From the Guidelines
Dialysis should be initiated emergently in patients with acute kidney injury when life-threatening changes in fluid, electrolyte, and acid-base balance exist, as recommended by the KDIGO clinical practice guideline for acute kidney injury 1.
Indications for Dialysis
The following are indications for dialysis:
- Severe hyperkalemia (potassium >6.5 mEq/L with ECG changes)
- Severe metabolic acidosis (pH <7.1)
- Uremic symptoms (encephalopathy, pericarditis, bleeding)
- Volume overload unresponsive to diuretics
- Certain drug overdoses (lithium, salicylates, methanol, ethylene glycol)
Decision to Initiate Dialysis
The decision to initiate dialysis should be based on the patient's clinical condition rather than absolute laboratory values alone, considering the broader clinical context, the presence of conditions that can be modified with RRT, and trends of laboratory tests—rather than single BUN and creatinine thresholds alone 1.
Management of Hyperkalemia
For hyperkalemia, medical management should be tried first with calcium gluconate, insulin, sodium bicarbonate, and potassium binders before proceeding to dialysis.
Role of Dialysis
Dialysis works by removing toxins, correcting electrolyte imbalances, and removing excess fluid through diffusion, convection, and ultrafiltration across a semipermeable membrane, providing life-saving support when kidneys cannot maintain homeostasis.
Additional Considerations
Other considerations for initiating dialysis include persistent hyperkalemia, severe metabolic acidosis, volume overload unresponsive to diuretic therapy, and overt uremic symptoms, including pericarditis and severe encephalopathy, as recommended by the consensus conference on the management of tumor lysis syndrome 1.
From the Research
Acute Indication for Dialysis
The decision to initiate dialysis in patients with acute kidney injury (AKI) is based on several factors, including the severity of the injury, the presence of electrolyte imbalances, and the patient's overall clinical condition. Some of the key indications for dialysis in AKI include:
- Hyperkalemia, which can be life-threatening if left untreated 2
- Metabolic acidosis, which can lead to serious complications if not promptly addressed 2, 3
- Volume overload, which can cause respiratory and cardiac complications 4, 5
- Uremia, which can lead to neurological and gastrointestinal symptoms 4, 6
- Electrolyte imbalances, such as hypocalcemia and hyperphosphatemia, which can cause muscle weakness, cramps, and other symptoms 2, 3
Dialysis Modalities
The choice of dialysis modality depends on the patient's clinical condition, the severity of the AKI, and the availability of resources. Some of the common dialysis modalities used in AKI include:
- Continuous renal replacement therapy (CRRT), which is often used in critically ill patients with hemodynamic instability 4, 5
- Intermittent hemodialysis (IHD), which is commonly used in patients with AKI who are hemodynamically stable 3, 6
- Peritoneal dialysis, which can be used in patients with AKI who have a functioning peritoneal membrane 4, 5
Management of AKI
The management of AKI involves a multidisciplinary approach, including:
- Identification of the underlying cause of the AKI and treatment of the underlying condition 3, 6
- Fluid management, including fluid resuscitation and diuretic therapy 4, 5
- Electrolyte management, including correction of electrolyte imbalances and monitoring of electrolyte levels 2, 3
- Nutritional support, including optimization of nutritional status and glycemic control 6
- Pharmacological management, including adjustment of medications according to renal function and avoidance of nephrotoxic medications 6