Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
Approach AKI by distinguishing pre‑renal, intrinsic, and post‑renal causes. Trend creatinine and urine output, perform urinalysis with microscopy, and assess hemodynamics and exposures (nephrotoxins, contrast, ACEi/ARB, NSAIDs). Point‑of‑care ultrasound helps evaluate volume status and obstruction. Anticipate complications—hyperkalemia, acidosis, and fluid overload—that drive urgent interventions.
Treatment Strategy & Disposition
Optimize perfusion with judicious fluids when hypovolemic; discontinue nephrotoxins and adjust drug dosing. Treat hyperkalemia and severe acidosis promptly; initiate renal replacement therapy for AEIOU indications. Coordinate imaging with contrast only when benefits outweigh risks, using preventive strategies. Disposition depends on trajectory and complications—ICU for refractory electrolyte/volume issues or hemodynamic instability; otherwise monitored ward care.
Epidemiology / Risk Factors
- Risk factors vary by condition and patient profile
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Baseline hematology | Abnormal counts | |
| BMP | Electrolytes/renal | Derangements |
Modality Selection
| Scenario | Preferred modality |
|---|---|
| Hemodynamic instability | CRRT |
| Raised intracranial pressure | CRRT |
| Stable ICU patient | Intermittent hemodialysis |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Balanced crystalloids | Volume expansion | Immediate | Pre-renal AKI | Fluid overload risk; ICU context |
| Hold nephrotoxins | N/A | Immediate | Stop NSAIDs, ACEi/ARBs if needed | —; ICU context |
| Loop diuretic (for overload) | Na-K-2Cl inhibition | Hours | Symptomatic volume removal | Electrolyte loss; ICU context |
Prognosis / Complications
- Prognosis depends on severity, comorbidities, and timeliness of care
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Coordinate with pharmacy for drug dosing during renal replacement. Consider regional citrate anticoagulation where expertise exists.
References
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