1. Overview and Rationale

Optimal supportive care aims to stabilize hemodynamics and ventilation, thereby mitigating further renal insult in the context of drug-induced Acute Kidney Injury (AKI). Interventions focusing on fluid management, vasopressor use, and appropriate ventilatory support are critical as they directly impact renal recovery and overall patient survival.

Key Points:

• Renal perfusion is intricately dependent on an adequate Mean Arterial Pressure (MAP), sufficient cardiac output, and optimized venous pressure.
• The application of positive-pressure ventilation, while potentially life-saving for respiratory compromise, can inadvertently reduce venous return to the heart, consequently diminishing renal blood flow and potentially exacerbating AKI.

2. Indications for Supportive Care

2.1 Hemodynamic Support

Assessment for hemodynamic instability is crucial. Key indicators include hypotension (defined as MAP <65 mmHg), an elevated serum lactate level (>2 mmol/L), oliguria (urine output <0.5 mL/kg/h), or other clinical signs suggestive of end-organ hypoperfusion. The use of dynamic indices of fluid responsiveness, such as pulse pressure variation (PPV), stroke volume variation (SVV), or central venous oxygen saturation (ScvO₂), can guide decisions regarding fluid administration versus vasopressor initiation.

2.2 Mechanical Ventilation

Indications for mechanical ventilation in the setting of AKI include acute respiratory failure (evidenced by a PaO₂/FiO₂ ratio <200), refractory metabolic acidosis (pH <7.2 despite other interventions), or severe hypoxemia (SpO₂ <88%). When ventilating, Positive End-Expiratory Pressure (PEEP) should be titrated carefully to optimize oxygenation while minimizing adverse hemodynamic effects. It's essential to monitor for signs of reduced preload and cardiac output, especially with higher PEEP levels.

3. Pharmacotherapy for Hemodynamic and Volume Management

3.1 Fluid Resuscitation

• Agents: Balanced crystalloid solutions (e.g., lactated Ringer’s, Plasma-Lyte) are generally preferred over normal saline (0.9% sodium chloride) to minimize the risk of hyperchloremic metabolic acidosis, especially with large volume resuscitation.
• Dosing: Initial fluid challenges typically involve 250–500 mL boluses. After each bolus, it is crucial to reassess perfusion parameters (e.g., MAP, lactate, capillary refill) and urine output.
• Monitoring: Utilize dynamic indices of fluid responsiveness, monitor urine output aiming for >0.5 mL/kg/h, and track daily weights to assess overall fluid balance.
• Pitfalls: Avoid iatrogenic fluid overload, which can worsen outcomes. Be mindful of the potential for hyperchloremic acidosis when administering large volumes of normal saline.

3.2 Vasopressor Therapy

When fluid resuscitation alone is insufficient to restore adequate MAP and tissue perfusion, vasopressor therapy is indicated.

Monitoring for Vasopressor Therapy: Continuously monitor MAP, assess lactate clearance, and track urine output. Be vigilant for signs of excessive vasoconstriction (e.g., cool extremities, worsening mottling) which could lead to peripheral or visceral ischemia.

3.3 Diuretic Use for Volume Overload

• Agents: Loop diuretics (e.g., furosemide 20–80 mg IV bolus, or a continuous infusion of 5–20 mg/h) are the mainstay. Thiazide diuretics (e.g., metolazone 2.5–5 mg PO) can be added for synergistic effect in cases of diuretic resistance.
• Mechanism: Enhance sodium and water excretion (natriuresis and diuresis). Combining different classes of diuretics can overcome diuretic resistance by blocking sodium reabsorption at multiple sites in the nephron.
• Monitoring: Closely monitor urine output, daily weights, serum electrolytes (especially potassium, magnesium, and sodium), and hemodynamic status.
• Pitfalls: Over-diuresis can lead to hypovolemia, electrolyte imbalances, and potentially worsen AKI. Diuretics are generally ineffective and may be harmful in anuric AKI if not for specific indications like managing hyperkalemia.

3.4 Electrolyte Repletion Strategies

Address common electrolyte abnormalities promptly:

• Hypokalemia (K < 3.5 mEq/L): Administer potassium chloride (KCl) 10–20 mEq/h IV. If infusion rates exceed 10 mEq/h, a central line and continuous ECG monitoring are recommended. Monitor serum potassium levels frequently.
• Hypomagnesemia (Mg < 1.5 mg/dL or < 0.6 mmol/L): Administer magnesium sulfate 1–2 grams IV infused over 1 hour. Monitor for hypotension during infusion.
• Hypophosphatemia (PO₄ < 2.5 mg/dL or < 0.8 mmol/L): Administer potassium phosphate or sodium phosphate 15–30 mmol IV over 4–6 hours. Monitor serum calcium and phosphate levels.

Monitor electrolyte levels every 4–6 hours during active repletion and adjust therapy accordingly.

4. Prevention of ICU Complications

4.1 Volume Overload Management

• Implement meticulous daily weights and accurate fluid balance charting (ins and outs).
• If diuretic therapy is insufficient to manage volume overload, consider escalating diuretic doses, adding a synergistic agent, or initiating renal replacement therapy (RRT) for ultrafiltration (typically aiming for 1–2 mL/kg/h net fluid removal, adjusted to hemodynamic tolerance).

4.2 Electrolyte Disturbance Prevention

• Monitor serum electrolytes (potassium, magnesium, phosphate, calcium, sodium) at least every 12–24 hours, or more frequently if unstable or undergoing aggressive therapy.
• Intervene proactively when levels approach critical thresholds (e.g., K <3.5 mEq/L, Mg <1.5 mg/dL, PO₄ <2.5 mg/dL).
• Prioritize enteral supplementation if the gut is functional; use parenteral routes when enteral administration is not feasible or insufficient.

4.3 Infection Prevention

• Adhere strictly to central line bundles, including aseptic insertion techniques, chlorhexidine skin antisepsis, and daily review of line necessity to minimize central line-associated bloodstream infections (CLABSIs).
• Practice antibiotic stewardship: Tailor antibiotic choices and dosing regimens to estimated or measured renal clearance. Avoid unnecessary or prolonged antibiotic exposure to reduce the risk of resistance and further nephrotoxicity.

5. Management of Iatrogenic Complications

5.A Electrolyte Disturbances

• Hyponatremia: Correct chronic hyponatremia slowly to avoid osmotic demyelination syndrome. The rate of correction should generally not exceed 8 mEq/L per 24 hours.
• Hyperkalemia: Acute management includes stabilizing cardiac membranes (calcium gluconate or calcium chloride), shifting potassium intracellularly (insulin with glucose, β₂-agonists), and promoting potassium removal (loop diuretics, cation exchange resins, or RRT).

5.B Fluid Shifts During RRT

• Ultrafiltration: Titrate the rate of fluid removal carefully based on hemodynamic tolerance. Rapid or excessive ultrafiltration (e.g., >13 mL/kg/h in intermittent therapies, or net negative balance exceeding tolerance in CRRT) can lead to intradialytic hypotension and organ hypoperfusion.
• Modality Choice: Continuous Renal Replacement Therapy (CRRT) is generally preferred for hemodynamically unstable patients due to slower, more controlled fluid and solute removal. Intermittent Hemodialysis (IHD) or Sustained Low-Efficiency Dialysis (SLED) may be suitable for more stable patients.

6. Multidisciplinary Goals of Care for Invasive Therapies

6.1 RRT Initiation and Modality Selection

Common indications for initiating RRT in AKI include:

• Refractory hyperkalemia (e.g., K >6.5 mEq/L or with ECG changes, unresponsive to medical therapy)
• Severe metabolic acidosis (e.g., pH <7.15-7.20) not correctable by other means
• Significant volume overload unresponsive to diuretic therapy, leading to respiratory compromise
• Uremic complications such as pericarditis or encephalopathy
• Certain drug toxicities/poisonings where the substance is dialyzable

Modality Selection:

• CRRT (Continuous Renal Replacement Therapy): Provides continuous, slow solute and fluid removal. Preferred for hemodynamically unstable patients.
• IHD (Intermittent Hemodialysis): Provides rapid, efficient solute and fluid removal over shorter sessions (3-5 hours). Suitable for hemodynamically stable patients.
• SLED (Sustained Low-Efficiency Dialysis): A hybrid modality offering extended treatment times (6-12 hours) with lower blood and dialysate flow rates than IHD, providing better hemodynamic stability than IHD but more rapid clearance than CRRT.

6.2 Interprofessional Collaboration

Effective management of drug-induced AKI, especially when RRT is involved, necessitates a coordinated multidisciplinary team approach:

• Pharmacists: Play a crucial role in optimizing drug regimens, adjusting doses based on changing renal function and RRT modality/intensity, monitoring for drug-drug interactions, and advising on drug removal by dialysis.
• Nephrologists: Guide the indications for RRT, select the appropriate modality and dose (prescription), and manage RRT-related complications.
• Critical Care Physicians: Oversee overall patient management, including hemodynamic and ventilatory support, and integrate RRT into the comprehensive care plan.
• Nursing Staff: Critical for implementing RRT protocols, continuous patient monitoring, early detection of complications, and ensuring adherence to prescribed therapies.

7. Monitoring Plan and Decision Algorithms

A structured monitoring plan is essential for managing patients with drug-induced AKI:

• Hemodynamics: Monitor MAP, heart rate, and lactate levels every 1–2 hours initially, then as clinically indicated once stable.
• Urine Output: Measure hourly. The goal is typically >0.5 mL/kg/h. Report oliguria or anuria promptly.
• Daily Weights: Crucial for assessing fluid balance.
• Laboratory Tests: Serum creatinine, BUN, electrolytes (K, Na, Mg, PO₄, Ca), and acid-base status (blood gas) should be monitored daily, or more frequently (e.g., every 4-12 hours) during acute interventions, vasopressor use, or RRT. Monitor relevant drug levels if applicable.

Algorithmic Pathway for Supportive Care