Hypertension management in Acute Kidney Injury (AKI)?

From the Guidelines

Hypertension management in Acute Kidney Injury (AKI) should prioritize the continuation of renin-angiotensin system (RAS) blockers, such as ACE inhibitors and ARBs, even with minor increases in serum creatinine (<30%) in the absence of volume depletion.

Key Considerations

• Diagnosis of AKI: A 50% or greater sustained increase in serum creatinine over a short period of time, reflected as a rapid decrease in eGFR 1.
• Risk Factors for AKI: Preexisting CKD, use of medications that cause kidney injury (e.g., nonsteroidal anti-inflammatory drugs), and use of medications that alter renal blood flow and intrarenal hemodynamics, such as diuretics, ACE inhibitors, and ARBs 1.
• Management of Hypertension in AKI: ACE inhibitors and ARBs should not be discontinued for minor increases in serum creatinine (<30%) in the absence of volume depletion, as they are beneficial in slowing kidney disease progression and reducing mortality 1.
• Importance of Maximally Tolerated Doses: ACE inhibitors and ARBs should be used at maximally tolerated doses, as low doses may not provide benefit in slowing kidney disease progression 1.

Medication Considerations

• Sodium–glucose cotransporter 2 (SGLT2) inhibitors: Do not increase the risk of AKI when used to slow kidney disease progression, even when combined with diuretics or other medications that reduce glomerular filtration 1.
• Nonsteroidal mineralocorticoid receptor antagonists (MRAs): Do not increase the risk of AKI when used to slow kidney disease progression 1.

From the Research

Hypertension Management in Acute Kidney Injury (AKI)

• Hypertension is a common finding in patients with AKI, with a prevalence of 70% in one study 2.
• The management of hypertension in AKI is crucial, as uncontrolled hypertension can lead to further kidney damage and increase the risk of cardiovascular complications.
• The use of antihypertensive medications, such as diltiazem, has been associated with an increased risk of AKI in patients with acute intracerebral hemorrhage 3.
• Early blood pressure reduction using intravenous vasodilators has been linked to an increased risk of AKI in patients with hypertensive acute decompensated heart failure 4.

Hemodynamic Management of AKI

• Hemodynamic management of AKI involves optimizing renal perfusion and function, and may include the use of fluids, inotropes, and vasopressors 5.
• The optimal mean arterial pressure (MAP) target level remains undefined, and individualization of MAP targets may be necessary, taking into account central venous and intraabdominal pressures, as well as the response to an increase in MAP 5.
• The administration of certain medications, such as carperitide, has been independently associated with an increased incidence of AKI in patients with hypertensive ADHF 4.

Cardiovascular Outcomes in AKI

• AKI is associated with an increased risk of cardiovascular complications, including heart failure, non-ST-elevation myocardial infarction, and cardiac arrest 6.
• Any degree of AKI is associated with a greater risk of morbidity and mortality, and chronic kidney disease is a common comorbidity among patients admitted with acute severe hypertension 6.
• The development of AKI during hospitalization is independently associated with an increased risk of death, and other independent predictors of mortality include increasing age, male gender, and worse baseline kidney function 6.