Before initiating RRT, all reversible causes of AKI should be addressed. This means optimising renal perfusion (correcting hypovolaemia, improving cardiac output, reducing vasopressor requirements), stopping all nephrotoxic drugs, removing urinary obstruction, and treating the underlying condition causing the AKI. Fluid management should be guided by clinical assessment and dynamic measures — excessive fluid administration worsens outcomes by increasing renal venous congestion and intra-abdominal pressure.

Drug dosing must be adjusted for the degree of renal impairment. Renally-cleared drugs accumulate in AKI — this includes many antibiotics (vancomycin, gentamicin, piperacillin-tazobactam), antifungals, digoxin, metformin (should be stopped), LMWH, and many others. Regular review of the drug chart is essential.