Urgent Dialysis Indications (KDIGO)

Algorithm Steps

1. ▶

   Start

   AKI or ESRD with Complications

   Consider need for renal replacement therapy

   1. ◆

      Decision

      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
      1. ⚠

         Warning

         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
         1. ◆

            Decision

            Choose RRT Modality

            HD vs CRRT

            • HD: Hemodynamically stable, need rapid correction
            • CRRT: Hemodynamically unstable, cerebral edema risk, slower correction needed
            • SLED: Hybrid approach
            1. ●

               Action

               Intermittent HD

               Standard hemodialysis

               • Duration: 3-4 hours
               • Faster solute clearance
               • Better for severe hyperkalemia, toxins
               • Requires hemodynamic stability
               1. ✓

                  Outcome

                  RRT Initiated

                  Monitor for recovery, reassess daily

            2. ●

               Action

               CRRT

               Continuous renal replacement therapy

               • CVVH, CVVHD, or CVVHDF
               • Better hemodynamic tolerance
               • Slower solute clearance
               • ICU setting required
               • Anticoagulation considerations
      2. ●

         Action

         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
      3. ●

         Action

         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
      4. ●

         Action

         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
      5. ●

         Action

         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
      6. ●

         Action

         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
      7. ◆

         Decision

         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
         1. ●

            Action

            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
            1. ✓

               Outcome

               Renal Recovery

               Continue monitoring, avoid future nephrotoxins

         2. ●

            Action

            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)