Acute Kidney Injury Management

Introduction to AKI Management

The American Diabetes Association recommends using dihydropyridine calcium channel blockers (e.g., amlodipine) to effectively lower blood pressure without reducing renal blood flow, as they do not typically worsen kidney function 1
The American Journal of Transplantation suggests that ACE inhibitors and ARBs can cause AKI and hyperkalemia, and may impair intrarenal blood flow, and should be discontinued during AKI episodes 2

For patients with blood pressure 140-159/90-99 mmHg, the American Diabetes Association recommends starting with a single agent (dihydropyridine CCB) 1
For patients with blood pressure ≥160/100 mmHg, the American Diabetes Association suggests considering two agents 1, 3
The American Diabetes Association recommends avoiding ACE inhibitors and ARBs during AKI episodes, as they can worsen kidney function 1, 4

The American Journal of Kidney Diseases states that diuretics are not recommended to prevent or treat AKI, except for managing volume overload, as they can worsen pre-renal AKI by reducing intravascular volume 5
The American Diabetes Association advises against combining ACE inhibitors and ARBs, as it increases the risk of hyperkalemia and AKI without additional cardiovascular benefit 1, 4
The American College of Cardiology, American Heart Association, American Diabetes Association, and European Society of Cardiology recommend ACE inhibitors or ARBs (not both together), thiazide/thiazide-like diuretics, and calcium channel blockers as first-line agents for hypertension 6, 7, 8
Preferred combinations for patients requiring multiple antihypertensive medications include a RAAS blocker + dihydropyridine CCB or a RAAS blocker + thiazide/thiazide-like diuretic 7, 8
For three-drug combinations, use a RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, as recommended by the European Society of Cardiology 8

The American Journal of Transplantation recommends monitoring serum creatinine and potassium regularly, assessing for signs of volume overload or depletion, and watching for hypotensive episodes, especially in dialysis patients 2
The American Diabetes Association suggests reassessing antihypertensive regimen and considering reintroduction of ACE inhibitors or ARBs if appropriate, especially for patients with albuminuria, once AKI resolves 1, 7
When using a single RAAS blocker, monitor serum creatinine/eGFR and potassium levels at least annually, as recommended by the American Diabetes Association and Mayo Clinic Proceedings 7, 9
Titrate to maximally tolerated doses for patients with albuminuria, as recommended by the Mayo Clinic Proceedings 9, 7

The American Journal of Transplantation advises against continuing nephrotoxic medications during AKI episodes (NSAIDs, aminoglycosides, contrast media) 2, 10
The American Diabetes Association warns against aggressive blood pressure lowering, leading to hypoperfusion and worsening kidney function, and using ACE inhibitors or ARBs during acute kidney injury episodes 1, 4
For patients with specific comorbidities, such as albuminuria or chronic kidney disease (CKD), ACE inhibitors or ARBs are preferred 10
For patients with established coronary artery disease, ACE inhibitors or ARBs are recommended 7
If additional RAAS blockade is needed beyond an ACE inhibitor or ARB monotherapy, consider adding a mineralocorticoid receptor antagonist (such as spironolactone or eplerenone) instead of combining ACE inhibitor and ARB, as recommended by the Mayo Clinic Proceedings and European Society of Cardiology 9, 11, 7
The recently approved nonsteroidal mineralocorticoid receptor antagonist finerenone has lower rates of hyperkalemia, as stated by the Mayo Clinic Proceedings 9
For patients with diabetes and kidney disease, ACE inhibitors or ARBs are particularly beneficial for preventing progression of kidney disease 10
In stages 1-3 CKD with severely increased urine albumin excretion, ACEIs or ARBs reduce the risk of kidney endpoints, as stated by the American Journal of Kidney Diseases 6