Acute Kidney Injury

Background
• Acute kidney injury (previously known as acute renal failure)
covers a wide spectrum of injury to the kidneys, not just
kidney failure

• Defined as measurable increase in the serum creatinine

concentration (ussually relative increase of 50% or absolute
increase by 44-88 mmol/L [0,5-1,0 mg/dL])

• Up to 18% of all hospital admissions have AKI

• Inpatient AKI-related mortality is between 25 and 30%

• Between 20 and 30% of cases of AKI are preventable.

Prevention could save up to 12,000 lives each year

• NHS costs related to AKI are between £434 and £620 million
per year

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 NCEPOD: Key findings

• AKI avoidable in 14% of cases

• Only 50% of patients received “good care”
• Post admission AKI: poor recognition and
care
• 24% did not receive adequate senior review
 Quality of care in this group was judged to be less good

• 85% did not have documented evidence of

critical care outreach involvement

June 2009
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 Background: prevention and early
identification
• AKI can be readily identified by close monitoring of
routine serum creatinine and urine output results

• AKI can be prevented by early recognition and treatment

of the underlying cause, for example:
– Early treatment of infections/sepsis
– Early treatment/prevention of dehydration
– Correcting hypovolaemia

• AKI can also be prevented by:

– Monitoring use of drugs such as NSAIDs and ACE inhibitors,
especially if a patient is acutely unwell
– Taking care with at-risk patients who need iodinated contrast
agents with scans

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 Observations and assessment

Use an
early warning score
that recognises
and responds to
deterioration
and acute illness

Staff should have competencies in:

• monitoring
• measurement
• interpretation
• recognition and prompt response to acute illness (CG50)

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 • Identifying acute kidney injury in patients with acute illness
• Identifying acute kidney injury in patients with no obvious acute
illness*
• Assessing risk factors in adults having iodinated contrast agents
and in adults having surgery
• Ongoing assessment of patients in hospital
• Detecting acute kidney injury
• Identifying the cause(s) of acute kidney injury AKI:
• Urinalysis* Key priorities
• Ultrasound
for implementation
• Managing acute kidney injury
• Relieving urological obstruction*
• Pharmacological management*
• Referring for renal replacement therapy*
• Referring to nephrology
• Information and support for patients and carers
* not a KPI, but considered a key issue by the guideline development group

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 Risk factors: adults
• Chronic kidney disease (or history of)
• Diabetes
• Heart failure
• Sepsis
• Hypovolaemia
• Age 65 years or over
• Use of drugs with nephrotoxic potential (for example,
NSAIDs, ACE inhibitors)
• Use of iodinated contrast agents within past week
• Oliguria
• Liver disease
• Limited access to fluids, e.g. via neurological impairment
• Deteriorating early warning scores
• Symptoms or history of urological obstruction

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 Risk factors: children and young people

As for adults, with the following additional risks:

• Abnormal or deteriorating paediatric early
warning score
• Young age, disability or cognitive impairment with
dependency on carers for access to fluids
• Severe diarrhoea, especially bloody diarrhoea
• Signs or symptoms of nephritis (for example,
oedema or haematuria)
• Haematological malignancy
• Hypotension

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 etiology

 Pre Renal
 Renal
 Post Renal

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 Assessing risk of AKI

• Acute illness:
– in adults
– in children and young people

 Adults having iodinated contrast agents

 Adults having surgery

 In patients with no obvious acute illness,

with risk factors

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 Acute kidney injury stages
AKI Serum creatinine criteria Urine output criteria
STAGE
1 Increase in serum creatinine of 26 Less than 0.5 ml/kg/hour
micromol/litre or more within 48 hours for more than 6 hours*
OR
1.5 to 2-fold increase from baseline

2 Increase in serum creatinine to more Less than 0.5 ml/kg/hour

than 2 to 3-fold from baseline for more than 12 hours

3 Increase in serum creatinine to more Less than 0.3 ml/kg/hour

than 3-fold from baseline for 24 hours or anuria for
OR 12 hours
Serum creatinine more than 354
micromol/litre with an acute increase of
at least 44 micromol/ litre
* Urine output of less than 0.5 ml/kg/hour more than 8 hours in children and young people

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 Detecting AKI
 Investigate for AKI when risks factors are present
 Compare serum creatinine with the patient’s baseline

Detect AKI using (p)RIFLE, AKIN, KDIGO criteria:

Serum creatinine rise ≥ 26 micromol/litre from baseline within

48 hours
Serum creatinine rise by 50% or more in 7 days

Urine output < 0.5ml/kg body weight/hour for 6

consecutive hours in adults

• Urine output < 0.5ml/kg/hour for more than 8 hours in children

and young people
• In children and young people – a 25% or greater fall in eGFR

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 AKI

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Interventions: iodinated contrast agents
in adults
Offer intravenous volume expansion to adults having
iodinated contrast agents if at increased risk of contrast-
induced AKI because:
They have any of the risk Or they have an acute
factors from slide 12 illness
Discuss care with a nephrology team before offering
iodinated contrast agent to adults with contraindications to
IV fluids if they:
Are at increased risk of Have an acute illness
contrast-induced acute kidney
injury
Are on renal replacement
therapy

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 Managing AKI

• Pharmacological management

• Relieving urological obstruction

• Referral

• Information and support for patients and carers

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 Relieving urological obstruction
• Refer all patients with upper tract urological
obstruction to a urologist.

• Immediate referral if one or more of following

present:
• Pyonephrosis
• Obstructed single kidney
• Bilateral upper urinary tract obstruction
• Complications of AKI secondary to urological obstruction

• When nephrostomy or stenting required – undertake

as soon as possible and within 12 hours of diagnosis

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 Referral
Nephrology:
Discuss AKI management with a nephrologist/paediatric nephrologist as
soon as possible (and within 24 hours) if one of the following is present:
Potential diagnosis requiring AKI with no clear Inadequate treatment
specialist treatment (for example, cause response
vasculitis or glomerulonephritis)
Complications associated with AKI Stage 3 AKI eGFR is less than < 30
ml/min/1.73 m2 after
AKI episode
Patients with renal transplant and CKD stage 4 or 5
AKI
Renal replacement therapy:
Refer adults, children and young people immediately for RRT if any of the
following are not responding to medical management:
Hyperkalaemia Metabolic Symptoms or complications Fluid overload
acidosis of uraemia such as +/- pulmonary
pericarditis or oedema
encephalopathy
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 Chronic kidney disease
stages
Stage eGFR
(ml/min/1.73m )
Description
2
Qualifier

1 ≥90 Kidney damage, Kidney damage

normal or increased (presence of
GFR structural
2 60–89 Kidney damage, abnormalities
mildly reduced GFR and/or persistent
haematuria,
3A 45–59 Moderately reduced proteinuria or
GFR +/- other microalbuminuria)
evidence of kidney for ≥3 months
damage
3B 30–44

4 14–29 Severely reduced GFR GFR < 60

+/- other evidence of ml/min/1.73 m2 for ≥
kidney damage 3months +/- kidney
damage
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