Role of Hydrocortisone in Acute Kidney Injury
Hydrocortisone has no established role in the primary management of acute kidney injury (AKI) except in cases of refractory shock or adrenal insufficiency, where it may indirectly benefit kidney function by improving hemodynamics.
Hydrocortisone in Specific Clinical Scenarios Related to AKI
1. Septic Shock with AKI
Hydrocortisone may be beneficial in patients with septic shock who also have AKI when:
- The shock is refractory to fluid resuscitation and moderate-to-high dose vasopressors (>0.1 μg/kg/min of norepinephrine or equivalent) 1
- Recommended dosing: IV hydrocortisone <400 mg/day for at least 3 days at full dose 1
The Society of Critical Care Medicine and European Society of Intensive Care Medicine guidelines suggest using corticosteroids in septic shock that is not responsive to fluid and moderate-to-high-dose vasopressor therapy, which may indirectly benefit kidney function by improving hemodynamics 1.
2. Adrenal Insufficiency with AKI
In patients with relative adrenal insufficiency and AKI:
- Relative adrenal insufficiency is common in critically ill patients and may contribute to hemodynamic instability
- Hydrocortisone (50 mg IV every 6 hours or 200-mg infusion for 7 days or until ICU discharge) is recommended for refractory shock requiring high-dose vasopressors 1
The American Association for the Study of Liver Diseases (AASLD) guidance suggests screening for adrenal insufficiency or an empiric trial of hydrocortisone for treatment of refractory shock requiring high-dose vasopressors in patients with cirrhosis, which may include those with AKI 1.
Important Considerations
Diagnostic Assessment
- The 250-μg ACTH stimulation test is recommended over the low-dose test for diagnosing critical illness-related corticosteroid insufficiency 1
- Corticotropin levels are not recommended for routine diagnosis of adrenal insufficiency in critical illness 1
Lack of Direct Evidence for AKI Treatment
Current guidelines and research do not support the use of hydrocortisone specifically for:
- Prevention of AKI
- Treatment of established AKI without shock
- Acceleration of recovery from AKI
The Kidney Disease: Improving Global Outcomes (KDIGO) conference on AKI controversies does not mention hydrocortisone as a therapeutic option for primary AKI management 1.
Pediatric Considerations
In pediatric post-cardiac arrest care:
- Relative adrenal insufficiency is common after adult cardiac arrest but has not been well evaluated in children
- There is insufficient evidence to support routine use of corticosteroids after cardiac arrest in children 1
- Patients should be treated per recommendations for critically ill children 1
Potential Risks of Hydrocortisone Use
- Hyperglycemia
- Hypernatremia
- Potential for secondary infections (though this risk appears lower with low-dose, short-duration therapy)
Clinical Algorithm for Hydrocortisone Use in AKI Settings
Assess for presence of shock (particularly septic shock)
- If shock is present and refractory to fluids and vasopressors → Consider hydrocortisone
- If no shock → Hydrocortisone not indicated for AKI management
Evaluate for adrenal insufficiency in refractory shock
- Consider 250-μg ACTH stimulation test
- Consider empiric hydrocortisone in life-threatening situations
If hydrocortisone is indicated:
- Use low dose (<400 mg/day)
- Continue for at least 3 days at full dose
- Monitor for hyperglycemia and electrolyte abnormalities
For primary AKI management:
- Focus on established interventions (fluid management, nephrotoxin avoidance)
- Do not use hydrocortisone solely for AKI treatment or prevention
In conclusion, while hydrocortisone plays an important role in managing refractory shock that may accompany AKI, it is not directly indicated for the prevention or treatment of AKI itself. Management should focus on addressing the underlying cause of AKI, optimizing hemodynamics, and avoiding nephrotoxins.