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.

Paper search

Using your research question "What is the standard of care for acute kidney injury?", we searched across over 126 million academic papers from the Semantic Scholar corpus. We retrieved the 1000 papers most relevant to the query.

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.

Results

Characteristics of Included Studies

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.

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.