What are the next steps for a patient with acute kidney injury (AKI) and impaired renal function, given a creatinine level of 3.25, which is elevated from her baseline of 1.1-1.7?

From the Guidelines

For a patient with acute kidney injury (AKI) and a creatinine of 3.25 (elevated from baseline 1.1-1.7), immediate management should focus on identifying and treating the underlying cause while preventing further kidney damage. The patient's elevated creatinine level indicates a significant increase from their baseline, suggesting acute kidney injury as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, which includes an increase in serum creatinine by 0.3 mg/dL within 48 hours or an increase in serum creatinine to 1.5 times baseline within 7 days 1. Given this, the following steps are crucial:

• Discontinue all nephrotoxic medications, including NSAIDs, certain antibiotics, and contrast agents, to prevent further kidney damage.
• Ensure adequate hydration with intravenous fluids, typically isotonic crystalloids like normal saline, if the patient is hypovolemic, but avoid fluid overload.
• Monitor urine output closely, aiming for at least 0.5 mL/kg/hour, as reduced urine output can indicate worsening kidney function.
• Obtain urinalysis, urine electrolytes, and kidney ultrasound to assess for obstruction or structural abnormalities.
• Check electrolytes, BUN, and creatinine daily to track kidney function and adjust medication dosages for reduced kidney function, particularly for renally cleared drugs.
• Consider nephrology consultation, especially if the patient has severe AKI, requires dialysis evaluation, or has complex comorbidities. Indications for urgent dialysis include severe hyperkalemia (>6.5 mEq/L), volume overload unresponsive to diuretics, uremic symptoms (encephalopathy, pericarditis), or severe metabolic acidosis (pH <7.2), as outlined in recent clinical practice updates 1. These interventions are crucial as AKI increases mortality risk and can progress to chronic kidney disease if not properly managed, emphasizing the need for prompt and effective treatment based on the most recent guidelines and evidence 1.

From the Research

Next Steps for Patient with Acute Kidney Injury (AKI)

The patient's creatinine level of 3.25 is elevated from her baseline of 1.1-1.7, indicating impaired renal function. The following steps should be taken:

• Evaluate the patient's medication list to identify potential nephrotoxic medications that may be contributing to the AKI, as certain medications such as aminoglycosides, nonsteroidal anti-inflammatory drugs, ACE inhibitors, and radiographic contrast media can increase the risk of nephrotoxicity 2, 3, 4.
• Assess the patient's volume status and intravascular volume depletion, as this can exacerbate AKI 3.
• Perform a physical examination to identify skin rashes indicative of systemic illness and assess intravascular volume status 3.
• Order laboratory tests, including serum creatinine level, complete blood count, urinalysis, and fractional excretion of sodium, to evaluate the patient's renal function and identify potential causes of AKI 3.
• Consider ultrasonography of the kidneys to rule out obstruction, particularly in older men 3.
• Manage the patient's AKI with fluid resuscitation, avoidance of nephrotoxic medications and contrast media exposure, and correction of electrolyte imbalances 3.
• Consider referral to a nephrologist for further evaluation and management, as earlier referral has been shown to lead to better health care outcomes and lower costs 5.
• If the patient requires renal replacement therapy, consider continuous renal replacement therapy (CRRT) to manage electrolyte and acid-base imbalances 6.

Potential Interventions

Potential interventions for the patient include:

• Discontinuation of potential nephrotoxic medications 2, 3, 4.
• Fluid resuscitation to correct volume depletion 3.
• Avoidance of contrast media exposure 3.
• Correction of electrolyte imbalances 3.
• Referral to a nephrologist for further evaluation and management 5.
• Consideration of CRRT for management of electrolyte and acid-base imbalances 6.