Synopsis
Identify life-threatening electrolyte, acid–base, fluid and uraemic complications of acute kidney injury, begin immediate medical treatment, and obtain renal replacement therapy before physiology becomes irreversible.
- Dialysis in AKI is triggered by dangerous physiology and the whole clinical trajectory, not by a single creatinine, urea, potassium value or AKI stage in isolation.
- NICE indications for immediate renal replacement referral, when not responding to medical management, are hyperkalaemia, metabolic acidosis, uraemic symptoms or complications, fluid overload and pulmonary oedema.
- Severe hyperkalaemia or characteristic ECG change is an arrest risk: protect the myocardium, shift potassium into cells, remove potassium from the body and call renal or critical care concurrently.
Key red flags
Potassium at or above 6.5 mmol/L is severe under UKKA guidance, and any compatible ECG toxicity increases urgency. Peaked T waves, PR prolongation, P-wave loss, QRS widening, sine-wave change, bradyarrhythmia or ventricular arrhythmia can evolve rapidly.
Investigation priorities
Confirm the electrolyte threat and detect cardiac membrane toxicity requiring immediate calcium.
Management branches
Severe hyperkalaemia, respiratory failure, profound acidaemia, pericardial compromise or altered consciousness is present.
- 1. Use ABCDE, call senior renal and critical-care help, obtain continuous monitoring and place reliable intravenous access while sending urgent bloods and gas.
- 2. Deliver complication-specific immediate care: cardiac calcium for hyperkalaemic ECG toxicity, protocol insulin–glucose, oxygen or non-invasive ventilation, and treatment of shock or sepsis.
Key medicines
Intravenous calcium for hyperkalaemic ECG toxicityFollow the current UKKA and local emergency algorithm: an equivalent 6.8 mmol calcium dose is 30 mL calcium gluconate 10% over 10 minutes, or 10 mL calcium chloride 10% over 5 minutes in resuscitation settings.
Soluble insulin with intravenous glucoseUKKA recommends 10 units soluble insulin with 25 g glucose intravenously for severe hyperkalaemia; use the approved prescription and add the specified glucose infusion when pretreatment glucose is below 7 mmol/L.