Acute Kidney Injury - Adult Leeds

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2 Information Resource for Patients and Carers

Quick info:
Acute Kidney Injury Patient Information Leaflet
Chronic Kidney Disease Patient Information Leaflet
Keep Kidneys Healthy Patient Information Leaflet

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4 Training and Further Resources

Quick info:
University of Wales website for CPD on AKI
Communities at risk of AKI

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5 Identification of Patients At Risk of Acute Kidney Injury (AKI)

Quick info:
Identify patients at risk.
Two thirds of AKI starts in the community. Primary care therefore has a role to play in the early detection of AKI. Those patients who have annual reviews for existing co-morbidity can be assessed for risk of AKI:

  • Elderly
  • CKD (eGFR<60ml/min)
  • Heart failure
  • Liver disease
  • Diabetes
  • Vascular disease
  • History of AKI
  • Use of drugs with nephrotoxic potential (NSAIDs)
  • Use of drugs nkown to exacerbate hypotension (diuretics, ACEi, ARBs)
  • Neurological or cognitive impairment or disability which may mean limited access to fluids because of reliance on carer
  • Patients with symptoms or history of urological obstruction or conditions that may lead to obstruction
  • Patients with cancer

Potential mechanisms of AKI:

  • Sepsis and hypoperfusion/hypovolaemia
  • Toxicity (new medication - including over-the-counter NSAIDs)
  • Obstruction to urinary tract
  • Parenchymal kidney disease

Pre renal - As kidney function is dependent upon adequate blood pressure, any patient who has a significant, prolonged fall in their blood pressure is at risk of developing AKI. The cause of AKI in this group is known as ‘pre-renal’, and includes the following patient groups:

  • Patients with sepsis - this is because the blood pressure falls during sepsis as a result of vasodilatation
  • Patients with increased losses leading to volume depletion, for example vomiting and diarrhoea, severe bleeding
  • Patients who are at risk of dehydration because they are unable to maintain good hydration without help from others
  • Patients with reduced cardiac output or heart failure that leads to hypotension

Intrinsic - There are also patient groups who are at risk because of ‘intrinsic’ causes. Intrinsic means that the kidneys are damaged. Intrinsic renal causes include:

  • Prolonged ‘pre-renal’ AKI, whereby a sustained drop in blood pressure results in cell damage (most common cause)
  • Medications that may exacerbate hypovolaemia and hypotension, Angiotensin Converting Enzyme inhibitors (ACEi), Angiotensin Receptor Blockers (ARBs), Loop diuretics
  • Medications that are can be potentially harmful to the kidneys in the setting of acute illness. Non-steroidal, anti-inflammatory drugs (NSAIDs) – some of these drugs can be bought as over the counter medications e.g. Ibuprofen
  • Diseases of the kidney e.g. glomerulonephritis, tubulointerstitial nephritis
  • Systemic disease processes that can involve the kidney e.g. vasculitis and myeloma

Post renal - Another group of patients at risk of AKI include those who may develop obstruction to urinary flow within the renal tract, which is often referred to as a ‘post-renal’ AKI. Examples of this include:

  • Males with enlarged prostate
  • Pelvic/abdominal masses
  • Kidney/renal tract stones
  • Congenital obstructive uropathy presenting in neonates (especially males with posterior urethral valves). This can be detected with antenatal ultrasound scans. Delays in relieving the obstruction will increase the degree of damage to the kidneys.

Prescribing in patients at risk of AKI
There are a number of medications that may exacerbate an episode of AKI through direct toxicity or indirectly by reducing the blood pressure to an inappropriately low level. Other medications are metabolised and excreted by the kidneys and may accumulate in patients with AKI resulting in adverse side effects. The list provided is not meant to exhaustive and for a more comprehensive list refer to Medicines Optimisation Toolkit for AKI
Medications that should be avoided or used with caution in patients at risk of AKI

  • NSAIDS
  • Gentamicin
  • Amphotericin

Medications that should be reviewed in patients at risk of AKI who develop acute illness

  • May exacerbate low blood pressure (Angiotensin Converting Enzyme inhibitors (ACEi) Angiotensin Receptor Blockers (ARBs) Diuretics)
  • Drugs excreted by the kidneys and may accumulate if kidney function is reduced (consider reducing dose or stopping during acute illness) Opiates, Digoxin, Lithium, Metformin

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6 Patient and Carer Education

Quick info:
Discuss risk of developing AKI - particularly risk associated with conditions leading to dehydration (e.g. diarrhoea and vomiting) and drugs with nephrotoxic potential (including over-the-counter NSAIDs)

Advise patients to temporarily stop ACEi, ARBs, metformin and diuretics if they develop diarrhoea, vomiting or sepsis until their clinical condition has improved and stabilised (advice given needs to take into account patients underlying co-morbidities)

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7 Patient with Acute Illness

Quick info:
Adults with acute illness
Investigate for AKI, by routinely measuring serum creatinine and comparing with baseline, in adults with acute illness if any of the following are likely or present:

  • Non-Modifiable risk factors
    • age 65 years or over
    • chronic kidney disease (adults with an estimated glomerular filtration rate [eGFR] less than 60 ml/min/1.73 m2 are at particular risk)
    • heart failure
    • liver disease
    • diabetes
    • history of acute kidney injury
    • renal transplant
    • oliguria (urine output less than 0.5 ml/kg/hour)
    • neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer
    • symptoms or history of urological obstruction, or conditions that may lead to obstruction
  • Modifiable risk factors
    • hypovolaemia
    • drugs which could be harmful to the patients kidneys within the past week especially if hypovolaemic:
      • non-steroidal anti-inflammatory drugs [NSAIDs]
      • aminoglycosides
      • angiotensin-converting enzyme [ACE] inhibitors
      • angiotensin II receptor antagonists [ARBs]
      • diuretics
      • use of iodinated contrast agents within the past week
      • sepsis

Consider whether pre-existing risk factors for development of AKI
Consider whether potential causes of AKI are present
Undertake patient assessment

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8 History, Examination and Investigations

Quick info:
History:
Fluid intake and output, medication including OTC
New onset or significant worsening of urological symptoms

Examination:
Volume status (moistness of mucous membranes/axillae, skin turgor, JVP, pulse rate and blood pressure (and for postural changes if possible)
Evidence of urinary tract obstruction
Evidence of potential parenchymal renal disease (e.g. purpuric skin rash) Consideration of need for temporary cessation of ACEi/ARB, diuretics and NSAID

Investigation:
Investigate for AKI by measuring serum creatinine and comparing with baseline
Perform dipstick urine testing for blood, protein, leucocytes, nitrates and glucose
Think about diagnosis of parenchymal renal disease in setting of AKI with no obvious cause and haematoproteinuria without urinary tract infection

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12 Review Modifiable Factors Repeat Serum Creatinine Within a Week

Quick info:
Modifiable factors include medication/treatment or infection/rehydration.
Consider referral directly to renal team if you think there may be intrinsic renal disease.

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13 If Patient Requires Admission Contact PCAL

Quick info:
If you are sure admission is required contact PCAL
If you are unsure or need urgent advice contact the renal registrar at LTHT - 07786250622
If you wish to seek advice on a chronic problem please use the advice and guidance function on e-Referral, you will receive a response within 24 hours.

Referring to nephrology:
Discuss the management of acute kidney injury with a nephrologist as soon as possible and within 24 hours of detection when one or more of the following is present:

  • A possible diagnosis that may need specialist treatment (for example, vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma)
  • Acute kidney injury with no clear cause
  • Inadequate response to treatment
  • Complications associated with acute kidney injury
  • Stage 3 acute kidney injury
  • A renal transplant
  • Chronic kidney disease stage 4 or 5

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14 After Episode of AKI

Quick info:
Monitor serum creatinine; consider referral to renal unit where eGFR is 30ml/min or less in patients who have recovered from AKI
and or who have persistant haematoproteinuria
Discuss ongoing need for monitoring and self-management with patient (and/or their carer if appropriate) Review which medications to re-start/discontinue

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