Acute Kidney Injury (AKI)

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Patient at risk of AKI

  • Known CKD
  • Heart failure
  • Diabetes mellitus
  • Ischaemic heart disease
  • Malignancy
  • Liver disease
  • Nephrotoxic drugs
  • IV contrast
  • Urinary obstruction

Stage 1 AKI

Stage 2 AKI Stage 3 AKI

ALERT

Cr increase >1.5 – 1.9 x from baseline
or
acute ↑ Cr >26 micromol/L / 48 hrs
or
UO <0.5ml/kg/hr for > 6 hours

ALERT

Cr increase >2 - 2.9 x from baseline
or
UO <0.5ml/kg/hour >12 hours

ALERT

Cr increase >3x from baseline
or
Cr >354 micromol/L
or
UO <0.3ml/kg/hr for 24hrs
or anuric for 12 hrs
or
requires RRT irrespective of Cr

ASSESS

Clinical history

  • risk factors
  • accurate drug history

Examination

  • SEWS
  • volume status
  • GCS
  • Respiratory status
  • Palpable bladder
  • Signs of sepsis
  • Signs of vasculitis
  • Urine output

Investigations

  • serial U&Es
  • HCO3, FBC, CRP, LFTs, calcium
  • Urine PCR if proteinuria MSSU
  • CXR
  • ECG

Consider

  • Renal USS
  • Sepsis screen
  • ABGs, lactate, CK amylase
  • Vasculitic screen if haematuria & proteinuria
  • Myeloma screen

ASSESS

As Stage 1

AND

Renal US within 24 hrs
Sepsis screen

 

ASSESS

As Stage 2

AND

Look for multiorgan failure
Chase Renal US

 ACT

Correct hypovolaemia
Optimise BP
Accurate fluid balance
Avoid nephrotoxins
Rx sepsis
Relieve obstruction
Dose adjustment of renally excreted medication

Consider:
Urinary catheter
Senior review & CVP

ACT

As Stage 1 AND

Senior review
Catheterise, 1° urine volumes  

Consider:
CVP/cardiac monitoring
Referral to Renal Team
Dietician review
Transfer to Level 2 care

ACT

As Stage 2 AND

Senior review
Refer to Renal Team &
transfer to Level 2 care
Cardiac monitoring  

Consider:
CVP insertion
Referral to ICU

 

REFERRALS TO RENAL UNIT

1.Urgent In-Patient

  • High suspicion of rapidly progressive glomerulonephritis
  • Indication for dialysis*
  • Stage 3 AKI
  • Stage 2 AKI unresponsive to Rx after 24-48 hrs
  • Renal transplant patient admitted to hospital
  • Dialysis patient admitted to hospital

Urgent referrals speak directly to renal consultant. Renal referrals are usually seen by renal consultant covering ward 7C.

Renal secretaries extension 6342

Possible Indications for urgent dialysis

  • Refractory hyperkaleamia
  • Ur >30 +/- Cr >500
  • Refractory volume overload
  • Refractory acidosis pH <= 7.1
  • Complications of uraemia
  • Severe poisoning

 

Editorial Information

Last reviewed: 30 June 2015

Next review: 30 June 2017

Author(s): Renal Consultant

Version: 1

Approved By: high-uhb.tam@nhs.net

Reviewer Name(s): Dr Lambie, Dr Peel