From the Guidelines
Inpatient management of Acute Kidney Injury (AKI) involves careful fluid management and hemodynamic support.
Key Components of Inpatient Management
- Fluid management: determining the optimal indications and targets for fluid and vasoactive drugs to improve kidney outcomes in acute medical illness and in the perioperative setting 1
- Hemodynamic support: investigating the optimal method of administering fluid for preventing or mitigating AKI and exploring whether the optimal methods vary in different contexts where different levels of monitoring are available 1
- Renal replacement therapy (RRT): RRT should be discontinued “when it is no longer required, either because intrinsic kidney function has recovered to the point that it is adequate to meet patient needs, or because RRT is no longer consistent with the goals of care” 1
- Monitoring for renal recovery: hemodynamic status, intravascular volume, and urine output during dialysis should be carefully monitored to assess for renal recovery 1
Additional Considerations
- Optimal follow-up: patients recovering from critical illness and AKI should receive multidisciplinary, recovery-focused care, and those with AKI who continue to require RRT at hospital discharge often receive hemodialysis in outpatient dialysis facilities 1
- Risk factors for non-recovery of kidney function: patients with congestive heart failure are less likely to recover kidney function, and higher ultrafiltration rates and more intradialytic hypotensive episodes are associated with higher risk of non-recovery of kidney function 1
- Long-term risks: patients with AKD after hospital discharge are at risk for development of de novo CKD or progression of preexisting CKD, eventually leading to kidney failure, and should be reassessed at 3 months, or less, after hospital discharge, depending on the individual patient 1
From the Research
Inpatient Management of Acute Kidney Injury (AKI)
The inpatient management of AKI involves several key steps, including:
- Determination of baseline performance to identify areas for improvement 2
- Timely recognition and appropriate diagnostic workup to identify the cause of AKI 2, 3
- Implementation of known interventions to limit progression and severity, facilitate recovery, and mitigate AKI-associated complications 2, 4
- Fluid and electrolyte management, which are essential in AKI management 3, 5
- Initiation of renal replacement therapy (RRT) in patients with complications refractory to medical management 4, 5
Key Considerations
Some key considerations in the inpatient management of AKI include:
- The optimal choice of intravenous fluid therapy remains controversial 5
- Blood pressure targets are often higher in AKI, and these can be achieved with fluids and vasopressors 4
- There are no targeted pharmacotherapies for AKI itself, but some do exist for complications of AKI 4
- Critical care nurses play a vital role in identifying and managing AKI, and renal replacement therapy requires expertise from critical care nurses 6
Quality Improvement
Quality improvement initiatives are essential in the inpatient management of AKI, and should prioritize achievable goals likely to have the highest impact according to the setting and context 2. The Recognition-Action-Results framework can be used to plan, measure, and report progress toward improving AKI management quality 2.