What is the treatment for Acute Kidney Injury (AKI)?

From the Guidelines

The treatment for acute kidney injury (AKI) should focus on addressing the underlying cause, supporting kidney function, and preventing further injury, with the initial management including stopping nephrotoxic medications, ensuring adequate hydration, and maintaining proper blood pressure to support kidney perfusion, as recommended by the KDIGO clinical practice guideline for AKI 1.

Key Components of AKI Treatment

• Stopping nephrotoxic medications to prevent further kidney damage
• Ensuring adequate hydration with intravenous fluids like normal saline or lactated Ringer's solution to support kidney perfusion
• Maintaining proper blood pressure to support kidney function
• Correcting electrolyte imbalances, such as hyperkalemia, with insulin, glucose, sodium bicarbonate, or calcium gluconate
• Using diuretics, such as furosemide, in patients with fluid overload or oliguric AKI, although they do not improve kidney recovery

Renal Replacement Therapy (RRT)

• Severe AKI may necessitate RRT, particularly with persistent hyperkalemia, acidosis, uremic symptoms, or volume overload unresponsive to diuretics
• The decision to initiate RRT should be based on the patient's clinical condition, rather than a single blood urea nitrogen (BUN) or creatinine threshold 1

Nutritional Support

• Nutritional support is essential, with protein intake adjusted based on whether the patient is receiving dialysis
• The recommended protein intake is 0.8-1.0 g/kg/d for non-catabolic AKI patients without need for dialysis, 1.0-1.5 g/kg/d for patients with AKI on RRT, and up to a maximum of 1.7 g/kg/d for patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients 1

Prevention of Further Kidney Injury

• Prevention of further kidney injury by avoiding nephrotoxins and maintaining hemodynamic stability is crucial
• The use of vasoconstrictors, such as dopamine, should be avoided in patients with AKI, as they may increase the risk of adverse events and death 1

From the Research

Treatment Approaches for Acute Kidney Injury (AKI)

• The treatment of AKI is founded on addressing the underlying cause of the injury, as well as providing supportive care through fluid management, vasopressor therapy, and kidney replacement therapy (KRT) 2.
• Management strategies often involve higher blood pressure targets, which can be achieved with fluids and vasopressors, with some being more kidney-protective than others 2.
• The initiation of KRT is controversial, with studies not consistently demonstrating benefits to early start dialysis 2.

Supportive Care and Pharmacotherapies

• Supportive care is crucial in the management of AKI, including fluid management and the use of diuretics, although their use remains controversial 3.
• There are no targeted pharmacotherapies for AKI itself, but medications play a key role in managing complications of AKI, and changes in renal function and dialysis support can lead to issues with toxicities and underdosing 2.
• The use of intravenous fluids, such as hydroxyethylstarch, may contribute to or exacerbate AKI, and unnecessary accumulation of fluid and volume overload can negatively impact clinical outcomes 3.

Evaluation and Management

• A thorough history and physical examination can help categorize the underlying cause of AKI as prerenal, intrinsic renal, or postrenal, guiding initial evaluation and management 4.
• Initial management in the community setting includes laboratory work-up, medication adjustment, identification and reversal of the underlying cause, and referral to specialty care 4.
• Staging of AKI is recommended to stratify patients according to the severity of the condition, based on serum creatinine level and urine output 5.

Prevention and Complications

• Measures to prevent AKI should be taken, particularly before the administration of intravenous iodinated contrast media, which can cause contrast-induced nephropathy 5.
• AKI can result in short- and long-term complications, including chronic kidney disease and end-stage renal disease, emphasizing the importance of appropriate treatment and management 5, 6.
• The optimal choice of intravenous fluid therapy remains controversial, and there is renewed interest in more specific therapies for AKI secondary to hypoperfusion and/or sepsis 6.