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 = 960
  Papers screened out

• n = 40
  Papers included for extraction

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).

• Setting and Context:

Describe the specific healthcare setting where the study was conducted.

• Participant Population:

Describe the key characteristics of study participants.

• Intervention Details:

Describe the specific intervention for AKI management.

• Primary Outcomes:

List all primary outcomes measured.

• Risk of Bias Assessment:

Assess potential sources of bias.

Results

Characteristics of Included Studies

• Study: Sohaney et al., 2020
  Study Focus: Timing of Kidney Replacement Therapy (KRT) initiation in Acute Kidney Injury (AKI)
  Population: 3,019 critically ill adults with Kidney Disease: Improving Global Outcomes (KDIGO) stage 2/3 AKI
  Intervention/Topic: Accelerated vs. standard KRT initiation
  Key Outcomes Measured: 90-day mortality, KRT dependence, adverse events
  Full text retrieved: No

• Study: Kolhe et al., 2015
  Study Focus: AKI care bundle implementation
  Population: 2,297 patients, 2,500 AKI episodes
  Intervention/Topic: AKI care bundle with electronic alert
  Key Outcomes Measured: In-hospital case fatality, AKI progression
  Full text retrieved: Yes

• Study: Aitken et al., 2013
  Study Focus: Quality of AKI care
  Population: 1,577 hospital admissions
  Intervention/Topic: Standard care
  Key Outcomes Measured: Mortality, AKI recognition, documentation
  Full text retrieved: No

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.