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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Related Studies

Ontology: Kidney Failure, Acute (C0022660)

Definition (NCI_CTCAE) A disorder characterized by the acute loss of renal function and is traditionally classified as pre-renal (low blood flow into kidney), renal (kidney damage) and post-renal causes (ureteral or bladder outflow obstruction).
Definition (NCI) Sudden and sustained deterioration of the kidney function characterized by decreased glomerular filtration rate, increased serum creatinine or oliguria.
Definition (CSP) clinical syndrome characterized by a sudden decrease in glomerular filtration rate, usually associated with oliguria and always associated with biochemical consequences of the reduction in glomerular filtration rate such as a rise in blood urea nitrogen (BUN) and serum creatinine concentrations.
Concepts Disease or Syndrome (T047)
MSH D007675 , D058186
ICD9 584, 584.9
ICD10 N17 , N17.9
SnomedCT 14669001, 197653006, 155855008
English Kidney Failure, Acute, RENAL FAILURE ACUTE, RENAL SHUTDOWN ACUTE, Acute renal failure NOS, Acute renal failure, unspecified, ARF, acute renal failure, acute renal failure (diagnosis), ARF (acute renal failure), Failure kidney acute, Kidney failure acute, Renal failure acute, Renal shutdown acute, Acute kidney failure NOS, Acute and unspecified renal failure, Acute kidney failure, unspecified, Kidney Failure, Acute [Disease/Finding], Acute Kidney Failure, Kidney Failures, Acute, Acute Renal Failure, Renal Failure, Acute, Acute Kidney Failures, Acute Renal Failures, Renal Failures, Acute, kidney failure acute, Failure;renal;acute, syndrome acute renal failure, acute renal failures, renal failure acute, acute renal shutdown, acute failure kidney, acute kidney failure, arf, failure acute renal, acute failure renal, acute renal insufficiency, Acute renal failure, Acute renal failure NOS (disorder), Acute renal failure (disorder), Acute kidney failure, AKI, Acute kidney injury, Acute renal failure syndrome, ARF - Acute renal failure, Acute renal failure syndrome (disorder), Acute renal failure syndrome, NOS
French INSUFFISANCE RENALE AIGUE, Insuffisance rénale aiguë, Ligo-anurie aiguë, Insuffisance rénale aiguë, non précisée, SIDERATION RENALE, Défaillance rénale aigüe, Défaillance rénale aiguë
Portuguese INSUFICIENCIA RENAL AGUDA, Insuficiência renal aguda NE, Falência renal aguda, PARALIZACAO RENAL, Insuficiência renal aguda
Spanish INSUFICIENCIA RENAL AGUDA, Fallo renal agudo, Insuficiencia renal aguda no especificada, FALLO RENAL AGUDO, Insuficiencia renal aguda
Dutch niet-gespecificeerd acuut nierfalen, acuut falen nier, Acute nierinsufficiëntie, niet gespecificeerd, acuut nierfalen, Nierfalen, acuut, Acute nierinsufficiëntie, Insufficiëntie, acute nier-, Nierinsufficiëntie, acute, Renale insufficiëntie, acute
German akutes Nierenversagen, akutes Nierenversagen, unspezifisch, Versagen der Niere akut, Nierenausfall akut, Akutes Nierenversagen, nicht naeher bezeichnet, NIERENEMBOLIE, NIERENVERSAGEN AKUT, Renales Versagen, akutes, Akutes Nierenversagen, Nierenversagen, akutes, Nierenversagen akut
Italian Insufficienza renale acuta, non specificata, Insufficienza renale acuta
Japanese 急性腎不全、詳細不明, 急性腎不全, 急性腎機能停止, ｷｭｳｾｲｼﾞﾝﾌｾﾞﾝｼｮｳｻｲﾌﾒｲ, ｷｭｳｾｲｼﾞﾝｷﾉｳﾃｲｼ, ｷｭｳｾｲｼﾞﾝﾌｾﾞﾝ
Swedish Njursvikt, akut
Finnish Munuaisten äkillinen vajaatoiminta
Czech Akutní selhání ledvin, Renální selhání akutní, Akutní renální selhání, Akutní renální selhání blíže neurčené, akutní selhání ledvin, ledviny - selhání akutní
Korean 상세불명의 급성 콩팥(신장)기능상실, 급성 콩팥(신장)기능상실
Croatian BUBREŽNA INSUFICIJENCIJA, AKUTNA
Hungarian acut veseelégtelenség, Acut veseelégtelenség, Acut veseelégtelenség, k.m.n., Acut veseleállás
Norwegian Akutt nyresvikt
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute kidney injury (C2609414)

Definition (MSH) Abrupt reduction in kidney function. Acute kidney injury encompasses the entire spectrum of the syndrome including acute kidney failure; ACUTE KIDNEY TUBULAR NECROSIS; and other less severe conditions.
Concepts Injury or Poisoning (T037)
MSH D058186
Spanish Lesión renal aguda, Lesión Renal Aguda
English Acute kidney injury, Acute Kidney Injury, Acute Renal Injuries, Renal Injury, Acute, Acute Kidney Injuries, Acute Renal Injury, Renal Injuries, Acute, Kidney Injury, Acute, Kidney Injuries, Acute, Acute Kidney Injury [Disease/Finding]
Portuguese Lesão renal aguda, Lesão Renal Aguda
Dutch acuut nierletsel
German akute Nierenschaedigung, Akute Nierenschädigung, Akute Nierenschaedigung, Akute Nierenverletzung
Czech Akutní poranění ledvin, ledviny - akutní poškození, akutní poškození ledvin, AKI
Japanese 急性腎不全, ｷｭｳｾｲｼﾞﾝﾌｾﾞﾝ
French Lésion rénale aiguë, Atteinte rénale aigüe, Atteinte rénale aiguë, Lésion rénale aigüe
Italian Lesione renale acuta
Russian OSTROE POVREZHDENIE POCHEK, ОПП, POCHEK OSTROE POVREZHDENIE, OPP, ПОЧЕЧНАЯ НЕДОСТАТОЧНОСТЬ ОСТРАЯ, RENAL'NAIA NEDOSTATOCHNOST' OSTRAIA, ПОЧЕК ОСТРОЕ ПОВРЕЖДЕНИЕ, ОСТРОЕ ПОВРЕЖДЕНИЕ ПОЧЕК, ПОЧЕЧНАЯ НЕДОСТАТОЧНОСТЬ ФУНКЦИОНАЛЬНАЯ, ОСТРАЯ, POCHECHNAIA NEDOSTATOCHNOST' FUNKTSIONAL'NAIA, OSTRAIA, POCHECHNAIA NEDOSTATOCHNOST' OSTRAIA, РЕНАЛЬНАЯ НЕДОСТАТОЧНОСТЬ ОСТРАЯ
Hungarian Acut vesesérülés
Polish Niewydolność nerek ostra, Ostra niewydolność nerek, Ostre uszkodzenie nerek, Zaburzenia funkcji nerek ostre, Ostre zaburzenia funkcji nerek, Uszkodzenie nerek ostre, Ostra dysfunkcja nerek, Ostra niedomoga nerek
Norwegian Akutt nyreskade, Nyreskade, akutt
Derived from the NIH UMLS (Unified Medical Language System)

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