1. Acute Kidney Injury (AKI) Based on NICE Guidelines Tariq Rehman Consultant Physician

2. Presentation  Definition / Risk factors for AKI  Detection  Prevention  AKI Management Bundle  Guidance on seeking specialist opinion  Summary

3. Definition of AKI  Abrupt decline of renal function causing retention of nitrogenous waste products  Potentially reversible

4. ACUTE KIDNEY INJURY (AKI) ENCOMPASSES A WIDE SPECTRUM OF INJURY TO THE KIDNEYS, NOT JUST KIDNEY FAILURE Background  Detection is now based on monitoring level of serum creatinine with or without urine output  AKI is seen in 13–18% of all hospitalised people older people are at higher risk  NCEPOD in 2009 reported systemic deficiencies in the care of patients  Cost of inpatient NHS Kidney Care is high (estimated between £434 - £620 million/yr)

5. Risk factors for AKI (1)  eGFR <60 ml/min/1.73m2 or history of AKI  Heart failure, liver disease, diabetes  Oliguria (output <0.5ml/kg/hour)  Neurological or cognitive impairment/disability  Use of nephrotoxic drugs NSAIDs, aminoglycosides, ACE inhibitors, ARBs and diuretics etc.  Use of iodinated contrast agents within the past week  Symptoms or history of urological obstruction  Sepsis  Deteriorating NEWS  Age 65years or over

6. Risk factors for AKI (2) Identifying AKI in patients with no obvious acute illness  a rise in serum creatinine may indicate acute kidney injury  When patients with an illness without clear acute component has known risk factors for AKI, e.g. CKD, or urological disease

7. Risk factors for AKI Use of Iodinated Contrast Agents (3)  Before offering iodinated non-emergency imaging Measure eGFR or check eGFR result obtained in <3 months.  Before offering iodinated contrast agents, assess for presence of known risk factors.  Ensure risk assessment does not delay emergency imaging.  Risk of developing AKI should be included in the routine discussion with patients/relatives.

8. Risk factors for AKI for individuals undergoing Surgery (4)  Emergency surgery when the patient has sepsis or hypovolaemia  Intraperitoneal surgery  Patients with known risk factors for AKI  Use the risk assessment to inform a surgical management plan include the risks of developing AKI in the routine discussion of risks and benefits of surgery

9. Detection of AKI (1)  a rise in serum creatinine of 26µmol/litre or greater within 48hours  a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7days  a fall in urine output to less than 0.5ml/kg/hour for more than 6hours in adults  a 25% or greater fall in eGFR within the past 7days.  Monitor serum creatinine regularly in all people with or at risk of AKI

10. Severity of AKI is dependent on level of rise in Serum Creatinine compared to base line  Stage 1 >/= 26 µmol/L or 1.5 x baseline  Stage 2 > 2– 3 x baseline  Stage 3 > 3 x from baseline or serum creatinine >/= 350 umol/L (after a rise of 50µmol/L)

11. Prevention of AKI (1) On-going assessment of the condition of patients in hospital  NICE clinical guideline 50 recommends the use of track and trigger systems in monitoring acutely ill patients  NEWS to identify risk of AKI  When adults are at risk of AKI systems are in place to recognise and respond to oliguria if NEWS does not monitor urine output

12. Prevention of AKI (2) Offer intravenous volume expansion to adults having iodinated contrast agents if:  at increased risk of contrast-induced acute kidney injury because of risk factors  they have an acute illness Offer either isotonic sodium bicarbonate or 0.9% sodium chloride. consider temporarily stopping ACE inhibitors and ARBs in adults having iodinated contrast agents if they have CKD with eGFR <40  Discuss care with a nephrology team before offering iodinated contrast agent to adults with contraindications to intravenous fluids.

13. Prevention of AKI “monitoring” (3)  Consider electronic CDSS to support clinical decision making and prescribing  ensure they do not replace clinical judgement  In L&D, we seek opinion of senior colleagues Use alerts / (safe handover) for the healthcare professional to monitor and review Seek advice from a pharmacist about optimising medicines and drug dosing in adults, children and young people with or at risk of acute kidney injury.  Consider temporarily stopping all nephrotoxic agents till condition improves and stable

14. Identifying the cause/s of AKI (1)  Urinalysis urine dipstick testing  Document the results and ensure that appropriate action is taken  Think of acute nephritis and referral to the nephrology team when no obvious cause of AKI is identified Urine dipstick showing haematuria and proteinuria without UTI or trauma due to catheterisation.

15. Identifying the cause/s of AKI (2)  Ultrasound of Kidney/Urinary tract Do not routinely offer ultrasound  if the cause of the AKI has been identified. If pyelonephrosis is suspected  perform within 6hours of assessment When cause of AKI is not identified or at risk of urinary tract obstruction  perform within 24hours of assessment

16. Managing AKI key priorities (1)  Follow AKI management bundle  Relieve urological obstruction Refer to a urologist immediately if following is present:  pyelonephrosis  an obstructed solitary kidney  bilateral upper urinary tract obstruction  complications of AKI caused by urological obstruction.

17. AKI Management Bundle (2)  When you see an abnormal creatinine or AKI alert Confirm the results Simply follow Seven Steps (8S of AKI)

18. 7 Steps of AKI Management Bundle (3)  Confirm  Urgent senior review from your own team  Assess fluid status  Undertake full physiological observations (early warning score)  Urine dip  Stop nephrotoxic drugs  Daily U&Es  (Consider renal ultrasound and urinary catheter)

19. AKI Management Bundle (4) Step 1  Na 135  K 5.9  Ur 15.6  Creat 420 ICE “AKI Alert” (checking blood result) Confirm AKI & Stage the injury 1,2 or 3

20. AKI Management Bundle (5) Step 2 Urgent Senior Review  You do not have to be as old a SpR to provide a sound advice …. 64% of cases not reviewed by senior within 12 hrs in recent audit

21. AKI Management Bundle (6) Step 3 Assess fluid status

22. AKI Management Bundle (7) Step 4 National Early warning Score observations

23. AKI Management Bundle (8) Step 5 Urine dip Omitted in 58% cases in recent audit

24. AKI Management Bundle (9) Step 6 Remove ‘The usual suspects’ NSAIDS ACE I /ARBs Gentamicin Spironolactone X-ray contrast

25. AKI Management Bundle (10) Step 7 Monitor daily U&Es and urine output Omitted in 48% cases in recent audit

26. AKI Management Bundle Step 8 Consider ultrasound and urinary catheter (11)

27. AKI Management Bundle If AKI stage 2 or 3, or if anuric, or if not improving (12) Escalate  Medical SpR  Discuss with Consultant regarding nephrology YB or discuss with Renal SpR  Critical Care outreach If NEWS unstable or urgent dialysis support required

28. AKI Management Bundle (13) General Therapeutic Guidance  Do not routinely offer loop diuretics  Consider loop diuretics for treating fluid overload or oedema while awaiting renal replacement therapy or renal function is recovering without renal replacement therapy  Do not offer low-dose dopamine to treat AKI

29. AKI Management Bundle Indication of Renal Replacement Therapy (14)  Hyperkalaemia, metabolic acidosis, symptoms or complications of uraemia, fluid overload, pulmonary oedema.  Decision to start RRT should be based on the condition of patient as a whole and not on isolated urea, creatinine or potassium value.  If RRT is indicated, nephrologists' or critical care specialist should discuss the treatment with the patient or family/carer before starting treatment

30. AKI Management Bundle (15) Indications of Nephrology Opinion  Do not routinely refer If clear cause is known AKI is responding promptly to treatment  Refer/discuss ASAP if any of the following present Vasculitis, glomerulonephritis, tubulo-interstitial nephritis or myeloma AKI with no clear cause or inadequate response to treatment complications associated with AKI  Refer immediately only if meeting criteria for RRT  Refer / discuss all cases if AKI Stage 3 CKD 4 or 5 Previous renal transplant Doubt of benefit of RRT due to co-morbidities

31. Summary: AKI  Identify the risk Risk assessment  Prevention Follow principles of managing acutely ill patients  Detection Investigation  Management Remember to follow the Check List Monitor the response to treatment and consider in people not responding for  Renal Replacement therapy /ITU  Nephrology opinion / referral