Login to MyKarger

New to MyKarger? Click here to sign up.



Login with Facebook

Forgot your password?

Authors, Editors, Reviewers

For Manuscript Submission, Check or Review Login please go to Submission Websites List.

Submission Websites List

Institutional Login
(Shibboleth or Open Athens)

For the academic login, please select your country in the dropdown list. You will be redirected to verify your credentials.

Editorial - Role of the Nephrologist in Multidisciplinary Management of AKI

Free Access

Critical Care Nephrology: A Multidisciplinary Approach

Rizo-Topete L.a, c · Ronco C.a-c

Author affiliations

aInternational Renal Research Institute of Vicenza (IRRIV), and bDepartment of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy; cNephrology Department, Hospital Universitario ‘José Eleuterio González', Monterrey, Mexico

Corresponding Author

Claudio Ronco, MD

Department of Nephrology, Dialysis and Transplantation

International Renal Research Institute of Vicenza (IRRIV)

San Bartolo Hospital, Viale Rodolfi, 37, IT-36100 Vicenza (Italy)

E-Mail cronco@goldnet.it

Related Articles for ""

Blood Purif 2017;43:53-56

Abstract

Acute kidney injury (AKI) is a serious medical condition affecting millions of people. Patients in intensive care unit (ICU) who develop AKI have increased morbidity and mortality, prolonged length of stay in ICU and hospital and increased costs, especially when they require renal replacement therapy. In the latter case, morbidity and mortality increase further. In order to meet the needs of the critically ill patients, a multidisciplinary care team is required, combining the efforts of physicians and nurses from different disciplines as well as nephrologists and intensivists. A personalized patient management is strongly recommended as proposed by the recent criteria of precision medicine. Early identification of patients at risk and timely intervention in case of AKI diagnosis can be obtained by integrating the role of nephrologist in the ICU practice. An innovative model of organization by introducing the nephrology rapid response team is advocated to manage critically ill patients with kidney problems in order to make early diagnosis and interventions, to reduce progression toward CKD and improve renal recovery. The routine adoption of AKI biomarkers together with such a collegial teamwork may represent the pathway toward success.

© 2016 S. Karger AG, Basel


Introduction

Acute kidney injury (AKI) is a serious medical condition affecting more than 10 million people around the world [1] The incidence in the intensive care unit (ICU) population is between 20 and 30% depending on the used definition, and more than 10% of all patients admitted to the ICU require renal replacement therapy (RRT) for AKI [2]. The spectrum of AKI has recently expanded to the phase of recovery that may require a follow up for a period as long as 3 months. In this time window, the syndrome is called acute kidney disease (AKD) [3,4].

The Rise of Critical Care Nephrology

The diagnosis and management of AKD is complex and requires a multidisciplinary effort, which is the basis for the new specialty called critical care nephrology (CCN). Not only nephrologists but also critical care physicians, cardiologists and cardiac surgeons should be involved collegially in this endeavor [5].

In fact, a multidisciplinary care team can address the multiple needs of a critically ill patients based on the pathophysiological foundations of the syndrome. In this setting, it is essential to identify the population and the single individual at risk of developing AKI [6,7]. As for mechanical ventilation, the teamwork in CCN could represent a lifesaving approach putting together all the specific knowledge to improve patient outcome.

It has been pointed out in multiple occasions that all ICU patients should be managed together by specialists in a large multidisciplinary department of critical care medicine, with adequate numbers of specially trained intensivists, nurses and other healthcare staff available to deal with all acute problems [8].

How many specialists are needed to effectively treat a critical ill patient? May be it is easier to think about a team with interacting colleagues that can share decisions, accept others points of view and have a well-structured work plan for a complex medical problem. It is almost impossible for a single individual to possess all the knowledge and information necessary to provide optimal therapy [9]. A symphony cannot be played by one individual. It takes an orchestra to play it. We can play different instruments but we need to be on the same key. The fine tuning of this team can be done by the case manager who will be identified among the different physicians of the CCN group.

It should be easy and logical for all members of the team (healthcare personnel) to accept help and advice from others. Joining the different points of view and the various elements of knowledge will help to multiply the understanding of the complex syndrome and will allow to minimize possibility of errors or oversights.

The expertise of the team in different areas of medicine can provide a good balance between effectiveness/experience and the basic principles of medicine, such as quality of care and patient safety, for a final result of good clinical practice and patients' improvement (fig. 1).

Fig. 1

It shows the ideal balance of an expert team with special training.

http://www.karger.com/WebMaterial/ShowPic/528555

In light of the recent recommendation of precision medicine [10,11,12,] a team may better allow targeting treatments specifically chosen for an individual to find the best fit for this specific patient. This will also provide a global vision of the patient rather than an organ-specific interpretation of a syndrome. Physicians should combine knowledge and expertise, be modest and collegial, be constructive and interdisciplinary in their approach to patient care [9].

AKI management is a continuum from detection to treatment, starts with an increase of susceptibility and might end with a complete failure of the organ because the approach of AKI does not often include continuous re-evaluation of treatment and need of RRT [6,13].

Once in ICU, a patient may develop a wide spectrum of AKI conditions: from kidney attack, subclinical AKI and complete AKI from non-severe (no need for RRT, KDIGO stages 1-2) to severe AKI (needs of RRT) [14].

The CCN Team

For all these reasons, we strongly recommend the creation of a CCN team (CCNT) in order to approach common problems in ICU patients such as fluid overload, cardiorenal syndromes and AKI [15] (fig. 2). In this endeavor, the implementation of AKI biomarkers in routine clinical practice may induce ICU physicians to involve nephrologists earlier in these clinical scenarios, not only to help resolving the already established problem, but also to contribute toward implementing preventive and protective measures in order to avoid the onset and progression of organ damage/dysfunction and further complications that may affect patient's quality of life during hospital stay and after discharge.

Fig. 2

The integration of the CCNT. * Nurses from nephrologist department and ICU should also work together as a team.

http://www.karger.com/WebMaterial/ShowPic/528554

Early nephrology consultation for hospital-acquired AKI has been associated with reduced need for RRT, reduced mortality and reduced length of hospital stay [16]. Early identification of AKI may allow the application of protective measures and suitable management, geared to reduce progression and improve renal recovery [6,17]. AKI is a short-term event that can, however, have a sequel up to 3 months or even later (late recovery) [18].

In this view, we strongly advocate the inclusion of nephrology divisions into the critical care and emergency departments rather than in the department of medicine. The need for a nephrologist in the ICU as a permanent staff member could be justified because of the high incidence of AKI. AKI is the most common organ dysfunction in ARDS patients, which increase mortality by 40% [15]. Nephrologists should make rounds in the ICU together with ICU physicians to avoid the development of emergency conditions that require urgent extracorporeal therapies [19,20]. The time of initiation of RRT can therefore be defined by every single patient need (as suggested by precision medicine) rather than being justified by conflicting randomized controlled trials [21,22].

Recently the ADQI consensus group proposed to uniform and harmonize the scientific language concerning RRTs in critically ill patients [23,24,25]. Standardization of terminology is also quintessential for the optimal utilization of big data files and electronic medical records in future pragmatic trials [10]. Clinicians must therefore take advantage of new technology to improve clinical care and patient outcome [6,26].

Conclusion

Previous efforts have been taken to make a consensus about the importance of working together as a team in the area of CCN. Ideally, this approach should provide significant benefits to the critically ill patients.

However, there is still a lot of room for further improvement in many clinical settings to achieve a real implementation of a multidisciplinary approach to AKI, preventive strategies, management options and all actions tailored to specific patient's need or specific disease condition [10].

Standard criteria and decision making algorithms necessary to encompass the variety of factors that can influence clinical outcomes can only be developed in a collegial environment. From our experience in Vicenza, the implementation of the nephrology rapid response team [27] is one of the most advanced applications of the concept of CCN philosophy. We hope that many other centers will implement the same project and will verify the utility of this multidisciplinary approach based on precision medicine.

Disclosure Statement

None of the authors have anything to disclose.


References

  1. Mehta RL, Burdmann EA, Cerda J, Feehally J, Finkelstein F, Garcia-Garcia G, Godin M, Jha V, Lameire NH, Levin NW, Lewington A, Lombardi R, Macedo E, Rocco M, Aronoff-Spencer E, Tonelli M, Zhang J, Remuzzi G: Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study. Lancet 2016;387:2017-2025.
  2. Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, Edipidis K, Forni LG, Gomersall CD, Govil D, Honore PM, Joannes-Boyau O, Joannidis M, Korhonen AM, Lavrentieva A, Mehta RL, Palevsky P, Roessler E, Ronco C, Uchino S, Vazquez JA, Vidal Andrade E, Webb S, Kellum JA: Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med 2015;41:1411-1423.
  3. McCullough P, Zhang J, Ronco C: Intravascular volume expansion for the prevention of contrast-induced acute kidney injury. Lancet 2016, in press.
  4. Ronco C, Ferrari F, Ricci Z: Recovery after acute kidney injury: a new prognostic dimension of the syndrome. Am J Respir Crit Care Med 2016, in press.
  5. Ronco C, Kellum JA, Haase M: Subclinical AKI is still AKI. Crit Care 2012;16:313.
  6. Cerda J, Baldwin I, Honore PM, Villa G, Kellum JA, Ronco C: Role of technology for the management of AKI in critically ill patients: from adoptive technology to precision continuous renal replacement therapy. Blood Purif 2016;42:248-265.
  7. Villa G, Ricci Z, Romagnoli S, Ronco C: Multidimensional approach to adequacy of renal replacement therapy in acute kidney injury. Contrib Nephrol 2016;187:94-105.
  8. Vincent JL: The future of critical care medicine: integration and personalization. Crit Care Med 2016;44:386-389.
  9. Ronco C, Bellomo R: Critical care nephrology: the time has come. Nephrol Dial Transplant 1998;13:264-267.
  10. Kellum JA, Ronco C: The 17th acute disease quality initiative international consensus conference: introducing precision renal replacement therapy. Blood Purif 2016;42:221-223.
  11. Bagshaw SM, Chakravarthi MR, Ricci Z, Tolwani A, Neri M, De Rosa S, Kellum JA, Ronco C: Precision continuous renal replacement therapy and solute control. Blood Purif 2016;42:238-247.
  12. Murugan R, Hoste E, Mehta RL, Samoni S, Ding X, Rosner MH, Kellum JA, Ronco C: Precision fluid management in continuous renal replacement therapy. Blood Purif 2016;42:266-278.
  13. Ronco C: Biomarkers for acute kidney injury: is NGAL ready for clinical use? Crit Care 2014;18:680.
  14. Kellum JA, Murugan R: Effects of non-severe acute kidney injury on clinical outcomes in critically ill patients. Crit Care 2016;20:159.
  15. Husain-Syed F, Birk HW, Seeger W, Ronco C: A protective kidney-lung approach to improve outcomes in mechanically ventilated patients. Blood Purif 2016;42:214-218.
  16. Maccariello ER, Valente C, Nogueira L, Ismael M, Valenca RV, Machado JE, Rocha E, Soares M: Performance of six prognostic scores in critically ILL patients receiving renal replacement therapy. Rev Bras Ter Intensiva 2008;20:115-123.
  17. Zaragoza JJ, Villa G, Garzotto F, Sharma A, Lorenzin A, Ribeiro L, Lu R, Bellomo R, Ronco C: Initiation of renal replacement therapy in the intensive care unit in Vicenza (IRRIV) score. Blood Purif 2015;39:246-257.
  18. Ronco C: Acute kidney injury: from clinical to molecular diagnosis. Crit Care 2016;20:201.
  19. Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Straaten HO, Ronco C, Kellum JA: Discontinuation of continuous renal replacement therapy: a post hoc analysis of a prospective multicenter observational study. Crit Care Med 2009;37:2576-2582.
  20. Cruz DN, Perazella MA, Bellomo R, Corradi V, de Cal M, Kuang D, Ocampo C, Nalesso F, Ronco C: Extracorporeal blood purification therapies for prevention of radiocontrast-induced nephropathy: a systematic review. Am J Kidney Dis 2006;48:361-371.
  21. Kipnis E, Garzotto F, Ronco C: Timing of RRT initiation in critically-ill patients: time for precision medicine. J Thorac Dis 2016;8:E1242-E1243.
  22. Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstadt H, Boanta A, Gerss J, Meersch M: Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA 2016;315:2190-2199.
  23. Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C: Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care 2016;20:318.
  24. Villa G, Neri M, Bellomo R, Cerda J, De Gaudio AR, De Rosa S, Garzotto F, Honore PM, Kellum J, Lorenzin A, Payen D, Ricci Z, Samoni S, Vincent JL, Wendon J, Zaccaria M, Ronco C: Nomenclature for renal replacement therapy and blood purification techniques in critically ill patients: practical applications. Crit Care 2016;20:283.
  25. Ronco C: The charta of Vicenza. Blood Purif 2015;40:I-V.
  26. Kashani K, Ronco C: Acute kidney injury electronic alert for nephrologist: reactive versus proactive? Blood Purif 2016;42:323-328.
  27. Rizo-Topete L, Ronco C, Rossner M: Acute kidney injury risk assessment and the nephrology rapid response team. Blood Purif 2016, in press.

Author Contacts

Claudio Ronco, MD

Department of Nephrology, Dialysis and Transplantation

International Renal Research Institute of Vicenza (IRRIV)

San Bartolo Hospital, Viale Rodolfi, 37, IT-36100 Vicenza (Italy)

E-Mail cronco@goldnet.it


Article / Publication Details

First-Page Preview
Abstract of Editorial - Role of the Nephrologist in Multidisciplinary Management of AKI

Published online: December 03, 2016
Issue release date: March 2017

Number of Print Pages: 4
Number of Figures: 2
Number of Tables: 0

ISSN: 0253-5068 (Print)
eISSN: 1421-9735 (Online)

For additional information: https://www.karger.com/BPU


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Mehta RL, Burdmann EA, Cerda J, Feehally J, Finkelstein F, Garcia-Garcia G, Godin M, Jha V, Lameire NH, Levin NW, Lewington A, Lombardi R, Macedo E, Rocco M, Aronoff-Spencer E, Tonelli M, Zhang J, Remuzzi G: Recognition and management of acute kidney injury in the International Society of Nephrology 0by25 Global Snapshot: a multinational cross-sectional study. Lancet 2016;387:2017-2025.
  2. Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, Edipidis K, Forni LG, Gomersall CD, Govil D, Honore PM, Joannes-Boyau O, Joannidis M, Korhonen AM, Lavrentieva A, Mehta RL, Palevsky P, Roessler E, Ronco C, Uchino S, Vazquez JA, Vidal Andrade E, Webb S, Kellum JA: Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med 2015;41:1411-1423.
  3. McCullough P, Zhang J, Ronco C: Intravascular volume expansion for the prevention of contrast-induced acute kidney injury. Lancet 2016, in press.
  4. Ronco C, Ferrari F, Ricci Z: Recovery after acute kidney injury: a new prognostic dimension of the syndrome. Am J Respir Crit Care Med 2016, in press.
  5. Ronco C, Kellum JA, Haase M: Subclinical AKI is still AKI. Crit Care 2012;16:313.
  6. Cerda J, Baldwin I, Honore PM, Villa G, Kellum JA, Ronco C: Role of technology for the management of AKI in critically ill patients: from adoptive technology to precision continuous renal replacement therapy. Blood Purif 2016;42:248-265.
  7. Villa G, Ricci Z, Romagnoli S, Ronco C: Multidimensional approach to adequacy of renal replacement therapy in acute kidney injury. Contrib Nephrol 2016;187:94-105.
  8. Vincent JL: The future of critical care medicine: integration and personalization. Crit Care Med 2016;44:386-389.
  9. Ronco C, Bellomo R: Critical care nephrology: the time has come. Nephrol Dial Transplant 1998;13:264-267.
  10. Kellum JA, Ronco C: The 17th acute disease quality initiative international consensus conference: introducing precision renal replacement therapy. Blood Purif 2016;42:221-223.
  11. Bagshaw SM, Chakravarthi MR, Ricci Z, Tolwani A, Neri M, De Rosa S, Kellum JA, Ronco C: Precision continuous renal replacement therapy and solute control. Blood Purif 2016;42:238-247.
  12. Murugan R, Hoste E, Mehta RL, Samoni S, Ding X, Rosner MH, Kellum JA, Ronco C: Precision fluid management in continuous renal replacement therapy. Blood Purif 2016;42:266-278.
  13. Ronco C: Biomarkers for acute kidney injury: is NGAL ready for clinical use? Crit Care 2014;18:680.
  14. Kellum JA, Murugan R: Effects of non-severe acute kidney injury on clinical outcomes in critically ill patients. Crit Care 2016;20:159.
  15. Husain-Syed F, Birk HW, Seeger W, Ronco C: A protective kidney-lung approach to improve outcomes in mechanically ventilated patients. Blood Purif 2016;42:214-218.
  16. Maccariello ER, Valente C, Nogueira L, Ismael M, Valenca RV, Machado JE, Rocha E, Soares M: Performance of six prognostic scores in critically ILL patients receiving renal replacement therapy. Rev Bras Ter Intensiva 2008;20:115-123.
  17. Zaragoza JJ, Villa G, Garzotto F, Sharma A, Lorenzin A, Ribeiro L, Lu R, Bellomo R, Ronco C: Initiation of renal replacement therapy in the intensive care unit in Vicenza (IRRIV) score. Blood Purif 2015;39:246-257.
  18. Ronco C: Acute kidney injury: from clinical to molecular diagnosis. Crit Care 2016;20:201.
  19. Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Straaten HO, Ronco C, Kellum JA: Discontinuation of continuous renal replacement therapy: a post hoc analysis of a prospective multicenter observational study. Crit Care Med 2009;37:2576-2582.
  20. Cruz DN, Perazella MA, Bellomo R, Corradi V, de Cal M, Kuang D, Ocampo C, Nalesso F, Ronco C: Extracorporeal blood purification therapies for prevention of radiocontrast-induced nephropathy: a systematic review. Am J Kidney Dis 2006;48:361-371.
  21. Kipnis E, Garzotto F, Ronco C: Timing of RRT initiation in critically-ill patients: time for precision medicine. J Thorac Dis 2016;8:E1242-E1243.
  22. Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstadt H, Boanta A, Gerss J, Meersch M: Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA 2016;315:2190-2199.
  23. Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C: Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care 2016;20:318.
  24. Villa G, Neri M, Bellomo R, Cerda J, De Gaudio AR, De Rosa S, Garzotto F, Honore PM, Kellum J, Lorenzin A, Payen D, Ricci Z, Samoni S, Vincent JL, Wendon J, Zaccaria M, Ronco C: Nomenclature for renal replacement therapy and blood purification techniques in critically ill patients: practical applications. Crit Care 2016;20:283.
  25. Ronco C: The charta of Vicenza. Blood Purif 2015;40:I-V.
  26. Kashani K, Ronco C: Acute kidney injury electronic alert for nephrologist: reactive versus proactive? Blood Purif 2016;42:323-328.
  27. Rizo-Topete L, Ronco C, Rossner M: Acute kidney injury risk assessment and the nephrology rapid response team. Blood Purif 2016, in press.
ppt logo Download Images (.pptx)


Figures
Thumbnail
Thumbnail

Tables