IM10.17-22 | AKI and CKD Management — Summary & Reflection

KEY TAKEAWAYS

Communication: Calibrate AKI communication to trajectory (most AKI recovers) and CKD communication to modifiable factors (BP, glucose, NSAID avoidance). Deliver bad news sensitively with 'warning shots'. Plan structured follow-up.

Renal diet: AKI non-dialysis = protein 0.8–1.0 g/kg/day, 25–35 kcal/kg/day, fluid = insensible + urine output. CKD non-dialysis = protein 0.6–0.8 g/kg/day; dialysis = 1.2–1.5 g/kg/day. Restrict K⁺ (boil vegetables, avoid coconut water/bananas), PO₄ (limit dairy/processed food + phosphate binders with meals), Na⁺ (<2 g/day), fluid (500–750 mL + urine output in dialysis patients). Never use KCl salt substitutes in CKD.

AKI management priorities: (1) remove cause + stop nephrotoxins; (2) fluid balance = insensible losses + urine output; (3) drug dose adjustment (metformin stop, NSAIDs contraindicated, aminoglycoside level monitoring); (4) electrolyte monitoring 4–6 hourly in Stage 2–3; (5) protein 0.8–1.0 g/kg/day.

CKD supportive therapy: BP target <130/80 (RAAS blockade first-line with proteinuria — up to 30% creatinine rise acceptable; hold if >30% or K⁺ >5.5); HbA1c <7% (relax to 8% in G4–G5); metformin hold at eGFR <30; SGLT-2i renoprotective; statins for CVD risk; anaemia: iron first (TSAT >20%, ferritin >100), then ESA (target Hb 10–11.5); hyperphosphataemia: Ca-based binders (limit total Ca <1.5 g/day) or sevelamer; bicarbonate supplementation (target HCO₃⁻ >22 mEq/L).

Dialysis indications (AEIOU): Acidosis (pH <7.1), Electrolytes (refractory hyperkalaemia), Intoxication (salicylates, methanol, lithium), Overload (pulmonary oedema refractory to diuretics), Uraemia (pericarditis, encephalopathy, bleeding). Modalities: IHD (stable chronic ESRD — AVF access), PD (home-based, haemodynamically stable), CRRT (ICU/haemodynamically unstable), transplant (gold standard for eligible ESRD).

REFLECT

Ramu (pre-renal AKI from dehydration and NSAIDs) and Meena (CKD G4 from diabetic nephropathy on twelve medications including NSAIDs and metformin) both need a management plan today. For Ramu, the immediate actions are clear: isotonic saline, stop NSAIDs, stop ACE inhibitor temporarily, daily creatinine monitoring, and a dietary brief explaining fluid and potassium restrictions for the next few days. His family needs to hear that recovery is expected, that it takes time, and that these two medications must never be taken together with dehydration. For Meena, the first step is a complete medication reconciliation — stopping the NSAIDs and metformin today, not at the next visit. Then RAAS blockade optimisation, SGLT-2 inhibitor initiation, phosphate management with dietary counselling and a phosphate binder prescription, ESA initiation after iron repletion, and a referral to a nephrologist for pre-dialysis counselling given her eGFR of 22. Think about what you would say to Meena about dialysis — not a prescription, but a conversation. When would you start that conversation? How would you frame it? What does she need to know and feel to make an informed, autonomous decision about her care as her kidneys continue to decline?