Best Treatment for Acute Kidney Injury (AKI)
The best treatment for Acute Kidney Injury (AKI) is isotonic crystalloid fluid resuscitation, discontinuation of nephrotoxic medications, and addressing the underlying cause, with renal replacement therapy reserved for specific indications. 1
Initial Management
Fluid Management
- Use isotonic crystalloids (normal saline or balanced solutions) rather than colloids for initial volume expansion in patients with or at risk for AKI 2
- Target fluid administration of 20-25 ml/kg/h for patients with hypovolemia 1
- For patients with cirrhosis and ascites, consider albumin 1 g/kg/day (maximum 100g) for two consecutive days 1
- After initial resuscitation, aim for neutral to negative fluid balance to prevent fluid overload 1, 3
Medication Management
- Immediately discontinue nephrotoxic medications:
- NSAIDs
- Aminoglycosides
- Iodinated contrast agents
- Amphotericin B 1
- Adjust or temporarily hold:
- ACE inhibitors/ARBs (especially if creatinine rises ≥0.5 mg/dL from baseline)
- Diuretics
- Beta-blockers 1
Hemodynamic Support
- For patients with vasomotor shock, use vasopressors in conjunction with fluids 2
- Implement protocol-based management of hemodynamic and oxygenation parameters in high-risk perioperative patients or those with septic shock 2
Nutritional Support
- Provide 20-30 kcal/kg/day total energy intake 2, 1
- Avoid protein restriction; instead provide:
- Administer nutrition preferentially via the enteral route 2, 1
Glycemic Control
- Target plasma glucose of 110-149 mg/dL (6.1-8.3 mmol/L) in critically ill patients 2
Monitoring
- Monitor daily:
- Serum creatinine and BUN
- Electrolytes
- Fluid balance
- Daily weights
- Hemodynamic parameters
- Acid-base status 1
- For AKI Stage 1, monitor creatinine levels weekly 1
- For more severe AKI, more frequent monitoring is required 1
Renal Replacement Therapy (RRT)
Indications for RRT
Initiate RRT when any of the following are present:
- Severe metabolic acidosis
- Hyperkalemia unresponsive to medical management
- Volume overload unresponsive to diuretics
- Uremic symptoms (encephalopathy, pericarditis) 2, 1
RRT Modality Selection
- For hemodynamically unstable patients, use continuous RRT rather than intermittent hemodialysis 2
- For patients with increased intracranial pressure, continuous RRT is preferred 2
- For stable patients, intermittent hemodialysis is appropriate 2
RRT Dosing
- For intermittent hemodialysis: deliver Kt/V of at least 1.2 per treatment 3 times a week 2
- For continuous RRT: deliver effluent volume of 20-25 ml/kg/h 2
- For peritoneal dialysis: deliver a dose of 0.3 Kt/V per session 2
Vascular Access
- Use uncuffed non-tunneled dialysis catheter of appropriate length and gauge to initiate RRT
- First choice for site: right jugular vein or femoral vein (note: femoral site is inferior in patients with increased body mass)
- Alternative sites: left jugular vein followed by subclavian vein 2
Follow-up After AKI
- Patients who have recovered from AKI require follow-up to monitor for development of chronic kidney disease 1
- Intensity of follow-up should be proportionate to AKI severity:
Common Pitfalls and Caveats
- Avoid hydroxyethyl starch solutions as they increase AKI incidence 2
- Avoid overzealous fluid resuscitation which may lead to fluid overload and increased mortality 3
- Do not use dopamine for prevention or treatment of AKI 2
- Do not use diuretics for treatment of AKI unless there is volume overload 2
- Do not delay RRT when indicated, as earlier initiation may improve survival in trauma-associated AKI 2
- Remember that AKI increases the risk of chronic kidney disease, cardiovascular disease, and death even after apparent recovery 4, 5
By following this evidence-based approach to AKI management, you can optimize outcomes and reduce the risk of progression to chronic kidney disease.