28.5: Acute Kidney Injury V: Interprofessional Care

Acute Kidney Injury (AKI) requires a collaborative healthcare approach to restore renal function and prevent complications. Essential management strategies involve monitoring fluid and electrolyte balance, adjusting medications, initiating dialysis when necessary, and providing nutritional support.

Fluid and Electrolyte Management

• Fluid Monitoring: Regularly monitoring body weight, central venous pressure, and urine output helps detect fluid imbalances early. Patient intake and output are carefully documented to prevent fluid overload, which may cause pulmonary edema and dyspnea. The nurse monitors for signs of fluid excess, including distended neck veins, crackles on lung auscultation, and generalized edema.
• Diuretics: Loop diuretics, like furosemide, may be used to alleviate symptoms of fluid overload. However, diuretics do not directly improve kidney function and are typically prescribed for symptom relief. In cases of prerenal AKI, IV fluids or blood transfusions may be given to restore renal blood flow and reduce fluid retention.
• Electrolyte Adjustments: Hyperkalemia, a serious electrolyte imbalance in AKI, is initially treated with calcium gluconate to stabilize the cardiac membrane. Insulin and glucose are administered to temporarily shift potassium into cells, while patiromer or sodium polystyrene sulfonate (Kayexalate) can be used for ongoing potassium removal via the gastrointestinal tract. Severe hyperkalemia may require dialysis for rapid potassium reduction​.

Medication Management

Medications, including diuretics, antibiotics, and drugs like digoxin, must be adjusted to prevent toxicity, as kidney impairment slows their clearance from the body. Dosage adjustments are essential to prevent accumulation and adverse effects. Monitoring for potential toxic effects of these medications is crucial in AKI management​.

Dialysis Indications and Options

• Indications for Dialysis: Dialysis is indicated in cases of severe AKI complications, such as fluid overload, hyperkalemia, metabolic acidosis, or significantly elevated blood urea nitrogen (BUN) levels that cannot be managed conservatively. Additional clinical signs, such as altered mental status, may also necessitate dialysis​.
• Dialysis Options:
  • Hemodialysis (HD) is the preferred method for rapidly removing waste products and excess fluids. It filters blood through an artificial kidney, providing adequate clearance, but rapid fluid shifts may cause hypotension​.
  • Peritoneal Dialysis (PD) is a less common approach to AKI. It uses the peritoneal membrane for fluid exchange, providing a gentler filtration option in specific cases​.
  • Continuous Renal Replacement Therapy (CRRT) is particularly suited for hemodynamically unstable patients. It offers continuous, slower filtration that prevents rapid fluid and electrolyte shifts, minimizing risks in critically ill patients​.

Nutritional Therapy

• Caloric and Protein Requirements: Nutritional support is essential to prevent catabolism, with 30 to 35 kilocalories per kilogram of body weight provided daily. To reduce nitrogenous waste, protein intake is restricted to 0.8–1.0 grams per kilogram per day in non-dialysis patients. In patients on dialysis or CRRT, protein intake is increased to 1.2–2.5 grams per kilogram daily to compensate for protein losses during treatment​.
• Electrolyte and Fluid Adjustments: Sodium intake is restricted to prevent edema and hypertension. Potassium and phosphorus intake are also carefully adjusted according to serum levels to avoid further complications in AKI management.