What is the initial treatment protocol for acute kidney injury?

Acute Kidney Injury Treatment Protocol

The initial treatment of AKI focuses on identifying and removing nephrotoxic agents, optimizing hemodynamics with isotonic crystalloids, and providing supportive care tailored to the underlying cause rather than relying solely on stage-based protocols. 1, 2

Immediate Actions Upon AKI Recognition

Medication Review and Adjustment

• Discontinue all nephrotoxic medications immediately, including NSAIDs, aminoglycosides, ACE inhibitors, ARBs, and iodinated contrast agents 1, 2
• Withdraw or reduce diuretics in patients with suspected hypovolemia 1, 2
• Hold beta-blockers when AKI is diagnosed 2
• Review all medications including over-the-counter drugs that may contribute to kidney injury 2
• Each additional nephrotoxin increases AKI odds by 53%, making combination avoidance critical 2

Hemodynamic Optimization

Fluid Management:

• Use isotonic crystalloids (not colloids or starches) for initial volume expansion in patients with clinically suspected hypovolemia 3, 1, 2
• Avoid starch-containing fluids as they are associated with harm 3
• Monitor for fluid overload using urine output, vital signs, and when indicated, echocardiography or CVP 2

Blood Pressure Support:

• Target mean arterial pressure of at least 65 mmHg to ensure adequate renal perfusion 2
• Use vasopressors in conjunction with fluids for vasomotor shock 3
• Prefer norepinephrine over dopamine as first-line vasopressor 1
• Do not use dopamine to prevent or treat AKI 3

Cause-Specific Management

Prerenal AKI

• Optimize hemodynamics with fluid resuscitation targeting MAP ≥65 mmHg 2
• Consider vasopressor therapy if fluid resuscitation fails to restore adequate blood pressure 2

AKI in Cirrhotic Patients (Special Population)

• For Stage 1 AKI: Implement close monitoring, remove risk factors, and provide plasma volume expansion if hypovolemic 1, 2
• For Stage 2-3 AKI: Withdraw diuretics and administer intravenous albumin at 1 g/kg/day for two consecutive days (maximum 100g/day) 1, 2
• If hepatorenal syndrome criteria are met and creatinine remains elevated despite initial management, add vasoactive agents (terlipressin, norepinephrine, or midodrine plus octreotide) along with albumin 2

Supportive Care Measures

Nutritional Support

• Provide 20-30 kcal/kg/day total energy intake 1
• Adjust protein based on severity: 0.8-1.0 g/kg/day in noncatabolic AKI without dialysis, 1.0-1.5 g/kg/day on renal replacement therapy, up to 1.7 g/kg/day in hypercatabolic patients on continuous RRT 1

Metabolic Management

• Maintain glycemic control with target blood glucose 110-149 mg/dL 1
• Manage metabolic acidosis with sodium bicarbonate in selected cases 2
• Treat electrolyte disturbances as they arise 4

Monitoring Strategy

• Monitor kidney function closely in all patients with or at risk for AKI 1
• Stage AKI using established criteria (Stage 1: SCr increase ≥0.3 mg/dL or 1.5-2× baseline; Stage 2: >2-3× baseline; Stage 3: >3× baseline or ≥4.0 mg/dL or initiation of RRT) 1
• However, management should be based on overall clinical status, specific cause, trends in kidney function, comorbidities, volume status, and electrolyte disturbances—not stage alone 3

Critical Pitfalls to Avoid

• Do not use N-acetylcysteine for prevention of AKI in critically ill patients with hypotension or for postsurgical AKI prevention 1
• Avoid off-pump coronary artery bypass solely to reduce perioperative AKI 1
• Do not use diuretics, dopamine, or recombinant human IGF-1 to prevent or treat AKI 3
• Avoid the "triple whammy" combination of NSAIDs, diuretics, and ACE inhibitors/ARBs, which significantly increases AKI risk 2
• Do not rely on stage-based management protocols alone, as extreme heterogeneity of AKI makes this approach clinically unhelpful for many patients 3

Renal Replacement Therapy Considerations

• Individualize timing of RRT based on overall clinical condition rather than specific creatinine or BUN thresholds 2
• Consider RRT for refractory hyperkalemia, volume overload, intractable acidosis, uremic complications (encephalopathy, pericarditis, pleuritis), or toxin removal 5
• The guideline suggestion to consider RRT at Stage 2 is premature and should be based on clinical context 3

Nephrology Consultation

• Emergent referral for Stage 2-3 AKI, Stage 1 AKI with decompensated conditions, or unclear etiology 6
• Consider consultation if etiology is unclear or subspecialist care is needed 2