From the Guidelines
The management of acute kidney injury (AKI) should focus on identifying and treating the underlying cause, supporting kidney function, and preventing complications, with the most recent and highest quality study suggesting a protocol-based approach to hemodynamic and oxygenation parameters in high-risk patients 1.
Key Principles of AKI Management
- Assess volume status and correct any hypovolemia with isotonic crystalloids (normal saline or lactated Ringer's) at 10-20 ml/kg, titrated to clinical response, as recommended by the KDIGO guideline 1.
- Discontinue nephrotoxic medications, including NSAIDs, aminoglycosides, and contrast agents, to prevent further kidney damage.
- Monitor electrolytes closely, particularly potassium, and treat hyperkalemia promptly if levels exceed 6.0 mEq/L using insulin, sodium bicarbonate, or calcium gluconate for cardiac protection.
- Maintain adequate nutrition with 0.8-1.0 g/kg/day of protein and 20-30 kcal/kg/day of calories, as suggested by the KDIGO guideline 1.
- Consider renal replacement therapy for refractory hyperkalemia, severe acidosis (pH < 7.1), uremic symptoms, or volume overload unresponsive to diuretics.
Specific Considerations
- In patients with cirrhosis and ascites, the International Club of Ascites recommends a new algorithm for the management of AKI, including review of drug chart, plasma volume expansion, and prompt recognition and early treatment of bacterial infections 1.
- The use of vasoconstrictors in patients with AKI stage 1 and serum creatinine <1.5 mg/dl is not recommended, as it may worsen kidney function.
- The KDIGO guideline recommends not using diuretics to prevent AKI, but suggests their use in the management of volume overload 1.
Prevention of AKI
- Maintaining adequate hydration, avoiding nephrotoxins, and appropriate dosing of medications in high-risk patients are crucial in preventing AKI.
- The use of protocol-based management of hemodynamic and oxygenation parameters in high-risk patients, as suggested by the most recent and highest quality study, may help prevent AKI 1.
- Regular monitoring of kidney function, including serum creatinine and urine output, is essential in high-risk patients to detect AKI early and initiate prompt treatment.
From the Research
Management Plan for Acute Kidney Injury (AKI)
The management plan for AKI involves a multifaceted approach, including:
- Treating the underlying cause of AKI 2
- Supportive care, such as fluid management, vasopressor therapy, and kidney replacement therapy (KRT) 2, 3
- Management of electrolyte imbalances and avoidance of nephrotoxic medications 3, 4
- Recognition of risk factors, such as older age, sepsis, hypovolemia/shock, cardiac surgery, infusion of contrast agents, diabetes mellitus, preexisting chronic kidney disease, cardiac failure, and liver failure 3, 4
Diagnostic Evaluation
The diagnostic evaluation of AKI includes:
- Patient history to identify the use of nephrotoxic medications or systemic illnesses that might cause poor renal perfusion or directly impair renal function 3
- Physical examination to assess intravascular volume status and identify skin rashes indicative of systemic illness 3
- Laboratory evaluation, including measurement of serum creatinine level, complete blood count, urinalysis, and fractional excretion of sodium 3
- Ultrasonography of the kidneys to rule out obstruction, particularly in older men 3
Fluid Management
Fluid management is a crucial aspect of AKI management, with a focus on:
- Volume resuscitation as a cornerstone in the treatment of hemodynamic instability 5
- Preference for crystalloids over colloids, with synthetic colloids associated with increased risk of AKI 5
- Avoidance of fluid overload, with a paradigm shift towards achieving neutral and slightly negative fluid balance or 'dry' patients after initial fluid resuscitation 5
Renal Replacement Therapy
Renal replacement therapy (dialysis) is indicated for: