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 |
Who Needs Prophylaxis
| Group | Action |
|---|---|
| eGFR markedly reduced or AKI | Hydration and risk benefit discussion |
| Stable CKD with moderate eGFR | Consider hydration based on context |
| Normal kidney function | No routine prophylaxis |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Balanced crystalloids | Volume expansion | Immediate | Pre-renal AKI | Fluid overload risk |
| Hold nephrotoxins | N/A | Immediate | Stop NSAIDs, ACEi/ARBs if needed | — |
| Loop diuretic (for overload) | Na-K-2Cl inhibition | Hours | Symptomatic volume removal | Electrolyte loss |
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
Sodium bicarbonate and N acetylcysteine are not consistently beneficial. Coordinate with nephrology for very high risk cases.