Most decisions about when to start renal replacement therapy in acute kidney injury allow time. A few do not: hyperkalaemia or severe metabolic acidosis that does not respond to medical treatment, fluid overload with pulmonary oedema despite diuretics, uraemic complications such as pericarditis or encephalopathy, and certain dialysable poisons.
In the absence of these, earlier trials have not shown benefit from starting pre-emptively.
- Treat hyperkalaemia medically while arranging dialysis if it is refractory.
- Start dialysis for pulmonary oedema that does not respond to diuretics.
- Look for uraemic pericarditis or encephalopathy, which are urgent indications.
- Consider dialysable toxins such as lithium, methanol or salicylate.
Why it matters
Knowing the true emergencies keeps the start of dialysis from being either delayed or premature.
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