What are the treatment options for Acute Kidney Injury (AKI)?

From the Guidelines

The primary treatment approach for acute kidney injury (AKI) should focus on initiating renal replacement therapy (RRT) emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist, as recommended by the KDIGO clinical practice guideline 1.

Key Considerations

• The decision to start RRT should consider the broader clinical context, the presence of conditions that can be modified with RRT, and trends of laboratory tests, rather than single BUN and creatinine thresholds alone 1.
• For patients with AKI requiring RRT, the choice of anticoagulation should be based on an assessment of the patient's potential risks and benefits from anticoagulation, with recommendations for using anticoagulation during RRT if a patient does not have an increased bleeding risk or impaired coagulation 1.

Management Strategies

• Discontinue RRT when it is no longer required, either because intrinsic kidney function has recovered to the point that it is adequate to meet patient needs, or because RRT is no longer consistent with the goals of care 1.
• Consider using CRRT rather than standard intermittent RRT for hemodynamically unstable patients or those with acute brain injury or other causes of increased intracranial pressure or generalized brain edema 1.
• Use bicarbonate, rather than lactate, as a buffer in dialysate and replacement fluid for RRT in patients with AKI, especially those with circulatory shock or liver failure and/or lactic acidemia 1.

Monitoring and Adjustment

• Regular monitoring of kidney function, electrolytes, and acid-base status is essential to track recovery and adjust management accordingly.
• The dose of RRT to be delivered should be prescribed before starting each session of RRT, with frequent assessment of the actual delivered dose to adjust the prescription 1.
• Deliver a Kt/V of 3.9 per week when using intermittent or extended RRT in AKI, and an effluent volume of 20-25 mL/kg/h for CRRT in AKI 1.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, Furosemide tablets should be discontinued.

Treatment for Acute Kidney Injury (AKI): Furosemide may be used in the treatment of AKI, but it should be used with caution.

• The drug label warns against using Furosemide in patients with severe progressive renal disease if increasing azotemia and oliguria occur.
• It is recommended to discontinue Furosemide if these conditions worsen.
• The label does not provide a specific treatment protocol for AKI, but it suggests that Furosemide can be used in a hospital setting for patients with hepatic cirrhosis and ascites 2.

From the Research

Treatment for Acute Kidney Injury (AKI)

• The treatment of AKI involves addressing the underlying cause, with specific attention to reversible causes 3.
• Measures to prevent AKI include optimization of volume status and avoidance of nephrotoxic medications 3, 4.
• Crystalloids are preferred over colloids for most patients, and hydroxyethyl starches should be avoided 3.
• Volume overload in the setting of AKI is associated with adverse outcomes, so attention should be paid to overall fluid balance 3, 5.
• The use of balanced crystalloids during the initial resuscitation is associated with higher odds of kidney function recovery in AKI patients with sepsis-associated community-acquired AKI 5.
• General management principles for AKI include determination of volume status, fluid resuscitation with isotonic crystalloid, treatment of volume overload with diuretics, discontinuation of nephrotoxic medications, and adjustment of prescribed drugs according to renal function 4.

Pharmacotherapies and Renal Replacement Therapy

• Currently, there are no targeted pharmacotherapies approved for the treatment of AKI 3, 6.
• The optimal timing of renal replacement therapy in critically ill patients with AKI is unclear, but is an area of active investigation 3.
• Initiation of kidney replacement therapy (KRT) is controversial, and studies have not consistently demonstrated any benefit to early start dialysis 6.

Supportive Care Measures

• Additional supportive care measures may include optimizing nutritional status and glycemic control 4.
• Pharmacist-led quality-improvement programs reduce nephrotoxic exposures and rates of AKI in the hospital setting 4.
• AKI care bundles are associated with improved in-hospital mortality rates and reduced risk of progression 4.
• Nephrology consultation should be considered when there is inadequate response to supportive treatment and for AKI without a clear cause, stage 3 or higher AKI, preexisting stage 4 or higher chronic kidney disease, renal replacement therapy, and other situations requiring subspecialist expertise 4.