# Prevention and General Management of AKI — KDIGO 2012

## Hemodynamic Management

### Volume Expansion

- In the absence of hemorrhagic shock, suggest using **isotonic crystalloids** rather than colloids (albumin or starches) as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI (Grade 2B).
- Suggest using **vasopressors in conjunction with fluids** in patients with vasomotor shock with, or at risk for, AKI (Grade 1C).

### Protocol-Based Hemodynamic Optimization

- Suggest using **protocol-based management of hemodynamic and oxygenation parameters** to prevent development or worsening of AKI in high-risk patients in the **perioperative setting** (Grade 2C).
- Suggest using **protocol-based management of hemodynamic and oxygenation parameters** to prevent development or worsening of AKI in patients with **septic shock** (Grade 2C).

## Glycemic Control

- In critically ill patients, suggest **insulin therapy targeting plasma glucose 110-149 mg/dL (6.1-8.3 mmol/L)** (Grade 2C).
- Avoid hypoglycemia; target should prevent hyperglycemia without inducing hypoglycemic episodes.

## Nutritional Support

- Suggest achieving a **total energy intake of 20-30 kcal/kg/d** in patients with any stage of AKI (Grade 2C).
- Suggest **not restricting protein intake** with the aim of preventing or delaying initiation of RRT (Grade 2D).
- Suggest providing nutrition preferentially via the **enteral route** in patients with AKI (Grade 2C).

### Protein Recommendations by Clinical Setting

| Clinical Setting | Protein Intake | Grade |
|---|---|---|
| **Noncatabolic AKI, not on dialysis** | 0.8-1.0 g/kg/d | 2D |
| **AKI on RRT** | 1.0-1.5 g/kg/d | 2D |
| **CRRT and/or hypercatabolic patients** | Up to a maximum of 1.7 g/kg/d | 2D |

## Pharmacological Agents — What NOT to Use

The KDIGO guideline provides strong recommendations against several agents commonly considered for AKI prevention or treatment:

### Diuretics

- **Do not use diuretics to prevent AKI** (Grade 1B).
- Suggest **not using diuretics to treat AKI**, except in the management of **volume overload** (Grade 2C).
- Diuretics may be used for management of fluid overload but should not be used as a strategy to convert oliguric to non-oliguric AKI.

### Vasodilators

- **Do not use low-dose dopamine to prevent or treat AKI** (Grade 1A).
- Suggest **not using fenoldopam** to prevent or treat AKI (Grade 2C).
- Suggest **not using atrial natriuretic peptide (ANP) to prevent AKI** (Grade 2C).
- Suggest **not using ANP to treat AKI** (Grade 2B).

### Growth Factors and Hormones

- **Do not use recombinant human IGF-1 (rhIGF-1)** to prevent or treat AKI (Grade 1B).

### N-Acetylcysteine (NAC)

- **Do not use oral or IV NAC for prevention of postsurgical AKI** (Grade 1A).
- Suggest **not using NAC to prevent AKI in critically ill patients with hypotension** (Grade 2D).
- Note: NAC recommendations for contrast-induced AKI differ (see contrast_induced_aki section).

### Theophylline

- Suggest that a **single dose of theophylline may be given in neonates with severe perinatal asphyxia** who are at high risk of AKI (Grade 2B).
- This recommendation is specific to the neonatal population and should not be extrapolated to adults.

## Nephrotoxic Drug Management

### Aminoglycosides

- Suggest **not using aminoglycosides** for the treatment of infections unless no suitable, less nephrotoxic, therapeutic alternatives are available (Grade 2A).
- If aminoglycosides must be used, suggest administering them as a **single dose daily** rather than multiple-dose daily treatment regimens in patients with normal kidney function in steady state (Grade 2B).
- Recommend **monitoring aminoglycoside drug levels** when treatment with multiple daily dosing is used for more than 24 hours (Grade 1A).

### Amphotericin B

- In the treatment of systemic mycoses or parasitic infections, recommend using **lipid formulations of amphotericin B** rather than conventional formulations of amphotericin B (Grade 2A).
- Recommend using **azole antifungal agents and/or echinocandins rather than conventional amphotericin B**, if equal therapeutic efficacy can be assumed (Grade 1A).

### General Nephrotoxin Avoidance

- Avoid or discontinue potentially nephrotoxic agents whenever possible, including: NSAIDs, ACE inhibitors, ARBs, aminoglycosides, and conventional amphotericin B (Not Graded).
- When nephrotoxic agents cannot be avoided, ensure adequate volume status and monitor kidney function closely (Not Graded).

## Decision Algorithm — AKI Prevention

1. **Identify at-risk patients** based on susceptibilities (CKD, diabetes, advanced age, heart failure) and exposures (surgery, sepsis, nephrotoxins, contrast).
2. **If at risk:**
   - Ensure euvolemia with isotonic crystalloids (Grade 2B).
   - Avoid nephrotoxic agents or adjust doses (Not Graded).
   - Monitor SCr and urine output to detect AKI early (Not Graded).
   - Use protocol-based hemodynamic management in perioperative or sepsis settings (Grade 2C).
3. **If AKI develops:**
   - Do NOT use diuretics unless for volume overload (Grade 1B/2C).
   - Do NOT use low-dose dopamine (Grade 1A).
   - Maintain glycemic control (110-149 mg/dL) (Grade 2C).
   - Provide adequate nutrition via enteral route (Grade 2C).
   - Adjust all renally-cleared medications.
   - Stage the AKI and manage per stage-based recommendations.

## Limitations

- Evidence for most preventive strategies is of low to moderate quality.
- The guideline acknowledges the lack of any proven pharmacological therapy to prevent or treat established AKI.
- Hemodynamic targets (e.g., specific MAP thresholds) are not defined by the guideline; protocol-based management is recommended without specifying a universal hemodynamic protocol.
