New insights in prevention and treatment of sepsis-induced acute kidney injury

Sepsis-induced acute kidney injury (SAKI) remains an important challenge for intensive care unit clinicians. We reviewed current available evidence regarding prevention and treatment of SAKI thereby incorporating some major recent advances and developments. Prevention includes early and ample administration of "balanced" crystalloid solutions such as Ringer's lactate. For monitoring of renal function during resuscitation, lactate clearance rate is preferred above ScvO2 or renal Doppler. Aiming at high central venous pressures seems to be deleterious in light of the novel "kidney afterload" concept. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of acute kidney injury in postoperative and trauma patients, should not be neglected in sepsis. Renal replacement therapy (RRT) must be started early in fluid-overloaded patients refractory to diuretics. Continuous RRT (CRRT) is the preferred modality in hemodynamically unstable SAKI but its use in more stable SAKI is increasing. In the absence of hypervolemia, diuretics should be avoided. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.