5 Principles of AKI Management

5 Principles of AKI Management

Acute Kidney Injury (AKI) is a very common clinical condition (affecting 20% of hospital admissions) associated with significant morbidity and mortality if not recognised and managed promptly.

Early identification of the underlying cause, appropriate supportive care, and timely specialist involvement are essential to prevent further kidney damage and improve patient outcomes.

Here are the 5 principles of AKI management.

1. Initial Assessment and Monitoring

Effective AKI management begins with identifying the cause and severity while monitoring for complications.

• Determine the underlying cause and stage of AKI.
• Use staging to guide monitoring frequency and risk assessment.
• Regularly monitor electrolytes and acid-base status.
• Adjust investigation frequency according to AKI stage and patient risk factors.

2. Fluid Management and Reversible Causes

Optimizing volume status and correcting reversible factors are key to preventing further kidney injury.

• Correct hypovolemia promptly with appropriate intravenous fluids.
• Avoid fluid overload, particularly in patients with oliguria or heart failure.
• Identify and treat reversible causes:
  • Sepsis: Perform urgent septic screening and follow local protocols.
  • Nephrotoxins: Stop and avoid kidney-damaging medications.
  • Obstruction: Relieve urinary tract obstruction through urgent specialist referral.

3. STOP AKI Protocol

The STOP AKI framework provides a practical approach to immediate management.

• S – Sepsis: Initiate local sepsis bundles within one hour when indicated.
• T – Toxins: Stop nephrotoxic drugs such as NSAIDs and aminoglycosides.
• O – Optimise volume status/BP: Assess fluid status, administer IV fluids, and review antihypertensives and diuretics.
• P – Prevent harm: Manage complications, adjust drug doses, and avoid excessive fluid administration.

4. Sepsis and Acute Complications

Sepsis and severe AKI complications require rapid recognition and treatment.

“Always ask yourself ‘is this sepsis’?”

• Consider sepsis in any acutely deteriorating patient with evidence of infection.
• Seek urgent senior clinical review and follow local sepsis guidance.
• Promptly manage its 4 life-threatening complications (and indications for dialysis):
  • Severe hyperkalaemia
  • Metabolic acidosis
  • Pulmonary oedema
  • Uraemia

5. Renal Replacement Therapy and Specialist Referral

Specialist involvement is required when AKI is severe, complicated, or diagnostically uncertain.

• Consider Renal Replacement Therapy (RRT) for:
  • Refractory fluid overload
  • Severe electrolyte abnormalities
  • Uraemic complications despite optimal medical treatment
• Refer urgently to nephrology or critical care for:
  • RRT requirement
  • Uncontrolled complications
  • Haemodynamic instability or multi-organ failure
• Discuss with nephrology within 24 hours if:
  • Diagnosis is unclear
  • Intrinsic renal disease is suspected
  • Stage 3 AKI is present
  • Pre-existing Stage 4/5 CKD exists
  • The patient is a kidney transplant recipient
• Refer urgently to urology/radiology for upper urinary tract obstruction, especially with pyonephrosis, bilateral obstruction, or a solitary obstructed kidney.
• Arrange nephrology follow-up after recovery if eGFR remains ≤30 mL/min/1.73 m² or persistent hypertension or proteinuria is present.