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.
Data extraction
We asked a large language model to extract each data column below from each paper. We gave the model the extraction instructions shown below for each column.
Primary Outcomes
- Mortality rate
- Estimated glomerular filtration rate (eGFR)
- Urine albumin:creatinine ratio
Results
Characteristics of Included Studies
| Study | Study Focus | Population | Intervention/Topic | Key Outcomes Measured |
|---|---|---|---|---|
| Sohaney et al., 2020 | Timing of Kidney Replacement Therapy (KRT) initiation in AKI | 3,019 critically ill adults with KDIGO stage 2/3 AKI | Accelerated vs. standard KRT initiation | 90-day mortality, KRT dependence, adverse events |
| 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 |
| Aitken et al., 2013 | Quality of AKI care | 1,577 hospital admissions | Standard care | Mortality, AKI recognition, documentation |
| Landoni et al., 2013 | Interventions affecting AKI mortality | >300 physicians (survey); literature review | Systematic review and survey | Mortality, intervention-practice gap |
| STARRT-AKI Investigators, 2020 | Timing of 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 |
| 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 |
| 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 |
| Graham-Brown et al., 2024 | National audit of AKI care | 989 AKI stage 2/3 episodes | Standard care | 30-day mortality, care standard completion |
Effects
- Most studies reported no clear difference in mortality or renal recovery options in the general AKI population.
- Early renal replacement therapy initiation did not reduce mortality compared to standard or delayed strategies.
- Rural observational data reported that local expertise and resource availability often drive modality choice.
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.
- 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.
- Ongoing quality improvement efforts are needed to address persistent gaps in acute kidney injury recognition and management.