Septic shock with stage 3 acute kidney injury — the timing decision

Presentation

A 66-year-old man is in the ICU on day 3 of septic shock from a perforated diverticulitis, for which he had a laparoscopic washout and defunctioning colostomy on the day of admission. He was initially in vasoplegic shock requiring noradrenaline at 0.4 mcg/kg/min; this has weaned to 0.1 mcg/kg/min and his lactate has fallen from 5.2 to 1.8 mmol per litre.^[6]

The concern today is his kidneys. His baseline creatinine was 78 micromol per litre; it is now 352 micromol per litre. His urine output has fallen to 12 mL per hour despite two assessments of fluid responsiveness and a 250 mL crystalloid challenge that produced no sustained response. He is now 4 litres in positive balance since admission. His potassium is 5.0 mmol per litre, his pH is 7.32 (standard bicarbonate 18), and his chest is clear. He is not uraemic.^[5]

The surgical and renal teams both ask whether he should "start dialysis before he gets into trouble."^[3]