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peds.aki.v1

Pediatric acute kidney injury (AKI)

pediatricsacutepediatricneonatal
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Apply pediatric KDIGO (Cr rise ≥0.3 mg/dL within 48 h OR ≥1.5× baseline within 7 d OR oliguria <0.5 mL/kg/h × 6-12 h); stage 1/2/3 (KDIGO 2012 AKI; KDIGO 2024)

Inputs
2
Actions
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Advance rule
Set
Advance when

AKI confirmed + staged (KDIGO 2012 AKI; KDIGO 2024)

Patient inputs (19)

Reference Cr varies by age; neonatal physiology differs (Schwartz 2009; AWAKEN Jetton Neonatology 2017; AAP 2022)

All fluid + drug + dialysis dosing weight-based (KDIGO 2012 AKI; AAP 2022)

Pre-renal vs intrinsic; volume status (KDIGO 2012 AKI; AAP 2022)

Tachycardia from hypovolemia (KDIGO 2012 AKI; AAP 2022)

KDIGO oliguria criterion (KDIGO 2012 AKI; KDIGO 2024)

Diarrhea (HUS), strep pharyngitis (PSGN), drug, sepsis (KDIGO 2012 AKI; IPNA 2016 HUS; AAP 2022)

NSAID, aminoglycoside, vancomycin, contrast, ACEi/ARB (KDIGO 2012 AKI; KDIGO 2024; AAP 2022)

Bedside Schwartz eGFR uses height (Schwartz 2009)

KDIGO Cr-based staging (KDIGO 2012 AKI; KDIGO 2024)

K+, Na, Ca, phos, bicarb; rescue if K+ critical (KDIGO 2012 AKI; AAP 2022)

Casts (muddy brown ATN, RBC GN, WBC AIN) (KDIGO 2012 AKI)

Pre-renal vs intrinsic (FeNa <1 vs >2) (KDIGO 2012 AKI)

HUS — schistocytes + thrombocytopenia + AKI (IPNA 2016 HUS; KDIGO 2012 AKI)

Obstruction, stones, congenital anomalies, hydro (KDIGO 2012 AKI; AAP 2022)

Post-streptococcal GN (KDIGO 2012 AKI; AAP 2022)

Low C3 → MPGN, post-strep, lupus, atypical HUS (KDIGO 2012 AKI; IPNA 2016 HUS)

Lupus nephritis (KDIGO 2012 AKI)

STEC-HUS (IPNA 2016 HUS)

KDIGO % rise; if unknown back-calculate via Schwartz from height (Schwartz 2009; KDIGO 2012 AKI)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (13)

13 need judgement
  • informationallife_threateningsevere_hyperkalemia_with_ecg_changes — KDIGO 2012
    K+ ≥6.5 with peaked T waves, widened QRS, sine-wave (KDIGO 2012 AKI; AAP 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningkdigo_stage_3_with_rrt_indication
    KDIGO peds stage 3 (Cr >= 3x baseline OR Cr >= 4.0 mg/dL OR UOP < 0.3 mL/kg/h x 24 h OR anuria x 12 h OR eGFR < 35 mL/min/1.73 m^2) with one or more classical RRT indications: refractory hyperkalemia (K+ > 6.5 despite medical management), refractory acidosis (pH < 7.15 despite bicarb), volume overload > 15% admit weight with respiratory compromise, uremic encephalopathy or pericarditis, dialyzable toxin (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningatypical_hus_features
    Microangiopathic hemolytic anemia (schistocytes + thrombocytopenia + elevated LDH + low haptoglobin) + AKI WITHOUT bloody diarrhea — atypical HUS (aHUS) until excluded; complement-pathway defect (factor H/I deficiency, MCP/CD46, CFB/C3 gain-of-function); requires eculizumab + meningococcal vaccination + complement genetic evaluation (IPNA 2016 HUS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsepsis_aki_in_peds
    Concurrent sepsis + AKI in a child — sepsis-AKI is the most common etiology in PICU (~50-60% of septic peds patients per AWARE Kaddourah NEJM 2017); presents with oliguria + rising Cr after fluid resuscitation; furosemide stress test predicts progression to KDIGO stage 3; routes to id.sepsis.peds.v1 with carryover state (KDIGO 2012 AKI; AWARE Kaddourah NEJM 2017; SSC peds 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevolume_overload_with_respiratory_distress — KDIGO 2012
    Fluid overload >10% of admit weight + respiratory distress (AWARE Kaddourah NEJM 2017; KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereuremic_encephalopathy_or_pericarditis — KDIGO 2012
    Confusion, asterixis, pericardial rub in setting of high BUN (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereshiga_toxin_hus — KDIGO 2012
    Bloody diarrhea + AKI + hemolytic anemia + thrombocytopenia (IPNA 2016 HUS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereatypical_hus_aHUS — KDIGO 2012
    AKI + microangiopathic hemolysis + thrombocytopenia without diarrhea OR genetic complement defect (IPNA 2016 HUS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_progressive_glomerulonephritis_peds — KDIGO 2012
    Glomerular pattern + rapidly rising Cr + high-titer ANCA / anti-GBM / lupus serology (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereobstructive_uropathy — KDIGO 2012
    Hydronephrosis on US + AKI (KDIGO 2012 AKI; AAP 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestec_hus_features
    Microangiopathic hemolytic anemia (schistocytes + thrombocytopenia + elevated LDH + low haptoglobin) + AKI + bloody diarrhea — Shiga-toxin-producing E. coli (STEC) HUS; supportive care only; AVOID empiric antibiotics (may increase Shiga-toxin release and worsen HUS); plasmapheresis controversial (IPNA 2016 HUS; AAP 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereglomerulonephritis_features
    Proteinuria (UACR > 300 mg/g OR dipstick >= 2+) + hematuria (>= 5 RBC/hpf OR RBC casts) + hypertension (BP >= 95th percentile + 12 mmHg) in a child with AKI — glomerulonephritis pattern (PSGN / IgA / lupus / ANCA / anti-GBM / MPGN); requires renal biopsy planning + pediatric nephrology + rheumatology if serology-positive (KDIGO 2012 AKI; AAP 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenephrotoxin_attributable_aki
    Active AKI in a child with concurrent exposure to >= 1 nephrotoxic medication (NSAIDs, aminoglycosides, vancomycin, iodinated contrast, chemotherapy, amphotericin, tacrolimus, cisplatin, methotrexate) — immediate discontinuation + substitution per NINJA stewardship + pharmacy review of all renal-dosed meds (KDIGO 2012 AKI; KDIGO 2024; NINJA Goldstein Pediatrics 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Pediatric AKI — fluid resuscitation, nephrotoxin removal, etiology-directed (KDIGO 2012 AKI; KDIGO 2024; AAP 2022)
axis: peds_aki_resuscitation_and_etiology
Selected axis "Pediatric AKI — fluid resuscitation, nephrotoxin removal, etiology-directed (KDIGO 2012 AKI; KDIGO 2024; AAP 2022)" by default fallback (first axis)
  • normal saline / lactated Ringer's 10-20 mL/kg
    first line
    crystalloid_isotonic
    10-20 mL/kg over 30-60 min • IV • reassess after each bolus
    triggers: hypovolemic_AKI
    Pre-renal AKI — judicious fluid; reassess for fluid overload (KDIGO 2012 AKI; AAP 2022)
    rxcui 9863
  • furosemide
    add on
    loop_diuretic
    1-2 mg/kg IV • IV • q6-12 h titrated
    triggers: volume_overload_with_responsive_kidneys
    For volume control only; does not improve mortality (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
    rxcui 4603
  • calcium_gluconate
    rescue
    electrolyte
    100 mg/kg IV (max 3 g) over 5-10 min • IV • single dose; repeat if persistent ECG changes
    triggers: hyperkalemia_with_ECG_changes
    Membrane stabilization; does not lower K+ (KDIGO 2012 AKI; AAP 2022)
    rxcui 1908
  • insulin_regular
    rescue
    short_acting_insulin
    0.1 U/kg IV with dextrose 0.5 g/kg • IV • single, may repeat
    triggers: hyperkalemia
    Drives K+ intracellular (KDIGO 2012 AKI; AAP 2022)
    rxcui 253182
  • albuterol
    add on
    short_acting_beta2_agonist
    2.5-5 mg nebulised • inhaled • q20 min × 3
    triggers: hyperkalemia
    Drives K+ intracellular; tachycardia caution (KDIGO 2012 AKI; AAP 2022)
    rxcui 435
  • sodium_polystyrene_sulfonate
    add on
    cation_exchange_resin
    1 g/kg PO/PR • PO/PR • q4-6 h
    triggers: hyperkalemia_outside_acute
    Off-label in peds; bowel necrosis risk in neonates / post-op (AAP 2022)
    rxcui 56512
  • sodium_bicarbonate
    rescue
    alkalinizing_agent
    1-2 mEq/kg IV slow • IV • single
    triggers: severe_metabolic_acidosis_pH_lt_7_15, hyperkalemia_with_acidosis
    Reserve for severe acidosis or hyperkalemia adjunct (KDIGO 2012 AKI; AAP 2022)
    rxcui 36676
  • eculizumab
    first line
    C5_complement_inhibitor
    600-900 mg/dose × 4-6 doses (per weight band) • IV • weekly initial then maintenance
    triggers: atypical_HUS_aHUS
    IPNA 2016 HUS — first-line aHUS; mandatory meningococcal vaccination
    rxcui 591781
  • ceftriaxone
    first line
    3rd_gen_cephalosporin
    50-100 mg/kg/day IV (max 2 g/day) • IV • daily
    triggers: pyelonephritis_with_AKI, sepsis_AKI
    IDSA peds UTI / sepsis (AAP 2022)
    rxcui 2193

outpatient playbook — drug actions (6)

  1. 1. ACEi or ARB if proteinuria persistent (UACR > 30 mg/g at 6 mo) AND BP elevated
    lisinopril 0.1 mg/kg PO daily (max 10 mg starting; titrate to 20-40 mg/day) OR losartan 0.7 mg/kg PO daily (max 50 mg) • PO • daily
    trigger: Persistent proteinuria + HTN at >= 6 mo post-AKI
    KDIGO 2024 — proteinuria + HTN is the principal CKD-progression lever in children; ACEi/ARB monotherapy is first-line (Flynn AAP 2017)
  2. 2. iron supplementation if iron-deficient AND eGFR < 60
    ferrous sulfate 3-6 mg elemental iron/kg/day PO divided BID-TID • PO • BID-TID
    trigger: Ferritin < 100 OR TSAT < 20% + eGFR < 60
    CKD anemia management (KDIGO 2024)
  3. 3. cholecalciferol (vit D3) if 25-OH-D < 30 ng/mL
    600-2000 IU/day per age + deficiency severity • PO • daily
    trigger: Vit D deficiency + eGFR < 60
    CKD-MBD (KDIGO 2017)
  4. 4. phosphate binder if hyperphosphatemia + eGFR < 30
    calcium carbonate 30-65 mg/kg/dose with meals (max 1500 mg elemental Ca/day); switch to non-Ca binder (sevelamer) if hypercalcemia • PO • with meals
    trigger: Phosphate > age-appropriate upper limit + eGFR < 30
    CKD-MBD prevention (KDIGO 2017)
  5. 5. PCV20 vaccination if CKD stage 3-5 (one-time)
    PCV20 0.5 mL IM • IM • one-time
    trigger: CKD stage 3-5 + ACIP eligibility
    ACIP 2024 — CKD is a high-risk condition for invasive pneumococcal disease
  6. 6. meningococcal vaccination if on chronic eculizumab maintenance (aHUS)
    MenACWY + MenB per ACIP schedule • IM • per ACIP schedule
    trigger: Eculizumab therapy ongoing
    IPNA 2016 HUS; ACIP 2024 — eculizumab patients are at ~1,000-2,000x baseline meningococcal-disease risk

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Creatinine rise meeting KDIGO criteria in a child (KDIGO 2012 AKI; KDIGO 2024); Oliguria <0.5 mL/kg/h × 6-12 h or anuria in a child (KDIGO 2012 AKI; KDIGO 2024); Edema or volume overload in a child (KDIGO 2012 AKI; AWARE Kaddourah NEJM 2017).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric acute kidney injury (AKI)** (peds.aki.v1).
Phenotype framing: Pre-renal / intrinsic (ATN, drug, sepsis, GN — PSGN/IgA/lupus/HUS, AIN) / post-renal (obstruction) (KDIGO 2012 AKI; IPNA 2016 HUS; AAP 2022)
Scope: Apply pediatric KDIGO (Cr rise ≥0.3 mg/dL within 48 h OR ≥1.5× baseline within 7 d OR oliguria <0.5 mL/kg/h × 6-12 h); stage 1/2/3 (KDIGO 2012 AKI; KDIGO 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric AKI — fluid resuscitation, nephrotoxin removal, etiology-directed (KDIGO 2012 AKI; KDIGO 2024; AAP 2022)**.
1. normal saline / lactated Ringer's 10-20 mL/kg 10-20 mL/kg over 30-60 min IV reassess after each bolus (crystalloid_isotonic, first line) — Pre-renal AKI — judicious fluid; reassess for fluid overload (KDIGO 2012 AKI; AAP 2022)
2. furosemide 1-2 mg/kg IV IV q6-12 h titrated (loop_diuretic, add on) — For volume control only; does not improve mortality (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
3. calcium_gluconate 100 mg/kg IV (max 3 g) over 5-10 min IV single dose; repeat if persistent ECG changes (electrolyte, rescue) — Membrane stabilization; does not lower K+ (KDIGO 2012 AKI; AAP 2022)
4. insulin_regular 0.1 U/kg IV with dextrose 0.5 g/kg IV single, may repeat (short_acting_insulin, rescue) — Drives K+ intracellular (KDIGO 2012 AKI; AAP 2022)
5. albuterol 2.5-5 mg nebulised inhaled q20 min × 3 (short_acting_beta2_agonist, add on) — Drives K+ intracellular; tachycardia caution (KDIGO 2012 AKI; AAP 2022)
6. sodium_polystyrene_sulfonate 1 g/kg PO/PR PO/PR q4-6 h (cation_exchange_resin, add on) — Off-label in peds; bowel necrosis risk in neonates / post-op (AAP 2022)
7. sodium_bicarbonate 1-2 mEq/kg IV slow IV single (alkalinizing_agent, rescue) — Reserve for severe acidosis or hyperkalemia adjunct (KDIGO 2012 AKI; AAP 2022)
8. eculizumab 600-900 mg/dose × 4-6 doses (per weight band) IV weekly initial then maintenance (C5_complement_inhibitor, first line) — IPNA 2016 HUS — first-line aHUS; mandatory meningococcal vaccination
9. ceftriaxone 50-100 mg/kg/day IV (max 2 g/day) IV daily (3rd_gen_cephalosporin, first line) — IDSA peds UTI / sepsis (AAP 2022)

Setting playbook (outpatient) — Post-AKI pediatric nephrology follow-up — confirm renal recovery (Cr trajectory + Schwartz eGFR), screen for CKD progression (BP + UACR), reinforce nephrotoxin avoidance (NINJA stewardship), update vaccinations (PCV20 + influenza + meningococcal if post-eculizumab), track growth + nutrition (CKD-MBD + anemia screen if eGFR < 60), and maintain long-term BP + proteinuria monitoring (KDIGO 2012 AKI; KDIGO 2024; AWARE Kaddourah NEJM 2017; NINJA Goldstein Pediatrics 2016; Flynn AAP 2017 hypertension guideline)
10. ACEi or ARB if proteinuria persistent (UACR > 30 mg/g at 6 mo) AND BP elevated lisinopril 0.1 mg/kg PO daily (max 10 mg starting; titrate to 20-40 mg/day) OR losartan 0.7 mg/kg PO daily (max 50 mg) PO daily — Persistent proteinuria + HTN at >= 6 mo post-AKI (KDIGO 2024 — proteinuria + HTN is the principal CKD-progression lever in children; ACEi/ARB monotherapy is first-line (Flynn AAP 2017))
11. iron supplementation if iron-deficient AND eGFR < 60 ferrous sulfate 3-6 mg elemental iron/kg/day PO divided BID-TID PO BID-TID — Ferritin < 100 OR TSAT < 20% + eGFR < 60 (CKD anemia management (KDIGO 2024))
12. cholecalciferol (vit D3) if 25-OH-D < 30 ng/mL 600-2000 IU/day per age + deficiency severity PO daily — Vit D deficiency + eGFR < 60 (CKD-MBD (KDIGO 2017))
13. phosphate binder if hyperphosphatemia + eGFR < 30 calcium carbonate 30-65 mg/kg/dose with meals (max 1500 mg elemental Ca/day); switch to non-Ca binder (sevelamer) if hypercalcemia PO with meals — Phosphate > age-appropriate upper limit + eGFR < 30 (CKD-MBD prevention (KDIGO 2017))
14. PCV20 vaccination if CKD stage 3-5 (one-time) PCV20 0.5 mL IM IM one-time — CKD stage 3-5 + ACIP eligibility (ACIP 2024 — CKD is a high-risk condition for invasive pneumococcal disease)
15. meningococcal vaccination if on chronic eculizumab maintenance (aHUS) MenACWY + MenB per ACIP schedule IM per ACIP schedule — Eculizumab therapy ongoing (IPNA 2016 HUS; ACIP 2024 — eculizumab patients are at ~1,000-2,000x baseline meningococcal-disease risk)

Non-pharmacologic actions:
- Pediatric-nephrology follow-up at 1-3 mo + 6 mo + then per CKD-stage protocol (KDIGO 2024)
- PCP follow-up at 2 wk post-discharge for BP recheck + med reconciliation (Flynn AAP 2017)
- Nephrotoxin-avoidance counseling for family (NSAIDs OTC, aminoglycosides if hospitalized elsewhere, iodinated contrast, herbal/supplement nephrotoxins) (NINJA Goldstein 2016)
- Growth + nutrition counseling — adequate protein per RDA + caloric density; dietitian referral if percentile drop or eGFR < 60 (KDIGO 2024)
- School re-entry plan if extended hospitalization — accommodations for fatigue, frequent labs, fluid + bathroom access (KDIGO 2024)
- BP cuff at home with size-appropriate cuff; family-taught technique; log brought to clinic (Flynn AAP 2017)
- Mental-health referral if family-impact screen positive OR post-PICU syndrome features (KDIGO 2024)
- Vaccination catch-up review at every visit (ACIP 2024)

AVOID / contraindication checks:
- Withhold_NSAID_aminoglycoside_contrast_during_AKI (KDIGO 2012 AKI; KDIGO 2024)
- Hold_ACEi_ARB_during_AKI (KDIGO 2012 AKI; AAP 2022)
- Eculizumab_meningococcal_vaccine_pre_initiation (IPNA 2016 HUS)
- Sps_bowel_necrosis_caution_neonates (AAP 2022)
- Reassess_fluid_after_each_bolus_to_avoid_overload (KDIGO 2012 AKI; AWARE Kaddourah NEJM 2017)

Monitoring

Regimen monitoring:
- strict IO (KDIGO 2012 AKI; AAP 2022)
- daily weights (KDIGO 2012 AKI; AAP 2022)
- BMP q12 to 24h (KDIGO 2012 AKI)
- fluid overload percent calculation (AWARE Kaddourah NEJM 2017; KDIGO 2024)
- urine output q1h (KDIGO 2012 AKI; AAP 2022)

Setting (outpatient) monitoring:
- Cr + Schwartz eGFR at every visit (Schwartz 2009; KDIGO 2024)
- BP at every visit; ABPM if office BP >= 90th percentile (Flynn AAP 2017)
- UACR Q6 mo (KDIGO 2024)
- CBC + iron studies Q6 mo if eGFR < 60 (KDIGO 2024)
- Ca + Phos + PTH + vit D Q6 mo if eGFR < 60 (KDIGO 2017 CKD-MBD)
- Growth + weight + height percentiles at each visit (KDIGO 2024)
- Annual renal US if etiology obstruction (KDIGO 2012 AKI)
- Mental-health rescreen annually if post-PICU OR RRT (KDIGO 2024)

Follow-up plan: Pediatric nephrology, growth tracking, BP screening, recurrence prevention, vaccination (esp. eculizumab → meningococcal) (KDIGO 2012 AKI; KDIGO 2024; AAP 2022; IPNA 2016 HUS)
- Close-out criterion: Follow-up scheduled (KDIGO 2024; AAP 2022)

Monitoring phase: Strict I/O, daily weights, BMP q12-24 h, ECG if hyperkalemia, weight-based fluid balance (KDIGO 2012 AKI; KDIGO 2024; AAP 2022)

Disposition

Current setting: outpatient — Post-AKI pediatric nephrology follow-up — confirm renal recovery (Cr trajectory + Schwartz eGFR), screen for CKD progression (BP + UACR), reinforce nephrotoxin avoidance (NINJA stewardship), update vaccinations (PCV20 + influenza + meningococcal if post-eculizumab), track growth + nutrition (CKD-MBD + anemia screen if eGFR < 60), and maintain long-term BP + proteinuria monitoring (KDIGO 2012 AKI; KDIGO 2024; AWARE Kaddourah NEJM 2017; NINJA Goldstein Pediatrics 2016; Flynn AAP 2017 hypertension guideline)

Disposition criteria:
- Stable post-AKI — Cr recovered to baseline OR stable new baseline; BP < 90th percentile OR controlled on ACEi/ARB; UACR < 30 mg/g OR stable; no nephrotoxin exposure; growth on percentile; vaccination current; family engaged with nephrology + PCP (KDIGO 2024)
- CKD stage 1-2 stable — annual nephrology visit; continued BP + UACR monitoring (KDIGO 2024)
- CKD stage 3-5 — Q3-6 mo nephrology visit; CKD-MBD + anemia + growth management; transition planning to adult nephrology at age 18 (KDIGO 2024)

Escalation triggers (move to higher acuity):
- New Cr rise OR eGFR drop >= 25% from baseline -> ED + nephrology urgent (KDIGO 2024)
- BP > 95th + 12 mmHg OR symptomatic HTN -> ED (Flynn AAP 2017)
- New proteinuria UACR > 300 mg/g OR new hematuria -> nephrology urgent + glomerulonephritis workup (KDIGO 2012 AKI)
- Recurrent AKI episode -> nephrology + pharmacy nephrotoxin audit + NINJA review (Goldstein 2016)
- Growth percentile drop > 1 SD OR weight loss in CKD stage 3-5 -> nutrition + nephrology (KDIGO 2024)
- New symptom of CKD-MBD (bone pain, fracture) -> bone-health workup + nephrology (KDIGO 2017)
- Mental-health screen positive -> mental-health referral + family-impact assessment (KDIGO 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] K+ ≥6.5 with peaked T waves, widened QRS, sine-wave (KDIGO 2012 AKI; AAP 2022)
- [LIFE_THREATENING] KDIGO peds stage 3 (Cr >= 3x baseline OR Cr >= 4.0 mg/dL OR UOP < 0.3 mL/kg/h x 24 h OR anuria x 12 h OR eGFR < 35 mL/min/1.73 m^2) with one or more classical RRT indications: refractory hyperkalemia (K+ > 6.5 despite medical management), refractory acidosis (pH < 7.15 despite bicarb), volume overload > 15% admit weight with respiratory compromise, uremic encephalopathy or pericarditis, dialyzable toxin (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
- [LIFE_THREATENING] Microangiopathic hemolytic anemia (schistocytes + thrombocytopenia + elevated LDH + low haptoglobin) + AKI WITHOUT bloody diarrhea — atypical HUS (aHUS) until excluded; complement-pathway defect (factor H/I deficiency, MCP/CD46, CFB/C3 gain-of-function); requires eculizumab + meningococcal vaccination + complement genetic evaluation (IPNA 2016 HUS)

Citations

- KDIGO 2012 AKI (PMID 22890468) + KDIGO 2024 AKI update + Schwartz 2009 (PMID 19158356) + AWARE Kaddourah NEJM 2017 (PMID 28076862) + AWAKEN Jetton Neonatology 2017 + STARRT-AKI NEJM 2020 (PMID 32668115) + IPNA 2016 HUS + AAP 2022 neonatal AKI [PMID:19158356](https://pubmed.ncbi.nlm.nih.gov/19158356/)
- Cited evidence (PMID 28076862) [PMID:28076862](https://pubmed.ncbi.nlm.nih.gov/28076862/)
- Cited evidence (PMID 26956617) [PMID:26956617](https://pubmed.ncbi.nlm.nih.gov/26956617/)
- Cited evidence (PMID 22890468) [PMID:22890468](https://pubmed.ncbi.nlm.nih.gov/22890468/)
- Cited evidence (PMID 32668115) [PMID:32668115](https://pubmed.ncbi.nlm.nih.gov/32668115/)

Last reconciled with current guidelines: 2026-05-15.
References
  • KDIGO 2012 AKI (PMID 22890468) + KDIGO 2024 AKI update + Schwartz 2009 (PMID 19158356) + AWARE Kaddourah NEJM 2017 (PMID 28076862) + AWAKEN Jetton Neonatology 2017 + STARRT-AKI NEJM 2020 (PMID 32668115) + IPNA 2016 HUS + AAP 2022 neonatal AKI — PMID:19158356
  • Cited evidence (PMID 28076862) — PMID:28076862
  • Cited evidence (PMID 26956617) — PMID:26956617
  • Cited evidence (PMID 22890468) — PMID:22890468
  • Cited evidence (PMID 32668115) — PMID:32668115