Management of Acute Impaired Renal Function

Initial Assessment and Classification

The Kidney International guideline recommends that AKI is defined as an increase in serum creatinine by ≥0.3 mg/dL within 48 hours or ≥50% within 7 days, or urine output <0.5 mL/kg/h for 6 hours 3, 4
The Nature Reviews Nephrology guideline suggests that the rise in creatinine from 1.2 to a higher value the next day indicates possible Stage 1 AKI, requiring prompt intervention 1
The Kidney International guideline states that traditional classification of AKI as pre-renal, renal, and post-renal is less helpful than distinguishing between conditions that reduce glomerular function, cause tubular/glomerular injury, or both 2
The Nature Reviews Nephrology guideline recommends that staging AKI severity (Stages 1-3) helps guide management intensity and predicts outcomes 3, 5

The Kidney International guideline recommends using isotonic crystalloids rather than colloids (albumin or starches) for initial intravascular volume expansion 1, 2
The Kidney International guideline suggests that balanced crystalloids (e.g., lactated Ringer's) may be preferable to 0.9% saline due to emerging evidence of fewer adverse outcomes 2
The Clinical Gastroenterology and Hepatology guideline recommends that fluid administration should be guided by hemodynamic assessment and reassessed frequently to avoid volume overload 2, 6
The Clinical Gastroenterology and Hepatology guideline states that in patients with cirrhosis and AKI, albumin at 1 g/kg (maximum 100 g/day) may be considered after discontinuing diuretics 7, 6

The Clinical Gastroenterology and Hepatology guideline recommends discontinuing all nephrotoxic medications including NSAIDs, ACE inhibitors, ARBs, and aminoglycosides 7, 6, 4
The Nature Reviews Nephrology guideline suggests adjusting dosages of all medications according to current renal function 3, 8
The Clinical Gastroenterology and Hepatology guideline recommends that if patient is on diuretics, these should be temporarily held 7, 6
The Clinical Gastroenterology and Hepatology guideline states that if on beta-blockers and has cirrhosis, consider temporarily discontinuing these medications 7, 6

The Clinical Gastroenterology and Hepatology guideline recommends evaluating for infections and treating promptly if present 7, 6
The Nature Reviews Nephrology guideline suggests evaluating for potential obstruction with renal ultrasound 3

The Kidney International guideline recommends monitoring serum creatinine daily until stabilization 1, 3
The Nature Reviews Nephrology guideline suggests monitoring urine output hourly in critically ill patients 3, 2
The Kidney International guideline recommends assessing fluid status regularly to avoid both hypovolemia and fluid overload 2
The Nature Reviews Nephrology guideline states that consideration for more intensive monitoring for patients with pre-existing CKD, heart failure, cirrhosis, or malignancy is recommended 3, 8

The Nature Reviews Nephrology guideline recommends that Stage 2 or 3 AKI (creatinine 2.0-2.9 times baseline or ≥3.0 times baseline) is an indication for nephrology consultation 3, 5
The Kidney International guideline suggests that persistent AKI despite initial management is an indication for nephrology consultation 1, 3
The Nature Reviews Nephrology guideline recommends that severe electrolyte abnormalities are an indication for nephrology consultation 3
The Kidney International guideline states that acid-base disturbances are an indication for nephrology consultation 2
The Nature Reviews Nephrology guideline recommends that consideration for renal replacement therapy is an indication for nephrology consultation 3, 6

The Nature Reviews Nephrology guideline recommends considering RRT for refractory volume overload, severe metabolic acidosis, uremic symptoms, or refractory hyperkalemia 3, 6
The Kidney International guideline suggests that the decision for RRT should be individualized based on clinical context and overall patient condition 2
The Nature Reviews Nephrology guideline recommends early involvement of nephrology for potential RRT planning 3

The Nature Reviews Nephrology guideline states that AKI increases risk for future CKD, cardiovascular disease, and mortality even after apparent recovery 3, 5, 8
The Kidney International guideline recommends follow-up of renal function at regular intervals after discharge 1, 3
The Kidney International guideline suggests that patients with residual renal damage should be managed according to CKD guidelines 1
The Nature Reviews Nephrology guideline recommends avoiding nephrotoxic medications and maintaining appropriate hydration after AKI episode 3, 8
The Nature Reviews Nephrology guideline states that the severity of AKI should determine the frequency and intensity of follow-up care 3, 8

The Clinical Gastroenterology and Hepatology guideline recommends that in patients with cirrhosis, AKI may progress to hepatorenal syndrome requiring vasoconstrictors plus albumin 7, 6
The Kidney International guideline suggests that careful attention to drug dosing is required during and after AKI 4