Initial Management Steps for Acute Kidney Injury
The initial management of acute kidney injury (AKI) should focus on identifying and removing risk factors, optimizing hemodynamics, and providing appropriate supportive care to prevent progression and reduce mortality. 1
Risk Factor Identification and Removal
- Review all medications and discontinue nephrotoxic agents, vasodilators, and NSAIDs as soon as AKI is identified 1
- Withdraw or reduce diuretic therapy in patients with suspected hypovolemia 1
- Promptly identify and treat infections, which are common precipitants of AKI, particularly in cirrhotic patients 2
- Avoid use of hydroxyethyl starches for fluid resuscitation as they increase risk for renal replacement therapy and mortality 3
Hemodynamic Optimization
- Provide plasma volume expansion with isotonic crystalloids (not hydroxyethyl starches) in patients with clinically suspected hypovolemia 1, 3
- For cirrhotic patients with AKI, administer intravenous albumin at the dose of 1 g per kg bodyweight per day for two consecutive days 1, 2
- Maintain adequate blood pressure using vasopressors when necessary, with norepinephrine preferred over dopamine as first-line agent 1
- Consider protocol-based management of hemodynamic parameters in high-risk patients, but only using previously validated protocols 1
Monitoring and Staging
- Monitor kidney function closely in all patients with AKI or at risk for AKI 1
- Stage AKI according to established criteria to guide management decisions:
- Stage 1: Increase in serum creatinine ≥0.3 mg/dL or 1.5-2 times baseline
- Stage 2: Increase in serum creatinine >2-3 times baseline
- Stage 3: Increase in serum creatinine >3 times baseline or ≥4.0 mg/dL with acute increase ≥0.3 mg/dL or initiation of renal replacement therapy 2
Supportive Care Measures
- Adjust medication dosages according to current renal function 4
- Provide appropriate nutritional support with 20-30 kcal/kg/day total energy intake 1
- Adjust protein intake based on AKI severity:
- 0.8-1.0 g/kg/day in noncatabolic AKI patients without dialysis
- 1.0-1.5 g/kg/day in patients on renal replacement therapy
- Up to 1.7 g/kg/day in hypercatabolic patients on continuous renal replacement therapy 1
- Maintain glycemic control with target blood glucose of 110-149 mg/dL 1
Management of Fluid Overload
- Use diuretics to control fluid overload but not for prevention or treatment of AKI itself 5
- Consider renal replacement therapy for severe fluid overload unresponsive to diuretic therapy 5
Special Considerations in Cirrhotic Patients
- For cirrhotic patients with AKI Stage 1, implement close monitoring, removal of risk factors, and plasma volume expansion for hypovolemia 2, 6
- For cirrhotic patients with AKI Stage 2 or 3, withdraw diuretics, expand volume with albumin, and consider vasoconstrictors plus albumin if hepatorenal syndrome criteria are met 6
When to Consider Nephrology Consultation
- Stage 3 or higher AKI 4
- AKI without a clear cause 4
- Inadequate response to supportive treatment 4
- Preexisting stage 4 or higher chronic kidney disease 4
- When considering renal replacement therapy 4
Pitfalls to Avoid
- Do not use N-acetylcysteine for prevention of AKI in critically ill patients with hypotension or for prevention of postsurgical AKI 1
- Avoid off-pump coronary artery bypass graft surgery solely for the purpose of reducing perioperative AKI 1
- Do not delay appropriate treatment while waiting for serum creatinine to rise, as early intervention is critical for preventing AKI progression 3
- Avoid rapid or excessive fluid removal with diuretics or extracorporeal therapy as this might lead to hypovolemia and recurrent renal injury 5