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RRT Initiation in AKI Algorithm

RRT Initiation in AKI Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Urology and Nephrology, Related


Patient with
Acute Kidney Injury
Stage 1 or 2
AKI?
Discontinue
nephrotoxic agents
when possible
YES
Does
patient have
≥ 1 indication
for renal
replacement
therapy?
NO
Acute Kidney Injury defined as:
Increase in SCr by ≥0.3 mg/dL within 48 hours; or
Increase in SCr to ≥1.5 times baseline, which is known or presumed to
have occurred within the prior 7 days; or
Urine volume < 0.5mL/kg/h for 6 hrs
Stage Serum creatinine Urine output
1 1.5-1.9 times baseline OR
≥0.3 mg/dl increase OR GFR
decrease ≥25%
< 0.5 mL/kg/h for 6-12 hours
2 2.0-2.9 times baseline OR
GFR decrease ≥50%
< 0.5 mL/kg/h for ≥ 12 hours
3 3.0 times baseline OR
Increase in serum creatinine to
4.0 mg/dl OR GFR decrease
≥75%
< 0.3 mL/kg/h for ≥ 24 hours
OR Anuria for ≥ 12 hours

Indications for renal replacement therapy
Refractory hyperkalemia (e.g., K+> 6.5 mmol/l, rapidly increasing, or
cardiac toxicity)
Refractory acidemia and metabolic acidosis (e.g, pH ≤7.2 despite normal
or low arterial pCO2)
Fluid overload (e.g., secondary respiratory distress, diuretic resistant,
increase in weight by 10-15% from baseline)
Uremia (e.g., bleeding, asterixis, encephalopathy, pericarditis)
Note: Renal replacement therapy may be initiated as continuous veno-venous
hemofiltration (CVVH) or intermittent hemodialysis (IHD). Trials data shows
that there is no significant difference in terms of patient survival rates.
It is recommended to consult Nephrology regarding which RRT modality is
best to initiate.
Does pt have
relative
contraindication
to RRT?
Treat as indicatedYES
Relative contraindications for
RRT:
Futile prognosis
Patient receiving hospice
care
High likelihood renal
function will not recover in
patient who is not candidate
for long-term dialysis
Patient with hepatorenal
syndrome (HRS) with
cirrhosis, high MELD score
and is not a liver transplant
candidate
Obtain relevant labs,
imaging and tests to
investigate cause of AKI
Tests and imaging to consider when investigating AKI:
Labs
Urinalysis
Basic metabolic panel , magnesium, phosphorus
Urine sodium, urine urea and urine creatinine
Urine protein to creatinine ratio
Urine microscopy and culture
Ultrasound of kidney and urinary tract if cause of AKI is unknown or
obstruction suspected
Correct hypovolemia/
hypotension
(i.e., administer fluids
as necessary)
Treat complications of
AKI
(e.g., hyperkalemia,
pulmonary edema)
Resolution
of renal
insufficiency?
NO
NO
Treat as clinically
indicated
YES
Consider initiating renal
replacement therapy if
patient has indication for
RRT
NO
Renal Replacement Therapy Initiation in Acute Kidney Injury
Document
cause for
Stage 3 AKI
YES
Initiate renal
replacement
therapy
Exclusion criteria: Patients with non-native kidneys
Last reviewed/revised 08/2017
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org