Prevention and Treatment of AKI

• In the absence of hemorrhagic shock, we 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. (2B)
• We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for, AKI. (1C)
• We 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 (2C) or in patients with septic shock (2C).
• In critically ill patients, we suggest insulin therapy targeting plasma glucose of 6.1–8.3mmol/l. (2C) This should only be attempted in a setting where adequate monitoring of blood glucose is possible to prevent hypoglycemia.
• We suggest achieving a total energy intake of 20–30 kcal/kg/d in patients with any stage of AKI. (2C)
• We suggest avoiding restriction of protein intake with the aim of preventing or delaying initiation of RRT. (2D)
• We suggest administering 0.8–1.0 g/kg/d of protein in noncatabolic AKI patients without need for dialysis (2D), 1.0–1.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients. (2D)
• We suggest providing nutrition preferentially via the enteral route in patients with AKI. (2C)
• We recommend not using diuretics to prevent AKI. (1B)
• We suggest not using diuretics to treat AKI, except in the management of volume overload. (2C)
• We recommend not using low-dose dopamine to prevent or treat AKI. (1A)
• We suggest not using fenoldopam to prevent or treat AKI. (2C)
• We suggest not using atrial natriuretic peptide (ANP) to prevent (2C) or treat (2B) AKI.
• We recommend not using recombinant human (rh) IGF-1 to prevent or treat AKI. (1B)
• We suggest that a single dose of theophylline may be given in neonates with severe perinatal asphyxia, who are at high risk of AKI. (2B)
• We suggest not using aminoglycosides for the treatment of infections unless no suitable, less nephrotoxic therapeutic alternatives are available. (2A) SARS recommendation: In our setting, starting a very ill patient on a combination of antibiotics including a single loading dose of aminoglycoside to cover gram-negative bacteria may be appropriate until downscaling can be done when cultures become available.
• We suggest that, in patients with normal kidney function in steady state, aminoglycosides are administered as single dose daily rather than multiple-dose daily treatment regimens. (2B)
• We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A)
• We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used for more than 48 hours. (2C)
• We suggest using topical or local applications of aminoglycosides (e.g., respiratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. (2B)
• We suggest using lipid formulations of amphotericin B rather than conventional formulations of amphotericin B. (2A)
• In the treatment of systemic mycoses or parasitic infections, we recommend using azole antifungal agents and/or the echinocandins rather than conventional amphotericin B, if equal therapeutic efficacy can be assumed. (1A)
• We suggest that off-pump coronary artery bypass graft surgery not be selected solely for the purpose of reducing perioperative AKI or need for RRT. (2C)
• We suggest not using NAC to prevent AKI in critically ill patients with hypotension. (2D)
• We recommend not using oral or i.v. NAC for prevention of postsurgical AKI. (1A)

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Van Rensburg B, Naicker S, Paget G, et al. Guideline for the Care of Patients with Acute Kidney Injury. South African Renal Society (Adopted KDIGO Guideline); 2015.