Patient handout

Acute Kidney Injury — Pre-renal Mechanism

PRODUCTION

1. Your condition

This handout is for acute kidney injury — pre-renal mechanism. Your care team identified this based on: creatinine rise with fena <1% + bun:cr >20 (kdigo 2012 aki; carvounis kidney int 2002).

Other reasons your team may use this plan: oliguria + dehydration / volume loss / gi losses (kdigo 2012 aki); vomiting / diarrhea / hemorrhage / diuretic overuse (kdigo 2012 aki); cirrhosis with aki not responsive to albumin challenge — hrs-aki suspicion (aasld 2023; ica 2019).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
lactated_ringers	500-1000 mL bolus over 30 min, repeat to UOP >0.5 mL/kg/h + MAP >65 (max 2-3 L without reassessment)	IV	titrate to MAP/UOP	SMART Semler NEJM 2018 PMID 29485925 + SALT-ED Self NEJM 2018 PMID 29485926 — balanced crystalloid lowers MAKE30 vs saline; avoids hyperchloremic acidosis (KDIGO 2012 AKI)
plasmalyte	500-1000 mL bolus over 30 min	IV	titrate to MAP/UOP	Equivalent balanced crystalloid alternative to LR — BaSICS PMID 34375394 + PLUS PMID 35041780 no harm signal (KDIGO 2012 AKI)
sodium_chloride_0.9%	500-1000 mL bolus over 30 min	IV	titrate	Acceptable when balanced unavailable; avoid large-volume to prevent hyperchloremic acidosis (KDIGO 2012 AKI; SMART NEJM 2018)

Plan: Pre-renal AKI — volume + perfusion + cause-specific (balanced crystalloid preferred per SMART/SALT-ED; albumin + terlipressin for HRS) (KDIGO 2012 AKI; SMART NEJM 2018; CONFIRM NEJM 2021)

3. When to call your provider

Contact your care team if any of the following happen:

Sustained eGFR <60 at 3 months → neph.ckd.core.v1 (KDIGO 2024 CKD)
Recurrent AKI → nephrology comprehensive evaluation (KDIGO 2012 AKI)
Cirrhosis decompensation → hepatology + reassess HRS risk (AASLD 2023)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Pre-renal AKI from third-spacing — pancreatitis, liver failure, sepsis, burns, post-operative; reduced effective circulating volume despite total-body fluid overload (KDIGO 2012 AKI; AASLD 2023)
Cardiorenal type 1 — acute HF → AKI; volume overload (NOT depletion) + WRF + elevated JVP + edema + pulmonary congestion (DOSE NEJM 2011; AHA/ACC HF 2022)
HRS-AKI per ICA 2019 — cirrhosis + AKI + failure to respond to 48h albumin 1 g/kg + no shock + no nephrotoxin + no parenchymal disease on UA/US (AASLD 2023; ICA 2019)(life-threatening)
Bilateral renal artery stenosis unmasked by ACEi/ARB — abrupt Cr rise upon initiation; asymmetric kidneys on US + audible renal bruit (KDIGO 2012 AKI)
Abdominal compartment syndrome — IAP >20 mmHg + new organ dysfunction; pre-renal AKI from reduced renal perfusion pressure (KDIGO 2012 AKI; WSACS 2013)(life-threatening)
Sustained hypoperfusion → ischemic ATN — FeNa rises >2%, BUN:Cr falls <15, muddy-brown casts replace hyaline; recovery 1-3 weeks (KDIGO 2012 AKI)
KDIGO Stage 3 pre-renal AKI — Cr ≥3× baseline OR Cr ≥4.0 OR UOP <0.3 mL/kg/h × 24h OR anuria ≥12h OR RRT initiated (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)

5. Follow-up

Re-introduce ACEi/ARB cautiously post-recovery (KDIGO 2024 CKD); permanent NSAID avoidance; sick-day med-rec for diuretic/SGLT2i/ACEi during AGE; hepatology follow-up for cirrhosis; cardiology for HF (KDIGO 2012 AKI; KDIGO 2024 CKD; AASLD 2023)

6. Sources

Guideline: KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + ICA 2015 HRS-AKI consensus + AASLD 2023 ACLF/HRS guidance + AHA/ACC HF 2022 + SMART/SALT-ED NEJM 2018 + CONFIRM NEJM 2021 (terlipressin HRS-AKI) + DOSE NEJM 2011 + KDIGO 2024 CKD progression + WSACS 2013 (abdominal compartment syndrome)