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NephrologyManagement

Acute Kidney Injury (AKI) Management (KDIGO)

Acute Kidney Injury (AKI) Management (KDIGO): Suspected acute kidney injury (adult) → Meets KDIGO AKI criteria? → First: check and treat any life threat...

Pathway Overview

16 steps

Algorithm Steps

16 total

  1. 01Start

    Suspected acute kidney injury (adult)

    Adult with a rising creatinine or low urine output.

  2. 02Decision

    Meets KDIGO AKI criteria?

    Adults only. Children: use paediatric criteria and paediatric advice. Any one of:

    • Creatinine rise ≥26.5 µmol/L (0.3 mg/dL) within 48 h
    • Creatinine ≥1.5 × baseline, known or presumed to have occurred within 7 days
    • Urine output <0.5 mL/kg/h for 6 h
  3. If Yes
    1. 03Action

      First: check and treat any life threat now

      Get K+, venous blood gas and a 12-lead ECG now. If any threat below: treat it, call nephrology or ICU, then continue. Adult doses. DKA or HHS: follow the DKA protocol for insulin and K+.

      • Hyperkalaemia with ECG changes: calcium gluconate 10% 30 mL IV over 10 min (calcium chloride 10% 10 mL IV over 5 min if peri-arrest)
      • K+ ≥6.5 mmol/L or any ECG changes: insulin (soluble) 10 units with glucose 25 g IV. K+ 6.0–6.4 mmol/L: consider the same
      • After insulin: check blood glucose often for 6 h. Pre-treatment glucose <7 mmol/L: then glucose 10% IV 50 mL/h for 5 h
      • Add nebulised salbutamol 10–20 mg as an adjunct only (10 mg if ischaemic heart disease; caution in tachyarrhythmia)
      • Cardiac monitor if K+ ≥6.5 mmol/L, ECG changes, or K+ 6.0–6.4 mmol/L and unwell. Recheck K+ at 1, 2, 4, 6 and 24 h
      • Digoxin toxicity suspected: still give IV calcium for ECG changes; call Poisons Information Centre 13 11 26 about digoxin antibody (Fab)
      • Pulmonary oedema or fluid overload with hypoxia: oxygen, ventilatory support as needed, loop diuretic while RRT is arranged
      • Shock: vasopressors and fluids to restore perfusion; no fluid bolus if cardiogenic shock or fluid overload
      • Severe metabolic acidosis, uraemic encephalopathy, pericarditis or bleeding, or dialysable poison (for example lithium, toxic alcohol, salicylate): urgent RRT referral
      • Any threat not responding to treatment: urgent RRT
    2. 04Action

      Stage the AKI (KDIGO)

      Use the highest stage met by creatinine or urine output.

      • Stage 1: creatinine 1.5–1.9 × baseline or rise ≥26.5 µmol/L; or urine <0.5 mL/kg/h for 6–12 h
      • Stage 2: creatinine 2.0–2.9 × baseline; or urine <0.5 mL/kg/h for ≥12 h
      • Stage 3: creatinine ≥3 × baseline, or ≥354 µmol/L, or RRT started; or urine <0.3 mL/kg/h for ≥24 h, or anuria for ≥12 h
      • Stage 2–3: review all drug doses and consider ICU. Stage 3, or known CKD G4–5: discuss with nephrology within 24 h
    3. 05Action

      Find the cause: reversible causes first

      Pregnancy: think of pre-eclampsia, HELLP or acute fatty liver; get obstetric and renal advice. Kidney transplant: discuss with the transplant team within 24 h. Cirrhosis with ascites: think of hepatorenal AKI; stop diuretics and nephrotoxins; get early hepatology advice.

      • Urine dipstick for blood, protein, leucocytes, nitrites and glucose now
      • CK if crush injury, long lie, seizures or drug-induced muscle injury (rhabdomyolysis)
      • Blood and protein without UTI or clear cause: possible nephritis; discuss with nephrology within 24 h
      • Review drugs and contrast in the past week (NSAID, ACE inhibitor, ARB, diuretic, aminoglycoside)
      • Bladder scan. Renal ultrasound within 24 h if no clear cause or risk of obstruction
      • Suspected infected obstructed kidney (pyonephrosis): ultrasound within 6 h
      • Pre-renal: hypovolaemia, hypotension, sepsis, heart failure. Intrinsic: ATN, AIN, GN, vasculitis, myeloma. Post-renal: obstruction
    4. 06Decision

      Urinary obstruction?

      Urinary retention on bladder scan, or hydronephrosis on ultrasound.

    5. If Yes
      1. 07Action

        Obstruction: relieve it urgently

        Bladder outlet: urinary catheter. Upper tract: urology referral for nephrostomy or stent.

        • Bladder outlet obstruction: insert a urinary catheter
        • Upper tract obstruction: refer to urology; immediately if pyonephrosis, solitary kidney, bilateral obstruction or AKI complications
        • Nephrostomy or stent as soon as possible, within 12 h of diagnosis
        • After relief: watch for post-obstructive diuresis; replace fluid and electrolyte losses
      2. 08Action

        All patients: fluids, perfusion and medicines

        Assess volume status first. Give fluid only if hypovolaemic. Heart failure or fluid overload: no fluid bolus. Cirrhosis with ascites: stop diuretics; get hepatology advice before repeated fluid (possible hepatorenal AKI).

        • Hypovolaemic: isotonic crystalloid in boluses; reassess after each
        • Shock: vasopressor with fluids; septic shock target MAP ≥65 mmHg
        • Withhold (SADMANS): sulfonylureas, ACE inhibitors, diuretics, metformin, ARBs, NSAIDs, SGLT2 inhibitors
        • Diuretics only to treat fluid overload, not to treat AKI
        • Stop potassium supplements and potassium-sparing drugs if K+ is high
        • Avoid aminoglycosides and iodinated contrast if an alternative exists; do not delay essential imaging or treatment
        • Review all doses with a pharmacist, especially anticoagulants (enoxaparin, DOACs), digoxin, lithium and vancomycin; check drug levels
        • Avoid hyperglycaemia. No low-dose dopamine
      3. 09Action

        Monitor and reassess

        Creatinine, K+ and bicarbonate at least daily; more often if unstable.

        • Strict fluid balance, urine output and daily weight
        • Watch for hyperkalaemia, acidosis, fluid overload and uraemia
        • No clear cause, no improvement or complications: discuss with nephrology within 24 h
      4. 10Decision

        Complication not responding to treatment?

        Refer at once for renal replacement therapy (RRT) if any of these do not respond to medical treatment:

        • Hyperkalaemia
        • Metabolic acidosis
        • Fluid overload or pulmonary oedema
        • Uraemic complications (pericarditis, encephalopathy)
        • Dialysable poison
      5. If Yes
        1. 11Warning

          Not responding: urgent RRT now

          Call nephrology or ICU now. Decide on the whole patient, not a single urea, creatinine or K+ value.

          • Haemodynamically unstable: continuous RRT (CRRT) preferred
          • Stable: intermittent haemodialysis is an option
          • Major comorbidity: discuss goals of care with the patient before RRT
        2. 12Outcome

          RRT or referral criteria met: nephrology follow-up

          Stage 3 AKI, RRT, eGFR ≤30 mL/min/1.73 m² after recovery, CKD G4–5, transplant or intrinsic kidney disease. Review for CKD at 3 months.

        If No
        1. 13Action

          Responding: continue supportive care

          Daily review until creatinine returns towards baseline.

          • Restart withheld medicines when well and kidney function is stable
          • Adjust drug doses as kidney function changes
        2. 14Decision

          Needs nephrology follow-up?

          Yes if any of these apply:

          • Stage 3 AKI or RRT needed
          • eGFR ≤30 mL/min/1.73 m² after recovery
          • CKD G4–5 or kidney transplant
          • Suspected GN, vasculitis, AIN or myeloma
        3. If Yes
          1. Path rejoins step 12Shared downstream outcome
          If No
          1. 15Outcome

            No nephrology criteria: GP review at 3 months

            Record the AKI in the discharge summary. Check eGFR, urine ACR and blood pressure at 3 months, then yearly for 3 years.

      If No
      1. Path rejoins step 08Shared downstream outcome
    If No
    1. 16Outcome

      No AKI by KDIGO criteria: monitor if at risk

      If at risk, repeat creatinine and watch urine output. Reassess if the clinical state changes. Raised but stable creatinine: assess for CKD.

Guideline Source

KDIGO Clinical Practice Guideline for Acute Kidney Injury (2012)

DOI: 10.1159/000339789View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Not for children, AKI in pregnancy or kidney transplant recipients without specialist advice.
  • Based on KDIGO 2012. The KDIGO 2026 AKI/AKD guideline was a public review draft at last review (Sep 2026); recheck when final.
  • Baseline creatinine may be unknown or inaccurate (low muscle mass, fluid overload, cirrhosis).
  • Does not cover RRT dose, access or anticoagulation, contrast-associated AKI prevention, HRS-AKI treatment or rhabdomyolysis management in detail.

Contraindicated Populations

neonateschildren (use paediatric AKI criteria)pregnancy (obstetric causes of AKI)kidney transplant recipients

Applicable Regions

AUEUUSglobal

AU: Creatinine in µmol/L. Kidney Health Australia sick day plan (SADMANS) for medicines to withhold; Kidney Health Check at 3 months after AKI, then yearly for 3 years.

global: KDIGO criteria are the international standard for AKI diagnosis and staging.

Version 2Next review: 2027-03-31

Related Nephrology Pathways

Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024)

Management

Contrast-Associated AKI Prevention (ACR-NKF/RANZCR)

Risk Assessment

Glomerulonephritis Evaluation (KDIGO 2021)

Diagnostic

Hepatorenal Syndrome (HRS-AKI) Management (ICA-ADQI 2024 / EASL)

Management

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eGFR (CKD-EPI 2021)

Estimated glomerular filtration rate using CKD-EPI 2021 equation (race-free)

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Frequently Asked Questions

What is the Acute Kidney Injury (AKI) Management (KDIGO)?

The Acute Kidney Injury (AKI) Management (KDIGO) is a management clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on KDIGO Clinical Practice Guideline for Acute Kidney Injury (2012).

What guideline is the Acute Kidney Injury (AKI) Management (KDIGO) based on?

This algorithm is based on KDIGO Clinical Practice Guideline for Acute Kidney Injury (2012) (DOI: 10.1159/000339789).

What are the limitations of the Acute Kidney Injury (AKI) Management (KDIGO)?

Known limitations include: Adults only. Not for children, AKI in pregnancy or kidney transplant recipients without specialist advice.; Based on KDIGO 2012. The KDIGO 2026 AKI/AKD guideline was a public review draft at last review (Sep 2026); recheck when final.; Baseline creatinine may be unknown or inaccurate (low muscle mass, fluid overload, cirrhosis).; Does not cover RRT dose, access or anticoagulation, contrast-associated AKI prevention, HRS-AKI treatment or rhabdomyolysis management in detail.. Individual patient factors may require deviation from these recommendations.

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