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There are many types of exposures that may cause AKI (Table 6) and these are discussed in detail in Appendix C.
| Exposures | Susceptibilities |
|---|---|
| Sepsis | Dehydration or volume depletion |
| Critical illness | Advanced age |
| Circulatory shock | Female gender |
| Burns | Black race |
| Trauma | CKD |
| Cardiac surgery (especially with CPB) | Chronic diseases (heart, lung, liver) |
| Major noncardiac surgery | Diabetes mellitus |
| Nephrotoxic drugs | Cancer |
| Radiocontrast agents | Anemia |
| Poisonous plants and animals |
CKD, chronic kidney disease; CPB, cardiopulmonary bypass.
However, the chances of developing AKI after exposure to the same insult differ among different individuals. This is attributed to a number of susceptibility factors which vary widely from individual to individual. Our understanding of susceptibility factors (Table 6) is based on many observational studies that address different settings with regards to the type, severity, duration, and multiplicity of insults. While this heterogeneity provides insight into some susceptibility factors that are common across various populations, the generalizability of results from one particular setting to the next is uncertain.
The course and outcome of AKI are modified by other factors, but since these are manifested within the context of actual disease, they must be categorized as ‘‘prognostic’’ rather than ‘‘risk’’ factors, hence being discussed separately in Appendix D. Lastly, the fact that some 30% of patients who recover from AKI remain at increased risk of CKD, cardiovascular disease, and death calls for the identification of the risk factors that can identify such patients in the hopes of providing them with timely preventive measures.50–52
Finally, it is important to screen patients who have undergone an exposure (e.g., sepsis, trauma) and to continue monitor high-risk patients until the risk has subsided. Exact intervals for checking SCr and in which individuals to monitor urine output remain matters of clinical judgment; however, as a general rule, high risk in-patients should have SCr measured at least daily and more frequently after an exposure, and critically ill patients should have urine output monitoring. This will necessitate urinary bladder catheterization in many cases, and the risks of infection should also be considered in the monitoring plan.
A recent clinical practice assessment in the UK concluded that only 50% of patients with AKI were considered to have received a ‘‘good’’ overall standard of care. This figure fell to just over 30% if AKI developed during a hospital admission rather than being diagnosed before admission.53 The authors also felt that there was an unacceptable delay in recognizing AKI in 43% of those that developed the condition after admission, and that in a fifth of such patients its development was predictable and avoidable. Their recommendations were simple: risk assessment for AKI as part of the initial evaluation of emergency admissions, along with appropriate serum biochemistry on admission and at frequent intervals thereafter.53
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