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 while supporting kidney function, with the primary approach including ensuring adequate hydration, discontinuing nephrotoxic medications, and correcting electrolyte imbalances, as recommended by the most recent guidelines 1. The goal of AKI treatment is to prevent further kidney damage while allowing recovery, as the kidneys have remarkable regenerative capacity when the underlying cause is addressed promptly. Key steps in management include:

• Ensuring adequate hydration with intravenous fluids like normal saline or Lactated Ringer's solution, typically at rates of 1-2 mL/kg/hour, adjusted based on volume status.
• Discontinuing medications that may harm the kidneys, particularly NSAIDs, certain antibiotics (aminoglycosides, vancomycin), and ACE inhibitors/ARBs, as suggested by recent guidelines 1.
• Correcting electrolyte imbalances, such as potassium levels above 6.5 mEq/L, which may require treatment with calcium gluconate, insulin with glucose, or sodium bicarbonate for metabolic acidosis.
• Monitoring urine output, serum creatinine, electrolytes, and fluid balance closely to guide treatment decisions.
• Considering renal replacement therapy for severe cases, with indications including refractory hyperkalemia, severe acidosis, volume overload unresponsive to diuretics, or uremic symptoms, as outlined in recent recommendations 1. It is essential to follow the most recent and highest-quality guidelines, such as those from the American Gastroenterological Association (AGA) 1, to ensure optimal outcomes for patients with AKI.

From the Research

Treatment Approaches for Acute Kidney Injury (AKI)

• The treatment of AKI is founded on addressing the underlying cause, alongside supportive care measures such as fluid management, vasopressor therapy, and kidney replacement therapy (KRT) 2.
• Supportive care includes managing blood pressure, with targets often being higher in AKI patients, achievable through fluids and vasopressors, some of which may offer kidney protection 2.
• The initiation of KRT is a subject of controversy, with studies not consistently showing benefits of early start dialysis 2, 3.

Renal Replacement Therapy (RRT) in AKI

• RRT is a crucial supportive measure for patients with severe AKI, with the KDIGO guidelines recommending its initiation when absolute indications exist 3.
• The choice between continuous and intermittent RRT techniques depends on the patient's condition, with continuous RRT preferred in hemodynamically unstable patients or those with increased intracranial pressures 3, 4.
• Regional citrate anticoagulation is suggested for patients undergoing continuous RRT, while systemic heparin anticoagulation is recommended for those receiving intermittent RRT, although evidence is weak 3.

Initial Management and Evaluation

• The initial management of AKI involves assessing contributing causes, clinical course, volume status, and instituting therapeutic measures to reverse or prevent kidney injury worsening 5.
• Differentiating between prerenal, renal, and postrenal causes is crucial, with an emphasis on identifying reversible causes and optimizing volume status 5, 6.
• Preventive measures include optimizing volume status and avoiding nephrotoxic medications, with crystalloids preferred over colloids for fluid management 6.

Pharmacotherapies and Outcomes

• Currently, there are no targeted pharmacotherapies approved for AKI treatment, although medications play a key role in managing AKI complications and adjusting for changes in renal function and dialysis 2, 6.
• AKI is associated with increased risks of chronic kidney disease, subsequent AKI, and future mortality, highlighting the need for prompt and effective management 6.