Acute Kidney Injury (AKI)

Protect renal perfusion - Maintain blood pressure and volume to preserve renal blood flow; avoid hypotension and hypovolemia, the commonest further insults.

Hyperkalemia and electrolytes - Watch for hyperkalemia (avoid succinylcholine when significant), acidosis, and other derangements; correct dangerous levels before induction.

Drug clearance - Renally cleared drugs accumulate; avoid or dose-adjust (favor relaxants and opioids with non-renal clearance) and titrate to effect.

Avoid nephrotoxins - Avoid nephrotoxic drugs and minimize contrast; be cautious with certain fluids.

Fluid balance and dialysis - Manage volume carefully (overload versus depletion) and coordinate timing around dialysis for those receiving it.

Acute kidney injury is an abrupt fall in renal function, from pre-renal hypoperfusion, intrinsic renal injury (ischemia, nephrotoxins), or post-renal obstruction.

The consequences that matter to the anesthetist are volume overload, hyperkalemia and other electrolyte and acid-base derangements, impaired clearance of renally excreted drugs, uremic platelet dysfunction, and the vulnerability of injured kidneys to any further insult. Perioperatively the priority is preventing further injury.