Brief Comment: The KDIGO AKI Guidelines

The KDIGO guideline for acute kidney injury just got published as a supplement to Kidney International. It is available open access here.

Like you, I am still digesting many of the recommendations. Having said that, there is already chat in cyberspace about it’s usefulness in management of patients. Arif Khwaja who is a nephrologist at Sheffield Kidney Institute in the UK questions the value of these guidelines. For example, he wonders whether there is much value in staging AKI into 3 stages arguing that this won’t be important to “many “real world” practicing physicians”. He goes on: “In particular it is not clear how staging will alter immediate management and outcomes. As with the CKD classification system the danger is that an epidemiological tool gets imposed onto clinical practice without any evidence that the classification system per se can improve outcomes or can lead to specific interventions. Furthermore the evidence that monitoring people with resolved AKI as being at risk of CKD can i) prevent the onset of CKD or ii) is cost-effective is not presented.”

Arif also questions some of the recommendations. For example, the recommended use of oral NAC in contrast nephropathy – I personally do use NAC but I recognize that there is conflicting data. Second, that dialysis dose be measured in AKI either by using Kt/V - Arif argues that measurement of KT/V is “almost certainly meaningless in a catabolic patient with AKI” or the effluent flow rate in CRRT – he argues that “again no evidence from the Veterans and Australasian studies that dose of RRT in AKI has any impact on survival.”

There are several controversial recommendations that really do need to be fleshed out and I plan to take these on in future articles. But, first, there are more philosophical questions that can be raised. Do you value guidelines if these are not evidence based but mostly opinion and experience based? Does the recommendation from a guideline muddy the water by changing clinical practice - performing a clinical trial then becomes difficult?

My own bias is that guideline bodies should take a narrower approach. Many other specialities take this tack and we should learn from them. As well, the anemia guideline debacle should make KDIGO think again about swimming in the uncertain waters of experience based guidelines. Obviously this is not an approach shared by many of my colleagues who participate in KDIGO (perhaps explaining why I haven’t participated in guideline development).