From the Guidelines
Urgent dialysis in acute kidney injury (AKI) is indicated when life-threatening changes in fluid, electrolyte, and acid-base balance exist, as stated in the KDIGO clinical practice guideline 1. The primary indications for urgent dialysis include:
- Severe hyperkalemia with ECG changes
- Refractory metabolic acidosis
- Volume overload causing pulmonary edema unresponsive to diuretics
- Uremic encephalopathy
- Uremic pericarditis
- Certain drug overdoses requiring removal The decision to initiate dialysis should be based on the broader clinical context, the presence of conditions that can be modified with renal replacement therapy (RRT), and trends of laboratory tests, rather than single blood urea nitrogen (BUN) and creatinine thresholds alone 1. It is essential to consider the patient's hemodynamic stability when choosing the type of dialysis, with continuous renal replacement therapy (CRRT) often preferred for hemodynamically unstable patients 1. Early nephrology consultation is crucial when AKI is diagnosed to ensure timely intervention before life-threatening complications develop. The KDIGO guideline recommends initiating RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist, and considering the broader clinical context when making the decision to start RRT 1.
From the Research
Indications for Urgent Dialysis in Acute Kidney Injury (AKI)
The following are indications for urgent dialysis in AKI:
- Refractory pulmonary edema 2
- Hyperkalemia 2, 3
- Metabolic acidosis 2, 3
- Uremic symptoms or signs 2
- Sustained anuria or persistent oliguria with progressive azotemia and a probable glomerular filtration rate < 10 ml/min 2
- To prevent uncontrolled positive fluid balance in patients with AKI 2
- Severe electrolyte disturbances 4, 5
- Fluid and electrolyte management are essential in AKI management, and dialysis may be required to achieve this 5
Specific Conditions Requiring Urgent Dialysis
Certain conditions may require urgent dialysis, including:
- Hepatorenal syndrome 4
- Cardiorenal syndrome 4
- Rhabdomyolysis 4
- Tumor lysis syndrome 4
- Septic AKI 5
- Trauma-related AKI 5
Timing and Type of Kidney Support
The timing and type of kidney support, including dialysis, are crucial in AKI management 5. The approach to renal replacement therapy (RRT) initiation in AKI is largely supported by retrospective analyses rather than prospective clinical trials 2. However, the provision of an effectively delivered standard dose of RRT in AKI is recommended 2, 6.