Acute kidney injury
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
prerenal azotemia
treatment of underlying condition
Prerenal azotemia is managed with techniques to improve the hemodynamic status of the patient. The underlying cause must be identified and treated, along with restoring euvolemia and hemodynamic stability.
Patients may have a history of excessive fluid loss from hemorrhage, the gastrointestinal (GI) tract, or sweating. There may be a history of sepsis, burns, major surgery, pancreatitis, or congestive heart failure.[90]Ronco C, Bellomo R, Kellum JA. Acute kidney injury. Lancet. 2019 Nov 23;394(10212):1949-64. http://www.ncbi.nlm.nih.gov/pubmed/31777389?tool=bestpractice.com [93]Folkestad T, Brurberg KG, Nordhuus KM, et al. Acute kidney injury in burn patients admitted to the intensive care unit: a systematic review and meta-analysis. Crit Care. 2020 Jan 2;24(1):2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6941386 http://www.ncbi.nlm.nih.gov/pubmed/31898523?tool=bestpractice.com
In practice, a fluid challenge can be both diagnostic and therapeutic in suspected hypovolemic prerenal azotemia. The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
Electrolyte and acid-base balance should be monitored and optimized. For management of hyperkalemia, see Hyperkalemia in adults.
Management is often difficult if prerenal azotemia results from impaired cardiac function due to poor left or right ventricular systolic function, when volume overload/venous congestion may occur concurrently with renal hypoperfusion.[118]Tang WHW, Bakitas MA, Cheng XS, et al. Evaluation and management of kidney dysfunction in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2024 Oct 15;150(16):e280-95. https://www.doi.org/10.1161/CIR.0000000000001273 http://www.ncbi.nlm.nih.gov/pubmed/39253806?tool=bestpractice.com
It requires optimization of cardiac output and volume status as indicated by the clinical scenario, along with close monitoring of renal function and urine production during therapy.[5]Sharfuddin AA, Weisbord SD, Palevsky PM, et al. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, et al, eds. Brenner and Rector's the kidney. 9th ed. Philadelphia, PA: Saunders; 2012.[113]Flamm SL, Wong F, Ahn J, et al. AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis: expert review. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2707-16. https://www.cghjournal.org/article/S1542-3565(22)00829-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36075500?tool=bestpractice.com
review drugs and stop nephrotoxins
Treatment recommended for ALL patients in selected patient group
Review and adjustment of drugs is required in all cases to reduce exposure to nephrotoxic agents (e.g., aminoglycosides and other nephrotoxic antibiotics, many cancer therapies, nonsteroidal anti-inflammatory drugs [NSAIDS]).[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
Consult your local drug information source for more information on nephrotoxic drugs.
volume expansion
Treatment recommended for ALL patients in selected patient group
Crystalloid (normal saline or balanced solutions, such as Ringer lactate [Hartmann solution]) is sufficient in most cases for volume expansion.[5]Sharfuddin AA, Weisbord SD, Palevsky PM, et al. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, et al, eds. Brenner and Rector's the kidney. 9th ed. Philadelphia, PA: Saunders; 2012.[113]Flamm SL, Wong F, Ahn J, et al. AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis: expert review. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2707-16. https://www.cghjournal.org/article/S1542-3565(22)00829-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36075500?tool=bestpractice.com Colloid might be used if there is significant hypoalbuminemia.
In the US, the Food and Drug Administration (FDA) issued safety labeling changes in July 2021 for solutions containing hydroxyethyl starch (HES) stating that HES products should not be used unless adequate alternative treatment is unavailable.[114]US Food and Drug Administration. Labeling changes on mortality, kidney injury, and excess bleeding with hydroxyethyl starch products. Jul 2021 [internet publication]. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/labeling-changes-mortality-kidney-injury-and-excess-bleeding-hydroxyethyl-starch-products Solutions containing HES are associated with adverse outcomes including kidney injury and death, particularly in critically ill patients and those with sepsis.[115]Lewis SR, Pritchard MW, Evans DJ, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018 Aug 3;8:CD000567. https://www.doi.org/10.1002/14651858.CD000567.pub7 http://www.ncbi.nlm.nih.gov/pubmed/30073665?tool=bestpractice.com [116]Zarychanski R, Abou-Setta AM, Turgeon AF, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA. 2013 Feb 20;309(7):678-88. http://www.ncbi.nlm.nih.gov/pubmed/23423413?tool=bestpractice.com In view of the serious risks posed to these patient populations, the Pharmacovigilance Risk Assessment Committee of the European Medicines Agency in February 2022 recommended suspending HES solutions for infusion in Europe.[117]European Medicines Agency. PRAC recommends suspending hydroxyethyl-starch solutions for infusion from the market. Feb 2022 [internet publication]. https://www.ema.europa.eu/en/news/prac-recommends-suspending-hydroxyethyl-starch-solutions-infusion-market-0
The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
Hemorrhage requires blood product replacement.
vasopressor
Treatment recommended for SOME patients in selected patient group
Vasopressors are recommended for severe hypotension, often with the goal of keeping mean arterial pressure (MAP) >65 mmHg. (MAP is the diastolic pressure plus one third of the pulse pressure, where the pulse pressure is the systolic pressure minus the diastolic pressure.) All vasopressors should be used only with appropriate hemodynamic monitoring in place.[1]Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012 Mar;2(1):1-138. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf
The septic patient requires hemodynamic support with vasopressors as needed to support MAP and organ perfusion.
Consult a specialist for guidance on suitable vasopressor regimen.
diuretic
Treatment recommended for SOME patients in selected patient group
The use of diuretics may be helpful to manage volume in patients with ineffective circulating volume and prerenal AKI. Diuretic-unresponsive volume overload is an indication to proceed to renal replacement therapy by means of dialysis or filtration.
Impaired urine production and volume expansion are commonly seen in cases of AKI.
Loop diuretics (e.g., furosemide) and metolazone may be effective in promoting diuresis, although diuretic resistance is often seen.[118]Tang WHW, Bakitas MA, Cheng XS, et al. Evaluation and management of kidney dysfunction in advanced heart failure: a scientific statement from the American Heart Association. Circulation. 2024 Oct 15;150(16):e280-95. https://www.doi.org/10.1161/CIR.0000000000001273 http://www.ncbi.nlm.nih.gov/pubmed/39253806?tool=bestpractice.com
Patients may also require sodium restriction.[119]Kanagasundaram S, Ashley C, Bhojani S, et al; The Renal Association. Clinical practice guideline: acute kidney injury (AKI). Aug 2019 [internet publication]. https://www.ukkidney.org/health-professionals/guidelines/acute-kidney-injury-aki
Primary options
furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response
Secondary options
torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day
OR
bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day
OR
metolazone: 5-20 mg orally once daily
These drug options and doses relate to a patient with no comorbidities.
Primary options
furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response
Secondary options
torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day
OR
bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day
OR
metolazone: 5-20 mg orally once daily
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
furosemide
Secondary options
torsemide
OR
bumetanide
OR
metolazone
renal replacement therapy
Treatment recommended for SOME patients in selected patient group
Nephrologist consultation is required.
Conventional hemodialysis for 4 to 6 hours is used in hemodynamically stable patients.
Other modes of renal replacement include sustained low-efficiency dialysis (SLED), extended daily dialysis (EDD), or continuous renal replacement therapy (CRRT).[124]Palevsky PM, Zhang JH, O'Connor TZ, et al; VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008 Jul 3;359(1):7-20. https://www.nejm.org/doi/full/10.1056/NEJMoa0802639 http://www.ncbi.nlm.nih.gov/pubmed/18492867?tool=bestpractice.com Major commonly used modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF).
CRRT is mostly used in hemodynamically unstable patients (e.g., patients with sepsis, or with severe congestive heart failure) or those in whom aggressive ultrafiltration within the conventional 4- to 6-hour treatment of hemodialysis would not be tolerated.
Studies have shown that intensive dialysis in critically ill patients with AKI confers no increased benefit.[124]Palevsky PM, Zhang JH, O'Connor TZ, et al; VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008 Jul 3;359(1):7-20. https://www.nejm.org/doi/full/10.1056/NEJMoa0802639 http://www.ncbi.nlm.nih.gov/pubmed/18492867?tool=bestpractice.com [125]Tolwani AJ, Campbell RC, Stofan BS, et al. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol. 2008 Jun;19(6):1233-8. https://jasn.asnjournals.org/content/19/6/1233.full http://www.ncbi.nlm.nih.gov/pubmed/18337480?tool=bestpractice.com [126]Bellomo R, Cass A, Cole L, et al; RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009 Oct 22;361(17):1627-38. https://www.nejm.org/doi/10.1056/NEJMoa0902413 http://www.ncbi.nlm.nih.gov/pubmed/19846848?tool=bestpractice.com [127]Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005 Nov;16(11):3365-70. http://jasn.asnjournals.org/cgi/content/full/16/11/3365 http://www.ncbi.nlm.nih.gov/pubmed/16177006?tool=bestpractice.com [139]Jun M, Heerspink HJ, Ninomiya T, et al. Intensities of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2010 Jun;5(6):956-63. http://www.ncbi.nlm.nih.gov/pubmed/20395356?tool=bestpractice.com
Early dialysis appeared to reduce mortality compared with a delayed strategy in one small single-center randomized trial of critically ill patients with AKI.[128]Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016 May 24-31;315(20):2190-9. https://jamanetwork.com/journals/jama/fullarticle/2522434 http://www.ncbi.nlm.nih.gov/pubmed/27209269?tool=bestpractice.com However, a larger study and meta-analysis found no benefit associated with early initiation of renal replacement therapy.[129]Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016 Jul 14;375(2):122-33. http://www.ncbi.nlm.nih.gov/pubmed/27181456?tool=bestpractice.com [140]Bhatt GC, Das RR. Early versus late initiation of renal replacement therapy in patients with acute kidney injury - a systematic review & meta-analysis of randomized controlled trials. BMC Nephrol. 2017 Feb 28;18(1):78. https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-017-0486-9 http://www.ncbi.nlm.nih.gov/pubmed/28245793?tool=bestpractice.com
intrinsic renal failure
treatment of underlying condition
Management of intrinsic renal failure varies according to etiology. The patient should be referred to a nephrologist if specific treatment is required. This might include dialysis or consideration for corticosteroids, immunosuppressants, or other immune-modifying drugs.[1]Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012 Mar;2(1):1-138. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf
Electrolyte, fluid, and acid-base balance should be monitored and optimized. For management of hyperkalemia, see Hyperkalemia in adults.
review drugs and stop nephrotoxins
Treatment recommended for ALL patients in selected patient group
Review and adjustment of drugs is required in all cases to reduce exposure to nephrotoxic agents (e.g., aminoglycosides and other nephrotoxic antibiotics, many cancer therapies, nonsteroidal anti-inflammatory drugs [NSAIDS]).[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
Consult your local drug information source for more information on nephrotoxic drugs.
diuretic
Treatment recommended for SOME patients in selected patient group
The use of diuretics in the management of AKI is primarily for volume control.[1]Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012 Mar;2(1):1-138. https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf Diuretic-unresponsive volume overload is an indication to proceed to renal replacement therapy by means of dialysis or filtration.
Impaired urine production and volume expansion are commonly seen in cases of AKI.
Loop diuretics (e.g., furosemide) and metolazone may be effective in promoting diuresis, although diuretic resistance is often seen.
Patients may also require sodium restriction.[119]Kanagasundaram S, Ashley C, Bhojani S, et al; The Renal Association. Clinical practice guideline: acute kidney injury (AKI). Aug 2019 [internet publication]. https://www.ukkidney.org/health-professionals/guidelines/acute-kidney-injury-aki
Primary options
furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response
Secondary options
torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day
OR
bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day
OR
metolazone: 5-20 mg orally once daily
These drug options and doses relate to a patient with no comorbidities.
Primary options
furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response
Secondary options
torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day
OR
bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day
OR
metolazone: 5-20 mg orally once daily
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
furosemide
Secondary options
torsemide
OR
bumetanide
OR
metolazone
volume expansion
Treatment recommended for SOME patients in selected patient group
Crystalloid (normal saline or balanced solutions, such as Ringer lactate [Hartmann solution]) is sufficient in most cases for volume expansion.[5]Sharfuddin AA, Weisbord SD, Palevsky PM, et al. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, et al, eds. Brenner and Rector's the kidney. 9th ed. Philadelphia, PA: Saunders; 2012.[113]Flamm SL, Wong F, Ahn J, et al. AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis: expert review. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2707-16. https://www.cghjournal.org/article/S1542-3565(22)00829-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36075500?tool=bestpractice.com Colloid might be used if there is significant hypoalbuminemia.
In the US, the Food and Drug Administration (FDA) issued safety labeling changes in July 2021 for solutions containing hydroxyethyl starch (HES) stating that HES products should not be used unless adequate alternative treatment is unavailable.[114]US Food and Drug Administration. Labeling changes on mortality, kidney injury, and excess bleeding with hydroxyethyl starch products. Jul 2021 [internet publication]. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/labeling-changes-mortality-kidney-injury-and-excess-bleeding-hydroxyethyl-starch-products Solutions containing HES are associated with adverse outcomes including kidney injury and death, particularly in critically ill patients and those with sepsis.[115]Lewis SR, Pritchard MW, Evans DJ, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018 Aug 3;8:CD000567. https://www.doi.org/10.1002/14651858.CD000567.pub7 http://www.ncbi.nlm.nih.gov/pubmed/30073665?tool=bestpractice.com [116]Zarychanski R, Abou-Setta AM, Turgeon AF, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA. 2013 Feb 20;309(7):678-88. http://www.ncbi.nlm.nih.gov/pubmed/23423413?tool=bestpractice.com In view of the serious risks posed to these patient populations, the Pharmacovigilance Risk Assessment Committee of the European Medicines Agency in February 2022 recommended suspending HES solutions for infusion in Europe.[117]European Medicines Agency. PRAC recommends suspending hydroxyethyl-starch solutions for infusion from the market. Feb 2022 [internet publication]. https://www.ema.europa.eu/en/news/prac-recommends-suspending-hydroxyethyl-starch-solutions-infusion-market-0
The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
renal replacement therapy
Treatment recommended for SOME patients in selected patient group
Nephrologist consultation recommended.
Conventional hemodialysis is used in hemodynamically stable patients.
Other modes of renal replacement include sustained low-efficiency dialysis (SLED), extended daily dialysis (EDD), rapid-start peritoneal dialysis, or continuous renal replacement therapy (CRRT).[122]Dalbhi SA, Alorf R, Alotaibi M, et al. Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: a comparative meta-analysis. Medicine (Baltimore). 2021 Dec 23;100(51):e28118. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8702221 http://www.ncbi.nlm.nih.gov/pubmed/34941056?tool=bestpractice.com [123]Blake PG, Jain AK. Urgent start peritoneal dialysis: defining what it is and why it matters. Clin J Am Soc Nephrol. 2018 Aug 7;13(8):1278-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086705 http://www.ncbi.nlm.nih.gov/pubmed/30018049?tool=bestpractice.com Major commonly used modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF).
CRRT is mostly used in hemodynamically unstable patients (e.g., patients with sepsis or severe congestive heart failure) or those in whom aggressive ultrafiltration within the conventional 4-to 6-hour treatment of hemodialysis would not be tolerated.
Studies have shown that intensive dialysis in critically ill patients with AKI confers no increased benefit.[124]Palevsky PM, Zhang JH, O'Connor TZ, et al; VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008 Jul 3;359(1):7-20. https://www.nejm.org/doi/full/10.1056/NEJMoa0802639 http://www.ncbi.nlm.nih.gov/pubmed/18492867?tool=bestpractice.com [125]Tolwani AJ, Campbell RC, Stofan BS, et al. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol. 2008 Jun;19(6):1233-8. https://jasn.asnjournals.org/content/19/6/1233.full http://www.ncbi.nlm.nih.gov/pubmed/18337480?tool=bestpractice.com [126]Bellomo R, Cass A, Cole L, et al; RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009 Oct 22;361(17):1627-38. https://www.nejm.org/doi/10.1056/NEJMoa0902413 http://www.ncbi.nlm.nih.gov/pubmed/19846848?tool=bestpractice.com [127]Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005 Nov;16(11):3365-70. http://jasn.asnjournals.org/cgi/content/full/16/11/3365 http://www.ncbi.nlm.nih.gov/pubmed/16177006?tool=bestpractice.com [139]Jun M, Heerspink HJ, Ninomiya T, et al. Intensities of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2010 Jun;5(6):956-63. http://www.ncbi.nlm.nih.gov/pubmed/20395356?tool=bestpractice.com
Early dialysis appeared to reduce mortality compared with a delayed strategy in one small single-center randomized trial of critically ill patients with AKI, but subsequent meta-analyses found no clear benefit associated with early initiation of renal replacement therapy.[71]Mercado MG, Smith DK, Guard EL. Acute kidney injury: diagnosis and management. Am Fam Physician. 2019 Dec 1;100(11):687-94. https://www.aafp.org/pubs/afp/issues/2019/1201/p687.html http://www.ncbi.nlm.nih.gov/pubmed/31790176?tool=bestpractice.com [128]Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016 May 24-31;315(20):2190-9. https://jamanetwork.com/journals/jama/fullarticle/2522434 http://www.ncbi.nlm.nih.gov/pubmed/27209269?tool=bestpractice.com [129]Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016 Jul 14;375(2):122-33. http://www.ncbi.nlm.nih.gov/pubmed/27181456?tool=bestpractice.com [130]Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev. 2022 Nov 23;11(11):CD010612. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010612.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/36416787?tool=bestpractice.com [131]Gaudry S, Hajage D, Benichou N, et al. Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet. 2020 May 9;395(10235):1506-15. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30531-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/32334654?tool=bestpractice.com
obstructive renal failure
bladder catheterization
Treatment of obstructive renal failure requires mechanical decompression at the level of obstruction.
Bladder catheter placement should be done in all cases of AKI if bladder outlet obstruction cannot be quickly ruled out by ultrasound.
Electrolyte, fluid, and acid-base balance should be monitored and optimized. For management of hyperkalemia, see Hyperkalemia in adults.
review drugs and stop nephrotoxins
Treatment recommended for ALL patients in selected patient group
Review and adjustment of drugs is required in all cases to reduce exposure to nephrotoxic agents (e.g., aminoglycosides and other nephrotoxic antibiotics, many cancer therapies, nonsteroidal anti-inflammatory drugs [NSAIDS]).[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
Consult your local drug information source for more information on nephrotoxic drugs.
relief of obstruction above bladder neck
Further decompression more proximal in the genitourinary tract may be required if bladder neck obstruction is not the cause of the obstruction.
Urologic, radiologic, or surgical assistance for ureteral stenting, urinary diversion, debulking procedures, or other case-specific requirements may become necessary.
Ureteral stenting is indicated if there is a ureteral stricture, stone, or extrinsically obstructing mass. If obstruction is caused by stones at the ureteropelvic junction, lithotripsy or surgical removal may be needed.[121]Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society guideline, PART I. J Urol. 2016 Oct;196(4):1153-60. https://www.auanet.org/guidelines-and-quality/guidelines/kidney-stones-surgical-management-guideline http://www.ncbi.nlm.nih.gov/pubmed/27238616?tool=bestpractice.com
Percutaneous nephrostomy (placement of a catheter into the renal pelvis percutaneously for drainage of urine from a distal obstruction) may be undertaken by a surgeon (usually a urologist) or interventional radiologist.[121]Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society guideline, PART I. J Urol. 2016 Oct;196(4):1153-60. https://www.auanet.org/guidelines-and-quality/guidelines/kidney-stones-surgical-management-guideline http://www.ncbi.nlm.nih.gov/pubmed/27238616?tool=bestpractice.com
Surgical consultation may be needed if the cause is tumor with mass effect. Exploratory laparotomy may be indicated with a view to surgical removal of a compressing tumor; this may be done following ureteral stenting.
volume expansion
Treatment recommended for SOME patients in selected patient group
Crystalloid (normal saline or balanced solutions, such as Ringer lactate [Hartmann solution]) is sufficient in most cases for volume expansion.[5]Sharfuddin AA, Weisbord SD, Palevsky PM, et al. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, et al, eds. Brenner and Rector's the kidney. 9th ed. Philadelphia, PA: Saunders; 2012.[113]Flamm SL, Wong F, Ahn J, et al. AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis: expert review. Clin Gastroenterol Hepatol. 2022 Dec;20(12):2707-16. https://www.cghjournal.org/article/S1542-3565(22)00829-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36075500?tool=bestpractice.com Colloid might be used if there is significant hypoalbuminemia.
In the US, the Food and Drug Administration (FDA) issued safety labeling changes in July 2021 for solutions containing hydroxyethyl starch (HES) stating that HES products should not be used unless adequate alternative treatment is unavailable.[114]US Food and Drug Administration. Labeling changes on mortality, kidney injury, and excess bleeding with hydroxyethyl starch products. Jul 2021 [internet publication]. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/labeling-changes-mortality-kidney-injury-and-excess-bleeding-hydroxyethyl-starch-products Solutions containing HES are associated with adverse outcomes including kidney injury and death, particularly in critically ill patients and those with sepsis.[115]Lewis SR, Pritchard MW, Evans DJ, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018 Aug 3;8:CD000567. https://www.doi.org/10.1002/14651858.CD000567.pub7 http://www.ncbi.nlm.nih.gov/pubmed/30073665?tool=bestpractice.com [116]Zarychanski R, Abou-Setta AM, Turgeon AF, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA. 2013 Feb 20;309(7):678-88. http://www.ncbi.nlm.nih.gov/pubmed/23423413?tool=bestpractice.com In view of the serious risks posed to these patient populations, the Pharmacovigilance Risk Assessment Committee of the European Medicines Agency in February 2022 recommended suspending HES solutions for infusion in Europe.[117]European Medicines Agency. PRAC recommends suspending hydroxyethyl-starch solutions for infusion from the market. Feb 2022 [internet publication]. https://www.ema.europa.eu/en/news/prac-recommends-suspending-hydroxyethyl-starch-solutions-infusion-market-0
The US National Kidney Foundation states that crystalloids are preferred over colloids for most patients with AKI, and recommends that hydroxyethyl starches are avoided.[110]Moore PK, Hsu RK, Liu KD. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018 Jul;72(1):136-48. https://www.ajkd.org/article/S0272-6386(17)31141-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/29478864?tool=bestpractice.com
diuretic
Treatment recommended for SOME patients in selected patient group
Diuretics should not be used in suspected complete obstruction.
The use of diuretics in the management of AKI is primarily for volume control.
Diuretic-unresponsive volume overload is an indication to proceed to renal replacement therapy by means of dialysis or filtration.
Impaired urine production and volume expansion are commonly seen in cases of AKI.
Loop diuretics (e.g., furosemide) and metolazone may be effective in promoting diuresis, although diuretic resistance is often seen.
Patients also require sodium restriction.
Primary options
furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response
Secondary options
torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day
OR
bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day
OR
metolazone: 5-20 mg orally once daily
These drug options and doses relate to a patient with no comorbidities.
Primary options
furosemide: 40-80 mg intravenously initially, increase by 20 mg/dose increments every 2 hours as necessary until clinical response
Secondary options
torsemide: 20 mg intravenously once daily initially, increase gradually according to response, maximum 200 mg/day
OR
bumetanide: 1-2 mg intravenously initially, may repeat in 2-3 hours for up to 2 doses if necessary, maximum 10 mg/day
OR
metolazone: 5-20 mg orally once daily
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
furosemide
Secondary options
torsemide
OR
bumetanide
OR
metolazone
renal replacement therapy
Treatment recommended for SOME patients in selected patient group
Nephrologist consultation is recommended.
Conventional hemodialysis is used in hemodynamically stable patients. Other modes of renal replacement include sustained low-efficiency dialysis (SLED), extended daily dialysis (EDD), or rapid-start peritoneal dialysis; continuous renal replacement therapy (CRRT) is used if the patient is hemodynamically unstable despite full support.[122]Dalbhi SA, Alorf R, Alotaibi M, et al. Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: a comparative meta-analysis. Medicine (Baltimore). 2021 Dec 23;100(51):e28118. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8702221 http://www.ncbi.nlm.nih.gov/pubmed/34941056?tool=bestpractice.com [123]Blake PG, Jain AK. Urgent start peritoneal dialysis: defining what it is and why it matters. Clin J Am Soc Nephrol. 2018 Aug 7;13(8):1278-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086705 http://www.ncbi.nlm.nih.gov/pubmed/30018049?tool=bestpractice.com
Renal replacement therapy may be required to manage complications of obstruction while surgical interventions are planned and implemented.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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