Advocacy for broader inclusion to combat the global threat of acute kidney injury

If you want to go fast, go alone. If you want to go far, go together. —African proverb

In 2002, we wrote about the need to develop a consensus classification system for what was then called acute renal failure [1]. Since then, the term acute kidney injury (AKI) has dominated the literature and with it a rich tapestry of definitions [2–4], epidemiologies [5, 6] and treatment protocols [7, 8] has been introduced. It has been remarkable to see that progress is being made across different areas of medicine, including nephrology, intensive care, cardiology, surgery, hepatology, oncology and obstetrics. Although nephrology has led the way, the impact of partnerships with colleagues across this spectrum has been far greater than what any specialty could do on its own. Indeed, AKI is not a single disease, but a broad clinical syndrome encompassing various etiologies, including specific kidney diseases (e.g. acute interstitial nephritis, acute glomerular and vasculitic renal diseases), nonspecific conditions (e.g. ischaemia and toxic injury), extrarenal pathology (e.g. cardiorenal and hepatorenal syndrome) and acute postrenal obstructive nephropathy. As such, AKI arises in different settings and is recognized and managed by different providers, each playing essential roles in combating this global threat [4, 9].

We are encouraged by advocacy for more work in this area, but at the same time we are cautious that the message should be one of inclusion [10]. Nephrology has much to offer for AKI, but so does anesthesiology and emergency medicine and many others. We believe that the challenges will be universal and that the solutions may be found in far-flung places. Working together, we will have more opportunities to find them. Table 1 lists some of the important areas for progress in AKI prevention and management and some of the stakeholders involved.

We had the good fortune to cochair the Kidney Disease: Improving Global Outcomes guideline on AKI, published in 2012 [4]. The guideline workgroup included nephrologists, intensivists, radiologists, cardiologists and infectious disease specialists from around the world and from pediatrics as well as adult medicine. The workgroup was supported by an ‘evidence review team’ specialized in the field of guideline development, which formulated recommendations and provided reasoning for their guidance depending upon the quality of available evidence. Provisional guidelines were then sent to individual clinicians in different parts of the world for review. Following external comments, the revised guidelines were finally published. Furthermore, several international and national nephrological societies, including the ERA-EDTA [12, 13], have critically evaluated this international guideline and have placed it in the context of local care practices.

In the coming years, the guideline will be revised and efforts are already under way to ensure broad representation from different countries, different specialties and differing points of view are included in the process. This approach may be more difficult, but the consensuses achieved is likely to be more enduring and the guidelines more likely to be followed. Everyone has a role to play in combating AKI.

CONFLICT OF INTEREST STATEMENT

None declared.

(See related article by Rondeau et al. Advocacy for a European network of renal intensive care units. Nephrol Dial Transplant 2019; 34: 1262–1264)

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