Indications for Emergent Dialysis in Acute Kidney Injury

Absolute Indications for Emergent Dialysis

The American Journal of Kidney Diseases recommends emergent dialysis should be initiated immediately when life-threatening changes in fluid, electrolyte, and acid-base balance exist in patients with acute kidney injury (AKI) 1
Severe hyperkalemia (high potassium levels) or rapidly rising potassium levels, especially with ECG changes, is an indication for emergent dialysis 2
Severe dysnatremia that is symptomatic or resistant to medical management is an indication for emergent dialysis 3
Severe metabolic acidosis with impaired compensation is an indication for emergent dialysis 2
Lactic acidemia that is severe and refractory to medical management is an indication for emergent dialysis 3
Pulmonary edema unresponsive to diuretics is an indication for emergent dialysis 1
Severe fluid overload causing respiratory compromise is an indication for emergent dialysis 4
Anuria or oliguria with progressive volume overload is an indication for emergent dialysis 3
Uremic encephalopathy is an indication for emergent dialysis 6
Uremic pericarditis is an indication for emergent dialysis 6
Uremic bleeding is an indication for emergent dialysis 6

Rapidly rising blood urea nitrogen (BUN) and creatinine levels is a relative indication for emergent dialysis 1
Rhabdomyolysis with progressive AKI and myoglobinuria is a relative indication for emergent dialysis 3

Earlier initiation of RRT may be associated with improved survival in trauma-associated AKI, according to Kidney International 2
Crush-related AKI often requires earlier initiation and more frequent dialysis due to higher incidence of life-threatening complications such as hyperkalemia and acidosis, according to Kidney International 3
Continuous renal replacement therapy (CRRT) is preferred over intermittent hemodialysis for patients with acute brain injury or increased intracranial pressure, as recommended by the American Journal of Kidney Diseases 7
CRRT provides more stable hemodynamics and better control of intracranial pressure, according to Kidney International 4
CRRT is recommended over standard intermittent hemodialysis for hemodynamically unstable patients requiring vasopressor support, as recommended by the American Journal of Kidney Diseases 7
CRRT allows for gentler fluid removal and better hemodynamic tolerance, according to Kidney International 8

Intermittent hemodialysis is preferred for rapid correction of severe hyperkalemia due to faster clearance, according to Kidney International 3
CRRT is preferred for hemodynamically unstable patients and those with increased intracranial pressure, as recommended by the American Journal of Kidney Diseases 7
Peritoneal dialysis may be considered in small children or when other options are not available, though rapid exchanges may be required for efficient potassium removal, according to Kidney International 3

Uncuffed non-tunneled dialysis catheters should be used for initial access in emergent situations, according to Kidney International 4
Adequate dialysis dose should be delivered: Kt/V of 3.9 per week for intermittent RRT or effluent volume of 20-25 mL/kg/h for CRRT, as recommended by the American Journal of Kidney Diseases 7 and 1
Bicarbonate-based dialysate should be used rather than lactate, especially in patients with shock, liver failure, or lactic acidemia, as recommended by the American Journal of Kidney Diseases 7
Regional citrate anticoagulation should be considered for CRRT in patients without contraindications, as recommended by the American Journal of Kidney Diseases 7 and 1