of AKI on kidney lifespan.
Fig. 3: Systemic consequences of AKI.
Fig. 4: Main principles of the pathophysiology of AKI.
Fig. 5: Severity of AKI and long-term kidney outcome.
Fig. 6: Fluid management in acute kidney injury.
Fig. 7: Management of AKI.

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Acknowledgements

The European Research Council under the Consolidator Grant RENOIR supported P.R. (ERC-2014-CoG, grant number 648274). The Deutsche Forschungsgemeinschaft supported H.-J.A. (AN372/14-4, AN372/16-2, AN372/20-2, AN372/27-1 and AN372/30-1) and A.Z. (KFO342/1, ZA428/18-1 and ZA428/21-1). J.A.K. is supported by a grant (UH3DK114861) from the National Institute of Diabetes and Kidney Disease (NIDDK).

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Authors and Affiliations

  1. Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    John A. Kellum

  2. Nephrology and Dialysis Unit, Meyer Children’s University Hospital, Florence, Italy

    Paola Romagnani

  3. Faculty of Medicine and Biomedical Sciences, Yaounde General Hospital, University of Yaounde, Yaounde, Cameroon

    Gloria Ashuntantang

  4. Department of Medicine, University of Padova, Padua, Italy

    Claudio Ronco

  5. Department of Nephrology, Dialysis and Kidney Transplant, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy

    Claudio Ronco

  6. Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany

    Alexander Zarbock

  7. Division of Nephrology, Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany

    Hans-Joachim Anders

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  1. John A. Kellum
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Contributions

Sections of the Primer were written by the authors as follows: Introduction (H.-J.A., J.A.K.); Epidemiology (H.-J.A., J.A.K., G.A.); Mechanisms/pathophysiology (P.R., H.-J.A.); Diagnosis, screening and prevention (H.-J.A., A.Z.); Management (H.-J.A., J.A.K., C.R.); Quality of life (H.J.A.); Outlook (H.-J.A., P.R.); Overview of the Primer (H.-J.A.).

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Correspondence to Hans-Joachim Anders.

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Competing interests

H.-J.A. received consultancy fees from Bayer, Boehringer, AstraZeneca, Janssen, Novartis, GlaxoSmithKline, Previpharma, Inositec and Secarna, unrelated to this publication. J.A.K. received consulting fees and/or grant support from Baxter, NxStage and Astute Medical/BioMerieux. J.A.K. became a full-time employee of Spectral Medical after submission of this manuscript. C.R. has been consulting or part of advisory boards for Asahi Kasei Pharma, Astute, Baxter, Biomerieux, B. Braun, Cytosorbents, Estor, Fresenius Medical Care, General Electric, Jafron, Medtronic and Toray. A.Z. has received consulting and/or lecture fees from Astute Medical/BioMerieux, Fresenius, Baxter, AM Pharma, La Jolla Pharmaceuticals and Astellas. A.Z. has received grant support from Astute Medical/BioMerieux, unrelated to this publication. G.A. and P.R. declare no competing interests.

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Nature Reviews Disease Primers thanks M. Ostermann, R. Evans, E. Daher, who co-reviewed with G. C. Meneses, K. Doi, J. Prowle, S. Menez, D. Ponce, and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Supplementary information

Glossary

Hepatorenal syndrome

Impaired kidney perfusion and function in patients with advanced liver failure as a consequence of marked abnormalities in arterial and venous circulation, as well as overactivity of endogenous vasoactive systems.

Kidney failure

Complete (and life-threatening) loss of kidney function; kidney failure replaces the term end-stage kidney disease in new nomenclature put forward by the KDIGO.

Glomerular filtration rate

The volume of filtrate passing the glomerular filtration barrier per unit of time; a marker of excretory kidney function.

Third-space effusions

Accumulation of fluid in body cavities.

Pulmonary congestion

An accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxaemia.

Fixed acid

An acid that accumulates in the body as a result of digestion, disease or metabolism and cannot be excreted by the lungs (non-volatile or fixed).

Anion gap

The difference between the sum of routinely measured cations (Na+ and K+) and the sum of routinely measured anions (Cl− and HCO3−) in serum.

Azotaemia

Abnormally high levels of nitrogen-containing compounds in the blood, occurring when the kidneys are no longer able to excrete nitrogen waste products via the urine.

Venous congestion

A distention of veins filled with blood as a result of mechanical obstruction or right ventricular failure.

Acute tubular necrosis

A form of AKI that involves loss of entire tubule segments due to necrotic death of tubular epithelial cells.

Fluid resuscitation

Large-volume intravenous fluid replacement to treat AKI and circulatory shock due to severe intravascular volume depletion.

G1 phase

The G1 phase is the first of four cell cycle phases that takes place in eukaryotic cell division and describes the period from the end of cell division to the beginning of DNA replication.

Peritoneal dialysis

A treatment for kidney failure that uses the inside lining of the abdomen as a filtration membrane via intermittent filling and emptying of the peritoneal cavity with a dialysate solution to extract salt, uraemic toxins and other solutes from the blood.

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Kellum, J.A., Romagnani, P., Ashuntantang, G. et al. Acute kidney injury. Nat Rev Dis Primers 7, 52 (2021). https://doi.org/10.1038/s41572-021-00284-z

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