From the Guidelines
Urgent dialysis in acute kidney injury (AKI) is indicated for life-threatening conditions, including severe metabolic acidosis, electrolyte abnormalities, intoxication with dialyzable toxins, fluid overload, and uremic complications, as outlined in the KDIGO guideline 1. These conditions can be summarized by the mnemonic AEIOU: Acidosis (severe metabolic acidosis with pH <7.2), Electrolyte abnormalities (particularly hyperkalemia >6.5 mEq/L or rapidly rising potassium), Intoxication with dialyzable toxins (such as lithium, salicylates, methanol, ethylene glycol), Overload of fluid causing pulmonary edema unresponsive to diuretics, and Uremic complications (including pericarditis, encephalopathy, bleeding, or severe nausea/vomiting). The decision to initiate dialysis should be individualized based on the patient's clinical status rather than absolute laboratory values alone, as suggested by the KDIGO conference 1. Some key points to consider when deciding to initiate urgent dialysis include:
- Severe metabolic acidosis with pH <7.2
- Electrolyte abnormalities, such as hyperkalemia >6.5 mEq/L or rapidly rising potassium
- Intoxication with dialyzable toxins, such as lithium, salicylates, methanol, or ethylene glycol
- Fluid overload causing pulmonary edema unresponsive to diuretics
- Uremic complications, including pericarditis, encephalopathy, bleeding, or severe nausea/vomiting Medical management should be attempted first for conditions like hyperkalemia and metabolic acidosis, but dialysis becomes necessary when these measures fail or the condition is severe, as recommended by the KDIGO guideline 1. The choice of dialysis modality should be tailored to the patient's clinical status, with continuous renal replacement therapy (CRRT) being more physiologically appropriate for hemodynamically unstable patients, as suggested by the KDIGO conference 1. Ultimately, the decision to initiate urgent dialysis should be based on the patient's individual clinical status and the presence of life-threatening conditions that require immediate intervention, as outlined in the KDIGO guideline 1 and conference 1.
From the Research
Indications for Urgent Dialysis in Acute Kidney Injury (AKI)
The following are indications for urgent dialysis in a patient with acute kidney injury (AKI):
- Refractory pulmonary edema 2
- Hyperkalemia or metabolic acidosis 2, 3, 4, 5
- Uremic symptoms or signs 2
- Sustained anuria, 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
- Life-threatening cardiac conduction disturbances and neuromuscular dysfunction due to severe hyperkalemia 6, 3, 4
Hyperkalemia as an Indication for Urgent Dialysis
Hyperkalemia is a significant indication for urgent dialysis in AKI patients. It can lead to life-threatening cardiac conduction disturbances and neuromuscular dysfunction 6, 3, 4. The treatment of hyperkalemia includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 4. Dialysis is the most efficient means to enable removal of excess potassium 4.
Other Indications for Urgent Dialysis
Other indications for urgent dialysis in AKI patients include refractory pulmonary edema, metabolic acidosis, uremic symptoms or signs, and sustained anuria or oliguria with progressive azotemia 2. These conditions can lead to severe complications and even death if left untreated. Urgent dialysis can help alleviate these conditions and improve patient outcomes.