What is the latest treatment for acute kidney injury (AKI)?

Latest Treatment for Acute Kidney Injury

The management of acute kidney injury (AKI) requires a systematic approach focusing on fluid optimization, discontinuation of nephrotoxic agents, and appropriate renal replacement therapy when indicated, with treatment tailored to the underlying cause. 1

Initial Assessment and Management

• Identify and treat the underlying cause of AKI, including discontinuation of nephrotoxic medications (NSAIDs, aminoglycosides) when possible 1, 2
• Administer isotonic crystalloids rather than colloids for initial expansion of intravascular volume in patients with or at risk for AKI 1
• Use balanced crystalloids (e.g., lactated Ringer's) rather than 0.9% saline when possible, as evidence shows better outcomes with physiological crystalloids 3
• Avoid synthetic colloids, particularly in critically ill patients with sepsis, due to increased risk of kidney dysfunction and mortality 3
• Monitor fluid status closely to prevent pulmonary edema from excessive fluid administration 1

Hemodynamic Management

• Implement protocol-based management of hemodynamic parameters in high-risk patients, particularly in perioperative settings or septic shock 1
• Administer vasopressors in conjunction with fluids in patients with vasomotor shock with or at risk for AKI 1
• Consider earlier use of vasoactive medications rather than excessive fluid administration for hypotension in certain clinical contexts 3
• Base fluid administration on repeated assessment of overall fluid status and dynamic tests of fluid responsiveness 3

Medication Management

• Avoid diuretics specifically for 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
• Adjust medication dosages according to renal function 2

Metabolic Management

• Target plasma glucose of 110-149 mg/dL 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

Renal Replacement Therapy (RRT)

• Consider RRT when there are severe metabolic derangements such as refractory hyperkalemia, severe acidosis, volume overload unresponsive to diuretics, or uremic complications 3, 4
• The optimal timing for acute RRT remains controversial, but should be considered when metabolic and fluid demands exceed the kidney's capacity 3
• For hemodynamically unstable patients, continuous RRT is more physiologically appropriate than intermittent hemodialysis, though RCTs have not demonstrated better outcomes 3
• When using intermittent or extended RRT, deliver a Kt/V of at least 1.2 per treatment 3 times a week 3
• For continuous RRT, deliver an effluent volume of 20-25 ml/kg per hour 3
• Use regional citrate anticoagulation for continuous RRT in patients without contraindications 3
• Discontinue RRT when kidney function has recovered or when RRT becomes inconsistent with shared care goals 3

Special Considerations for AKI in Cirrhosis

• Hold diuretics and nonselective beta-blockers when AKI is diagnosed in patients with cirrhosis 3
• 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, initiate albumin with vasoactive agents 1
• Consider RRT for AKI secondary to acute tubular necrosis or hepatorenal syndrome-AKI in potential liver transplant candidates 1

Follow-up After AKI

• Target follow-up to high-risk populations, including patients with baseline CKD and those with severe AKI or incomplete recovery of kidney function at discharge 1
• Monitor for development or progression of chronic kidney disease 1
• Assess for proteinuria, which is associated with worse long-term outcomes after AKI 3

Common Pitfalls and Caveats

• While albumin is generally not recommended as initial fluid therapy for most AKI cases, it may be beneficial in specific scenarios such as patients with cirrhosis and spontaneous bacterial peritonitis 1
• Biomarkers should not be used alone when deciding whether to initiate RRT 3
• Excessive fluid administration can worsen outcomes; fluid overload and venous congestion have adverse effects on kidney function 3
• Nephrotoxic medication avoidance is not always possible when treating certain infections; in these cases, careful monitoring and dose adjustment are essential 1