What are the initial orders for a patient with Acute Kidney Injury (AKI)?

Initial Orders for Acute Kidney Injury (AKI)

The initial management of AKI should focus on isotonic crystalloid fluid resuscitation, discontinuation of nephrotoxic medications, and daily monitoring of kidney function while addressing the underlying cause. 1

Immediate Orders

Diagnostic Workup

• Serum creatinine and BUN
• Complete metabolic panel (electrolytes, glucose)
• Complete blood count
• Urinalysis with microscopy
• Urine output monitoring (target >0.5 mL/kg/hr)
• Renal ultrasound (to rule out obstruction)
• ECG (if electrolyte abnormalities suspected)

Volume Status Assessment and Management

• Assess volume status (vital signs, physical exam findings, daily weights)
• For hypovolemic patients:
  • Isotonic crystalloids (normal saline or balanced solutions) as initial volume expansion 1
  • Initial bolus of 500-1000 mL, then reassess 2
  • For patients with cirrhosis and ascites: consider albumin 1 g/kg/day (maximum 100g) for two consecutive days 1
• For euvolemic/hypervolemic patients:
  • Avoid excessive fluid administration
  • Target neutral to negative fluid balance after initial resuscitation 2
  • Avoid rapid fluid removal (>1.5-2 L/day) 2

Medication Management

• Discontinue nephrotoxic medications:
  • NSAIDs
  • Aminoglycosides (unless no alternatives available) 1
  • Iodinated contrast agents
  • Amphotericin B (use lipid formulations if needed) 1
• Hold or adjust doses of:
  • ACE inhibitors/ARBs
  • Diuretics (except for volume overload management) 1
  • Beta-blockers (in appropriate cases)
• Avoid low-dose dopamine (not effective for AKI prevention or treatment) 1

Nutritional Support

• Provide 20-30 kcal/kg/day total energy intake 1, 2
• Protein intake:
  • 0.8-1.0 g/kg/day for non-catabolic AKI patients without dialysis 1, 2
  • 1.0-1.5 g/kg/day for patients on RRT 1, 2
  • Up to 1.7 g/kg/day for hypercatabolic patients on CRRT 1
• Preferentially use enteral route for nutrition 1

Monitoring and Follow-up

• Daily monitoring of:
  • Serum creatinine
  • BUN and electrolytes
  • Fluid balance
  • Daily weights
  • Hemodynamic parameters
  • Acid-base status 2

Special Considerations

Cirrhosis with AKI

• Follow specific diagnostic criteria for hepatorenal syndrome (HRS-AKI) 1
• For patients with cirrhosis and ascites, use albumin 1 g/kg/day (maximum 100g) for two consecutive days 1
• Monitor response to volume expansion to guide further management 1

Indications for Nephrology Consultation

• All Stage 3 AKI patients 2
• Stage 2 AKI with multiple comorbidities 2
• AKI in patients with pre-existing Stage 4-5 CKD 2
• Need for renal replacement therapy
• Rapidly worsening kidney function
• Uncertain etiology of AKI

Consider Renal Replacement Therapy for:

• Severe metabolic acidosis
• Hyperkalemia unresponsive to medical therapy
• Volume overload unresponsive to diuretics
• Uremic symptoms 2

Common Pitfalls to Avoid

• Delayed recognition of AKI (monitor high-risk patients closely)
• Continued use of nephrotoxic medications
• Excessive fluid administration in non-hypovolemic patients
• Using diuretics to treat AKI outside of volume overload management 1
• Inadequate follow-up after AKI episode (increases risk of CKD) 3
• Relying solely on serum creatinine (may underestimate kidney injury)

Post-Discharge Follow-up

• Schedule follow-up within 3 months to assess for development of CKD 2
• More frequent monitoring for high-risk patients
• Long-term follow-up is essential as even one episode of AKI increases risk of cardiovascular disease, CKD, and death 2, 3

Remember that AKI is not just an acute condition but can lead to long-term complications including chronic kidney disease, cardiovascular events, and increased mortality 3, 4.