What is the immediate treatment for Acute Kidney Injury (AKI)?

Immediate Treatment for Acute Kidney Injury (AKI)

The first priority in treating AKI is to immediately discontinue all nephrotoxic medications—including NSAIDs, ACE inhibitors, ARBs, diuretics, beta-blockers, aminoglycosides, and iodinated contrast—while simultaneously identifying and reversing the underlying cause. 1, 2

Step 1: Immediate Medication Review and Discontinuation

• Stop all nephrotoxic drugs immediately upon AKI diagnosis, as each additional nephrotoxin increases AKI odds by 53% 1, 2
• Discontinue the "triple whammy" combination (NSAIDs + diuretics + ACE inhibitors/ARBs) which is particularly dangerous 1, 3
• Hold diuretics and beta-blockers when AKI is diagnosed to prevent further kidney injury 2, 3
• Review all medications including over-the-counter drugs that may contribute to kidney injury 1, 2

Step 2: Fluid Resuscitation and Hemodynamic Optimization

• Use isotonic crystalloids (preferably lactated Ringer's over 0.9% saline) as first-line therapy for volume expansion in patients with clinically suspected hypovolemia 1, 2, 3
• Target mean arterial pressure ≥65 mmHg to ensure adequate renal perfusion 1, 3
• Avoid hydroxyethyl starches as they increase the risk of worsening AKI 1, 2, 3
• Consider earlier use of vasoactive medications instead of excessive fluid administration for hypotension 1
• Avoid excessive fluid administration leading to volume overload >10-15% body weight, as this is associated with adverse outcomes 1

Fluid Management Guidance:

• Base fluid administration on repeated assessment of overall fluid and hemodynamic status, as both the physiological response and underlying condition are dynamic over time 1
• Use dynamic indices (passive leg-raising test, pulse/stroke volume variation) rather than static measurements to guide fluid therapy 1
• Monitor for fluid overload using urine output, vital signs, and when indicated, echocardiography or CVP 1, 2

Step 3: Vasopressor Therapy (If Needed)

• Use norepinephrine as first-line vasopressor if fluid resuscitation fails to restore adequate blood pressure 2
• Do NOT use dopamine to prevent or treat AKI, as it is ineffective based on level 1A/B evidence 4, 1, 2

Step 4: Monitoring During Acute Phase

• Measure serum creatinine and electrolytes every 12-24 hours during acute management 1, 3
• Monitor urine output, vital signs, and fluid balance closely in the first 48-72 hours 1, 3
• Perform urine sediment analysis for differential diagnosis 1

Step 5: Special Population Considerations

For Cirrhotic Patients with AKI:

• Discontinue BOTH diuretics AND beta-blockers (not just diuretics) 1, 3
• Administer IV albumin 1 g/kg bodyweight (maximum 100g) for two consecutive days to differentiate prerenal AKI from hepatorenal syndrome 1, 2, 3
• If serum creatinine remains elevated despite initial management, administer vasoactive agents (terlipressin, norepinephrine, or midodrine plus octreotide) along with albumin for hepatorenal syndrome-AKI 1, 2

Step 6: Renal Replacement Therapy Considerations

• Consider RRT for persistent AKI despite appropriate interventions, particularly for refractory hyperkalemia, acidosis, or fluid overload 1, 2
• Individualize timing of RRT based on overall clinical condition rather than specific creatinine or BUN thresholds 1, 2

Critical Pitfalls to Avoid

• Never use furosemide in hemodynamically unstable patients with prerenal AKI—it worsens volume depletion and reduces renal perfusion 1, 3
• Do not use diuretics to treat AKI except for managing volume overload after adequate renal perfusion is restored 1, 3
• Do not delay fluid resuscitation in truly hypovolemic patients 1, 3
• Do not use eGFR equations (MDRD, CKD-EPI) designed for CKD to assess renal function in AKI—they require steady-state creatinine and are inaccurate in acute settings 1
• Avoid indiscriminate fluid administration based solely on the label "prerenal" without hemodynamic assessment 1

What Does NOT Work (High-Quality Evidence)

Based on level 1A/B evidence, do NOT use the following for AKI treatment 4, 1:

• Dopamine
• Diuretics (for treatment of AKI itself)
• N-acetylcysteine (NAC)
• Recombinant human insulin-like growth factor 1 (IGF-1)