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.

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)?
Standard Care Interventions: Does the study examine therapeutic interventions that are considered standard care for AKI?
Clinical Outcomes: Does the study report clinical outcomes such as renal recovery, mortality, or dialysis requirement?
Study Design: Is the study a randomized controlled trial, observational study, or systematic review?
Population and Setting: Does the study include adult patients (≥18 years)?
Treatment Focus: Does the study focus on treatment of established AKI?
Primary AKI Focus: Does the study have AKI management as a primary focus?
Human Studies: Is this a human study?

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

Data extraction

We extracted the following data:

Study Design: Specify the exact type of study design.
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	Study Focus	Population	Intervention/Topic	Key Outcomes Measured
Sohaney et al., 2020	Timing of Kidney Replacement Therapy	3,019 critically ill adults	Accelerated vs. standard KRT initiation	90-day mortality, KRT dependence
Kolhe et al., 2015	AKI care bundle implementation	2,297 patients	AKI care bundle with electronic alert	In-hospital case fatality, AKI progression
Aitken et al., 2013	Quality of AKI care	1,577 hospital admissions	Standard care	Mortality, AKI recognition, documentation
Landoni et al., 2013	Interventions affecting AKI mortality	>300 physicians; literature review	Systematic review and survey	Mortality, intervention-practice gap
STARRT-AKI Investigators, 2020	Timing of Renal Replacement Therapy	3,019 ICU patients	Accelerated vs. standard RRT	90-day mortality, RRT dependence
Kolhe et al., 2016	AKI care bundle compliance	3,518 patients	AKI care bundle (fluid, drugs)	In-hospital case fatality, AKI progression
Thanapongsatorn et al., 2021	Multidisciplinary post-AKI care	98 AKI stage 2-3 survivors	Multidisciplinary Care Team	Feasibility, eGFR, BP control
Graham-Brown et al., 2024	National audit of AKI care	989 AKI stage 2/3 episodes	Standard care	30-day mortality, care standard completion

Key Outcomes Measured

Mortality was measured in 32 studies.
Acute kidney injury progression was measured in 3 studies.
Renal replacement therapy dependence was measured in 6 studies.

Summary

The included studies reported that the standard of care for acute kidney injury includes:

Initiation of renal replacement therapy for conventional indications.
Use of standard renal replacement therapy dosing targets.
Modality selection based on patient context, with peritoneal dialysis as a viable option.
Implementation of care bundles and early nephrology involvement, which improved process measures and may reduce adverse outcomes.

The evidence was strongest for renal replacement therapy timing and dosing, indicating the need for ongoing quality improvement efforts to address gaps in acute kidney injury recognition and management.