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”.

• Include timeframe of data collection if mentioned.

• 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.

• Use percentages or absolute numbers where possible.

• If any characteristic is not reported, write “Not reported”.

• 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.

• Specific protocols or care bundles used.

• If no specific intervention, note “Standard care” or “Control group”.

• Primary Outcomes: List all primary outcomes measured:

• Specify exact outcome measures.

• Include statistical results (means, percentages, p-values).

• Note measurement time points.

• Include units of measurement.

• If outcomes are not clearly defined, write “Not clearly reported”.

• Risk of Bias Assessment: Assess potential sources of bias:

• Randomization method (for RCTs).

• Blinding procedures.

• Loss to follow-up rates.

• Potential conflicts of interest.

• Funding sources.

• Use standard risk of bias tools if referenced.

• Categorize bias as low, unclear, or high risk.

• Provide brief justification for each assessment.

Results

Characteristics of Included Studies

Intervention/Focus:

• 15 studies focused on the timing of kidney or renal replacement therapy initiation (including early, late, standard, or accelerated strategies).
• 4 studies evaluated renal replacement therapy or kidney replacement therapy intensity or dose.
• 5 studies assessed care bundles, including electronic alerts, compliance, outreach, or meta-analyses.
• 3 studies examined post-acute kidney injury follow-up, multidisciplinary care, or acute kidney injury clinics.
• 4 studies focused on standard care as the main intervention or comparator.
• 1 study evaluated restrictive fluid management.
• 1 study assessed early nephrology consult.
• 2 studies focused on peritoneal dialysis in acute kidney injury.
• 4 studies addressed other interventions, including goal-directed therapy, renal replacement therapy modality/fluid balance, algorithm for renal replacement therapy initiation, or practice variation.
• 1 study was a guideline, review, or survey not otherwise categorized.

Key Outcomes Measured:

• Mortality was measured in 32 studies.
• Renal replacement therapy, kidney replacement therapy, or dialysis dependence was measured in 6 studies.
• Acute kidney injury progression was measured in 3 studies.
• Renal or kidney recovery, estimated glomerular filtration rate, or albuminuria were measured in 5 studies.
• Adverse events or complications were measured in 3 studies.
• Hospitalization or rehospitalization/death was measured in 1 study.
• Major adverse kidney events were measured in 2 studies.
• Protocol adherence, compliance, or care standard completion were measured in 3 studies.
• Acute kidney injury incidence, recognition, or documentation were measured in 3 studies.
• Fluid balance, blood pressure control, or medication use were measured in 3 studies.
• Serum creatinine or peak serum creatinine was measured in 2 studies.
• Renal replacement therapy need was measured in 4 studies.
• Renal replacement therapy-free days was measured in 1 study.
• Outcomes not clearly specified were found in 1 study.
• Chronic kidney disease progression was measured in 1 study.
• Intervention-practice gap was measured in 1 study.
• Feasibility was measured in 1 study.

We did not find outcome information for one study (Griffin, 2023), and for some studies, not all outcomes were clearly specified.

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, such as those in surgical intensive care unit populations or continuous renal replacement therapy recipients, reported possible benefit, but these findings were inconsistent across studies.
• Some studies reported that early renal replacement therapy may increase adverse events and dialysis dependence in certain settings.

Renal Replacement Therapy Dosing and Adequacy Targets

• We found three studies evaluating continuous renal replacement therapy, three evaluating intermittent hemodialysis, one evaluating sustained low-efficiency dialysis, one evaluating extended dialysis, and two evaluating peritoneal dialysis. Some studies included more than one modality.
• Two studies compared high versus standard (or equivalent) dosing, two studies compared intensive versus less-intensive or minimal dosing, one study compared intensified versus standard dosing, and one study used Kt/V targets.
• The evidence included two meta-analyses of randomized controlled trials, three individual randomized controlled trials, and one guideline.
• All studies were conducted in the context of acute kidney injury or critical illness.

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 (such as medication reconciliation and dietary review), 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.
• Most studies in this area were observational or quasi-experimental, which limits the strength of conclusions.

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.
• Restrictive fluid management was reported to reduce renal replacement therapy need and adverse events in one study.
• National audits and registry studies reported persistent gaps in acute kidney injury recognition, documentation, and adherence to best practices, with significant inter-hospital variation.

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.

The evidence was strongest for renal replacement therapy timing and dosing, with multiple large randomized controlled trials and meta-analyses. Evidence for care bundles and early nephrology involvement was promising but less robust, often limited by study design and implementation context. Real-world audits revealed substantial variability in care quality, underscoring the need for system-level interventions.