From the Guidelines
Patients with acute kidney injury (AKI) should be admitted to the hospital from the emergency department if they have severe AKI, as defined by an increase in creatinine by 0.3 mg/dL within 48 hours or an increase in serum creatinine to 1.5 times baseline, or urine volume less than 0.5 mL/kg/hr for 6 hours, as this indicates a high risk of morbidity and mortality 1.
Indications for Admission
The following conditions indicate the need for hospital admission:
- Severe AKI (creatinine elevation >3 times baseline)
- Oliguria (<0.5 mL/kg/hr for >6 hours)
- Volume overload unresponsive to diuretics
- Electrolyte abnormalities (particularly hyperkalemia >6.0 mEq/L)
- Metabolic acidosis (pH <7.2)
- Uremic symptoms (encephalopathy, pericarditis, nausea/vomiting)
- AKI with underlying chronic kidney disease
Initial Management
Initial management of AKI includes:
- Stopping nephrotoxic medications
- Ensuring adequate hydration with isotonic fluids (typically normal saline at 1-2 mL/kg/hr)
- Correcting electrolyte imbalances
- Treating the underlying cause
- For hyperkalemia, administering calcium gluconate 1g IV, insulin 10 units with dextrose 50g, and sodium bicarbonate 50 mEq IV if acidotic
- Furosemide 40-80mg IV may be given for volume overload if the patient is not oliguric
Ongoing Care
Continuous renal replacement therapy or hemodialysis should be considered for refractory hyperkalemia, severe acidosis, uremic symptoms, or volume overload unresponsive to diuretics. Close monitoring of urine output, daily weights, fluid balance, and serial creatinine/BUN measurements is essential, as AKI increases mortality risk and requires prompt intervention to prevent further kidney damage 1.
From the FDA Drug Label
Parenteral therapy should be reserved for patients unable to take oral medication or for patients in emergency clinical situations. Furosemide is indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome The intravenous administration of furosemide is indicated when a rapid onset of diuresis is desired, e.g., in acute pulmonary edema.
The use of furosemide (IV) in emergency medicine for admission with Acute Kidney Injury (AKI) is not directly supported by the provided drug label. However, it does mention that furosemide is indicated for the treatment of edema associated with renal disease.
- Key points:
- Furosemide is used in emergency situations.
- It is indicated for edema associated with renal disease.
- The label does not explicitly mention AKI as an indication. Given the information provided in the label 2, furosemide (IV) may be considered in emergency situations, but its use in AKI admission should be approached with caution and considered on a case-by-case basis.
From the Research
Emergency Medicine Indication Admission AKI
- Acute kidney injury (AKI) is a common complication associated with increased mortality in hospital-admitted patients 3.
- The diagnosis of AKI relies on the ascertainment of peak increase in serum creatinine (SCr) 3, 4.
- The Kidney Disease: Improving Global Outcomes (KDIGO) defines AKI as an increase in the SCr level of 0.3 mg/dL or more within 48 hours, an SCr level increase of 1.5 times or more of the baseline level within 7 days, or a decrease in urine output to less than 0.5 mL/kg/hour for 6 hours 4, 5.
- AKI severity is determined by the degree of SCr increase or decrease in urine output 4, 6.
- Patients with AKI have increased all-cause mortality compared with those without AKI during all follow-up periods 3.
- Even minor increases in SCr, below those required for the classification of AKI, were associated with increased mortality 3.
- Management of AKI includes control of the underlying cause, achievement and maintenance of euvolemia, nutritional optimization, blood glucose control, and pharmacotherapy 4, 7.
- Emergent referral to a nephrology subspecialist is recommended for patients with stage 2 or 3 AKI; patients with stage 1 AKI and a concomitant, decompensated condition; or if the etiology of the AKI is unclear 4.
- Recognition of risk factors (e.g., older age, sepsis, hypovolemia/shock, cardiac surgery, infusion of contrast agents, diabetes mellitus, preexisting chronic kidney disease, cardiac failure, liver failure) is important for improving outcomes 7.