How to manage acute pancreatitis with worsening Acute Kidney Injury (AKI)?

From the Guidelines

Aggressive fluid resuscitation is crucial in managing acute pancreatitis with worsening acute kidney injury (AKI), as it helps restore intravascular volume and maintain renal perfusion. Initially, administer intravenous crystalloid fluids at 5-10 mL/kg/hr (typically lactated Ringer's solution) to restore intravascular volume and maintain renal perfusion, with adjustment based on clinical response 1. Monitor fluid status carefully using parameters such as urine output (target >0.5 mL/kg/hr), vital signs, and possibly central venous pressure. Avoid nephrotoxic medications including NSAIDs and certain antibiotics. Pain management should utilize opioids like fentanyl or hydromorphone rather than morphine, which can cause spasm of the sphincter of Oddi.

Key Considerations

• Nutritional support should be initiated early, preferably enteral feeding within 24-48 hours if tolerated, as parenteral nutrition may be associated with complications such as overfeeding, hyperglycemia, and hepatic dysfunction 1.
• For severe cases with hemodynamic instability, vasopressor support may be necessary.
• Consider nephrology consultation for possible renal replacement therapy if the patient develops severe metabolic acidosis, hyperkalemia, volume overload, or uremic symptoms.
• The connection between pancreatitis and AKI stems from inflammatory mediators, third-spacing of fluids, and potential direct nephrotoxicity from pancreatic enzymes, making fluid resuscitation crucial to interrupt this pathophysiologic cycle.

Ongoing Management

Regular reassessment of renal function with serum creatinine, electrolytes, and acid-base status is essential to guide ongoing management. Additionally, careful attention to fluid and electrolyte balance is mandatory to prevent complications such as salt and water overload, which can be aggravated by parenteral nutrition 1.

Disease Severity and Nutritional Status

Assessment of disease severity and nutritional status is crucial in determining the need for artificial nutrition, with severe malnutrition potentially adversely affecting outcomes 1. However, the primary focus in managing acute pancreatitis with worsening AKI should remain on aggressive fluid resuscitation and supportive care to address the immediate life-threatening complications.

From the Research

Management of Acute Pancreatitis with Worsening Acute Kidney Injury (AKI)

• The management of acute pancreatitis with worsening AKI requires careful consideration of fluid resuscitation strategies to balance the need for adequate hydration with the risk of fluid overload and exacerbation of AKI.
• According to a systematic review published in 2025 2, moderate fluid resuscitation using crystalloids, such as Ringer's lactate, is recommended for managing acute pancreatitis, as it reduces the risk of fluid overload, respiratory failure, and AKI.
• The use of lactated Ringer's solution has been shown to be superior to normal saline in reducing systemic inflammation and organ failure in patients with acute pancreatitis 3, 4.
• Aggressive fluid resuscitation has been associated with increased mortality and severe adverse events, including AKI, and is therefore not recommended 5.
• The optimal rate and amount of fluid resuscitation remain unclear, but current guidelines recommend a goal-directed approach, with careful monitoring of fluid status and adjustment of fluid rates as needed 6.

Fluid Resuscitation Strategies

• Crystalloids, such as Ringer's lactate, are the recommended fluids for management of acute pancreatitis 2, 6.
• Colloids are not recommended due to the risk of adverse events, including renal impairment and coagulopathy 2.
• The use of normal saline is not recommended due to its association with increased systemic inflammation and organ failure compared to lactated Ringer's solution 3, 4.

Monitoring and Adjustment of Fluid Resuscitation

• Close monitoring of fluid status, including urine output, blood pressure, and serum creatinine, is essential to adjust fluid rates and prevent fluid overload and AKI 2, 6.
• The use of goal-directed fluid resuscitation protocols can help to optimize fluid management and reduce the risk of complications 5, 4.