What is the immediate management of acute kidney injury?

Immediate Management of Acute Kidney Injury

The immediate management of acute kidney injury (AKI) should focus on identifying and treating underlying causes, discontinuing nephrotoxic medications, optimizing fluid status, and considering renal replacement therapy when indicated. 1

Initial Assessment and Interventions

• Immediately discontinue all nephrotoxic medications including NSAIDs, ACE inhibitors, ARBs, and diuretics to prevent further kidney damage 1, 2
• Obtain kidney ultrasound to rule out obstructive uropathy as a reversible cause of AKI 1
• Assess volume status through clinical examination and potentially central venous pressure monitoring to guide fluid management 1
• Administer isotonic fluid cautiously with close monitoring in hypovolemic patients; avoid hypotonic fluids which could worsen hyponatremia 1
• Monitor serum electrolytes, BUN, and creatinine every 4-6 hours initially, with strict input/output measurements 1, 3

Management of Medications

• Implement a comprehensive drug stewardship program that includes identification of patients at risk for AKI and review of potentially nephrotoxic medications 1
• Avoid the "triple whammy" combination of NSAIDs, diuretics, and ACE inhibitors/ARBs, which more than doubles the risk of AKI 1, 2
• Adjust medication dosages based on current estimated GFR and reassess frequently as kidney function changes 1, 4
• If nephrotoxic agents cannot be avoided, use the lowest effective dose for the shortest duration and maintain adequate hydration 2

Indications for Renal Replacement Therapy

• Consider urgent renal replacement therapy (RRT) for severe oliguria unresponsive to fluid resuscitation, severe metabolic derangements, uremic symptoms, and fluid overload 1
• Do not delay RRT when clear indications exist, as this increases mortality 1
• Monitor for signs of uremic complications and reassess the need for continued RRT daily 1

Management of Underlying Causes

• Identify and treat infections and other precipitating causes of AKI promptly 1
• For patients with AKI and suspected UTI, obtain urinalysis and urine culture prior to initiating antibiotics 5
• Start broad-spectrum antibiotics whenever infection is strongly suspected in patients with AKI 5
• For UTI-associated AKI, select antibiotics based on local antibiogram patterns and the patient's renal function 5

Common Pitfalls to Avoid

• Avoid overly rapid correction of hyponatremia, which can lead to osmotic demyelination syndrome 1
• Avoid fluid overload from excessive resuscitation, which can worsen respiratory status and tissue oxygenation 1
• Do not treat asymptomatic bacteriuria in patients with AKI 5
• Avoid combining multiple nephrotoxic medications, as each additional nephrotoxin increases the odds of developing AKI by 53% 6
• Avoid inappropriate continuation of nephrotoxic medications during the AKI recovery phase 1

Patient Education

• Provide education regarding medication avoidance, especially over-the-counter NSAIDs 1
• Instruct patients on when to seek medical attention for symptoms of worsening kidney function 1
• Educate patients to avoid taking new medications without consulting their nephrologist 7