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Urgent Dialysis Indications (KDIGO)

Urgent Dialysis Indications (KDIGO): Adult: possible need for urgent dialysis → Treat the emergency now; do not wait for dialysis → If hyperkalaemia: me...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Adult: possible need for urgent dialysis

    Adult with acute kidney injury or kidney failure (including people already on dialysis) and a possible emergency indication. Not for children. Pregnancy: get nephrology and obstetric advice early.

  2. 02Warning

    Treat the emergency now; do not wait for dialysis

    A dialysis catheter and machine take hours to set up. Call nephrology and ICU early.

    • ECG changes of hyperkalaemia: IV calcium now, even if the patient takes digoxin. K+ 6.5 mmol/L or more: insulin-glucose; check glucose often.
    • Suspected digoxin toxicity: digoxin antibody fragments (DigiFab). Dialysis does not remove digoxin.
    • Poisoning: call Poisons Information Centre 13 11 26. Give antidotes now (methanol or ethylene glycol: fomepizole or IV ethanol).
  3. 03Action

    If hyperkalaemia: medical treatment, then dialysis if not controlled

    K+ 6.5 mmol/L or more, or ECG changes, that persists or returns despite medical treatment.

    • Medical treatment: IV calcium, insulin-glucose, salbutamol, potassium binder. Doses: see the hyperkalaemia pathway (UKKA 2023).
    • Suspected digoxin toxicity: digoxin antibody fragments, not dialysis. Call 13 11 26.
    • On haemodialysis with K+ 6.5 mmol/L or more: urgent dialysis. Give IV calcium first if ECG changes.
    • Insulin in kidney failure: high risk of hypoglycaemia. Check glucose often.
    • DKA: IV fluids and insulin lower K+. Dialysis is rarely needed for DKA alone.
    • Tumour lysis, rhabdomyolysis or oliguria: K+ keeps rising; involve nephrology early. Recheck K+ often: it rebounds as treatment wears off.
  4. 04Action

    If severe metabolic acidosis: IV bicarbonate or dialysis

    Metabolic acidaemia with pH 7.20 or less and AKI. Dialysis if the pH stays at 7.15 or less despite treatment, or bicarbonate is unsafe.

    • Treat the cause: shock, sepsis, poisoning, DKA.
    • IV sodium bicarbonate to pH 7.30 or more reduced dialysis use in AKI (BICAR-ICU2). It did not change mortality.
    • Fluid overload or high sodium: bicarbonate adds sodium and volume. Dialysis instead.
    • Bicarbonate lowers ionised calcium and K+: check them. Do not give it in the same IV line as calcium.
    • DKA: IV fluids and insulin usually correct the acidosis and the K+. Routine bicarbonate is not recommended.
  5. 05Action

    If dialysable poisoning: antidote and haemodialysis

    Severe poisoning with a toxin that dialysis removes. Call Poisons Information Centre 13 11 26 or a toxicologist.

    • Examples: lithium, salicylate, methanol, ethylene glycol, metformin with severe lactic acidosis, valproate, theophylline.
    • Methanol or ethylene glycol: fomepizole (or IV ethanol) now. Methanol: also folinic or folic acid.
    • Continue antidotes during dialysis. The antidote dose needs adjustment.
    • Intermittent haemodialysis is preferred. CRRT only if haemodialysis is not possible.
    • Digoxin: dialysis does not help. Give digoxin antibody fragments.
    • Recheck drug levels after dialysis: levels can rebound.
  6. 06Action

    If fluid overload: diuretic trial, then dialysis

    Pulmonary oedema or fluid overload with hypoxia that does not respond to diuretics, or anuria.

    • Oxygen, and CPAP or NIV, while dialysis is arranged.
    • Still passing urine: trial of IV furosemide. Adult dose: see furosemide PI, section 4.2.
    • High doses: infuse no faster than 4 mg/min (2.5 mg/min if creatinine above 440 µmol/L). Fast rates can cause deafness.
    • Anuria or no response to diuretics: dialysis with ultrafiltration. Do not delay for more diuretic.
  7. 07Action

    If uraemic complications: dialysis

    Uraemic encephalopathy, pericarditis or bleeding is an indication for dialysis.

    • Encephalopathy: confusion, drowsiness, asterixis, seizures. Exclude other causes.
    • Pericarditis: use no heparin or minimal heparin during dialysis. Tamponade: urgent drainage.
    • Uraemic bleeding: dialysis. Desmopressin can help.
    • Very high urea: make the first session short and gentle to avoid dialysis disequilibrium syndrome.
  8. 08Decision

    Emergency indication for dialysis present?

    A life-threatening problem not controlled by medical treatment, or a poisoning that meets dialysis criteria (KDIGO 5.1.1).

    • Hyperkalaemia not controlled
    • Severe metabolic acidosis not controlled
    • Dialysable poisoning
    • Fluid overload with hypoxia, diuretics failed or anuria
    • Uraemic encephalopathy, pericarditis or bleeding
  9. If Yes
    1. Emergency indication
    2. 09Action

      Yes: start urgent dialysis

      Emergency indication present. Keep up medical treatment until dialysis runs.

      • Call nephrology and ICU now.
      • Check goals of care and any advance care directive. If unclear, do not delay.
      • Access: non-tunnelled catheter with ultrasound. Right internal jugular first, then femoral, then left jugular. Subclavian last.
      • Chest X-ray before first use of a jugular or subclavian catheter.
      • Already on haemodialysis: use the existing access. On peritoneal dialysis: ask their renal unit.
    3. 10Decision

      Shock, or raised intracranial pressure?

      Haemodynamically unstable, or acute brain injury or cerebral oedema (KDIGO 5.6.2 and 5.6.3).

      • Yes: CRRT
      • No: intermittent haemodialysis
    4. If Yes
      1. Unstable or brain oedema
      2. 11Action

        Unstable or brain oedema: CRRT

        Continuous kidney replacement therapy in ICU. Better tolerated in shock; slower removal of solutes.

        • Anticoagulation: regional citrate rather than heparin, unless citrate is contraindicated (for example severe liver failure).
        • Heparin-induced thrombocytopenia: stop all heparin, including catheter locks. Use a non-heparin anticoagulant (for example danaparoid) with haematology advice.
        • No CRRT: prolonged intermittent dialysis (SLED) is an option.
        • Life-threatening hyperkalaemia or poisoning: intermittent haemodialysis clears faster. Discuss with nephrology or toxicology.
      3. 12Outcome

        Dialysis started: review every day

        Stop when kidney function meets the patient's needs or dialysis no longer fits the goals of care. Do not give diuretics to speed recovery (KDIGO 5.2).

      If No
      1. Stable
      2. 13Action

        Stable: intermittent haemodialysis

        Fastest removal of potassium and dialysable poisons. Needs a stable blood pressure.

        • K+ falls about 1 mmol/L in the first hour, then about 1 mmol/L over the next 2 hours.
        • Very high urea: short, gentle first session to avoid disequilibrium syndrome.
        • Pericarditis or high bleeding risk: no heparin or minimal heparin.
        • Recheck K+ and drug levels after the session: they can rebound.
        • Watch for low blood pressure during dialysis.
      3. Path rejoins step 12Shared downstream outcome
    If No
    1. No emergency indication
    2. 14Decision

      No emergency: other reasons to start dialysis?

      Oliguria over 72 hours, urea above 40 mmol/L, fluid building up despite diuretics, or fluid limits that block nutrition or drugs. Judge the trend, not one value (KDIGO 5.1.2). Pregnancy: nephrology and obstetric decision; do not use these thresholds alone.

      • Oliguria for more than 72 hours, or urea above 40 mmol/L: discuss a start. Waiting longer gave no benefit and possible harm (AKIKI 2).
      • Fluid still accumulating despite diuretics
      • Fluid limits stop needed nutrition or drugs
      • Without these, an early start gave no survival benefit and more dialysis dependence (STARRT-AKI).
    3. If Yes
      1. 15Action

        Yes: plan dialysis with nephrology

        Non-urgent start. Plan it in working hours where possible.

        • Agree goals of care with the patient and family.
        • Plan access with ultrasound guidance.
        • Choose CRRT or intermittent haemodialysis: shock or brain oedema favours CRRT.
      2. Path rejoins step 10Shared downstream outcome
      If No
      1. 16Action

        No: supportive care and daily review

        No dialysis now. Watch for an emergency indication.

        • Optimise fluid status and blood pressure.
        • Stop nephrotoxins. Adjust drug doses to kidney function.
        • Check K+, bicarbonate, urea and creatinine at least daily. Strict fluid balance.
        • Any emergency indication: go back to the top of this pathway.
        • Nephrology review.
      2. 17Outcome

        No dialysis now: keep monitoring

        Recovery: urine output and creatinine improve. Keep monitoring and avoid nephrotoxins. Check kidney function 3 months after AKI (KDIGO 2.3.4).

Guideline Source

KDIGO Clinical Practice Guideline for Acute Kidney Injury (2012), Section 5: Dialysis Interventions for Treatment of AKI

DOI: 10.1038/kisup.2011.35View 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. Children need paediatric nephrology and ICU advice.
  • Start emergency treatment first; use the hyperkalaemia, poisoning and pulmonary oedema pathways for doses.
  • KDIGO 2026 AKI/AKD guideline (timing, modality, dosing of kidney replacement therapy) is in preparation; update when published.
  • Pregnancy, peritoneal dialysis patients and dialysis prescription (dose, dialysate, anticoagulation dosing) need specialist advice.

Contraindicated Populations

Children and adolescents under 18 years

Applicable Regions

AUNZEUUSGlobal

AU: Poisons Information Centre 13 11 26. Fomepizole (Antizol, ARTG 263913), DigiFab (ARTG 203623) and danaparoid (Orgaran, ARTG 46096) are on the ARTG; argatroban is not. Check local stock. Urea and creatinine in mmol/L and µmol/L.

Global: KDIGO 2012 AKI guideline Section 5 remains the current published KDIGO guidance; local practice may vary.

Version 2Next review: 2027-09-30

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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 (2012), Section 5: Dialysis Interventions for Treatment of AKI.

What guideline is the Urgent Dialysis Indications (KDIGO) based on?

This algorithm is based on KDIGO Clinical Practice Guideline for Acute Kidney Injury (2012), Section 5: Dialysis Interventions for Treatment of AKI (DOI: 10.1038/kisup.2011.35).

What are the limitations of the Urgent Dialysis Indications (KDIGO)?

Known limitations include: Adults only. Children need paediatric nephrology and ICU advice.; Start emergency treatment first; use the hyperkalaemia, poisoning and pulmonary oedema pathways for doses.; KDIGO 2026 AKI/AKD guideline (timing, modality, dosing of kidney replacement therapy) is in preparation; update when published.; Pregnancy, peritoneal dialysis patients and dialysis prescription (dose, dialysate, anticoagulation dosing) need specialist advice.. Individual patient factors may require deviation from these recommendations.

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