Acute Tubular Necrosis (incl. Rhabdomyolysis)Emergency

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Ischemic/nephrotoxic; muddy brown casts, FENa >2%

ABCDE

Exclude hyperkalaemia (ECG); aggressive fluids; stop nephrotoxins; dialysis if AEIOU.

Calculators:
  1. Rhabdo — FIRST: Exclude hyperkalemia (it kills); ECG
  2. Treat: Aggressive IV fluids (rhabdo: isotonic fluids targeting urine output ~200–300 mL/h until CK falling; no proven role for routine bicarbonate/mannitol); avoid nephrotoxins; dose-adjust drugs; dialysis if AEIOU — deferred, indication-driven RRT start (no early/pre-emptive dialysis absent urgent indications; STARRT-AKI)

Order set

  • U&E, CK
  • Urinalysis (casts, myoglobin)
  • K⁺, Ca, PO₄
  • ECG
  • IV fluids

Criteria

AdmitAll established AKI
ICUHyperkalaemia with ECG changes, refractory overload/acidosis
DialysisAEIOU (esp. refractory K⁺/overload)
CRRTIf used: regional citrate anticoagulation first-line; delivered effluent dose 20–25 mL/kg/h
DischargeRenal function recovering, electrolytes stable, off nephrotoxins
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Hyperkalaemia with ECG changes
  • Refractory acidosis/overload
Differentials
  • Prerenal AKI
  • Contrast/drug nephrotoxicity
  • AIN
Common mistakes
  • Missing hyperkalaemia in rhabdo
  • Nephrotoxins
Disposition & follow-up

Supportive; dialysis if AEIOU indications.

Discharge package
MedicationsAvoid nephrotoxins; dose-adjust drugs
Follow-upNephrology if not recovered
Warning symptomsReduced urine, dark urine, swelling
💊 Treatment detail — doses & preparation
0.9% Sodium chloridecrystalloid
DoseBolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Potassium chlorideelectrolyte
DosePO 40–100 mmol/day divided. IV: 10 mmol/h peripheral, 20 mmol/h central with cardiac monitor
PreparationIV: NEVER undiluted push — 10 mmol in 100 mL or 40 mmol/L bag via pump
MonitorK⁺ q4–6 h during replacement, ECG, urine output >0.5 mL/kg/h
Calcium gluconate 10%membrane stabiliser
Dose10–30 mL of 10% IV over 2–5 min for hyperK ECG changes; repeat q10 min ×3 PRN
Preparation10 mL ampoules (2.2 mmol Ca²⁺ each), undiluted slow push with cardiac monitor
MonitorECG immediately (QRS narrows); effect 1–3 min, lasts 30–60 min — shift/remove K⁺ in parallel
Dialysis triggers (AEIOU)rescue
DoseAcidosis, Electrolytes (K⁺), Ingestions, Overload, Uraemia — renal consult
PreparationCVVH/intermittent HD per nephrology
MonitorDaily K⁺/phosphate/creatinine
📖 KDIGO AKI + 2026 AKI/AKD draft (indication-driven RRT, citrate CRRT)Reviewed July 2026

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