Treatment Plan for Acute Kidney Injury (AKI)
The management of acute kidney injury should be based on assessment of overall clinical status, including specific cause of AKI, trends in kidney function over time, comorbid conditions, assessment of volume status, and concomitant acid-base and electrolyte disturbances, rather than following a stage-based approach. 1
Initial Management
Volume Status Assessment and Fluid Management
- Use isotonic crystalloids rather than colloids (albumin or starches) as initial management for expansion of intravascular volume in patients at risk for or with AKI 1
- Administer vasopressors in conjunction with fluids in patients with vasomotor shock with or at risk for AKI 1
- Implement protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in perioperative settings or in patients with septic shock 1
- Monitor fluid status closely to avoid pulmonary edema with excessive fluid administration 1
Medication Management
- Discontinue nephrotoxic medications when possible (NSAIDs, aminoglycosides, etc.) 1
- Avoid diuretics specifically for the prevention or treatment of AKI (unless treating volume overload) 1
- Avoid dopamine and recombinant human IGF-1 for prevention or treatment of AKI 1
- Implement therapeutic drug monitoring when using potentially nephrotoxic medications that cannot be avoided 1
Metabolic Management
- Target plasma glucose of 110-149 mg/dL (6.1-8.3 mmol/L) in critically ill patients 1
- Provide total energy intake of 20-30 kcal/kg/day 1
- Administer protein at 0.8-1.0 g/kg/day in noncatabolic AKI patients without need for dialysis, 1.0-1.5 g/kg/day in patients with AKI on RRT, and up to 1.7 g/kg/day in patients on CRRT and hypercatabolic patients 1
- Provide nutrition preferentially via the enteral route 1
Specialized Management Based on Etiology
AKI in Cirrhosis
- Hold diuretics and nonselective beta-blockers when AKI is diagnosed 1
- Discontinue NSAIDs 1
- Replace fluid losses, administering albumin 1 g/kg/day for 2 days if serum creatinine shows doubling from baseline 1
- For hepatorenal syndrome with AKI (HRS-AKI), initiate albumin (1 g/kg IV on day 1, then 20-40 g daily) with vasoactive agents (terlipressin, octreotide/midodrine, or norepinephrine) 1
- Consider renal replacement therapy for AKI secondary to acute tubular necrosis or HRS-AKI in potential liver transplant candidates 1
AKI in Crush Injuries
- Implement aggressive fluid resuscitation with 0.9% saline before, during, and after extrication 1
- Monitor for hyperkalemia, acidosis, and fluid overload which may necessitate earlier and more frequent dialysis 1
- Consider intermittent hemodialysis as the preferred modality for crush-induced AKI due to rapid potassium clearance and ability to treat multiple patients per day 1
Renal Replacement Therapy (RRT) Considerations
- Consider RRT when there is:
Follow-up After AKI
- Target follow-up to high-risk populations, including:
- Monitor for development or progression of chronic kidney disease 1
- Determine follow-up on an individual basis rather than broadly applying to all AKI patients 1
Common Pitfalls and Caveats
- Avoid overzealous fluid resuscitation which can lead to tissue edema and worsen organ dysfunction 4, 3
- Recognize that fluid accumulation can substantially contribute to ongoing organ dysfunction, particularly in AKI 4
- Be aware that rapid or early excessive fluid removal with diuretics or extracorporeal therapy might lead to hypovolemia and recurrent renal injury 4
- Understand that while albumin is generally not recommended as initial fluid therapy, it may be beneficial in specific scenarios such as patients with cirrhosis and spontaneous bacterial peritonitis 1
- Remember that avoidance of nephrotoxins is not always possible, and some pathogens may require potentially nephrotoxic antimicrobial therapy 1