Acute Kidney Injury
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
N17.9
DESCRIPTION
Kidney injury may be due to a combination of factors.
Acute kidney injury (AKI) is defined as any of the following:
- Increase in serum creatinine by ≥26.5 μmol/L within 48 hours; or
- Increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or
- Urine volume <0.5 mL/kg/hour for 6 hours.
GENERAL MEASURES
A detailed history and good clinical examination are necessary to identify potentially reversible causes. Ensure volume status, perfusion and oxygenation. Monitor serum creatinine, potassium and urine output.
If radiocontrast diagnostic procedures are required, see Diagnostic contrast agents and related substances.
Diagnostic contrast agents and related substances.
Avoid any nephrotoxic medicines e.g. NSAIDs, aminoglycosides. Check all medicines for possible dose adjustments.
MEDICINE TREATMENT
Fluid overload
In patients with fluid overload where dialysis is not immediately available, a short trial of furosemide in consultation with a specialist may be appropriate.
Acute dialysis
Discuss all cases with the referral centre.
Common indications for acute dialysis include:
- Pulmonary oedema refractory to medical therapy.
- Severe metabolic acidosis (pH < 7.15) refractory to medical therapy
- Severe hyperkalaemia (>7 mmol/L) refractory to medical therapy
- Uraemic complications, e.g. pericarditis, encephalopathy and bleeding.
- Medication overdose if due to dialysable toxin. See Exposure to poisonous substances.
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Note:
HIV infection is not a contra-indication for acute dialysis.
Both haemodialysis and peritoneal dialysis are acceptable modalities of therapy in the acute setting.
Peritoneal dialysis effluent is potentially infectious when used in patients with HIV and viral hepatitis.
Hyperkalaemia
Serum K+ >6.0 mmol/L.
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Emergency measures
Calcium gluconate 10%, slow IV bolus, 10 mL over 10 minutes. Subsequent doses should be considered if ECG changes persist after 5 minutes or recur.
AND
- Dextrose 50%, IV bolus, 100 mL followed by soluble insulin, 10 units administered as a push over 5 minutes.
- Monitor blood glucose levels hourly up to 6 hours post-insulin administration.
AND
- Salbutamol nebulisation, 10-20 mg.
- Dilute Salbutamol 0.5% (5 mg/mL), solution, 1 mL (5 mg) salbutamol 0.5% solution made up to 4 mL with sodium chloride 0.9%.
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These are short-term measures - patients should be dialysed or if this is not feasible:
- Sodium polystyrene sulfonate, oral, 15 g with 15 mL lactulose, 6 hourly.
OR
- Sodium polystyrene sulfonate, rectal, 30–60 g as an enema.
- After 8 hours, wash out with phosphate enema.
Note:
Rectal administration is less effective.
Glycaemic control
Close glycaemic control can reduce the incidence and severity of AKI.
See Diabetes mellitus.
Some patients do not recover kidney function and should be treated as CKD.
(See Chronic kidney disease)
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_17 October 2024
Chapter 7 Nephrology/Urological Disorders_7.1 Nephrology Disorders_7.1.4 Acute Kidney Injury