What is the treatment protocol for urosepsis with acute kidney injury (AKI)?

Treatment Protocol for Urosepsis with Acute Kidney Injury

The treatment of urosepsis with acute kidney injury requires immediate fluid resuscitation with isotonic crystalloids, early appropriate antibiotic therapy, and vasopressors if needed, along with careful monitoring of hemodynamic parameters and kidney function. 1

Initial Management

Hemodynamic Stabilization

• Fluid Resuscitation:

  • Use isotonic crystalloids (not colloids or starches) for initial volume expansion 1
  • Initial bolus of 500-1000 mL for hypovolemic patients, then reassess 2
  • Target adequate tissue perfusion and blood pressure

• Vasopressor Support:

  • Initiate vasopressors in conjunction with fluids if vasomotor shock persists 1
  • No specific vasopressor (norepinephrine, vasopressin) is favored over others, but dopamine should be avoided 1
  • Use protocol-based management of hemodynamic parameters 1

Infection Control

• Obtain appropriate cultures (blood, urine) before antibiotic administration
• Administer broad-spectrum antibiotics within 1 hour of recognition of sepsis
• Adjust antibiotics based on culture results and susceptibility patterns
• Source control: Urgent urologic consultation for relief of obstruction if present

AKI Management

Nephroprotective Strategies

• Discontinue Nephrotoxic Medications:

  • Stop NSAIDs, ACE inhibitors/ARBs, aminoglycosides unless essential 1, 2
  • Evaluate all medications and adjust dosages based on kidney function 2

• Avoid Additional Kidney Injury:

  • Maintain adequate perfusion pressure
  • Avoid hypotension and hypovolemia
  • Prevent contrast-induced nephropathy by limiting contrast studies 3

Monitoring and Assessment

• Monitor serum creatinine every 2-4 days during hospitalization for Stage 1 AKI 2
• Calculate fractional excretion of sodium (FENa) to help determine AKI etiology 2
• Perform renal ultrasound to rule out obstruction, especially in older patients 2
• Monitor electrolytes, particularly potassium, and correct abnormalities 2

Renal Replacement Therapy Considerations

• Indications for RRT (consider when any of these are present):

  • Severe metabolic acidosis (pH < 7.15)
  • Hyperkalemia (K > 6.5 mEq/L) refractory to medical management
  • Volume overload unresponsive to diuretics
  • Uremic symptoms (encephalopathy, pericarditis)
  • BUN > 100 mg/dL 1

• RRT Modality Selection:

  • Both continuous RRT and intermittent hemodialysis are equivalent in effectiveness 1
  • Consider continuous therapies for hemodynamically unstable patients 1
  • Avoid initiating RRT solely for oliguria or elevated creatinine without other indications 1

Supportive Care

Glycemic Control

• Target blood glucose of 110-149 mg/dL (6.1-8.3 mmol/L) 1
• Monitor glucose every 1-2 hours until stable, then every 4 hours 1
• Use arterial blood rather than capillary blood for glucose testing if arterial catheters are in place 1

Nutritional Support

• Provide 20-30 kcal/kg/day total energy intake 1
• Do not restrict protein intake to delay RRT initiation 1
• Administer 0.8-1.0 g/kg/day protein in non-catabolic AKI patients without dialysis need 1
• Increase to 1.0-1.5 g/kg/day for patients on RRT 1
• Prefer enteral nutrition when possible 1

VTE Prophylaxis

• Provide pharmacologic prophylaxis with UFH or LMWH unless contraindicated 1
• If creatinine clearance is < 30 mL/min, use dalteparin or UFH 1

Follow-up After AKI Resolution

• Schedule follow-up within 3 months to assess for development of CKD 2
• Implement risk-based follow-up with more frequent monitoring for high-risk patients 2
• Monitor more frequently when eGFR < 45 mL/min/1.73 m², potentially daily when eGFR < 30 mL/min/1.73 m² 2

Common Pitfalls and Caveats

1. Delayed Antibiotic Administration: Each hour delay in appropriate antibiotic therapy increases mortality by 7.6% in septic shock.

2. Excessive Fluid Administration: While initial resuscitation is crucial, excessive fluid can worsen kidney function and lead to pulmonary edema, especially in patients with cardiac dysfunction 4.

3. Relying Solely on Creatinine: Serum creatinine rises late in AKI; monitor urine output and consider novel biomarkers when available 5.

4. Nephrotoxic Medication Combinations: Avoid the "triple whammy" of NSAIDs, diuretics, and ACE inhibitors/ARBs, which significantly increases AKI risk 1.

5. Neglecting Post-AKI Follow-up: Even transient AKI carries a 15% hospital mortality rate compared to 3% for no AKI, highlighting the importance of post-discharge monitoring 2.