Preventing acute kidney injury in high-risk patients

Abstract Acute kidney injury (AKI) is a complex and heterogeneous clinical syndrome associated with substantial short- and long-term morbidity and mortality. AKI outcomes are strongly influenced by severity, duration, and recovery trajectory, with persistent AKI conferring a worse prognosis and higher risk of progression to chronic kidney disease (CKD). Early AKI detection is limited by the impediments of traditional functional criteria based on serum creatinine and urine output. Stress and damage biomarkers have demonstrated promise for early identification of subclinical AKI and for assessing risk of progression before a functional decline becomes apparent. Preventive strategies remain the foundation of AKI management. The KDIGO AKI care bundle, comprising haemodynamic optimisation, close monitoring of kidney function parameters, and avoidance of nephrotoxins and hyperglycemia, has demonstrated the strongest evidence-based approach for preventing AKI, especially when stress is early identified by biomarkers. Evidence for adjunctive interventions, including remote ischaemic preconditioning and selected pharmacological agents, remains inconsistent and context-dependent. Current evidence supports a paradigm shift towards earlier risk identification, biomarker-guided stratification, and early proactive implementation of targeted preventive strategies.