What is the standard of care for acute kidney injury?

Standard Care

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.

Papers Identified with Elicit Search

• Papers screened using: AKI Population, Standard Care Interventions, Clinical Outcomes, Study Design, Population and Setting, Treatment Focus, Primary AKI Focus, Human Studies
  n = 1000
• Papers screened out
  n = 960
• Papers included for extraction
  n = 40

Screening Criteria

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

• AKI Population: Inclusion criteria based on established AKI definitions (KDIGO, RIFLE, or AKIN).
• Standard Care Interventions: Examination of therapeutic interventions considered standard care for AKI.
• Clinical Outcomes: Reporting of clinical outcomes such as renal recovery, mortality, dialysis requirement, length of stay, or complications.
• Study Design: Randomized controlled trial, observational study (cohort, case-control), clinical practice guideline, systematic review, or meta-analysis.
• Population and Setting: Inclusion of adult patients (≥18 years) in hospital or clinical settings.
• Treatment Focus: Focus on treatment of established AKI.
• Primary AKI Focus: AKI management as a primary focus.
• Human Studies: Exclusion of in vitro or animal research.

Data Extraction

We asked a large language model to extract each data column below from each paper.

Results Characteristics of Included Studies

• Study Focus:

1. Timing of Kidney Replacement Therapy (KRT) initiation in AKI
2. AKI care bundle implementation
3. Quality of AKI care
4. Interventions affecting AKI mortality
5. Multidisciplinary post-AKI care
6. National audit of AKI care
7. Timing of RRT in ICU AKI
8. RRT intensity and renal recovery

Key Outcomes Measured

• Mortality in 32 studies.
• Renal or kidney recovery in 5 studies.
• Major adverse kidney events in 2 studies.
• Acute kidney injury progression in 3 studies.

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 AKI patients.
• Use of standard renal replacement therapy dosing targets and modality selection based on patient context.
• Implementation of care bundles and early nephrology involvement, which improve process measures and may reduce adverse outcomes.

Ongoing quality improvement efforts are needed to address persistent gaps in AKI recognition and management, as reported in national audits and registry studies.