From the Guidelines
The management of acute kidney injury (AKI) should focus on treating the underlying cause, preventing further kidney damage, and supporting kidney function until recovery, with a priority on fluid management and hemodynamic support as outlined in the KDIGO conference 1. The initial management includes stopping nephrotoxic medications, ensuring adequate hydration while avoiding fluid overload, and maintaining hemodynamic stability with a target mean arterial pressure of 65-70 mmHg using intravenous fluids like normal saline or vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) if needed, as suggested by the ACR Appropriateness Criteria for renal failure 1. Key aspects of management include:
- Correcting electrolyte imbalances, particularly hyperkalemia, which may require insulin and calcium gluconate for urgent treatment
- Managing metabolic acidosis with sodium bicarbonate if severe
- Adjusting medication dosages based on estimated kidney function
- Providing nutritional support with 20-30 kcal/kg/day and 1.2-1.5 g/kg/day of protein
- Considering renal replacement therapy (dialysis) for severe cases with refractory hyperkalemia, severe acidosis, volume overload, uremic symptoms, or certain toxin ingestions, as indicated by the ACR Appropriateness Criteria 1. Close monitoring of urine output, serum creatinine, electrolytes, and acid-base status is essential to track recovery and adjust treatment accordingly, with early nephrology consultation recommended for severe AKI or when dialysis may be needed 1.
From the Research
Management of Acute Kidney Injury
The management of acute kidney injury (AKI) involves several key principles, including:
- Early identification of causes to prevent further deterioration of kidney function 2
- Striving for normovolemia, optimizing hemodynamics, treating electrolyte disturbances, discontinuing nephrotoxic agents, and adjusting dosages of medications that are renally eliminated 2
- Protocolized hemodynamic optimization, metabolic control, monitoring of intra-abdominal hypertension, use of diuretics to control fluid overload, and careful management of nephrotoxic factors 3
- Maintenance of renal perfusion and avoidance of precipitating factors, such as nephrotoxic drugs 3
Prevention of Acute Kidney Injury
Prevention of AKI is crucial, and key components include:
- Maintenance of adequate renal blood flow to assure renal oxygenation and prevent nephrotoxic drugs-associated AKI 3
- Avoidance of nephrotoxic medications and contrast media exposure 4
- Recognition of risk factors, such as older age, sepsis, hypovolemia/shock, cardiac surgery, infusion of contrast agents, diabetes mellitus, preexisting chronic kidney disease, cardiac failure, and liver failure 4
Treatment of Acute Kidney Injury
Treatment of AKI may involve:
- Fluid resuscitation 4
- Correction of electrolyte imbalances 4
- Renal replacement therapy (dialysis) for refractory hyperkalemia, volume overload, intractable acidosis, uremic encephalopathy, pericarditis, or pleuritis, and removal of certain toxins 4
- Management of acid-base and electrolyte abnormalities during renal support for AKI, including the use of continuous dialysis techniques to maintain balance 5