AKI or ESRD with Complications
Consider need for renal replacement therapy
All Pathways
NephrologyEmergency
Urgent Dialysis Indications (KDIGO)
Urgent Dialysis Indications (KDIGO): AKI or ESRD with Complications → Life-Threatening Indication? → EMERGENT DIALYSIS → Choose RRT Modality → Intermitt...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Decision Life-Threatening Indication?
Absolute indications for urgent RRT (AEIOU)
- A - Acidosis: pH <7.1 refractory to bicarb
- E - Electrolytes: Hyperkalemia K+ >6.5 refractory to medical Rx
- I - Intoxication: Dialyzable toxin (lithium, methanol, ethylene glycol, salicylate)
- O - Overload: Pulmonary edema refractory to diuretics
- U - Uremia: Encephalopathy, pericarditis, bleeding
03Warning EMERGENT DIALYSIS
Life-threatening - initiate RRT immediately
- Nephrology STAT consult
- Vascular access (temporary catheter if no access)
- ICU admission if not already
- HD preferred if hemodynamically stable
- CRRT if hemodynamically unstable
04Decision Choose RRT Modality
HD vs CRRT
- HD: Hemodynamically stable, need rapid correction
- CRRT: Hemodynamically unstable, cerebral edema risk, slower correction needed
- SLED: Hybrid approach
05Action Intermittent HD
Standard hemodialysis
- Duration: 3-4 hours
- Faster solute clearance
- Better for severe hyperkalemia, toxins
- Requires hemodynamic stability
06Outcome RRT Initiated
Monitor for recovery, reassess daily
07Action CRRT
Continuous renal replacement therapy
- CVVH, CVVHD, or CVVHDF
- Better hemodynamic tolerance
- Slower solute clearance
- ICU setting required
- Anticoagulation considerations
- Path rejoins step 06Shared downstream outcome
08Action Severe Metabolic Acidosis
pH <7.1 or HCO3 <10 mEq/L
- Trial of IV sodium bicarbonate first
- If refractory or volume overloaded → RRT
- HD superior for rapid correction
- Bicarbonate-based dialysate
- Path rejoins step 03Shared downstream outcome
09Action Refractory Hyperkalemia
K+ >6.5 mEq/L despite medical therapy
- Medical therapy: Calcium, insulin/glucose, albuterol, K+ binders
- If ECG changes persist or K+ not controlled → RRT
- HD removes 25-50 mEq K+/hour
- Watch for rebound post-dialysis
- Path rejoins step 03Shared downstream outcome
10Action Dialyzable Toxin
Severe poisoning with dialyzable substance
- Classic SLIME: Salicylates, Lithium, Isopropanol, Methanol, Ethylene glycol
- Also: Metformin (severe lactic acidosis), valproic acid
- Poison control consultation
- Prolonged/high-flux HD may be needed
- Path rejoins step 03Shared downstream outcome
11Action Refractory Volume Overload
Pulmonary edema not responding to diuretics
- High-dose IV diuretics first (furosemide up to 200-400mg)
- Diuretic resistance: CrCl <20, nephrotic syndrome
- If O2 requirement increasing despite diuretics → RRT
- Ultrafiltration or HD with UF
- Path rejoins step 03Shared downstream outcome
12Action Uremic Complications
End-organ manifestations of uremia
- Encephalopathy: Asterixis, confusion, somnolence
- Pericarditis: Friction rub, chest pain (avoid anticoag)
- Uremic bleeding: Platelet dysfunction
- Nausea/vomiting: Intractable
- Any uremic complication → strong indication for RRT
- Path rejoins step 03Shared downstream outcome
13Decision Relative Indications?
Non-emergent but may benefit from RRT
- Oliguria >72h despite optimization
- Progressive azotemia without improvement
- Nutrition: Cannot provide adequate nutrition due to fluid
- Drug clearance: Need to clear drug for dosing
14Action Continue Supportive Care
Optimize without RRT, monitor closely
- Optimize volume status and hemodynamics
- Avoid nephrotoxins
- Adjust medication dosing
- Daily labs, strict I/O
- Nephrology follow-up
15Outcome Renal Recovery
Continue monitoring, avoid future nephrotoxins
16Action Plan RRT Initiation
Non-emergent but RRT indicated
- Discuss with nephrology
- Consider vascular access planning
- Patient/family discussion
- Choose modality (HD vs CRRT vs PD)
- Path rejoins step 04Shared downstream outcome
Guideline Source
KDIGO Clinical Practice Guideline for Acute Kidney Injury
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address dialysis modality selection in detail
- Timing of non-emergent RRT initiation controversial
- Simplified criteria - clinical judgment essential
- Does not cover peritoneal dialysis initiation
Applicable Regions
EUUSglobal
global: KDIGO criteria widely accepted; local practice may vary
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the Urgent Dialysis Indications (KDIGO)?
The Urgent Dialysis Indications (KDIGO) is a emergency 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.
What guideline is the Urgent Dialysis Indications (KDIGO) based on?
This algorithm is based on KDIGO Clinical Practice Guideline for Acute Kidney Injury (DOI: 10.1159/000339789).
What are the limitations of the Urgent Dialysis Indications (KDIGO)?
Known limitations include: Does not address dialysis modality selection in detail; Timing of non-emergent RRT initiation controversial; Simplified criteria - clinical judgment essential; Does not cover peritoneal dialysis initiation. Individual patient factors may require deviation from these recommendations.
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