Elicit: Standard of Care in Acute Kidney Injury (public)

What is the standard of care for acute kidney injury?

Acute kidney injury standard care includes delayed rather than preemptive renal replacement therapy initiation, standard dosing targets, modality selection based on patient hemodynamics and resources, and care bundles with early nephrology consultation.

Abstract

Acute kidney injury care relies on initiating renal replacement therapy (RRT) only when conventional indications are present rather than preemptively. Large randomized trials and meta-analyses note that early or accelerated initiation does not reduce 90‐day mortality and may lead to more adverse events, as many patients in delayed arms avoid RRT altogether. Standard dosing targets provide outcomes similar to intensified regimens, and modality choice—whether continuous therapies, intermittent hemodialysis, or peritoneal dialysis—is guided by patient hemodynamic status, local expertise, and resource availability (with peritoneal dialysis endorsed by the International Society for Peritoneal Dialysis). Additionally, care bundles aligned with best practice guidelines and early nephrology involvement improve process measures such as AKI recognition and documentation, with some studies reporting reductions in progression and rehospitalization.

Methods

We analyzed 40 sources from an initial pool of 1000, using 8 screening criteria. Each paper was reviewed for 6 key aspects that mattered most to the research question.

Screening

We screened in sources based on their abstracts that met these criteria:

AKI Population: Does the study include patients diagnosed with acute kidney injury (AKI) as defined by established criteria (KDIGO, RIFLE, or AKIN)?
Standard Care Interventions: Does the study examine therapeutic interventions, management strategies, or treatment protocols that are considered standard care for AKI (excluding experimental treatments not in established practice)?
Clinical Outcomes: Does the study report clinical outcomes such as renal recovery, mortality, dialysis requirement, length of stay, or complications?
Study Design: Is the study a randomized controlled trial, observational study (cohort, case-control), clinical practice guideline, systematic review, or meta-analysis?
Population and Setting: Does the study include adult patients (≥18 years) in hospital or clinical settings?
Treatment Focus: Does the study focus on treatment of established AKI rather than solely on prevention strategies?
Primary AKI Focus: Does the study have AKI management as a primary focus rather than examining AKI only as a secondary outcome?
Human Studies: Is this a human study (not in vitro or animal research)?

Results

Characteristics of Included Studies

Study	Study Focus	Population	Intervention/Topic	Key Outcomes Measured	Full text retrieved
Sohaney et al., 2020	Timing of Kidney Replacement Therapy (KRT) initiation	3,019 critically ill adults with KDIGO stage 2/3 AKI	Accelerated vs. standard KRT initiation	90-day mortality, KRT dependence, adverse events	No
Kolhe et al., 2015	AKI care bundle implementation	2,297 patients, 2,500 AKI episodes	AKI care bundle with electronic alert	In-hospital case fatality, AKI progression	Yes
Aitken et al., 2013	Quality of AKI care	1,577 hospital admissions	Standard care	Mortality, AKI recognition, documentation	No
Landoni et al., 2013	Interventions affecting AKI mortality	>300 physicians (survey); literature review	Systematic review and survey	Mortality, intervention-practice gap	No
STARRT-AKI Investigators, 2020	Timing of Renal Replacement Therapy (RRT) in severe AKI	3,019 ICU patients with KDIGO stage 2/3 AKI	Accelerated vs. standard RRT	90-day mortality, RRT dependence, adverse events	Yes
Kolhe et al., 2016	AKI care bundle compliance	3,518 patients, 3,717 AKI episodes	AKI care bundle (fluid, drugs, nephrotoxins)	In-hospital case fatality, AKI progression	No
Thanapongsatorn et al., 2021	Multidisciplinary post-AKI care	98 AKI stage 2-3 survivors	Multidisciplinary Care Team (MDCT) post-AKI care vs. standard	Feasibility, eGFR, albuminuria, BP control	Yes
Graham-Brown et al., 2024	National audit of AKI care	989 AKI stage 2/3 episodes	Standard care	30-day mortality, care standard completion	No
Jeong et al., 2021	Timing of RRT in ICU AKI	No mention found	Early vs. delayed RRT	Survival, RRT dependence	No
Wang et al., 2017	RRT intensity and renal recovery	3,682 ICU AKI patients	High vs. standard RRT intensity	Mortality, RRT dependence	No

Summary

The included studies reported that the standard of care for acute kidney injury includes:

Initiation of renal replacement therapy for conventional indications, not preemptively, in critically ill acute kidney injury.
Use of standard renal replacement therapy dosing targets; higher intensity did not improve outcomes in the studies reviewed.
Modality selection based on patient context, with peritoneal dialysis as a viable option according to International Society for Peritoneal Dialysis guidelines.
Implementation of care bundles and early nephrology involvement, which improved process measures and may reduce adverse outcomes, though high-quality randomized controlled trial evidence was limited.
Ongoing quality improvement efforts are needed to address persistent gaps in acute kidney injury recognition and management, as reported in national audits and registry studies.