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. More on methods.

Papers identified with Elicit search

n = 1000

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

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)?

We considered all screening questions together and made a holistic judgement about whether to screen in each paper.

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.

Study Design:

Specify the exact type of study design (e.g., randomized controlled trial, prospective cohort, retrospective cohort).

Look in the methods section for explicit description of study design.
If multiple design elements are present, list all relevant characteristics.
If design is not clearly stated, write “Not clearly reported”.
Setting and Context:

Describe the specific healthcare setting where the study was conducted.

Identify location (country, specific type of healthcare facility).
Note any unique contextual features that might impact acute kidney injury (AKI) management.
If multiple settings were involved, list all.
If setting is not clearly described, write “Not reported”.
Participant Population:

Describe the key characteristics of study participants:

Total number of participants.
Inclusion criteria for AKI.
Severity of AKI (using standard staging criteria).
Mean/median age.
Gender distribution.
Key comorbidities.
Intervention Details:

Describe the specific intervention for AKI management:

Detailed components of the intervention.
Who delivered the intervention.
Frequency and duration of intervention.
Any multidisciplinary team components.
Primary Outcomes:

List all primary outcomes measured:

Specify exact outcome measures.
Include statistical results (means, percentages, p-values).
Note measurement time points.
Risk of Bias Assessment:

Assess potential sources of bias:

Randomization method (for RCTs).
Blinding procedures.
Loss to follow-up rates.
Potential conflicts of interest.

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 in Acute Kidney Injury (AKI)	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, estimated Glomerular Filtration Rate (eGFR), albuminuria, Blood Pressure (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

Effects

Renal Replacement Therapy Modality Selection

Most studies we reviewed that addressed renal replacement therapy modality (such as continuous renal replacement therapy, intermittent hemodialysis, peritoneal dialysis, or extended dialysis) reported no clear difference in mortality or renal recovery for the general acute kidney injury population in the intensive care unit. These findings are based on meta-analyses, randomized controlled trials, and guidelines.
The International Society for Peritoneal Dialysis guideline supports the use of peritoneal dialysis as a suitable modality in all settings, with specific recommendations for catheter type, dosing, and monitoring.
Observational data and reviews reported that local expertise, resource availability, and patient hemodynamic status often drive modality choice.

Timing of Renal Replacement Therapy Initiation

Multiple large randomized controlled trials and meta-analyses reported that early or accelerated initiation of renal replacement therapy in critically ill acute kidney injury did not reduce mortality compared to standard or delayed strategies.
A significant proportion of patients in delayed arms never required renal replacement therapy, suggesting that early initiation may lead to unnecessary treatment.
Some subgroup analyses reported possible benefit, but findings were inconsistent.

Renal Replacement Therapy Dosing and Adequacy Targets

Study	Renal Replacement Therapy Modality	Dosing Target	Clinical Context	Evidence Level
Wang et al., 2017	Continuous renal replacement therapy, intermittent hemodialysis	High vs. standard intensity	Intensive care unit acute kidney injury	Meta-analysis of randomized controlled trials
Palevsky et al., 2008	Intermittent hemodialysis, continuous renal replacement therapy	Intensive vs. less-intensive	Critically ill acute kidney injury	Randomized controlled trial
Van Wert et al., 2010	Continuous renal replacement therapy, intermittent hemodialysis, sustained low-efficiency dialysis	High vs. standard dose	Critical illness	Meta-analysis of randomized controlled trials
Faulhaber-Walter et al., 2009	Extended dialysis	Intensified vs. standard	Intensive care unit acute kidney injury	Randomized controlled trial
Parapiboon and Jamratpan, 2017	Peritoneal dialysis	Intensive vs. minimal	Acute kidney injury	Randomized controlled trial
Cullis et al., 2020	Peritoneal dialysis	Kt/V targets	Acute kidney injury (guideline)	Guideline

Early Nephrology Intervention and Monitoring

Several studies reported that early nephrology involvement, whether through early consults, multidisciplinary teams, or structured post-acute kidney injury follow-up, was associated with improved process measures, reduced acute kidney injury progression, and possibly lower mortality or rehospitalization.
The evidence was mixed, with some studies reporting no significant reduction in major adverse kidney events.

Strategies for Renal Recovery Optimization

Care bundles based on Kidney Disease: Improving Global Outcomes or similar guidelines, often incorporating electronic alerts and standardized protocols, were reported to be associated with reduced mortality, acute kidney injury progression, and need for renal replacement therapy in both observational studies and meta-analyses.
Bundles that included biomarker-based risk stratification may further improve outcomes.
National audits and registry studies reported persistent gaps in acute kidney injury recognition, documentation, and adherence to best practices.

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.
Ongoing quality improvement efforts are needed to address persistent gaps in acute kidney injury recognition and management.