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Acute Kidney Injury - Hospitalist Approach (KDIGO)

Acute Kidney Injury - Hospitalist Approach (KDIGO): Acute Kidney Injury Identified → KDIGO AKI Staging → Determine Etiology → Pre-renal AKI (Most common...

Pathway Overview

10 steps

Algorithm Steps

10 total

  1. 01Start

    Acute Kidney Injury Identified

    Rising creatinine or decreased UOP

  2. 02Action

    KDIGO AKI Staging

    Classify severity

    • STAGE 1:
    • - Cr 1.5-1.9x baseline, OR
    • - Cr increase ≥0.3 mg/dL, OR
    • - UOP <0.5 mL/kg/hr x 6-12h
    • STAGE 2:
    • - Cr 2.0-2.9x baseline, OR
    • - UOP <0.5 mL/kg/hr x ≥12h
    • STAGE 3:
    • - Cr ≥3x baseline, OR
    • - Cr ≥4.0 mg/dL, OR
    • - UOP <0.3 mL/kg/hr x ≥24h, OR
    • - Anuria x ≥12h, OR
    • - Initiation of RRT
  3. 03Decision

    Determine Etiology

    Pre-renal vs Intrinsic vs Post-renal

  4. 04Action

    Pre-renal AKI (Most common)

    Decreased renal perfusion

    • CAUSES:
    • - Hypovolemia (bleeding, dehydration)
    • - Hypotension (sepsis, cardiac)
    • - Decreased effective circulating volume
    • (CHF, cirrhosis, nephrotic)
    • - Renal artery stenosis
    • - ACEi/ARB in CKD
    • LABS:
    • - FENa <1%
    • - BUN/Cr ratio >20:1
    • - Urine Na <20 mEq/L
    • - Bland sediment
  5. 05Action

    Workup

    Diagnostic tests

    • BASIC:
    • - BMP, Mg, Phos, CBC
    • - UA with microscopy (sediment)
    • - Urine electrolytes (Na, Cr)
    • - Renal ultrasound (if not recent)
    • CALCULATE:
    • - FENa = (UNa × PCr)/(PNa × UCr) × 100
    • IF INTRINSIC SUSPECTED:
    • - Consider nephrology consult
    • - Complement (C3/C4)
    • - ANA, ANCA, anti-GBM
    • - Serum/urine protein electrophoresis
  6. 06Action

    Management Principles

    General approach

    • 1. TREAT UNDERLYING CAUSE
    • 2. OPTIMIZE VOLUME STATUS:
    • - Fluids if hypovolemic
    • - Diuretics if overloaded
    • 3. STOP NEPHROTOXINS:
    • - NSAIDs, aminoglycosides
    • - Hold ACEi/ARB temporarily
    • 4. ADJUST DRUG DOSES for GFR
    • 5. AVOID CONTRAST if possible
    • 6. MONITOR I/Os, daily weights
    • 7. NUTRITION: Avoid excessive protein
  7. 07Warning

    Dialysis Indications (AEIOU)

    When to call nephrology urgently

    • A - Acidosis (pH <7.1, refractory)
    • E - Electrolytes (K+ >6.5, refractory)
    • I - Intoxication (lithium, methanol, etc)
    • O - Overload (pulmonary edema, refractory)
    • U - Uremia (encephalopathy, pericarditis)
    • ALSO CONSIDER:
    • - Rapidly rising Cr without clear cause
    • - Oliguria/anuria >24h despite resuscitation
  8. 08Outcome

    Outcomes

    Monitoring and prognosis

    • Monitor Cr daily until stable
    • Recovery: Days to weeks depending on cause
    • Prerenal: Usually recovers quickly if treated
    • ATN: May take 1-3 weeks to recover
    • Increased CKD risk after AKI episode
    • Follow-up with nephrology if severe
  9. 09Action

    Intrinsic AKI

    Damage to kidney itself

    • ATN (most common intrinsic):
    • - Ischemic (prolonged prerenal)
    • - Nephrotoxic (contrast, aminoglycosides)
    • - Muddy brown casts
    • - FENa >2%
    • AIN (Interstitial nephritis):
    • - Drug-induced (NSAIDs, PPIs, abx)
    • - WBC casts, eosinophils
    • GLOMERULONEPHRITIS:
    • - RBC casts, proteinuria
    • - Systemic symptoms
  10. Path rejoins step 05Shared downstream outcome
  11. 10Action

    Post-renal AKI

    Obstruction

    • CAUSES:
    • - BPH (most common in men)
    • - Malignancy
    • - Nephrolithiasis (bilateral/solitary)
    • - Retroperitoneal fibrosis
    • DIAGNOSIS:
    • - Renal US: Hydronephrosis
    • - Bladder scan: Retention
    • TREATMENT:
    • - Foley catheter (lower)
    • - Nephrostomy tube (upper)
  12. Path rejoins step 05Shared downstream outcome

Guideline Source

KDIGO Clinical Practice Guideline for Acute Kidney Injury

DOI: 10.1038/kisup.2012.1

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Creatinine lags behind injury
  • Baseline Cr may be unknown
  • Volume status assessment challenging
  • FENa less reliable with diuretics

Applicable Regions

USEU
Version 1Next review: 2027-01-11

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Frequently Asked Questions

What is the Acute Kidney Injury - Hospitalist Approach (KDIGO)?

The Acute Kidney Injury - Hospitalist Approach (KDIGO) is a emergency clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on KDIGO Clinical Practice Guideline for Acute Kidney Injury.

What guideline is the Acute Kidney Injury - Hospitalist Approach (KDIGO) based on?

This algorithm is based on KDIGO Clinical Practice Guideline for Acute Kidney Injury (DOI: 10.1038/kisup.2012.1).

What are the limitations of the Acute Kidney Injury - Hospitalist Approach (KDIGO)?

Known limitations include: Creatinine lags behind injury; Baseline Cr may be unknown; Volume status assessment challenging; FENa less reliable with diuretics. Individual patient factors may require deviation from these recommendations.

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