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Managing Acute Kidney injury

From Mediwikis

This is a guest post by Think Kidneys

  • Think Kidneys Acute Kidney Injury Programme - The NHS campaign to improve the care of people at risk of, or with, acute kidney injury.
  • Acute kidney injury is a sudden and recent reduction in a person’s kidney function. It is not usually caused as a result of a physical blow to the body.
  • Our aims are to reduce avoidable harm and death for people with acute kidney injury, and to improve care for patients whether in hospital or at home.

Signs and Symptoms

Video about AKI, by the Think Kidneys project

A blood test is needed to detect AKI. Often there are no real symptoms or signs, however they might include the following[1] :

  • Changes to urine output, particularly a major reduction in the amount of urine passed
  • Nausea, vomiting
  • Abdominal pains and feeling generally unwell, similar to a hangover
  • Dehydration or thirst
  • Confusion and drowsiness

The Think Kidneys Communities at risk of developing acute kidney injury document may help you further in identifying those who may be at risk.

If a patient is in hospital and AKI has been detected and verified (i.e. non-AKI rises in creatinine excluded, such as post pregnancy), implementation of a minimum care bundle for AKI is recommended.

If the patient is in primary care, advice can be found in this document: Responding to AKI Warning Alerts In Primary Care

Diagnosis/ Investigations[2]

Initial assessment

  • Assessment for complications of AKI including
  • Pulmonary oedema
  • Tachypnoea (suggesting fluid overload and/or acidosis)
  • Pericardial / pleural rub
  • Neurological manifestations of uraemia, e.g. encephalopathy (having excluded other causes of confusion/delirium)
  • Full set of physiological observations
  • NEWS triggers to be applied according to local protocol
  • Follow NICE CG50 guidelines (‘Management of the Acutely Ill Patient’)

ABCDE examination to include

  • Any evidence of sepsis – start Sepsis Six Care Bundle
  • Haemodynamic (including volume) assessment
  • Signs of shock / hypoperfusion
  • Reagent strip urinalysis – documented in medical notes
  • Palpation for enlarged bladder
  • Evidence of vascular disease
  • Signs suggestive of a less common cause (e.g. Vasculitis)  

Relevant clinical history including:

  • Possible precipitants and risk factors also requiring full medication history (prescribed and non-prescribed drugs; iodinated radio-contrast investigations)
  • History of urinary tract symptoms
  • History suggestive of sepsis
  • History of vascular disease or recent vascular intervention (is cholesterol embolization possible?)
  • Systemic symptoms suggestive of a less common cause of AKI (e.g. vasculitis)

Treatment[2]

Prompt treatment of sepsis

If hypovolaemic, crystalloid boluses until fluid replete with regular clinical reviews of response

  • Maintenance fluids only once euvolaemic
  • Set daily fluid target (see Appendix 5: NICE CG174 ‘IV fluid therapy in adults in hospital’)

Medications

  • Consider stopping medications which could be potentially harmful in AKI (e.g. ACEi / ARB / NSAIDs)
  • Review need for drug dose adjustment in view of AKI (see Medicines Optimisation for AKl)
  • Remember physiological effects of some drugs – e.g. Trimethoprim causing hyperkalaemia and physiologically increasing serum creatinine levels

Relieve obstruction

  • The decision to place a urethral catheter should consider the individual risks (including trauma, infection, falls risk) and benefits (e.g. accuracy of urine OP recording, avoidance of skin breakdown associated with incontinence) for the patient. In bladder outflow obstruction the benefits will outweigh the risks,
  • The urethral catheter should be removed if it has been demonstrated that the patient remains anuric despite therapeutic interventions to restore circulating volume.
  • In cases of upper tract obstruction, clear referral pathways with urology or interventional radiology should be established as appropriate locally (e.g. for ureteric stenting or nephrostomy placement)

Discharge info

The following is a publication produced by Think Kidneys detailing the minimum contents for a discharge summary and why this is so important.

Medicines and AKI[3]

Many medications are cleared via the kidneys, so have the potential to accumulate during an episode of AKI. The result of this may be a further deterioration in kidney function, or there may be other adverse effects. Hence it is necessary to review the use of these medications and amend the doses appropriate to the level of the patient’s renal function.

References

  1. https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2015/07/Communities-at-risk-v16.pdf
  2. 2.0 2.1 https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2015/12/AKI-care-bundle-requirements-FINAL-12.07.16.pdf
  3. https://www.thinkkidneys.nhs.uk/aki/medicines-optimisation-for-aki/