From the Guidelines
The best treatment for persistent decreased kidney function after Acute Kidney Injury (AKI) involves a comprehensive approach focused on preventing further damage and supporting remaining kidney function, with the most recent and highest quality evidence supporting the use of ACE inhibitors or ARBs, such as lisinopril 10-40 mg daily or losartan 25-100 mg daily, as a crucial component of management, as noted in the 2022 study published in Diabetes Care 1. Management should include:
- Optimizing blood pressure control with ACE inhibitors or ARBs, which reduce intraglomerular pressure and proteinuria
- Strict glycemic control for diabetic patients, targeting HbA1c levels below 7%
- Dietary modifications, including:
- Sodium restriction to 2-3 g/day
- Protein limitation to 0.8 g/kg/day
- Adequate hydration
- Avoiding nephrotoxic medications like NSAIDs and certain antibiotics
- Regular monitoring of kidney function with serum creatinine, eGFR, and urinalysis every 3-6 months to track progression
- Diuretics like furosemide (20-80 mg daily) may be needed to manage fluid overload
- For patients with progressive decline despite these measures, nephrology referral is warranted to discuss advanced options including dialysis planning, as suggested by the 2020 study published in BMJ 1 and the 2021 study published in Clinical Nutrition 1. This approach addresses the underlying pathophysiology of kidney injury by reducing hyperfiltration, controlling metabolic factors, and minimizing additional insults to the kidneys, potentially slowing the progression to chronic kidney disease, as discussed in the 2017 studies published in Nature Reviews Nephrology 1.
From the FDA Drug Label
5.3 Renal Function Deterioration Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system and by diuretics.
Monitor renal function periodically in these patients Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on losartan
The FDA drug label does not answer the question.
From the Research
Treatment for Persistent Decreased Kidney Function after AKI
The best treatment for persistent decreased kidney function after Acute Kidney Injury (AKI) is a complex issue, and there are various approaches to manage this condition.
- The management of AKI is founded on treating the underlying cause of AKI, but supportive care, such as fluid management, vasopressor therapy, and kidney replacement therapy (KRT), is also crucial 2.
- There are no targeted pharmacotherapies for AKI itself, but some medications exist for complications of AKI, and changes in renal function and dialysis support can lead to issues with toxicities and underdosing 2.
- Recent clinical studies indicate a strong link between AKI and progression of Chronic Kidney Disease (CKD), and considerable gaps in knowledge exist regarding the connection between AKI and CKD 3.
- The timing of recovery from AKI provides an added dimension to AKI phenotyping and prognostic information regarding the future occurrence of loss of kidney function, and studies to identify effective interventions on the timing of recovery from AKI are warranted 4.
Medications for Hypertension in AKI Patients
For patients with hypertension and AKI, the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) is recommended.
- ACE inhibitors and ARBs have equal outcome efficacy, but ARBs have fewer adverse events, such as cough and angioedema, and lower overall withdrawal rates due to adverse events 5.
- The long-term prognosis after AKI varies depending on the cause and clinical setting, but it may also be explained by underlying pre-AKI and post-AKI renal function rather than the AKI episode itself 6.
Factors Affecting Long-term Prognosis after AKI
The presence of Chronic Kidney Disease (CKD) pre-AKI and non-recovery of kidney function are associated with greater mortality and CKD outcomes.
- The risk of poor outcome reduces over time post-AKI, and future AKI studies should report pre-AKI and post-AKI function consistently as additional factors that may modify AKI prognosis 6.