What is the treatment for Acute Kidney Injury (AKI)?

From the Guidelines

The treatment of acute kidney injury (AKI) should focus on addressing the underlying cause while supporting kidney function, with the most recent and highest quality study suggesting that diuretics and nonselective beta-blockers should be held, NSAIDs discontinued, the precipitating cause of AKI treated, and fluid losses replaced, administering albumin 1 g/kg/d for 2 days if the serum creatinine shows doubling from baseline 1.

Key Interventions

• Identify and treat the underlying cause of AKI, which may include stopping nephrotoxic medications, treating infections with appropriate antibiotics, or resolving obstructions through catheterization or stenting.
• Ensure adequate hydration with intravenous fluids like normal saline or lactated Ringer's solution, typically starting at 1-2 mL/kg/hour and adjusting based on response.
• Monitor fluid status carefully to avoid overload, using urine output, vital signs, and when indicated, echocardiography or CVP (if there is a pre-existing central line) to guide management.
• Maintain electrolyte balance by checking potassium, sodium, calcium, and phosphate levels regularly and correcting imbalances.
• For hyperkalemia, consider calcium gluconate (10 mL of 10% solution IV), insulin with glucose (10 units regular insulin with 50 mL of 50% dextrose), or sodium bicarbonate (50 mEq IV) for immediate management.

Additional Considerations

• Control blood pressure to prevent further kidney damage, targeting below 140/90 mmHg with medications like ACE inhibitors or ARBs if appropriate.
• In severe cases, renal replacement therapy (dialysis) may be necessary, particularly with severe fluid overload, refractory hyperkalemia (>6.5 mEq/L), or uremic symptoms.
• Throughout treatment, closely monitor urine output, serum creatinine, BUN, and electrolytes daily to assess the effectiveness of interventions and guide further management.

Specific Patient Populations

• In patients with cirrhosis, consider the use of terlipressin and albumin to manage hepatorenal syndrome (HRS)-associated AKI, as supported by recent guidelines 1.
• In general, prioritize the use of evidence-based treatments and avoid unnecessary interventions, such as the use of low-dose dopamine or fenoldopam, which have not been shown to be effective in preventing or treating AKI 1.

From the Research

Treatment Approaches for Acute Kidney Injury (AKI)

The treatment for AKI is multifaceted and involves addressing the underlying cause of the injury, as well as providing supportive care to manage the condition and prevent further complications.

• Treatment of the underlying cause of AKI is crucial, and this may involve managing conditions such as ischemic injury, nephrotoxic exposures, or other factors that may have contributed to the development of AKI 2.
• Supportive care for AKI includes fluid management, vasopressor therapy, and kidney replacement therapy (KRT) as needed 2, 3.
• The initiation of KRT is controversial, and studies have not consistently demonstrated any benefit to early start dialysis 2.
• Medications play a key role in AKI management, particularly in terms of managing complications and preventing issues related to toxicities and underdosing 2.
• Blood pressure targets are often higher in AKI, and these can be achieved with fluids and vasopressors, some of which may be more kidney-protective than others 2.

Management and Prevention Strategies

Management of AKI involves a range of strategies, including:

• Laboratory work-up and medication adjustment to identify and reverse the underlying cause of AKI 4.
• Referral to specialty care as needed, particularly for patients with severe or complex cases of AKI 4, 5.
• Measures to prevent AKI, such as avoiding nephrotoxic agents and optimizing fluid administration, are also important 5, 6.
• Staging of AKI has been recommended to stratify patients according to the severity of the condition, based on serum creatinine level and urine output 5.
• Classification of AKI into prerenal, intrinsic renal, and postrenal etiologies can help guide differential diagnosis and management 5.