Initial Management of Acute Kidney Failure
Immediately discontinue all nephrotoxic medications (especially NSAIDs, aminoglycosides, and contrast agents), provide isotonic crystalloid resuscitation for hypovolemia, and rapidly identify whether the cause is prerenal, intrinsic, or obstructive through targeted assessment. 1
Immediate Diagnostic Assessment
Diagnose AKI when serum creatinine increases ≥0.3 mg/dL within 48 hours, increases ≥50% from baseline, or urine output drops below 0.5 mL/kg/h for >6 hours. 1
- Check vital signs immediately to exclude shock and systemic infection 1
- Obtain serum creatinine, electrolytes (particularly potassium), blood urea nitrogen, and urinalysis 1
- Perform renal ultrasound to evaluate for obstruction 1
- Stage AKI severity using KDIGO criteria to determine management intensity 1
First-Line Interventions (Within Minutes to Hours)
Stop Nephrotoxic Agents
- Discontinue NSAIDs, aminoglycosides, ACE inhibitors/ARBs, diuretics, and any contrast agents immediately 1
- Avoid the "triple whammy" combination of NSAIDs, diuretics, and ACE inhibitors/ARBs, which dramatically increases AKI risk 1
- Review all medications and adjust dosages according to current renal function 1
Fluid Resuscitation
- Provide isotonic crystalloids (not colloids) for volume expansion in hypovolemic patients 1
- Timely resuscitation and goal-directed correction of fluid depletion are essential in preventing or limiting AKI progression 2
- Monitor fluid status using urine output, vital signs, and echocardiography or central venous pressure 1
Etiology-Specific Management
Post-Obstructive AKI
- Relieve obstruction promptly through percutaneous nephrostomy or ureteral stenting 1, 3
- Urgent decompression is mandatory in cases of sepsis and/or anuria in an obstructed kidney 3
Infection-Related AKI
- Start broad-spectrum antibiotics immediately when infection is strongly suspected 1, 4
- Obtain urine culture before initiating antibiotics to guide definitive therapy 4
- Select antibiotics based on local antibiogram patterns with appropriate dose adjustment for renal function 4
- Avoid TMP-SMX if creatinine clearance is <15 mL/min 4
- Do not treat asymptomatic bacteriuria in AKI patients 1, 4
Monitoring Requirements
- Perform serial serum creatinine measurements to track kidney function 1
- Monitor urine output continuously 1
- Assess for traditional complications: hyperkalemia, metabolic acidosis, and volume overload 5
- Watch for nontraditional complications including sepsis, lung injury, and heart failure, which arise from inflammatory cytokines and immune dysfunction 5
Indications for Hospital Admission
Admit patients with Stage 3 AKI or higher, failure to respond to initial interventions, presence of shock or fever, or those requiring renal replacement therapy. 1
- AKI requiring dialysis occurs in 5-8% of hospitalized patients and exceeds 13% in cardiogenic shock 6
- Arrange for renal replacement therapy before the onset of life-threatening uremic complications in advanced AKI 2
Critical Pitfalls to Avoid
- Never continue nephrotoxic medications when alternatives exist 1, 4
- Do not use standard opioid dosing in renal failure; start with lower doses and titrate carefully 3
- Avoid morphine, codeine, or tramadol as first-line agents in renal failure; use fentanyl instead as it does not accumulate active metabolites 3
- Be aware that dialysis itself may cause renal injury that prolongs recovery 7
- Recognize that AKI mortality exceeds 50% in intensive care settings, greater than acute lung injury or myocardial infarction 5