High: further research is very unlikely to change the confidence in the estimate of the effect.
Moderate: further research is likely to have an impact on the confidence in the estimate of the effect and may change the estimate of the effect itself.
Low: further research is very likely to have an impact on the confidence in the estimate of the effect and is likely to change the estimate of the effect itself.
Very low: any estimate of the effect is very unlikely.
Strong: we recommend or we recommend not to do (GRADE 1+ ou 1−).
Weak: we suggest or we suggest not to do (GRADE 2+ ou 2−).
The estimate of the effect.
The global level of evidence: the higher the level of evidence, the stronger the recommendation.
The balance between desirable and undesirable effects: the more favourable the balance, the stronger the recommendation.
Values and preferences: in case of uncertainty or large variability, the level of evidence of the recommendation is probably weak, and values and preferences must be more clearly obtained from the affected persons (patient, physician and decision-maker).
Cost: the greater the costs or the use of resources, the weaker the recommendation.
The elaboration of a recommendation requires that 50 % of participants should have an opinion and that <20 % of participants prefer the opposite proposition.
The elaboration of a strong recommendation requires the agreement of at least 70 % of participants.
For some questions, in the existence of several trials or meta-analyses with an acceptable methodological quality, the GRADE® method was totally applicable and allowed recommendations.
When no meta-analysis was available to answer the question, a qualitative analysis by the experts following the GRADE® method was possible and a systematic review was performed.
For some questions, in the absence of recent studies, no recommendation was possible.
1. How to establish the diagnosis of AKI and its severity
≥26.5 μmol/l or 1.5–1.9 times baseline serum creatinine level
<0.5 ml/kg/h for 6–12 h
2.0–2.9 times baseline serum creatinine level
<0.5 ml/kg/h for ≥12 h
3.0 times baseline serum creatinine level ou serum creatinine ≥354 µmol/l or initiation of renal replacement therapy
<0.3 ml/kg/h for ≥24 h or anuria for ≥12 h
a decrease in the estimated creatinine clearance >25 %
a urine output <0.5 ml/kg/h for 8 h
Estimated plasma creatinine clearance
Decrease >25 %
<0.5 ml/kg/h during >8 h
Decrease >50 %
<0.5 ml/kg/h during >16 h
Decrease >75 % or <35 ml/min/1.73 m2
<0.3 ml/kg/h during 24 h or anuria >12 h
Grade «failure» persisting for >4 weeks
End stage (chronic renal insufficiency)
Grade «failure» persisting for >3 months
2. Strategies for the early diagnosis of AKI
3. How to assess the risk of AKI
Age ≥65 yearsa
Chronic kidney diseasea
Major surgerya (emergency, abdominopelvic, cardiovascular, thoracic, bleeding surgeries)
Obesity (BMI >40 kg/m2)
Nephrotoxic agents (drugs, radiocontrast agents)
Congestive cardiac insufficiency
Severe respiratory insufficiency
Non-steroidal anti-inflammatory agents
β-Lactams (interstitial nephropathies)
Aciclovir, methotrexate, cisplatin
Angiotensin-converting-enzyme inhibitors (ACE)
4. Strategies for the non-specific prevention of AKI
5. How to manage nephrotoxic agents?
administer them with single dosing per day,
monitor their residual level in case of more than a single infusion,
administer them for a maximum of 3 days whenever possible.
6. Pharmacological strategies for the preventive and curative treatment of AKI
7. Nutritional modalities for AKI
2–3 g/kg/day from 0 to 2 years,
1.5–2 g/kg/day from 2 to 13 years,
1.5 g/kg/day above 13 years.