Immediate Treatment Recommendations for Acute Kidney Injury (AKI)
The immediate management of AKI should include discontinuation of nephrotoxic medications, fluid resuscitation with isotonic crystalloids, and treatment of underlying causes while monitoring kidney function closely. 1
Diagnosis and Assessment
Diagnose AKI using KDIGO criteria:
Staging of AKI:
Stage Serum Creatinine Urine Output 1 1.5-1.9× baseline or ≥0.3 mg/dL increase <0.5 mL/kg/h for 6-12h 2 2.0-2.9× baseline <0.5 mL/kg/h for ≥12h 3 ≥3.0× baseline or ≥4.0 mg/dL or RRT initiation <0.3 mL/kg/h for ≥24h or anuria for ≥12h
Immediate Interventions
Remove nephrotoxic agents 2, 1:
- Discontinue NSAIDs, aminoglycosides, contrast agents
- Hold ACE inhibitors and ARBs
- Discontinue diuretics (especially if hypovolemic)
- Consider discontinuing beta-blockers in patients with cirrhosis 2
Volume assessment and fluid management 1:
- For hypovolemic patients:
- Administer balanced crystalloids (Lactated Ringer's or PlasmaLyte) as first choice
- Initial bolus of 500-1000 mL given rapidly
- Limit 0.9% sodium chloride to 1-1.5L to avoid hyperchloremic acidosis
- For euvolemic or hypervolemic patients:
- Avoid excessive fluid administration
- Consider diuretics only after adequate volume restoration
- For hypovolemic patients:
- Infections: Obtain cultures and start appropriate antibiotics
- Sepsis: Follow sepsis protocols with fluid resuscitation and vasopressors
- Obstruction: Relieve urinary tract obstruction if present
- Cirrhosis with AKI: Consider albumin 1 g/kg/day (max 100g) for 2 consecutive days
Special Considerations for Specific Causes
Hepatorenal Syndrome (HRS-AKI) 2:
- Administer albumin 1 g/kg on day 1 (maximum 100g)
- Continue albumin 20-40g daily
- Add vasoactive agents:
- Terlipressin: 1 mg IV every 4-6 hours (if available), OR
- Norepinephrine: 0.5 mg/h IV, titrated up to 3 mg/h, OR
- Midodrine (7.5-12.5 mg TID) plus octreotide (100-200 μg TID)
Volume Depletion 2:
- Replace fluid losses with appropriate crystalloids
- For GI bleeding: Transfuse packed red blood cells to maintain hemoglobin 7-9 g/dL
- For diarrhea or excessive diuresis: Replace with crystalloids
Medication-Induced AKI 1:
- Discontinue offending agent immediately
- Adjust all medications for new level of renal function
- Monitor for recovery of kidney function
Monitoring and Supportive Care
Laboratory monitoring:
- Daily serum creatinine and electrolytes
- Urine output measurement
- Acid-base status
Electrolyte management:
- Treat hyperkalemia if present
- Monitor and correct acid-base disturbances
- Monitor calcium and phosphate levels
Nutritional support 1:
- Provide 20-30 kcal/kg/day total energy
- Protein intake of 0.8-1.0 g/kg/day in non-catabolic patients without dialysis
Indications for Renal Replacement Therapy (RRT)
Consider RRT when 1:
- Severe metabolic acidosis persists
- Hyperkalemia is refractory to medical management
- Volume overload remains unresponsive to conservative measures
- Uremic symptoms develop (encephalopathy, pericarditis)
Nephrology Consultation
Consult nephrology for 1:
- Stage 3 AKI
- AKI without clear cause
- Inadequate response to supportive treatment
- Preexisting CKD stage 4 or higher
- Need for renal replacement therapy
Common Pitfalls to Avoid
- Delayed recognition of AKI: Small changes in creatinine can indicate significant kidney injury
- Excessive fluid administration: Can worsen outcomes, especially in hypervolemic patients
- Continued use of nephrotoxic medications: Must be discontinued promptly
- Failure to identify and treat underlying cause: Essential for recovery
- Inappropriate use of diuretics: Should not be used to prevent or treat AKI without appropriate volume status assessment 2
AKI is a serious condition associated with increased mortality and risk of progression to chronic kidney disease. Prompt recognition and management are essential to improve outcomes and prevent long-term complications.