tion’, implying that most patients ‘should’ receive a particular action. In contrast, level 2 guidelines are essentially ‘suggestions’ and are deemed to be ‘weak’ or discretionary, recognising that management decisions may vary in different clinical contexts. Each recommendation was further graded from A to D by the quality of evidence underpinning them, with grade A referring to a high quality of evidence whilst grade D recognised a ‘very low’ evidence base. The overall strength and quality of the supporting evidence is summarised in table 1 . The guidelines focused on 4 key domains: (1) AKI definition, (2) prevention and treatment of AKI, (3) contrastinduced AKI (CI-AKI) and (4) dialysis interventions for the treatment of AKI. The full summary of clinical practice statements is available at www.kdigo.org, but a few key recommendation statements will be highlighted here.

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KDIGO clinical practice guidelines for acute kidney injury.

Scottish Intercollegiate Guidelines Network

Acute kidney injury

Current reports on acute kidney injury (AKI) in the intensive care unit (ICU) show wide variation in occurrence rate and are limited by study biases such as use of incomplete AKI definition, selected cohorts, or retrospective design. Our aim was to prospectively investigate the occurrence and outcomes of AKI in ICU patients. The Acute Kidney Injury–Epidemiologic Prospective Investigation (AKI-EPI) study was an international cross-sectional study performed in 97 centers on patients during the first week of ICU admission. We measured AKI by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, and outcomes at hospital discharge. A total of 1032 ICU patients out of 1802 [57.3 %; 95 % confidence interval (CI) 55.0–59.6] had AKI. Increasing AKI severity was associated with hospital mortality when adjusted for other variables; odds ratio of stage 1 = 1.679 (95 % CI 0.890–3.169; p = 0.109), stage 2 = 2.945 (95 % CI 1.382–6.276; p = 0.005), and stage 3 = 6.884 (95 % CI 3.876–12.228; p < 0.001). Risk-adjusted rates of AKI and mortality were similar across the world. Patients developing AKI had worse kidney function at hospital discharge with estimated glomerular filtration rate less than 60 mL/min/1.73 m2 in 47.7 % (95 % CI 43.6–51.7) versus 14.8 % (95 % CI 11.9–18.2) in those without AKI, p < 0.001. This is the first multinational cross-sectional study on the epidemiology of AKI in ICU patients using the complete KDIGO criteria. We found that AKI occurred in more than half of ICU patients. Increasing AKI severity was associated with increased mortality, and AKI patients had worse renal function at the time of hospital discharge. Adjusted risks for AKI and mortality were similar across different continents and regions.

Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study

Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever, international, multidisciplinary, clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. In this review we summarize key aspects of the guideline including definition and staging of AKI, as well as evaluation and nondialytic management. Contrast-induced AKI and management of renal replacement therapy will be addressed in a separate review. Treatment recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided.

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Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1).

Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury

Purpose
Sepsis commonly contributes to acute kidney injury (AKI); however, the frequency with which sepsis develops as a complication of AKI and the clinical consequences of this sepsis are unknown This study examined the incidence of, and outcomes associated with, sepsis developing after AKI

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Sepsis as a cause and consequence of acute kidney injury: Program to Improve Care in Acute Renal Disease

To determine whether a family history of osteoporosis identifies individuals with low bone mineral density (BMD), we studied 1477 white elderly (aged 60-89 years), noninstitutionalized ambulatory men (n = 600) and women (n = 877) from the Rancho Bernardo, California cohort. Family history data on biologic parents and full sisters were obtained by questionnaire. BMD of the lumbar spine and hip was measured using dual-energy x-ray absorptiometry. After adjustment for age, body mass index, history of cigarette smoking, thiazide use, and estrogen use, men and women with a family history of osteoporosis had lower BMD than those with a negative family history. In men, a positive family history was associated with lower BMD at the hip (p = 0.01), whereas in women a significant association was observed for the spine (p = 0.02). BMD decreased in a stepwise fashion with an increasing number of family members with a history of osteoporosis. Analysis of the effect of parental history of osteoporosis on BMD showed a significant relation between paternal (but not maternal) history and lumbar spine BMD in both sexes and a significant relation between maternal (but not paternal) history and hip BMD only in men. The relative risk of having categoric osteopenia was highest in those whose fathers had a history of osteoporosis (RR 2.16, 95% CI = 1.38-3.37). A similar association was found for subjects with fractures. These results were not explained by differential awareness of family history in individuals with known osteoporosis, because the prevalence of family history was unrelated to personal history of osteoporosis in men and only weakly related in women.(ABSTRACT TRUNCATED AT 250 WORDS)

Family history of osteoporosis and bone mineral density at the axial skeleton: the Rancho Bernardo Study.

Diuretics, mortality, and nonrecovery of renal function in acute renal failure

This study examined the relationship between lifetime milk consumption both axial and appendicular bone mineral density in 581 postmenopausal White women. Positive significant, graded associations between milk consumption in adulthood and bone mineral density at the spine, total hip, trochanter, intertrochanter, and midradius, but not the ultradistal wrist or femoral neck, were observed. Adolescent milk consumption showed similar, statistically significant associations (spine and midradius). Associations were independent of age, body mass index, years postmenopausal, thiazide, estrogen and alcohol use, smoking, and exercise. Regular milk consumption in youth and adulthood is associated with better bone mineral density at cortical and trabecular sites in elderly women.

Sharon B. Soroko

Papers

Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury

Sepsis as a cause and consequence of acute kidney injury: Program to Improve Care in Acute Renal Disease

Family history of osteoporosis and bone mineral density at the axial skeleton: the Rancho Bernardo Study.

Diuretics, mortality, and nonrecovery of renal function in acute renal failure

Lifetime milk consumption and bone mineral density in older women.