Acute Kidney Injury Management

Aka: Acute Kidney Injury Management, Acute Renal Failure Management

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II. Management: General

  1. Consult Nephrology early in course
  2. Most patients with Acute Kidney Injury require hospitalization (except mild cases with known reversible cause)
  3. Eliminate Nephrotoxic Drugs
    1. See Intravenous Contrast Related Acute Renal Failure
  4. Consider renal replacement therapy (see Dialysis indications below)
  5. Consider specific therapy for underlying Acute Kidney Injury cause
    1. Example: Corticosteroids or Immunosuppressants in Rapidly Progressive Glomerulonephritis
  6. Nutritional Intake
    1. Maintain 30-50 KCal/Kg/day
  7. Hemodynamic stability is critical to maintain renal perfusion
    1. See Volume status below
  8. Manage hyperglycemuia in Diabetes Mellitus
    1. Keep plasma Glucose 110-149 mg/dl
  9. Manage Electrolyte abnormalities (see below)
    1. Hyperkalemia (see below)
    2. Metabolic Acidosis (see below)
    3. Hyperphosphatemia
    4. Hypermagnesemia
    5. Hyponatremia
    6. Hypernatremia

III. Management: Volume Status

  1. Monitoring
    1. See Inferior Vena Cava Ultrasound for Volume Status
    2. Central venous catheter is often required
  2. Normal Volume Status
    1. Limit Fluid Intake to Urine Output + 300-500 ml/day
    2. Limit Sodium Intake to 2 grams per day
  3. Volume Overloaded
    1. Limit Fluid intake to less than Urine Output
    2. Limit Sodium Intake to less than 2 grams per day
    3. Consider Loop Diuretic (e.g. IV Furosemide)
    4. Consider Hemodialysis
  4. Volume Depleted
    1. First: Restore Volume with Isotonic Saline
      1. Crystalloid is preferred over albumin, Dextrans and other hyperoncotic solutions
        1. Finfer (2004) N Engl J Med 350(22): 2247-56 [PubMed]
      2. Balanced Crystalloid (Lactated Ringers, Plasmalyte) are preferred over Normal Saline
        1. Yunos (2012) JAMA 308(15): 1566-72 [PubMed]
    2. Next: Limit Intake to Urine Output + 300-500 ml/day
    3. Limit Sodium intake to 2 grams per day
  5. Hypotension
    1. Replace volume as above
    2. Maintain mean arterial pressure >65 mmHg
    3. Vasopressors may be needed for pressure support
      1. Renal dose Dopamine is not recommended (worse outcomes)

IV. Management: Potassium

  1. Hyperkalemia
    1. Look for Potassium source
    2. Eliminate ParenteralPotassium
    3. Reduce Dietary Potassium intake <50 meq per day
    4. Consider Potassium binding resin (Kayexalate)
    5. Aggressive management if Serum Potassium >6 mEq/L
      1. See Hyperkalemia Management
      2. Consider Dialysis
  2. Normokalemia
    1. Limit Potassium intake to 50 meq per day

V. Management: Acid-Base Status

  1. Acidemia
    1. Look for cause of acidosis (See Arterial Blood Gas)
    2. Reduce Protein intake to 0.6 g/kg/day
    3. Aggressive management if pH <7.2 or bicarbonate <15
      1. Consider oral bicarbonate or
      2. Consider isotonic IV bicarbonate
      3. Consider Dialysis
  2. Normal pH
    1. Limit Protein intake to 0.8 g/kg/day

VI. Management: Uremia

  1. Absent
    1. Limit Protein intake to 0.9 g/kg/day
  2. Present
    1. Reduce Protein to 0.6 g/kg/day
    2. Check for Gastrointestinal Bleeding
    3. See Dialysis indications below

VII. Management: Hemodialysis Indications

  1. See Hemodialysis Indications
  2. Blood Urea Nitrogen >100 mg/dl
  3. Serum Creatinine >10 mg/dl
  4. Uremic Signs (e.g. Pericarditis, Encephalopathy)
  5. Significant bleeding
  6. Refractory severe Metabolic Acidosis (pH <7.20 despite normal or low pCO2)
  7. Refractory severe Hyperkalemia (Potassium >6.0 to 6.5)
  8. Volume Overload (e.g. refractory pulomary edema)
  9. Anuria (minimal urine in 6 hours) or severe Oliguria (urine out <200 ml in 12 hours)

VIII. Management: Medications

  1. Assess medications for toxicity
    1. Check drug levels
    2. Adjust dosages for Renal Function
      1. See Drug Dosing in Chronic Kidney Disease
  2. Stop Nephrotoxic Drugs
    1. See Nephrotoxic Drug
    2. NSAIDs
    3. ACE Inhibitors
    4. Metformin (Glucophage)
    5. Aminoglycosides
    6. Avoid repeating Radiocontrast Material
      1. See Intravenous Contrast Related Acute Renal Failure
    7. Avoid high dose Diuretics in critically ill patients
      1. Avoid Diuretics in relatively resistant patients
      2. Associated with higher mortality
      3. Discourages prior strategy to overcome Oliguria
      4. Mehta (2002) JAMA 288:2547-53 [PubMed]
    8. Dopamine does not drop ARF risk in critically ill
      1. Kellum (2001) Crit Care Med 29:1526-31 [PubMed]

IX. Management: Post-Discharge Care

  1. Follow-up visit timing
    1. Within 3 weeks if slow renal recovery at time of discharge
    2. Three month follow-up
  2. Monitoring parameters at follow-up
    1. Blood Pressure
    2. Weight
    3. Serum Creatinine and GFR
  3. Nephrology Consultation
    1. Consult nephrology if GFR remains <60 ml/min
  4. ACE Inhibitor (ACE) or Angiotensin Receptor Blocker (ARB)
    1. Consider restarting ACE/ARB once Serum Creatinine returns to baseline (typically within 6 weeks)
      1. Consider in recent Myocardial Infarction, CHF with reduced EF, Diabetic Nephropathy
      2. May lower mortality despite risk of recurrent Acute Kidney Injury
    2. Protocol for ACE/ARB after Serum Creatinine returns to baseline
      1. Reintroduce the ACE/ARB at low dose
      2. Recheck Serum Creatinine and Serum Potassium every 2 weeks
        1. May titrate dose up as needed if labs are reassuring
        2. Decrease dose to 50% if the secrum Creatinine increases >30%
        3. Hold the ACE/ARB if Serum Creatinine remains high despite dose reduction
        4. Hold the ACE/ARB for Serum Potassium >5.5 meq/L
      3. Once labs and dosing are stable, may spread out lab rechecks
        1. Decrease lab frequency to every 6-12 months (every 3 months in higher risk patients)
    3. References
      1. (2019) Presc Lett 26(2): 7-8

X. Prognosis

  1. See Acute Kidney Injury Prognosis

XI. Prevention

  1. See Prevention of Kidney Disease Progression

XII. Resources

  1. Acute Kidney Injury Guidelines
    1. http://www.renal.org/clinical/guidelinessection/AcuteKidneyInjury.aspx

XIII. References

  1. Mercado (2019) Am Fam Physician 100(11): 687-94 [PubMed]
  2. Meyer (2007) N Engl J Med 357(13): 1316-25 [PubMed]
  3. Rahman (2012) Am Fam Physician 86(7): 631-9 [PubMed]
  4. Singri (2003) JAMA 289(6):747-51 [PubMed]

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