Acute kidney injury in the ICU: KDIGO staging, a structured work-up, rhabdomyolysis, contrast-associated AKI, practical renal drug dosing, and hepatorenal and cardiorenal syndromes, with Indian causes (tropical infections, snakebite, indigenous medicines).
6 topics
- 01
KDIGO definition and staging
Define and stage AKI with creatinine and urine output, and recognise who needs urgent nephrology/ICU input.
5 stepsAlgorithmNew - 02
AKI work-up
A structured bedside approach to the cause: pre-renal, intrinsic, post-renal, with urine tests, ultrasound and the furosemide stress test.
7 stepsAlgorithm1 dosesNew - 03
Rhabdomyolysis
Recognise rhabdomyolysis, give early aggressive fluids, manage hyperkalaemia and compartment syndrome, and know when to start RRT.
7 stepsAlgorithm1 dosesNew - 04
Contrast-associated AKI
Assess risk, avoid unnecessary withholding of contrast, and use isotonic fluids for high-risk patients.
7 steps1 dosesNew - 05
Drug dosing in AKI
Estimate kidney function correctly in unstable AKI and adjust common ICU drugs, with loading doses unchanged.
6 stepsNew - 06
Hepatorenal and cardiorenal syndromes
Diagnose HRS-AKI by ICA-ADQI 2024 criteria and treat with terlipressin and albumin; manage cardiorenal syndrome by decongestion.
7 stepsAlgorithm3 dosesNew
Drugs in this module
Doses written for this module's context. The same drug may read differently in another module.
Furosemide
Loop diuretic
Furosemide
Loop diuretic
- Indications
- Fluid overload in AKI; furosemide stress test; cardiorenal congestion
- Adult dose
- Stress test: 1 mg/kg IV (1.5 mg/kg if already on loop diuretics). Congestion: IV dose = 1-2.5x the total daily oral dose (start 20-40 mg IV if diuretic-naive), repeat/double at 6 h if natriuresis inadequate; infusion 5-20 mg/h.
- Preparation (India)
- 20 mg/2 mL ampoules; infusion 100 mg in 50 mL NS (2 mg/mL) or undiluted 10 mg/mL.
- Renal / hepatic
- Higher doses needed in AKI/CKD; ototoxicity with rapid high-dose bolus (> 4 mg/min).
- Cautions
- Do not use to 'treat' oliguric AKI without fluid overload (KDIGO).
- Monitoring
- Urine output at 2 and 6 h, spot urine sodium (> 50-70 mmol/L at 2 h = adequate response), K, Mg, creatinine.
Crystalloid (0.9% saline or balanced)
Isotonic crystalloid
Crystalloid (0.9% saline or balanced)
Isotonic crystalloid
- Indications
- Rhabdomyolysis; prevention of contrast AKI in high-risk patients
- Adult dose
- Rhabdomyolysis: 1-2 L/h initially (if not overloaded), then titrate to urine output 200-300 mL/h until CK < 5,000 U/L and urine clear. Contrast prophylaxis (high risk, not overloaded): 1 mL/kg/h for 6-12 h before and after.
- Preparation (India)
- 500 mL/1 L bags; RL also acceptable.
- Cautions
- Stop if oliguric/anuric with overload; RRT instead.
Terlipressin
Vasopressin V1 analogue
Terlipressin
Vasopressin V1 analogue
- Indications
- Hepatorenal syndrome-AKI; variceal bleeding
- Adult dose
- HRS-AKI: 0.5-1 mg IV every 4-6 h, or continuous infusion 2 mg/24 h (fewer side effects); if creatinine falls < 25% after 48-72 h, increase stepwise to max 12 mg/day. Continue until creatinine < 1.5 mg/dL or 14 days.
- Preparation (India)
- 1 mg vials (Indian generics widely available); infusion 2 mg in 50 mL NS over 24 h.
- Cautions
- Avoid if SpO2 < 90%, volume overload, ischaemic heart/peripheral vascular disease, ACLF grade 3, or creatinine ≥ 5 mg/dL. Watch for respiratory failure (CONFIRM), abdominal pain, digital ischaemia, hyponatraemia.
- Monitoring
- SpO2 and fluid status daily, creatinine, ECG.
Human albumin 20%
Colloid
Human albumin 20%
Colloid
- Indications
- HRS-AKI diagnosis and treatment; large-volume paracentesis; SBP
- Adult dose
- AKI in cirrhosis (diagnostic challenge): 1 g/kg (max 100 g) on day 1 after stopping diuretics. HRS-AKI with terlipressin: 20-40 g/day.
- Preparation (India)
- 20% 100 mL (20 g) vials; 5% also available.
- Cautions
- Pulmonary oedema: reduce/stop if overload (CONFIRM deaths from respiratory failure).