ICU · Renal/Metabolic
Acute kidney injury: prevention and nephroprotection in ICU
Also known as AKI prevention · Nephroprotection · Renal sparing strategies · KDIGO guidelines for AKI
AKI prevention in the ICU — AKI-EPI epidemiology, KDIGO 2012 definition, staging and prevention recommendations, fluid choice (SMART, 6S, CHEST, albumin), blood-pressure targets (SEPSISPAM), vasopressin (VANISH), venous congestion, glucose, agents that do not protect the kidney, contrast exposure (PRESERVE), aminoglycoside dosing, PrevAKI, Sapphire biomarkers and remote ischaemic preconditioning.
Checked against its sources on 8 Oct 2026
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Red flags
- AKI occurred in 57.3% of ICU patients in AKI-EPI, and stage 3 carried an adjusted mortality OR of 6.88
- KDIGO recommends not using diuretics or low-dose dopamine to prevent AKI
- Hydroxyethyl starch increased renal-replacement therapy (6S, CHEST)
- Contrast: IV isotonic saline or bicarbonate; acetylcysteine and bicarbonate gave no benefit in PRESERVE
- Venous congestion, not low output, tracked worsening renal function in decompensated heart failure
Meet the patient
A 68-year-old man with diabetes and chronic kidney disease is admitted with urinary sepsis, on noradrenaline after a large saline resuscitation. KDIGO recommends stratifying patients for AKI risk according to their susceptibilities and exposures — and this man has both.[1]
References21ShowHide
- [1]Kellum JA, Lameire N, KDIGO AKI Guideline Work Group Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Critical care (London, England), 2013.PMID 23394211
- [2]Lameire N, Kellum JA, KDIGO AKI Guideline Work Group Contrast-induced acute kidney injury and renal support for acute kidney injury: a KDIGO summary (Part 2). Critical care (London, England), 2013.PMID 23394215
- [3]Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive care medicine, 2015.PMID 26162677
- [4]Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. The New England journal of medicine, 2014.PMID 24635770
- [5]NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. The New England journal of medicine, 2009.PMID 19318384
- [6]Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. The New England journal of medicine, 2018.PMID 29485925
- [7]Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. The New England journal of medicine, 2012.PMID 22738085
- [8]Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. The New England journal of medicine, 2012.PMID 23075127
- [9]Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. The New England journal of medicine, 2004.PMID 15163774
- [10]Friedrich JO, Adhikari N, Herridge MS, et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Annals of internal medicine, 2005.PMID 15809463
- [11]Ho KM, Sheridan DJ Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ (Clinical research ed.), 2006.PMID 16861256
- [12]Coca SG, Singanamala S, Parikh CR Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney international, 2012.PMID 22113526
- [13]Zarbock A, Küllmar M, Ostermann M, et al. Prevention of Cardiac Surgery-Associated Acute Kidney Injury by Implementing the KDIGO Guidelines in High-Risk Patients Identified by Biomarkers: The PrevAKI-Multicenter Randomized Controlled Trial. Anesthesia and analgesia, 2021.PMID 33684086
- [14]Kashani K, Al-Khafaji A, Ardiles T, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Critical care (London, England), 2013.PMID 23388612
- [15]Weisbord SD, Gallagher M, Jneid H, et al. Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine. The New England journal of medicine, 2018.PMID 29130810
- [16]Barza M, Ioannidis JP, Cappelleri JC, et al. Single or multiple daily doses of aminoglycosides: a meta-analysis. BMJ (Clinical research ed.), 1996.PMID 8611830
- [17]Meybohm P, Bein B, Brosteanu O, et al. A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery. The New England journal of medicine, 2015.PMID 26436208
- [18]Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock: The VANISH Randomized Clinical Trial. JAMA, 2016.PMID 27483065
- [19]Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. Journal of the American College of Cardiology, 2009.PMID 19215833
- [20]Cho A, Lee YK, Sohn SY Beneficial effect of statin on preventing contrast-induced acute kidney injury in patients with renal insufficiency: A meta-analysis. Medicine, 2020.PMID 32150109
- [21]Ronco C, Bellomo R, Kellum JA Acute kidney injury. Lancet (London, England), 2019.PMID 31777389