Guidelines for the recognition and treatment of Acute

Guidelines for the recognition and treatment of Acute Kidney Injury (AKI) in the adult Written by: Senior Sister (Acute Kidney Injury Educator ) Review date: October 2020 RWF-THT-OUT-GUI-6 Version no.: 1.0 Page 1 of 31

MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST

Guidelines for the recognition and treatment of Acute Kidney Injury (AKI) in the adult

Target audience: All Trust clinical staff

Main author: Senior Sister (Acute Kidney Injury Educator, Critical Care Outreach Team) Contact details: Tunbridge Wells Hospital ext 35395 / 35804

Maidstone Hospital ext 24392 / 24396

Other contributors: Acute Kidney Injury Strategy Group

Executive lead: Medical Director

Directorate: Critical Care Directorate

Specialty: Critical Care Outreach

Supersedes: Not applicable

Approved by: Trust Clinical Governance Committee

Ratified by: Trust Clinical Governance Committee, 12th October 2017

Review date: October 2020

Disclaimer: Printed copies of this document may not be the most recent version. The master copy is held on Q-Pulse Document Management System

This copy – REV1.0


Document history

Requirement for document:

To ensure evidence based practice is applied for all adult patients with an acute kidney injury.

Cross references (external):

1. London AKI Network Manual 2.0 (2015) (www.londonaki.net) 2. Adding insult to injury. A review of the care of patients who died in

hospital with a primary diagnosis of acute kidney injury (acute renal failure). National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). 2009.

3. NICE Clinical Guideline 169 (2013) Acute Kidney Injury: prevention, detection and management

4. NICE Clinical Guideline 174 (2014) Intravenous fluid therapy in adults in hospital

5. NICE Quality Standard 76 (2014) Acute Kidney Injury 6. UK Renal Association Clinical Practice Guideline on Acute Kidney

Injury. 2011. 7. Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice

Guideline for Acute Kidney Injury. 2011. 8. National Institute for Clinical Excellence (NICE) Clinical Guideline 50:

Recognition and Response to Acute Illness in Adults in Hospital. 9. Imaging for Acute Kidney Injury (acute renal failure): Good Practice

Recommendations from the National Imaging Board. 2010. 10. Joint UK Renal Association, Royal College of radiologists and British

Cardiovascular Intervention Society Guidance on prevention of contrast – induced acute kidney injury in adult patients (2014)

11. NHS England Stage 3 National Patient Safety Alert: Standardising the early identification of acute kidney injury (2014)

12. London Health standards on inter-hospital transfers (2014) 13. British Consensus Guidelines on Intravenous Fluid Therapy for Adult

Surgical Patients. BAPEN Medical, the association for Clinical Biochemistry, the Association of Surgeons of Great Britain and Ireland, the Society of Academic and Research Surgery, the UK Renal Association and the Intensive Care Society. 2008 – update 2011.

14. Pre-operative Assessment and Patient Preparation: The Role of the Anaesthetist. The Association of Anaesthetists of Great Britain and Ireland. 2010.

15. Guidelines for the Transfer of the Critically Ill Adult. UK Intensive Care Society. 3rd Edition 2011.

Associated documents (internal):

Intravenous Fluid Therapy Guidelines [RWF-OPG-PS15]

Clinical Management Guideline for Acute Hyperkalaemia [RWF-OPG-PS16]

Policy and Procedure for the Early Management of Sepsis and Septic Shock (Adult Patients) [RWF-OPPPPS-C-TIO10]

Kidney injury, Acute [STANDARD PRINT LEAFLET][RWF-OPLF-PPS162]

Kidney injury, Acute [LARGE PRINT LEAFLET][ RWF-OPLF-PPS163]


Keywords: Acute Kidney Injury Recognition Treatment

Guidelines

Version control:

Issue: Description of changes: Date:

1.0 Original Document October 2017


Contents

Flow diagram of procedure to be followed ............................................................... 5

1.0 Introduction and scope ...................................................................................... 6

2.0 Definitions / glossary ......................................................................................... 6

3.0 Duties .................................................................................................................. 7

4.0 Training and competency requirements .......................................................... 8

5.0 Procedure ............................................................................................................ 8

APPENDIX 1 .............................................................................................................. 28

Process requirements .............................................................................................. 28

4.0 Archiving .......................................................................................................... 29

APPENDIX 2 .............................................................................................................. 30

CONSULTATION ON: Recognition and treatment of Acute Kidney Injury (AKI) in the Adult ........................................................................................................................... 30

APPENDIX 3 .............................................................................................................. 31

Equality impact assessment .................................................................................... 31


Flow diagram of procedure to be followed

Risk, Prevention and Recognition Some AKI is predictable, preventable and/or recognised late

Risk assess for AKI

The risk of AKI is contributed to by an acute insult and background morbidity

Background Acute ‘STOP’ Elderly Sepsis & hypoperfusion CKD Toxicity Cardiac failure Obstruction Liver disease Parenchymal kidney disease Diabetes Vascular disease Nephrotoxic medications Previous AKI

Prevent AKI – The 4 M’s

Monitor patient

Vital signs & PAR score, blood tests, pathology alerts, fluid balance & urine volumes

Maintain circulation Hydration, resuscitation, oxygenation

Minimise kidney insults Nephrotoxic medications (e.g. NSAIDS, aminoglycosides, ACE/ARB, diuretics), surgery or

high risk interventions, iodinated contrast and prophylaxis, hospital acquired infection

Manage the acute illness E.g. Sepsis, heart failure, liver failure

↓ Recognise AKI

Creatinine ≥ 1.5 above baseline (AKI stage 1, 2 and 3), > 26 umols creatinine rise in 48 hours, 6 hours of oliguria

↓

Institute AKI care bundle (Section 5.2)


1.0 Introduction and scope

All adult patients that present with an Acute Kidney Injury must have care and treatment that follows this guidance.

This guideline is to be used by all clinical staff caring for adult patients with acute kidney injury.

This guideline applies to all staff caring for adult patients with acute kidney injury.

It is designed to help staff recognise and treat acute kidney injury in the adult in a timely fashion.

It aims to reduce acute kidney injury developed within the hospital environment.

2.0 Definitions / glossary

Acute Kidney Injury (AKI) is defined by a rapid decline in renal filtration function.

NCEPOD 2009 showed suboptimal care in 50% of AKI cases reviewed in the UK

AKI occurs in up to 20% of all hospital admissions

AKI leads to a significant increase in mortality, morbidity, complications, length of stay and care costs

AKI patients have a 30% mortality rate

30% of AKI cases can be prevented with simple interventions such as stopping nephrotoxic medications, urine dipstick, senior medical review, reassessment of U&E’s and creatinine levels, early identification of clinical deterioration

Acute Kidney Injury is staged 1, 2 or 3 according to the magnitude of creatinine rise from the patient’s own baseline creatinine (within the last year) +/- the severity of oliguria.

Kidney Disease: Improving Global Outcomes (KDIGO) staging systems for acute kidney injury define each stage as follows:

AKI stage 1

Serum creatinine:

Increase ≥ 26 µmol/L within 48 hours

or,

increase ≥ 1.5 – 1.9 x patient’s baseline serum creatinine.

Urine output : < 0.5 mls/kg/hr for > 6 consecutive hours

AKI stage 2

Serum creatinine:

Increase ≥ 2 – 2.9 x patient’s baseline creatinine

Urine output : < 0.5 mls/kg/hr for > 12 consecutive hours


AKI stage 3

Serum creatinine:

Increase ≥ 3 x patient’s baseline serum creatinine

or,

Increase ≥ 354 µmol/L

or,

started on renal replacement therapy regardless of stage

Urine output :

< 0.3 mls/kg/hr for > 24 consecutive hours

or,

Anuria for 12 hours

3.0 Duties

Evidence based practice must be practiced at all times by professionals caring for patients with an Acute Kidney Injury, ensuring that the patient’s best interest is at the core of all care.

This guideline applies to all clinical staff caring for adult patients with acute kidney injury.

3.1 Clinical Directors

It is the responsibility of all Clinical Directors to ensure the following:

All AKI stage 2 and 3 patients are reviewed by a Consultant within 14 hours of the AKI trigger

That all trust Grade Staff/Locums and trainees are aware of the Acute Kidney Injury care bundle and implement it as required

That all trust Grade Staff/Locums and trainees know how to escalate concerns and are able to obtain Senior review/advice as required

That all trust Grade Staff/Locums and trainees know how to obtain nephrology advise

That all trust Grade Staff/Locums and trainees understand that it is their individual responsibility to deliver evidence based care according to these guidelines

The episode of AKI is documented accurately in the patient’s healthcare record and on their electronic discharge summary

3.2 Acute Kidney Injury Educator / Critical Care Outreach Team

This team strives to improve the management of inpatients with acute kidney injury by:

Reviewing patients with AKI stage 2 and 3 and working with ward staff to implement the AKI care bundle.

Ensuring all AKI patients have AKI alerts on patient centre

Education of medical & nursing staff and patients

Audit

Research


3.3 Ward Managers / Unit Managers

It is the responsibility of all Ward Managers/Unit managers to ensure the following:

All new substantive staff have Acute Kidney Injury training

All nursing staff have an awareness of and are able to implement the AKI care bundle as required

All Registered Nursing staff know how to escalate concerns and are able to obtain Senior review as required

All nursing staff (of all grades) are competent and compliant with fluid balance monitoring and documentation on paper and Nervecentre

3.4 Medical and registered nursing staff

It is the responsibility of all medical and nursing staff across the trust to be able to:

Recognise patients at risk of developing an AKI and modifying care appropriately according to these guidelines

Recognise patients with an established AKI of any stage and implement the AKI care bundle according to these guidelines

Ensure patients (if appropriate) receive an AKI information leaflet

4.0 Training and competency requirements

Training is provided by the Acute Kidney Injury Educator and Critical Care Outreach team for all grades of clinical staff across all specialities. New junior doctors and nurses and physiotherapists have AKI training on induction to the trust

At present there are no competency requirements, however monthly audits take place so care can be monitored on a continuous basis throughout the trust.

Advice and guidance is also available from the AKI Educator and the Critical Care Outreach team ext 35391(TWH) / 24392 (MH).

5.0 Procedure

5.1 Causes, prevention and treatment

A) Causes

AKI is potentially reversible, however to achieve this, the cause must be found. There will always be an underlying cause of an AKI.

Causes fall under three headings:

Pre-renal – problems affecting the flow of blood before it reaches the kidneys (most common cause of AKI, approximately 60-70% of all cases)

- Dehydration: vomiting, diarrhoea, diuretics, blood loss.

- Disruption of blood flow to the kidneys: hypotension, sepsis, liver failure, cardiac failure, burns.

Post-renal – problems affecting the movement of urine out of the kidneys, also known as obstructive renal failure (rarest cause of AKI, approximately 5-10% of all cases)


- Obstruction of one or both ureters: kidney stones, cancer/tumours, medications that cause crystalluria ie. High dose sulfonamides.

- Obstruction at the bladder level: bladder stone, enlarged prostate, blood clot, cancer, neurological disorder of the bladder impairing its ability to contract.

Intrinsic renal – problem with the kidney tissue itself that prevents proper filtration of blood or production of urine (most complicated cause of AKI, approximately 20-30% of cases)

- Blood vessel diseases, blood clots in the vessels of the kidneys, trauma, glomerulonephritis, acute interstitial nephritis, acute tubular necrosis, polycystic kidney disease, toxins including nephrotoxic medications/contrast, rhabdomyolysis.

Think ‘STOP AKI’ : Sepsis and hypoperfusion (pre-renal), Toxicity (intrinsic renal), Obstruction (post-renal), Primary renal disease (intrinsic renal)

B) Prevention Assess the risk of a patient developing an Acute Kidney Injury.

Risk factors include:

Age > 65 years

Diabetes Mellitus

Chronic kidney disease (CKD)

Vascular disease

Cardiac failure

Liver disease

Sepsis

Abnormal hypotension – dehydration, medication induced, sepsis

Nephrotoxic medications (NSAIDS, aminoglycosides, ACE inhibitors, angiotens II receptor antagonists, diuretics) – See page 26 for further pharmacy guided information

Emergency surgery especially in the presence of sepsis or hypovolaemia

Intraperitoneal surgery

Previous AKI

C) Prevention and treatment – the 4 ‘M’s

Monitor patient

- 1-2 hourly observations / PAR score

- Strict hourly fluid balance chart

- Continuous monitoring if indicated

- Consultant review within 14 hours of AKI trigger time

- Medication review and nephrotoxic medication stopped or doses reduced as appropriate within 12 hours of AKI trigger time

- Serum U&E’s of all acute patients within 6 hours of arrival in hospital


- When an AKI is established repeat U&E’s within 24 hours or sooner if patient shows signs of deterioration and/or hyperkalaemia/acidosis

- Urine Dipstick within 24 hours

- Establish the cause of the AKI

- Renal imaging if no clear cause of AKI is established within 24 hours of its onset or within 6 hours if obstruction is suspected

- Consider urinary catheterisation

- Arterial blood gas if indicated

Maintain circulation

- Resuscitation

- Hydration – assess fluid status and administer appropriate IV fluids if the patient is unable to drink adequately. Ensure U&E’s are checked so appropriate fluids can be administered.

- Oxygenation as appropriate

Minimise kidney insults

- Stop or reduce doses of nephrotoxic medication as appropriate (see page 26 for further guidance)

- Avoid iodinated contrast

- Prevent hospital acquired infection

- Ensure patient is adequately hydrated

Manage the acute illness - E.g. Sepsis, heart failure, liver failure

5.2 AKI Care Bundle

This is to be undertaken with all patients presenting with AKI stage 1, 2 or 3.

AKI should be considered a medical emergency

ABCDE and volume status assessment

- Observations (HR, BP, RR, Temperature, SaO2, conscious level (AVPU/GCS), urine output and Patient at Risk (PAR) score

- Refer to Critical Care Outreach team if PAR score of 3 in 1 area or 5 in total - Assess fluid status (CRT, JVP) - Monitor urine output - Consider urinary catheter - Strict hourly fluid balance chart - Daily weight

- Does this patient have complications of AKI (hyperkalaemia, acidosis, uraemia), if so and unresponsive to medical treatment refer to Intensive care (See Clinical Management Guideline for Acute Hyperkalaemia)

- Is this patient showing signs of SIRS / shock / sepsis?

↓


Diagnose the cause(s) and treat – STOP AKI

Sepsis and hypoperfusion, Toxicity, Obstruction, Primary renal disease

Sepsis and hypoperfusion - Sepsis screening, sepsis 6 within 1 hour for red flag sepsis (See Policy and

Procedure for the Early Management of Sepsis and Septic Shock (Adult patients))

- Stop antihypertensives if relative hypotension - Fluid status assessment:

Underfilled Euvolaemic Overloaded

↓ ↓ ↓ Fluid bolus (250-500mls Maintenance fluids Get senior help of crystalloid) and review response. Senior review if remains oliguric after 2 litres of filling

(See page 17 and refer to Trust Intravenous fluid therapy guidelines)

Toxicity - Ascertain full drug history including contrast exposures - If poisoning AKI (e.g. lithium, ethylene glycol) get specialist renal and toxicity

help - Avoid further nephrotoxic insults if possible - Medication review: - Document Medication review by MDT in healthcare record - As appropriate for the patient stop NSAID e.g. Ibuprofen, Angiotensin (ACE)

inhibitors e.g. lisinopril , Angiotensin receptor blockers (ARB) e.g. Candesartan, Metformin, K-sparing diuretics and review drug dosages

- See ‘Drugs to be reviewed in AKI’ for further guidance (Page 26)

Obstruction - Ascertain any urological history. High index of suspicion of malignancy - Examine or bedside scan for bladder and consider urinary catheter - Perform renal tract imaging (Ultrasound or CT KUB) within 24 hours of the

AKI trigger unless a non-obstructive cause is clear. Otherwise document in the healthcare record why not indicated.

- Urgent renal imaging within 6 hours if obstruction / pyonephrosis is suspected, patient is oligo-anuric or a renal transplant patient

- If likely / suspected obstructed AKI refer to Urology - Target time to relief of obstruction is 12 hours after diagnosis or immediate if

infected


Primary renal disease - Ascertain relevant history e.g. autoimmune disease, myeloma, HUS/TTP - Urine dipstick (including protein and blood) within 24 hours of AKI trigger

for all AKI patients. Document results on the AKI care bundle sticker and on Nerve centre. Send CSU / MSU if abnormal. Gain early nephrology advise if protein ++ and blood ++ are present in the absence of infection and perform urgent urine protein creatinine ratio (PCR)

- Check CK (Rhabdomyolysis), CRP, FBC, if platelets are low do a blood film, bill, LDH, relics (HUS/TTP)

- Consider myeloma screen (Igs, Ig electrophororesis, serum free light chains, urine bence jones

- Consider renal immune screen (ANCA, anti-GBM, ANA, complement, rheumatoid factor, Igs)

- If likely / suspected primary renal injury refer to nephrology

↓

General supportive care and escalation

- Consultant review within 14 hours of the AKI trigger - Whilst creatinine is rising repeat Creatinine 2x daily, daily renal profile,

bone profile, venous bicarbonate, consider ABG. Daily renal profile thereafter - Observations (HR, BP, RR, Temperature, SaO2, conscious level

(AVPU/GCS) and Patient at Risk (PAR) score at least 4 hourly - Refer to Critical Care Outreach team if PAR score of 3 in 1 area or 5 in total - Assess fluid status regularly (CRT, JVP) - Monitor urine output hourly if catheterised - Consider urinary catheter - Strict hourly fluid balance chart - Daily weight - Avoid nephrotoxic medications if possible - Consider proton pump inhibitor - Consider dietetic review and nutrition - Monitor for complications, treat and escalate - Severe AKI (AKI 3) should be discussed with nephrology and critical care

regardless of cause.

↓ Follow up

- Ensure patient / carers have adequate support and information (Acute kidney Injury information for patients leaflet can be found on the Trust intranet)

- Monitor recovery to completion and ensure adequate follow up arrangements in place


5.3 Fluids*

ADULT MAINTENANCE FLUIDS

↓

Baseline requirements

50-100mmol sodium, 40-80mmol potassium, 1.5-2.5L water per 24 hours

(oral, enteral or parenteral route)

↓

Adjust estimated requirements according to changes in sensible or

insensible losses

Sensible losses (measurable)

Surgical drains

Vomiting

Diarrhoea

Urine

(Variable amounts

of electrolytes lost)

Insensible losses

Respiration

Perspiration

Metabolism

Pyrexia

Tachypnoea

(Mainly water lost)

↓

Monitoring

Regularly review hydration status

Daily weights

Fluid chart

Monitor electrolyte levels

↓

Fluids

Available parenteral solutions

(if required)

Hartman’s solution/Ringers lactate

Normal saline

5% dextrose

0.4%/0.18% dextrose/saline

Potassium usually added

ADULT RESUSCITATION OR REPLACEMENT FLUIDS

↓

Give according to clinical scenario

↓

General volume replacement or expansion

Give balanced crystalloid solutions (Hartman’s solution/Ringer’s lactate)

These contain small amounts of potassium.

Avoid in hyperkalaemia. In AKI only use these if closely monitoring potassium (HDU)

Or

Colloids

Avoid high molecular weight (>200kDA) starches in severe sepsis due to risk of AKI

Assess vital signs, postural blood pressure, capillary refill, JVP and consider invasive or

non-invasive measurement using flow-based technology

↓

Haemorrhage

Give blood and blood products

Balanced crystalloid or colloid may be given while blood awaited

(Clinical assessment as above)

↓

Severe free water losses

(Hypernatraemia)

5% dextrose

Or

4%/0.18% dextrose/saline

↓

Hypochloraemia

(vomiting, NG drainage)

Give normal saline

(Potassium repletion usually also required)

*Please also refer to ‘Intravenous Fluid Therapy Guidelines’ on the trust intranet


5.4 AKI complications Hyperkalaemia, Acidosis, Pulmonary oedema, Reduced conscious level

↓ Begin medical therapy and get help from the critical care team and nephrology (if

onsite)

↓ Hyperkalaemia

Medical therapy of hyperkalaemia is a transient measure pending imminent recovery in renal function or transfer to kidney unit or intensive care for renal

replacement therapy

If there are ECG changes give 10mls of calcium gluconate 10%

If bicarbonate < 22mmol/L and no fluid overload give 500mls 1.26% sodium bicarbonate over 1 hour

If K >6.5mmol/L or ECG changes give *insulin 10units in 50mls of 50% dextrose over 15 minutes and salbutamol 10mg nebulised (caution with salbutamol in tachycardia or

ischaemic heart disease).

*Insulin/dextrose and salbutamol only reduce ECF potassium for < 4 hours.

*Also refer to ‘Clinical Management Guideline for Acute Hyperkalaemia’ on the trust intranet

↓ Acidosis

Medical therapy of acidosis with bicarbonate should be reserved for emergency management of hyperkalaemia (as above) pending specialist help

PH < 7.15 requires immediate critical care referral

↓ Pulmonary oedema

Sit patient up and give oxygen (60-100% unless contraindicated)

Give frusemide 80mg IV if haemodynamically stable. Consider further bolus and infusion at 10mg/hour

Consider GTN 1-10mg/hour titrating dose if haemodynamically stable

↓ Reduced conscious level

Manage uraemic coma as per all reduced consciousness (manage airway) pending critical care transfer and renal replacement therapy

These are holding measures prior to specialist help from Critical Care or Nephrology services


5.5 Contrast Induced Nephropathy (CIN) prophylaxis

Assess risk

↓ High volume (>100mls) of iodinated contrast procedure

and

CKD with eGFR<60 (particularly diabetic nephropathy)

or

an AKI

Other risk factors (>65yrs, dehydration, heart failure, severe sepsis, cirrhosis, nephrotoxins (NSAIDS, aminoglycosides etc.).High volume or arterial contrast.

Risk factors are multiplicative

↓ Is contrast necessary?

↓ Yes

↓ Resuscitate to euvolaemia

↓ Give prophylaxis if high risk

Volume expansion (unless hypervolaemic) with normal saline or 1.26% bicarbonate

For example: IV Na bicarbonate 1.26% 3mls/kg/hr for 1 hour pre-procedure and 6 hours post-procedure

or

IV 0.9% normal saline 1ml/kg/hr 12 hours pre and 12 hours post procedure

↓ Minimise contrast, use low or iso-osmolar contrast

↓ Monitor renal function for 72 hours post procedure

If oliguria or rising creatinine refer to Critical Care / Nephrologist

NB there is no proven role for N-Acetly cysteine or post-contrast dialysis / CVVH.

Cessation of Metformin should be considered if serum Creatinine above reference range of eGFR<60.

Cessation of ACE inhibitors should be considered if acutely ill.


5.6 Perioperative AKI

Pre-operative AKI risk assessment

(Anaesthetic and surgical teams) in pre-assessment clinic or ward

↓ ASA score, consider pre-operative CPEX testing.

Consider pre-morbid factors: CKD, Diabetes, vascular disease, cardiac failure, liver failure.

In emergency surgery consider current patient stability/illness severity.

Type of surgery: If ‘major’ operation or known high risk (e.g. cardiac bypass, intraperitoneal surgery, likely heavy blood loss or involving pelvis or renal tract).

Risk of perioperative nephrotoxic medications.

↓ Consider pre-optimisation in ward or critical care area and scheduled post-operative

admission to critical care.

There is no role for the routine use of dopamine or frusemide in perioperative AKI prevention.

Discontinue or avoid nephrotoxic drugs if possible.

If risk of long-term renal insufficiency (e.g. Nephrectomy in CKD discuss with nephrology team)

Optimise circulation and oxygenation during surgery.

↓ Post-operative AKI risk assessment

↓ As per pre-op assessment: Assess surgery undertaken, blood loss, perioperative

haemodynamic stability, perioperative oxygenation and perioperative oliguria

↓ Monitor

Observations (Heart rate, blood pressure, temperature, respiratory rate, oxygen saturations, AVPU, urine output, PAR score, regular blood tests)

↓ Post-operative resuscitation as appropriate

↓ If post-operative AKI develops INSTIGATE AKI CARE BUNDLE AND REFERRAL

PATHWAY

↓ Consider and treat specific surgical causes

Blood loss, hypovolaemia, surgical sepsis, hypotension due to epidural or opiate anaesthesia, post- operative urinary retention or obstruction of the renal tract as a surgical

complication


5.7 Obstetric AKI Pathway Institute in all cases with creatinine > 90 ummols/L or serial creatinine rise of 26 ummol/L

or 20ml/hr urine for 12 hours (if PET excluded)

THIS POTENTIALLY IS A MEDICAL EMERGENCY

↓ Full set of physiological observations (HR/BP/RR/Sats/Temp/AVPU/urine output)

Assess for signs of shock/hypoperfusion (Low BP/high HR/confusion/pale & cold skin)

Review history and past results if MEOWS triggering – high flow oxygen, senior review/HDU/ITU

↓ Fluid therapy in AKI

If hypovolaemic give crystalloid 250mls, followed by 125ml/hr (caution with PET) and reassess

Catheterise if obstruction and measure hourly urine output

↓ Monitoring in AKI

Venous blood gas and lactate, U&E twice a day while creatinine rising, fluid chart, regular fluid assessment and observations

↓ Investigations in AKI

If proteinuria URGENT PCR

Ultrasound (Obstruction)

Liver profile, if low platelets blood film (fragmented RBC/PLT), LDH, Bilirubin, Reticulocytes

↓ Supportive AKI care

↓ Sepsis – ANTIBIOTICS within an hour. Review drug chart / thromboprophylaxis

↓ Causes – Think ‘STOP AKI’

Pre-renal Sepsis/hypovolaemia (PPH)

Renal toxicity NSAIDS, PET, HELLP, HUS, TTP

Post-renal obstruction or ureteric damage during delivery


5.8 Drugs to be reviewed in AKI

Key

Stop

Avoid if possible

Think about dose adjustment

Initial considerations: Is patient receiving medication that may impair renal function?

Consider holding during AKI

Contrast media – stop / avoid if AKI NSAIDS – stop if AKI - Ibuprofen, Diclofenac, Naproxen + others COX II inhibitors - stop if AKI - Celecoxib, Etoricoxib Angiotensin (ACE) inhibitors* - Ramipril, Lisinopril, Perindopril + others Angiotensin receptor blockers (ARB)* - Losartan, Candesartan, Valsartan, Irbesartan + others

Diuretics# - Furosemide, Bumetanide, Spironolactone + others

*may be advantageous to continue in certain situations – e.g. heart failure with good blood

pressure #may need to be stopped during AKI

Other groups to consider:

Analgesics Morphine - Codeine - seek specialist advice for alternatives Tramadol -

Antibiotic / Antifungals / Antivirals

Gentamicin (and other Aminoglycosides) – if use unavoidable reduce dose/increase dose interval

Vancomycin Co-Trimoxazole Amphotericin – use Ambisome® product if required Aciclovir Fluconazole

Hypoglycaemic Agents

Metformin – avoid if GFR < 30 ml/min

Gliclazide Glimepiride Sitagliptin Saxagliptin

Others Methotrexate

Lithium – avoid if possible – monitor levels – seek specialist advice

Allopurinol

Digoxin

Gabapentin, Pregabalin

THIS IS NOT AN EXHAUSTIVE LIST. A review of all medications should be undertaken by a doctor and/or pharmacist at the earliest opportunity (within 12 hours of an AKI being identified)

Adapted from:

“Think Kidneys” – Guidelines for Medicines optimisation in Patients with Acute Kidney Injury in Secondary Care https://www.thinkkidneys.nhs.uk/

ACUTE KIDNEY INJURY (AKI) - MEDICATION OPTIMISATION TOOLKIT (Renal Pharmacy Group March 2012)

https://www.thinkkidneys.nhs.uk/


5.9 AKI Care Bundle Checklist

Patient name:……………………………………………………………………........................................................

No.: ……………………………………..……………………… DOB: ……………………………………...................

URGENT ASSESSMENT YES NO NA

ABCDE and full set of observations

Oxygen therapy

PAR score

Critical Care Outreach called if triggering

DIAGNOSE THE CAUSE (S) YES NO NA

Sepsis and hypoperfusion

Toxicity

Obstruction

Primary renal disease

TREAT THE CAUSE(S) YES NO NA

Bolus fluid to restore hypovolaemia

Sepsis screening and antibiotics

Severe sepsis (red flag) antibiotics <1hour and ‘sepsis six

Relative hypotension stop antihypertensives

Nephrotoxic medications stopped/reduced

If obstruction confirmed referred to urology

Obstruction relieved

If primary renal disease suspected referred to nephrology

If indicated therapy for renal disease given

GENERAL SUPPORTIVE CARE AND ESCALATION YES NO NA

Maintenance fluid prescription and monitoring plan

Physiological monitoring plan

Maintenance drugs and dosages reviewed

Monitoring blood tests arranged

AKI REFERRAL AND ESCALATION YES NO NA

Referral pathway reviewed

Referred nephrology (AKI 3, no recovery, complications cause unclear or primary renal disease)

Referred local critical care (AKI 3, no recovery, complications)

FOLLOW UP YES NO NA

Patient / carer adequate support and information

Follow up arrangements in place and communicated to relevant clinicians

Signed: ………………………………………………………………………………

Date: …………………………………………………………………………………

Position: …………………………………………………………………………….


5.10 Causes of AKI checklist

‘STOP AKI’

Sepsis & hypoperfusion, Toxicity, Obstruction, Primary renal disease

Patient name:…………………………………………………………........................................

No.: …………………………………………………… DOB:………………………………..........

Sepsis and hypoperfusion YES NO NA

Severe sepsis

Haemorrhage

Dehydration

Cardiac failure

Liver failure

Renovascular insult (e.g. Arotic surgery)

Toxicity YES NO NA

Nephrotoxic drugs

Iodinated radiological contrast

Obstruction YES NO NA

Bladder outflow

Stones

Tumour

Surgical ligation of ureters

Extrinsic compression (e.g. Lymph nodes)

Retroperitoneal fibrosis

Primary renal disease YES NO NA

Glomerulonephritis

Tubulointerstitial nephritis

Rhabdomylosis

Haemolytic uraemic syndrome

Myeloma kidney

Malignant hypertension

Signed: ………………………………………………………………………………

Date: …………………………………………………………………………………

Position: …………………………………………………………………………….


5.11 Referral from the ward

All AKI All AKI

With With

Blood and protein +++ on dipstick Obstruction on USS

Possible autoimmune disease/glomerulonephritis (NB partially obstructed patients may have

Possible HUS/TTP, hypertension poisoning normal or high urine volumes)

Renal transplant and CKD stage 4/5

↓ ↓

Refer to local renal team Refer to local urology team

If transfer decided see AKI transfer policy If nephrostomy or stenting required proceed

immediately

↓

PROGRESSION TO AKI 3 or AKI 3 AT RECOGNITION or AKI COMPLICATIONS NOT RESPONDING TO MEDICAL TREATMENT and IMMINENT RECOVERY UNLIKELY

↓

Refer to:

CRITICAL CARE TEAM (essential if the patient is developing multi-organ failure)

and

LOCAL RENAL TEAM

↓

Institute AKI care bundle while transfer pending

Dataset needed for kidney unit referrals

U&E’s, calcium, phosphate, ABG/lactate, FBC, coagulation, LFT’s.

Heart rate, respiratory rate, blood pressure, oxygen saturations, AVPU/GCS, urine output.

AKI grade and premorbid creatinine level.

Urine dipstick.

Renal ultrasound results if obtained.

Co-morbid history.

MRSA status (if known).


5.12 Referral from the ward to the kidney unit checklist

The following data are required for referral to the local renal service.

Please use this checklist to ensure you have all the essential information.

Patient name:………………………………………………………..………………

Number:……………………………………..…….. DOB:………………………....

Past medical history

ABCDE assessment

Heart Rate

Blood Pressure

Oxygen Saturations

Respiratory Rate

AVPU or GCS assessment of conscious level

Current urine volume

Baseline renal function (if known)

Urea and electrolytes

Calcium

Phosphate

Arterial blood gas and lactate

Urine dipstick

USS result

MRSA status

Whether diarrhoea in the last 48 hours

Signed:………………………………………………………………

Date:………………………………………………………………….

Position:……………………………………………………………..

YES NO N/A


5.13 Transfer from ward to kidney unit (inter-hospital transfer)

The following is a guideline for whether patients are safe to transfer from a ward to a kidney unit in another hospital.

All AKI patients for transfer should be assessed by a senior (ST4+) doctor

Hyperkalaemia No ECG changes

K < 6.0mmol/L If K lowered to < 6mmol/l after presentation this must be potentially sustained (e.g. bicarbonate therapy or dialysis/CVVH) not transient therapy (insulin and dextrose)

Renal Acidosis

PH > 7.2. Venous bicarbonate > 12mmols/L

Lactate < 4mmols/L

Respiratory Respiratory rate > 11 and < 26/min

Oxygen saturations > 94% on not more than 35% oxygen If patient required acute CPAP must have been independent of this treatment for 24 hours

Circulatory

Heart rate > 50/min and < 120/min Blood pressure > 100mmHg systolic

MAP > 65mmHg Lactate < 4mmol/L

(Lower BP values may be accepted if it has been firmly established these are pre-morbid)

Neurological Alert on AVPU score or GCS > 12

If criteria not met then emergency referral to critical care team

Once stabilised follow ITU to acute kidney unit transfer guideline


5.14 Transfer from ward to kidney unit checklist

The following is to allow renal teams to screen referrals for transfer safety

All AKI patients for transfer should be assessed by a senior (ST4+) doctor

Patient name:………………………………………………………………………………

Number:………………………………………………….. DOB:………………………....

Potassium < 6.0mmol/L

PH > 7.2

Venous bicarbonate > 12mmol/L

Calcium (ionised > 1mmol/L, total > 2mmol/L

Lactate (< 4mmol/L)

Blood pressure (> 100mmHg)

MAP (> 65mmHg)

Heart Rate ( > 50/min and < 120/min)

Oxygen Saturations (> 94% on not more than 35% O2)

Respiratory rate (> 11/min and < 26/min)

AVPU Alert or GCS > 12

Assessed by a senior (ST4+) doctor

MRSA status

Diarrhoea in Last 48 hours

YES NO N/A


5.15 Referral from the ward to the intensive care unit

Refer to the intensive care unit and critical care outreach if the following are unresponsive to medical treatment:

Hyperkalaemia

Metabolic acidosis

Fluid overload

Pulmonary oedema

Symptoms or complications of uraemia (i.e. weakness, fatigue, nausea, vomiting, seizure, coma)

All referrals to intensive care should be Consultant to Consultant

Please refer to the ‘Critical Care Units at Maidstone and Tunbridge Wells Hospitals, Operational Policy and Procedure for the – Admission Process’ on the trust intranet


5.16 Referral from Critical Care to Nephrology

Referral for nephrology opinion is at the discretion of the consultant intensivist and generally not necessary in patients with AKI in the context of multi-organ failure.

Referral is recommended if:

Possibility of AKI as an initiating event (with subsequent systemic decompensation) i.e. AKI in early illness

Single organ failure

AKI with possible vasculitis, lupus or autoimmune disease

AKI in myeloma, malignancy or tumour lysis

AKI with unexplained pulmonary infiltrates / pulmonary haemorrhage

HUS / TTP

AKI in pregnancy

AKI with urological abnormalities

AKI with malignant hypertension

AKI with poisoning


5.17 Transfer from Critical Care to Kidney Unit

(Interhospital transfer)

Phone local renal team

↓ If the patient is accepted for transfer, a handover to critical care in receiving

hospital should be done and Critical Care Outreach informed

(Further discussion with receiving hospital intensivist not required if condition is stable or improving)

Below is a guideline for what would be considered a safe ITU to kidney unit transfer. These transfers should be discussed at senior level.

Metabolic

- Potassium < 6.0mmol/L - Ionised Ca > 1mmol/L - PH normal - Bicarbonate > 16mmol/L - Lactate normal

Respiratory

- Respiratory rate > 11 and < 26/min - Oxygen saturations > 94% on not more than 35% oxygen - If patient required acute CPAP must have been independent of this treatment for 24

hours - If ventilated < 1 week should have been independent of respiratory support for 48 hours - If longer term invasive ventilation should have been independent of all respiratory support

for 1 day of each week ventilated and for a period of no less than 48 hours

Circulatory

- Heart rate > 50/min and < 120/min - Blood pressure > 100mmHg systolic - MAP > 65mmHg - If given inotropes must have been inotrope independent for > 24 hours Neurological -Alert AVPU (unless stable, chronic neurological impairment)


APPENDIX 1 Process requirements

1.0 Implementation and awareness

Once ratified the PA to the Clinical Governance Team will email this policy/procedural document to the Corporate Governance Assistant (CGA) who will activate it on the Trust approved document management database on the intranet, under ‘Policies & guidelines’.

A monthly publications table is produced by the CGA which is published on the Trust intranet under ‘Policies & guidelines’; notification of the posting is included on the intranet “News Feed” and in the Chief Executive’s newsletter.

On reading of the news feed notification all managers should ensure that their staff members are aware of the new publications.

FY1 / FY2 training

Trust induction training

NELF

2.0 Monitoring compliance with this document

All AKI 3 patients are audited for in hospital care against 6 key items for enhancing quality;

- Consultant clinical review within 14 hours of AKI trigger

- Medication review within 12 hours of AKI trigger

- Repeat U&E’s within 24 hours of AKI trigger

- Physiological scoring undertaken with 24 hours of AKI trigger

- Renal imaging within 24 hours of AKI trigger

- Urine dipstick within 24 hours of AKI trigger

This is an ongoing audit of which data is sent to and analysed by the NHS Observatory.

AKI stage 1, 2 and 3 will also be audited for compliance with urine dipstick and urine output monitoring.

Patients at risk of developing an AKI according to NICE Clinical Guideline 169 (2013) will be audited for compliance with urine output monitoring.

A trust wide fluid balance chart audit will be undertaken

Bi monthly audit of 4 key items on the electronic discharge summaries is undertaken of patients with AKI to satisfy the requirements of the recent National AKI CQUIN. The 4 key items are as follows;

- Documentation of AKI stage

- Evidence of medication review in view of AKI

- Type of blood tests required on discharge from hospital

- Frequency of blood tests on discharge from hospital

3.0 Review These guidelines and all its appendices will be reviewed at a minimum of once every 3 years.


4.0 Archiving

The Trust approved document management database on the intranet, under ‘Policies & guidelines’, retains all superseded files in an archive directory in order to maintain document history.


APPENDIX 2

CONSULTATION ON: Recognition and treatment of Acute Kidney Injury (AKI) in the Adult

Please return comments to: Senior Sister (Acute Kidney Injury Educator)

By date: 10th October 2017

Job title: Date sent dd/mm/yy

Date reply received

Modification suggested?

Y/N

Modification made?

Y/N

The following staff MUST be included in ALL consultations:

Chief Pharmacist 27/9/2017 NA No NA

Medical Director 27/9/2017 NA No NA

Chief Nurse 27/9/2017 9/10/2017 No NA

Deputy Medical Director- Planned Care Division

27/9/2017 NA No NA

Deputy Chief Nurse 27/9/2017 NA No NA

Associate Director Quality & Governance

27/9/2017 NA No NA

Associate Director of Nursing – Planned Care Division

27/9/2017 NA No NA

All Clinical Directors 27/9/2017 4/10/2017 No NA

Associate Director of Nursing - Urgent Care Division

27/9/2017 NA No NA

Clinical Pathology Lead 27/9/2017 NA No NA

Critical Care Outreach Lead 27/9/2017 28/9/2-17 No NA


APPENDIX 3 Equality impact assessment

This policy includes everyone protected by the Equality Act 2010. People who share protected characteristics will not receive less favourable treatment on the grounds of their age, disability, gender, gender identity, marital or civil partnership status, maternity or pregnancy status, race, religion or sexual orientation. The completion of the following table is therefore mandatory and should be undertaken as part of the policy development, approval and ratification process.

Title of document Recognition and treatment of Acute Kidney Injury (AKI) in the Adult

What are the aims of the policy? To ensure the best practice in care for adult patients with an Acute Kidney Injury

Is there any evidence that some groups are affected differently and what is/are the evidence sources?

NA

Analyse and assess the likely impact on equality or potential discrimination with each of the following groups.

Is there an adverse impact or potential discrimination (yes/no). If yes give details.

Gender identity No

People of different ages Yes – these guidelines are for adults only

People of different ethnic groups No

People of different religions and beliefs No

People who do not speak English as a first language (but excluding Trust staff)

No

People who have a physical or mental disability or care for people with disabilities

No

People who are pregnant or on maternity leave

No

Sexual orientation (LGB) No

Marriage and civil partnership No

Gender reassignment No

If you identified potential discrimination is it minimal and justifiable and therefore does not require a stage 2 assessment?

Yes

When will you monitor and review your EqIA?

Alongside this document when it is reviewed.

Where do you plan to publish the results of your Equality Impact Assessment?

As Appendix 3 of this document

Documents

Guidelines for the recognition and treatment of Acute