Acute Kidney Injury (AKI)

WHAT IS ACUTE KIDNEY INJURY(AKI) ? An abrupt decline in renal function defined by: An increase in serum creatinine > 26.5 umol/l within 48hours or > 1.9 times baseline known or presumed in the last 7 days OR A decrease in urine output to < 0.5ml / kg / hour for 6 hours or < 300mls in 12 hours

What is an adequate urine output? 60kg/ 30mls/ hr. 160 kg/ 80 mls /hr. 0.5ml per kg per hour looks different for different people

Morbidity and mortality from AKI AKI is associated with high mortality and adverse long-term outcomes and its prevalence in inpatients is believed to be rising. The NCEPOD report indicates that AKI risk factors are often not addressed and that a significant proportion of cases may be avoidable (NCEPOD 2009). Mortality ranges from 10 – 80% Renal Association (8th March 2011)

More than 20% of patients with an AKI will die rising to > 35% in those with AKI stage 3 (Think Kidneys) Uncomplicated AKI has a 10% mortality rate

Patient Risk factors for AKI AKI Risk Events Over 75 Have co-morbities such as Diabetes Heart failure Liver disease Peripheral vascular disease Chronic kidney disease Cognitive impairment Sepsis High risk medications Hypotension Hypovolaemia Major surgery Contrast scans Always treat underlying cause of the AKI

Signs and symptoms of AKI Evidence of dehydration Reduced urine output Changes to urine colour Nausea and vomiting Thirst Confusion or drowsiness

What can we do to: prevent, recognise and respond to an AKI Prevent Identify people at high risk of AKI Improved management of fluid prescription and fluid balance Reduce risk from medications Recognise IT solutions – algorithm and e-alerts Early recognition of deteriorating patients

Respond – Sepsis, hypovolaemia, obstruction, urinalysis, toxins Screen for sepsis or underlying cause. Assess and document fluid status Bladder scan and/or ultrasound Ensure urinalysis performed Stop/change high risk medications

High Risk Medications Be aware of medicines that may be harmful for your patient and may make them feel worse when they are already unwell ACE inhibitors e.g. Ramipril Angiotensin receptor blockers e.g. Losartan Metformin NSAID’s Diuretics Gentamicin/Vancomycin Certain medications can make our patients feel worse and it would be good if these could be avoided if possible The health professional teams will take an accurate history on admission and with support from the pharmacy team, will review medication

Why urinalysis? Simple , non-invasive easy to perform Early signs of kidney damage can cause protein and small amounts of blood to be leaked into your urine The earlier we spot and treat AKI the more chance we have of it not progressing

Healthy wee is 1 – 3 4 – 8 you MUST hydrate 

Importance of fluid balance Monitor fluid balance on a daily and cumulative basis Daily weights are also a good indicator of acute fluid loss or gain Accurately record fluid input and output

Summary Accurate recording of intake and output Urinalysis – urine colour Discontinuing and / or avoiding certain potentially high risk medicines Monitor NEWS and escalate as indicated for unwell patients Prevention, early identification and early management are key to preventing an AKI, reducing mortality and length of stay and improving our patient outcomes

NHS Tayside AKI video resource https://www.youtube.com/watch?v=gW0pgXrIdgo

References Adding insult to injury (2009) National confidential enquiry into patient outcome & death. http://www.ncepod.org.uk/2009aki.htm www.renal.org/guidelines www.thinkkidneys.nhs.uk/aki