AKI is defined by ANY ONE of the following criteria (KDIGO 2012, reaffirmed 2023):
Serum creatinine rise ≥0.3 mg/dL within 48 hours
Serum creatinine rise ≥1.5× baseline within 7 days
Urine output <0.5 ml/kg/h for ≥6 hours
Clinical PearlA single creatinine value is insufficient. Trend matters. Always establish the patient's baseline creatinine (prior bloods, CKD history, or estimated from age/sex/race using CKD-EPI).
S KDIGO Staging — Creatinine Criteria
Stage
Serum Creatinine Criterion
Urine Output Criterion
Severity
Stage 1
×1.5–1.9 baseline or +0.3 mg/dL within 48 h
<0.5 ml/kg/h for 6–12 h
Mild
Stage 2
×2.0–2.9 baseline
<0.5 ml/kg/h for ≥12 h
Moderate
Stage 3
×3.0 baseline or Cr >4.0 mg/dL or initiation of RRT
<0.3 ml/kg/h for ≥24 h or anuria ≥12 h
Severe
ImportantStage is determined by the HIGHER of creatinine OR urine output criteria. Never down-stage just because one criterion is better.
Minimise contrast volume — discuss with radiologist
HOLD metformin 48 h pre- and post-contrast if eGFR <45
Recheck creatinine 24–48 h post-procedure
GCC Context: High coronary angiography rates in GCC countries (high CAD prevalence) mean CIN prevention is a common nursing responsibility in cardiac units.
K Hyperkalaemia — ECG Changes by K+ Level
ECG changes are not always linear — act on clinical context, not ECG alone.
K+ <5.5
Normal / Baseline — no significant ECG changes expected
K+ 5.5–6.0
Peaked (tall, narrow) T-waves — earliest sign; most prominent in V2–V5 and II
GCC Defibrillator Note: In GCC ICUs, biphasic defibrillators are standard. For hyperkalaemic VF: charge to 200J biphasic (360J if monophasic). Ensure AED/defibrillator is at bedside for K+ >7.0. Concurrent calcium and insulin infusion while defibrillating.
T Hyperkalaemia Treatment Algorithm
Step 1: Cardiac Membrane Stabilisation
Does NOT lower K+ — protects the heart NOW
Calcium Gluconate 10% — 10 ml (1g) IV over 2–3 min
Repeat after 5 min if ECG unchanged
Onset: 1–3 minutes; Duration: 30–60 min
Monitor ECG continuously during infusion
Can also use Calcium Chloride 10% (3× more elemental Ca²⁺) — central line preferred
Caution: Digoxin toxicity (use 100 ml 10% over 20–30 min)
Step 2: K+ Redistribution (Into Cells)
Lowers plasma K+ within 15–30 min — buys time
Insulin + Dextrose: 10 units Actrapid in 50 ml 50% dextrose IV over 15–30 min (lowers K+ ~1 mmol/L; monitor BGL 30-60 min)
Salbutamol Nebuliser: 10–20 mg in 4 ml 0.9% NaCl via nebuliser (lowers K+ ~0.5–1 mmol/L; additive with insulin)
Sodium Bicarbonate: 50–100 mmol IV (mainly useful if severe metabolic acidosis — modest K+ lowering effect alone)
Step 3: K+ Elimination (From Body)
Definitively removes K+ — essential for sustained control
Calcium Resonium (Resonium-A): 15 g PO or 30 g PR in sorbitol; onset 4–6 h; GI side effects
Patiromer (Veltassa): 8.4–25.2 g PO daily — newer, better tolerated, avoid in ileus
Sodium Zirconium Cyclosilicate: 10 g PO TDS — rapid onset ~1h
Furosemide: 40–80 mg IV if residual renal function present
Dialysis (IHD or CRRT): most effective; use in refractory hyperkalaemia or oligo-anuric AKI
M Hyperkalaemia Monitoring Protocol
K+ Level
Frequency of Monitoring
Escalation
5.1–5.5 mmol/L (mild)
Every 4–6 hours; low K+ diet
Review K+-sparing drugs; dietary restriction
5.6–6.0 mmol/L (moderate)
Every 2–4 hours; 12-lead ECG
Start K+ elimination; notify physician; establish IV access
6.1–6.9 mmol/L (severe)
Continuous ECG; repeat K+ every 1–2 h
Calcium gluconate STAT; insulin/dextrose; emergency dialysis plan
≥7.0 mmol/L (critical)
Continuous cardiac monitoring; ICU
Immediate calcium; emergency IHD/CRRT; crash call team
Haemolysed samples give falsely HIGH K+. Repeat immediately in a new sample before treating — but do NOT delay treatment if ECG changes are present.
R Indications for RRT in AKI
Absolute Indications (AEIOU)
Acidosis — pH <7.1 refractory to treatment
Electrolytes — K+ >6.5 refractory, or severe hyponatraemia
No proven benefit to early vs late RRT in trials (STARRT-AKI, IDEAL-ICU)
Initiate when above indications present
Do not delay for absolute indications
Consider early if AKI not recovering after 48–72 h of conservative management
Nephrology/Intensivist discussion for RRT initiation required in all GCC centres. Document time of referral and decision.
D IHD vs CRRT — Modality Selection
Feature
IHD (Intermittent)
CRRT (Continuous)
Duration
3–5 h sessions, 3–7×/week
24 h/day continuous
Haemodynamic stability
Requires stable MAP >70
Preferred for unstable patients
Solute clearance
Efficient small solutes rapidly
Slower but continuous — better for cytokines
Fluid removal
Rapid (can cause hypotension)
Gentle, continuous (better tolerated)
Brain oedema / ICP
Risk of dialysis disequilibrium
Preferred in TBI, hepatic encephalopathy
Anticoagulation
Heparin during session
Systemic heparin or regional citrate
Nursing requirement
Renal/dialysis nurse per session
Continuous ICU nurse monitoring
Cost
Lower
Higher (consumables, fluids)
C CRRT Modalities
CVVH
Continuous Veno-Venous Haemofiltration
Convection only (no dialysate)
Replacement fluid pre- or post-filter
Good for large molecule clearance
Pre-dilution: less filter clotting but lower efficiency
Post-dilution: more efficient but filter clots faster
CVVHD
Continuous Veno-Venous Haemodialysis
Diffusion only (dialysate, no replacement fluid)
Better small solute clearance (urea, creatinine)
Used when primarily solute clearance needed
CVVHDF
Continuous Veno-Venous Haemodiafiltration
Convection + diffusion combined
Most common modality in GCC ICUs
Superior clearance across molecular weight spectrum
Standard dose: 20–25 ml/kg/h effluent
Prescribe 25 ml/kg/h to achieve delivered 20 ml/kg/h
Effluent Dose: Delivered dose of 20–25 ml/kg/h is evidence-based (ATN trial, RENAL trial). Higher doses do NOT improve outcomes and increase nursing workload.
A Vascular Access for RRT
Site
Advantages
Disadvantages
Recommendation
Right Internal Jugular (IJ)
Low infection risk, direct path to RA, good flow rates
Neck movement restriction
Preferred for medium/long-term
Femoral
Fastest insertion, compressible, no pneumothorax risk
High infection risk, patient must lie flat, recirculation if short catheter
Use ≥24 cm catheter; fastest access in emergency
Left IJ
Acceptable alternative
Longer curved path, higher malposition risk
Second choice IJ
Subclavian
Lower infection, more comfortable
AVOID — risk of subclavian stenosis, compromises future AVF creation
Last resort only
Use ultrasound guidance for all dialysis catheter insertions. Document in nursing notes: catheter length, blood flow rates achieved, side.
H CRRT Anticoagulation
Unfractionated Heparin (UFH)
Most common in GCC ICUs
Loading: 1000–2000 units IV bolus
Maintenance: 5–15 units/kg/h infusion pre-filter
Target: aPTT 45–60 s (systemic) or ACT 180–200 s (circuit)
Risk: HIT (heparin-induced thrombocytopenia) — monitor platelets daily
Reversal: Protamine sulphate
Regional Citrate Anticoagulation (RCA)
Preferred when systemic anticoagulation contraindicated (active bleeding, post-surgery, HIT)
Clamp circuit immediately; discard blood in filter; change filter urgently
Effluent bag full
Normal scheduled exchange
Swap bag quickly, document volume, ensure fluid balance calculation updated
Each circuit change means blood loss (~100–200 ml). Frequent clotting = 300–600 ml/day blood loss. Review anticoagulation and haemoglobin if filter lifespan <12 h.
G AKI Epidemiology in the GCC Region
Heat-Related AKI
Summer temperatures exceed 45°C across KSA, UAE, Kuwait, Qatar
Outdoor workers (construction, agriculture) at extreme risk
Heat stroke: core temp >40°C + neurological dysfunction → AKI in 30–50%
Mechanism: dehydration + rhabdomyolysis + direct thermal injury to tubules
Management: rapid cooling + aggressive IV fluids (2–3 L/h initially) + close UO monitoring
Diabetic Nephropathy
GCC has world's highest diabetes prevalence (20–25% in adults)
Diabetic CKD → heightened AKI risk from ANY insult
AKI on CKD — distinct from de novo AKI; harder to recover baseline
HbA1c >9% = 3× AKI risk post-contrast
Urolithiasis
Kidney stone incidence 2–3× higher in GCC vs Europe (heat, dehydration)
Bilateral or solitary kidney obstruction → obstructive AKI
Renal colic common ED presentation — check creatinine in all cases
Urgent urological decompression (stenting or nephrostomy) if bilateral stones + AKI
Contrast-Related AKI (CAG)
High rate of coronary angiography (CAG) in GCC due to CAD epidemic
Post-CAG AKI protocol should be standard in all GCC cardiac units
Pre-hydration, post-hydration, creatinine check at 24–48 h mandatory
H Hajj-Associated AKI
Epidemiology
2+ million pilgrims annually in Makkah (peak Dhul Hijja)
Outdoor activities in extreme heat (Mina, Arafat, Muzdalifah)
AKI affects 5–15% of hospitalised Hajj patients
Rhabdomyolysis is a leading cause — extensive walking, heat, muscle necrosis
Crush injuries during crowd events → rhabdomyolysis AKI
Rhabdomyolysis Management
CK >5000 IU/L = significant rhabdomyolysis; >10,000 = severe
Myoglobin clogs tubules → pigment nephropathy
IV fluid resuscitation: target UO 200–300 ml/h until CK falling
Urinary alkalinisation (sodium bicarb) — controversial; use if urine pH <6.5
Avoid calcium (can precipitate with phosphate released from damaged muscle)
GCC Hospital Preparedness
MNGHA, King Abdulaziz Medical City: large AKI cohorts during Hajj season
Mobile dialysis units deployed near Hajj sites in Saudi Arabia
Triage nurses trained to identify AKI signs in mass casualty settings
Nursing Role During Hajj Season
Rapid IV access and fluid resuscitation triage
Creatinine + CK + dipstick on all heat-related admissions
Hourly UO monitoring on all admitted pilgrims
Escalation pathway for dialysis when UO <0.3 ml/kg/h despite fluids
Cultural sensitivity — Arabic/Urdu/Bengali language translation
R Ramadan Fasting & CKD/AKI Risk
Physiological Risk
12–16 h fasting including fluid restriction during daylight
Dehydration risk highest in summer Ramadan (longer, hotter days)
Patients with CKD Stage 3–5 at significant AKI risk if they fast
Hydration strategy: front-load fluids at Iftar and Suhoor
Instruct to break fast if: severe thirst, dark urine, dizziness
Post-Ramadan creatinine check in all CKD patients
Islamic scholars permit breaking the fast when fasting poses genuine medical danger. Nurses can reassure patients that their religion supports this dispensation (Rukhsa).
UAE Cleveland Clinic Abu Dhabi Tawam Hospital Al Ain Rashid Hospital Dubai American Hospital Dubai
Saudi Arabia King Faisal Specialist Hospital (KFSH) King Abdulaziz University Hospital Prince Sultan Cardiac Centre (Riyadh) MNGHA network hospitals
Qatar / Kuwait / Bahrain HMC Hamad Medical Corporation (Qatar) Al Amiri Hospital (Kuwait) Salmaniya Medical Complex (Bahrain) Al Jahra Hospital (Kuwait)
KDIGO AKI Staging Calculator
Enter values below to determine AKI stage and priority care actions.
Q Practice MCQs — AKI Nursing Assessment
Click an answer to reveal instant feedback. 10 questions covering key concepts.
Q1. A 68-year-old male with CKD (baseline Cr 1.4 mg/dL) presents post-CABG. Repeat creatinine at 24 h is 2.1 mg/dL. His urine output has been 0.4 ml/kg/h for 10 hours. What is his KDIGO AKI stage?
Stage 1 (creatinine criterion only)
Stage 2 (creatinine ×1.5 criterion meets Stage 2)
Stage 1 (both creatinine and UO meet Stage 1)
Stage 3 (creatinine >4 mg/dL criterion)
Q2. You observe muddy brown granular casts on urine microscopy of a patient with AKI following a 6-hour hypotensive episode post-aortic surgery. This finding is most consistent with:
Glomerulonephritis
Post-renal obstruction
Acute Tubular Necrosis (ATN)
Interstitial nephritis from antibiotics
Q3. A patient's K+ is 6.8 mmol/L. ECG shows widened QRS complexes (140 ms) and absent P-waves. What is the FIRST priority intervention?
Insulin 10 units + 50 ml 50% dextrose IV
Calcium resonium 15 g orally
Calcium gluconate 10% — 10 ml IV over 2–3 minutes
Furosemide 80 mg IV bolus
Q4. FeNa calculation: Urine Na 12 mmol/L, Plasma Na 140 mmol/L, Urine Cr 60 mg/dL, Plasma Cr 2.0 mg/dL. What does this FeNa suggest?
Pre-renal AKI — FeNa <1%
Intrinsic AKI (ATN) — FeNa >2%
Post-renal obstruction — FeNa >2%
Normal renal function — FeNa <0.5%
Q5. A Hajj pilgrim is admitted with heat stroke (temp 41.5°C) and CK 18,000 IU/L. Urine dipstick shows 3+ blood but no RBCs on microscopy. The diagnosis and target UO are:
Haematuria — target UO 0.5 ml/kg/h
Glomerulonephritis — immunosuppression required
Rhabdomyolysis — target UO 200–300 ml/h with aggressive IV fluids
Urinary tract infection — IV antibiotics
Q6. Which vascular access site is AVOIDED for dialysis catheter insertion due to risk of central vein stenosis compromising future AVF creation?
Right internal jugular vein
Femoral vein
Left internal jugular vein
Subclavian vein
Q7. A haemodynamically unstable septic patient (MAP 55 on noradrenaline 0.25 mcg/kg/min, K+ 6.2, pH 7.15, anuric for 18 hours) requires RRT. Which modality is preferred?
Q8. Which contrast agent type is recommended for contrast-induced nephropathy prevention in high-risk CKD patients?
High-osmolar ionic contrast (diatrizoate)
Low-osmolar non-ionic contrast (iopromide)
Iso-osmolar non-ionic contrast (iodixanol)
Any contrast is acceptable — volume doesn't matter
Q9. A CKD patient's CRRT filter clots after only 8 hours (target >24 h). The anticoagulation used is citrate. Which parameter confirms adequate circuit anticoagulation?
Systemic aPTT 60–90 seconds
Systemic ionised calcium 1.0–1.2 mmol/L
Post-filter ionised calcium <0.35 mmol/L in circuit
Effluent volume output >20 ml/kg/h
Q10. A diabetic CKD patient (eGFR 28) wishes to fast Ramadan. As his renal nurse, your most appropriate action is:
Advise he must not fast under any circumstances
No action needed — creatinine is stable
Pre-Ramadan nephrology review, personalised hydration plan, medication timing, and teach warning signs to break fast
Increase his diuretic dose to compensate for reduced intake