What is the treatment for acute kidney failure?

Treatment of Acute Kidney Failure

The cornerstone of acute kidney injury (AKI) treatment is immediate volume resuscitation with isotonic crystalloids (avoiding 0.9% saline when possible), elimination of nephrotoxic medications, and initiation of renal replacement therapy when life-threatening complications develop—specifically refractory hyperkalemia, volume overload unresponsive to diuretics, intractable acidosis, or uremic symptoms. 1, 2, 3

Initial Hemodynamic Management

Volume Resuscitation

• Use isotonic crystalloids (not colloids) for initial volume expansion in patients with or at risk for AKI 2, 3
• Physiological crystalloids are preferable to 0.9% saline due to fewer biochemical abnormalities and better clinical outcomes 1
• Absolutely avoid synthetic colloids, particularly hydroxyethyl starches, as they directly increase AKI incidence and mortality, especially in septic patients 2, 3
• Adjust fluid therapy based on repeated assessment of overall fluid and hemodynamic status 1

Blood Pressure Targets

• Maintain mean arterial pressure of at least 50-60 mmHg 1
• Use vasopressors if fluid resuscitation alone is insufficient to achieve target blood pressure 1
• Monitor volumetric parameters for detecting intravascular volume changes while using pressure monitoring to prevent pulmonary edema 1

Drug Stewardship (Critical Priority)

Medications to Discontinue

• Stop all nephrotoxic medications immediately—this is the most preventable error in AKI management 2
• Avoid the "triple whammy" combination: renin-angiotensin system inhibitors + diuretics + NSAIDs 2
• Include a clinical pharmacist for comprehensive drug stewardship to prevent and mitigate drug-associated AKI 2

Medications NOT to Use

• Do not use dopamine, loop diuretics for prevention/treatment, N-acetylcysteine (NAC), or recombinant human IGF-1—none alter clinical outcomes 2
• Avoid goal-directed fluid therapy protocols in early septic shock, as large trials showed no survival or kidney outcome benefits 2

Renal Replacement Therapy (RRT) Indications

Absolute Indications for Emergency RRT

• Refractory hyperkalemia unresponsive to medical management 2, 4
• Volume overload unresponsive to diuretics, particularly with pulmonary edema 1, 2, 4
• Intractable metabolic acidosis 2, 4
• Uremic complications: encephalopathy, pericarditis, or pleuritis 2, 4
• Certain toxin removal 4

RRT Modality Selection

For hemodynamically unstable patients, use continuous renal replacement therapy (CRRT) rather than intermittent hemodialysis 1, 5, 3

CRRT is specifically preferred for:

• Hemodynamically unstable patients who cannot tolerate intermittent hemodialysis 5
• Patients with or at risk for cerebral edema 5
• Patients with acute renal failure and concomitant liver failure 1, 5
• Patients requiring continuous fluid removal or management of volume overload 5

CRRT Modalities (in order of complexity):

1. Continuous Venovenous Hemofiltration (CVVH): uses primarily convective clearance 1, 5
2. Continuous Venovenous Hemodialysis (CVVHD): uses primarily diffusive clearance 1, 5
3. Continuous Venovenous Hemodiafiltration (CVVHDF): combines both convective and diffusive methods 1, 5

CRRT Technical Specifications

Dosing

• Prescribe effluent volume of 20-25 mL/kg/h for AKI 1, 5
• Frequently assess actual delivered dose and adjust prescription accordingly 5

Vascular Access

• Use uncuffed nontunneled dialysis catheters for initiating CRRT 5
• Preferred vein selection order: right jugular vein → femoral vein → left jugular vein → subclavian vein 5
• Always use ultrasound guidance for catheter insertion 5
• Obtain chest radiograph after internal jugular or subclavian placement before first use 5
• Avoid subclavian veins due to thrombosis risk and late stenosis 5

Anticoagulation Strategy

• First choice: regional citrate anticoagulation for patients without increased bleeding risk 5
• If citrate contraindicated: use unfractionated or low-molecular-weight heparin 5
• For heparin-induced thrombocytopenia (HIT): use direct thrombin inhibitors or Factor Xa inhibitors 5

Fluid Composition

• Use bicarbonate-buffered solutions (not lactate), especially for patients with circulatory shock, liver failure, or lactic acidemia 5
• All dialysis and replacement fluids must comply with AAMI standards for bacterial and endotoxin contamination 5
• Consider pre-dilution fluid administration for patients with frequent filter clotting 5

Monitoring and Reassessment

• Reassess the need for continued RRT daily 2
• Monitor filter performance and achievement of goals: electrolyte balance, acid-base balance, solute clearance, and fluid balance 5
• Avoid volume overload, especially in patients with acute lung injury 5

Critical Pitfalls to Avoid

• Do not delay RRT when clear indications exist—this increases mortality 2
• Do not restart ACE inhibitors/ARBs too early; wait at least 3 months after AKI to evaluate for resolution 2
• Do not rely solely on BUN and creatinine thresholds for initiating RRT; consider the broader clinical context 5
• Avoid using lactate-buffered solutions in patients with liver failure or lactic acidosis 5
• Use integrated fluid balancing systems rather than adapted IV infusion pumps 5

Post-AKI Management

• Ensure adequate follow-up after AKI episodes to prevent progression to chronic kidney disease 6, 2
• Patients who "recover" from AKI still carry long-term increased risk of major adverse cardiac and kidney events 6
• Avoid unnecessary nephrotoxic drugs even after apparent recovery 6