Nonpharmacologic Management of Acute Renal Injury

Specific treatments for acute kidney injury (AKI) are still not available, so prevention of AKI is fundamental to reduce the impact of AKI in critically ill patients. This chapter reviews the recent scientific literature and describes the most important nonpharmacologic approaches in preventing AKI, focusing on monitoring and optimizing hemodynamic status and minimizing nephrotoxic exposures. Critically ill patients should benefit from the maintenance of adequate volume status, but fluid overload is associated with worse outcomes and should be avoided; however, protocolized-based resuscitation is not superior to the standard care in this setting. Use of crystalloids rather than colloids is preferred and suggested. Although data from randomized controlled trials did not describe the superiority of buffered solutions, chloride-rich solutions should be avoided for patients at high risk for hyperchloremic metabolic acidosis. The persistence of hypotension after optimization of volume status should be avoided; a mean arterial pressure of 65 mm Hg or greater is required in patients with distributive shock. In patients at high risk for AKI, nephrotoxic exposure should be minimized. Low- and iso-osmolar contrast agents should be preferred and used in the lowest volume consistent with a diagnostic result; volume expansion and adequate monitoring of renal function postprocedure should be performed. Other nephrotoxic drugs, such as amphotericin B and aminoglycosides, should be used only when necessary and with caution. The maintenance of adequate hemodynamic and volume status and the minimization of nephrotoxic exposures are the most effective nonpharmacologic strategies to prevent AKI.