What is the initial management of Acute Kidney Injury (AKI)?

From the Guidelines

The initial management of Acute Kidney Injury (AKI) should focus on identifying and treating the underlying cause, discontinuing nephrotoxic medications, and supporting kidney function to prevent complications, as recommended by the most recent guidelines 1.

Key Interventions

• Assess and correct volume status by administering intravenous fluids for hypovolemia or restricting fluids for volume overload.
• Discontinue nephrotoxic medications such as NSAIDs, aminoglycosides, contrast agents, and certain antibiotics.
• Monitor electrolytes closely, particularly potassium, and treat hyperkalemia promptly if levels exceed 6.0 mEq/L.
• Maintain acid-base balance with sodium bicarbonate if severe acidosis is present.
• Optimize hemodynamics to ensure adequate renal perfusion, targeting a mean arterial pressure of at least 65 mmHg using vasopressors if necessary.

Additional Considerations

• Adjust medication dosages based on estimated kidney function to prevent further injury.
• Initiate renal replacement therapy (dialysis) for severe cases with refractory hyperkalemia, volume overload, uremic symptoms, or severe acidosis.
• Ensure adequate nutrition while avoiding excessive protein load in severe AKI.
• Consider alternatives to radiocontrast and avoid subclavian catheters if possible, as suggested by recent guidelines 1.

Prioritizing Patient Outcomes

The management of AKI should prioritize preventing further kidney damage, reducing morbidity and mortality, and improving quality of life, as emphasized by the KDIGO guidelines 1 and recent consensus reports 1. By following these recommendations and considering the individual patient's needs and circumstances, healthcare providers can provide optimal care for patients with AKI.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults: Parenteral therapy with Furosemide Injection should be used only in patients unable to take oral medication or in emergency situations and should be replaced with oral therapy as soon as practical. The usual initial dose of furosemide is 20 to 40 mg given as a single dose, injected intramuscularly or intravenously

The initial management of Acute Kidney Injury (AKI) may involve the use of furosemide. The usual initial dose is 20 to 40 mg given as a single dose, injected intramuscularly or intravenously.

• The dose may be increased if needed, but should be done under close medical supervision.
• High dose parenteral therapy may be used, but requires careful monitoring and adjustment of the infusion solution's pH to prevent precipitation of the furosemide 2.
• It is essential to individualize therapy according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response.

From the Research

Initial Management of Acute Kidney Injury (AKI)

The initial management of AKI involves several key steps, including:

• Laboratory work-up to determine the underlying cause of AKI 3
• Medication adjustment to avoid nephrotoxic medications 4
• Identification and reversal of the underlying cause of AKI 3, 4
• Referral to appropriate specialty care 3
• Optimization of volume status and avoidance of nephrotoxic medications to prevent AKI 4

Role of Diuretics in AKI Management

Diuretics, such as furosemide, are commonly used in the management of AKI, but their effectiveness is still debated:

• Diuretics are associated with increased risk for AKI 5
• Furosemide may be useful in achieving fluid balance to facilitate mechanical ventilation in patients with acute lung injury without haemodynamic instability 6
• Furosemide administration was associated with improved short-term survival and recovery of renal function in critically ill patients with AKI 7

Prevention of AKI

Prevention of AKI is crucial to reduce the risk of cardiovascular disease, chronic kidney disease, and death:

• Optimization of volume status and avoidance of nephrotoxic medications can help prevent AKI 4
• Crystalloids are preferred over colloids for most patients, and hydroxyethyl starches should be avoided 4
• Positive fluid balance has emerged as an independent predictor of adverse outcomes, and diuretics may be used to manage fluid balance in AKI 5