Fluid management and use of diuretics in acute kidney injury

Critically ill adult patients at risk for or with acute kidney injury (AKI) require careful attention to their hemodynamic status because hypotension and hypovolemia may contribute to or worsen kidney injury. Increasing evidence suggests that isotonic crystalloids should be used instead of colloids for initial expansion of intravascular volume in patients at risk for AKI or with AKI, such as those with sepsis, septic shock, or trauma. The timing and amount of volume to be administered to prevent AKI and other organ damage is still debated, but an aggressive fluid repletion in the early setting is probably beneficial. However, fluid overload has also been associated with increased mortality and reduced rate of kidney recovery in observational studies in critically ill patients with AKI. Diuretics may prevent or treat fluid overload and may also affect kidney function. The efficacy of these procedures in critically ill AKI patients need to be confirmed with randomized controlled trials. This review focuses on early volume resuscitation, overall fluid management, and use of diuretics in critically ill adult patients at risk for or with AKI and their effect on mortality and kidney function in this setting.