Acute Kidney Injury (AKI)

Introduction to AKI for health care professionals

Louise Wild AKI Nurse Educator

Sarah Sampson AKI Nurse Educator

What is Acute Kidney Injury (AKI)?

• AKI is now the universal term used to describe sudden deterioration of renal function, and it replaces the previous term know as Acute Renal Failure (ARF)

• AKI is detected by monitoring creatinine blood levels, and urine output

Prevention, Recognition and early management

Risk Factors • Patients age is 65 and over • Patient has heart failure, liver

disease or diabetes • Chronic kidney disease – adults

with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 are at particular risk

• History of AKI • Multiple Myeloma

Risk Factors • Patients age is 65 and over • Patient has heart failure, liver

disease or diabetes • Chronic kidney disease – adults

with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 are at particular risk

• History of AKI • Multiple Myeloma

Insults • Hypotension (absolute

relative) • Sepsis • Use of iodinated contrast

agents (contrast scan) within the past week.

• Use of drugs with nephrotoxic potential such as:

• non-steroidal anti-inflammatory drugs (NSAIDs)

• aminoglycosides, e.g. Gentamicin

• angiotensin-converting enzyme (ACE) inhibitors, e.g. Ramipril

• angiotensin II receptor antagonists (ARBs), e.g. Losartan

• and diuretics

Insults • Hypotension (absolute

relative) • Sepsis • Use of iodinated contrast

agents (contrast scan) within the past week.

• Use of drugs with nephrotoxic potential such as:

• non-steroidal anti-inflammatory drugs (NSAIDs)

• aminoglycosides, e.g. Gentamicin

• angiotensin-converting enzyme (ACE) inhibitors, e.g. Ramipril

• angiotensin II receptor antagonists (ARBs), e.g. Losartan

• and diuretics

Identification Reduced urine output: • < 0.5mls/kg/hr for 6

hours (half body weight) Blood creatinine rise from baseline: • 26mmols rise within 48

hours • > 50% rise from baseline:

lowest value within 7 days, median value within 365 days

Identification Reduced urine output: • < 0.5mls/kg/hr for 6

hours (half body weight) Blood creatinine rise from baseline: • 26mmols rise within 48

hours • > 50% rise from baseline:

lowest value within 7 days, median value within 365 days

Management Plan Screen for Sepsis Toxins avoid/stop; • Review medication Optimise B/P –assess volume status; • Regular SHEWS monitoring • Should the urine output be monitored • Does the patient need IV fluids? • Hold antihypertensive’s Prevent Harm • Identify cause/urinalysis • Treat complications • Review medications/fluid • Daily U&Es, additional checks

following surgery or invasive procedures

• Patients identified as having AKI; “renal profile”, allows monitoring of bicarbonate in addition to creatinine and electrolytes

Management Plan Screen for Sepsis Toxins avoid/stop; • Review medication Optimise B/P –assess volume status; • Regular SHEWS monitoring • Should the urine output be monitored • Does the patient need IV fluids? • Hold antihypertensive’s Prevent Harm • Identify cause/urinalysis • Treat complications • Review medications/fluid • Daily U&Es, additional checks

following surgery or invasive procedures

• Patients identified as having AKI; “renal profile”, allows monitoring of bicarbonate in addition to creatinine and electrolytes

Risk Factors

• Patients age is 65 and over

• Patient has heart failure, liver disease or diabetes

• Chronic kidney disease – adults with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 are at particular risk

•History of AKI

•Multiple Myeloma

• Patients age is 65 and over

• Patient has heart failure, liver disease or diabetes

• Chronic kidney disease – adults with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 are at particular risk

•History of AKI

•Multiple Myeloma

• Hypotension (absolute relative) • Sepsis • Use of iodinated contrast agents

(contrast scan) within the past week. • Use of drugs with nephrotoxic

potential such as: • non-steroidal anti-inflammatory drugs

(NSAIDs) • aminoglycosides, e.g. Gentamicin • angiotensin-converting enzyme (ACE)

inhibitors, e.g. Ramipril • angiotensin II receptor antagonists

(ARBs), e.g. Losartan • and diuretics

• Hypotension (absolute relative) • Sepsis • Use of iodinated contrast agents

(contrast scan) within the past week. • Use of drugs with nephrotoxic

potential such as: • non-steroidal anti-inflammatory drugs

(NSAIDs) • aminoglycosides, e.g. Gentamicin • angiotensin-converting enzyme (ACE)

inhibitors, e.g. Ramipril • angiotensin II receptor antagonists

(ARBs), e.g. Losartan • and diuretics

Insults

Pre Renal AKI: Interruption to the blood flow to the kidneys due to severe injury or illness; Haemorrhage, Sepsis, Burns, Diarrhoea and vomiting, hypotension,

medications 60%

Pre Renal AKI: Interruption to the blood flow to the kidneys due to severe injury or illness; Haemorrhage, Sepsis, Burns, Diarrhoea and vomiting, hypotension,

medications 60%

Intrinsic AKI: Direct damage to the kidneys as a result of inflammation, toxins, drugs, infection or prolonged reduced

blood supply 10%

Intrinsic AKI: Direct damage to the kidneys as a result of inflammation, toxins, drugs, infection or prolonged reduced

blood supply 10%

Post renal AKI: sudden obstruction of urine flow i.e. enlarged prostate, tumour, kidney

stone, injury 30%

Post renal AKI: sudden obstruction of urine flow i.e. enlarged prostate, tumour, kidney

stone, injury 30%

Identification

• Reduced urine output:

• < 0.5mls/kg/hr for 6 hours (half body weight)

• Blood creatinine rise from baseline:

• 26mmols rise within 48 hours

• > 50% rise from baseline: lowest value within 7 days, median value within 365 days

• Reduced urine output:

• < 0.5mls/kg/hr for 6 hours (half body weight)

• Blood creatinine rise from baseline:

• 26mmols rise within 48 hours

• > 50% rise from baseline: lowest value within 7 days, median value within 365 days

Assessing urine output in the hospital If urine output is less than the minimum required output of 0.5mls/kg/hr (oliguria) as

per the identifying AKI criteria, medical staff need to be informed

None Catheterised Catheterised

• Always consider the urine output even if the patient is not catheterised.

• Explain to the patient the importance of monitoring urine output. Provide container to measure

• Record amount of incontinence; damp or saturated, weigh the pad

• Bladder scan as a none invasive intervention. Record findings

• Consider catheterising if patient shows signs of deterioration

• Report reduced urine output (oliguria) early so that appropriate management/treatments can be implemented

Assessing urine output in the community

Question the patient and or relatives: • Have you passed urine today? • How often? • Did it seem a normal amount for you? • What colour was it? • Have you been drinking ok? Other sources to gain information from: • Does the patient have regular carers (relatives and or

professionals)? • Do external carers have notes for assessments and

communication? Do you read them? • Do you communicate and advise carers or could you with

regards to hydration and urine output?

AKI Lab Alert (example from Sheffield Teaching Hospitals ICE system)

Management Plan • Screen for Sepsis

• Toxins avoid/stop; • Review medication • Optimise B/P –assess volume status; • Regular SHEWS monitoring • Should the urine output be monitored • Does the patient need IV fluids? • Hold antihypertensive medication • Prevent Harm • Identify cause/urinalysis • Treat complications • Review medications/fluid • Daily U&Es, additional checks following

surgery or invasive procedures • Patients identified as having AKI; “renal

profile”, allows monitoring of bicarbonate in addition to creatinine and electrolytes

• Screen for Sepsis • Toxins avoid/stop; • Review medication • Optimise B/P –assess volume status; • Regular SHEWS monitoring • Should the urine output be monitored • Does the patient need IV fluids? • Hold antihypertensive medication • Prevent Harm • Identify cause/urinalysis • Treat complications • Review medications/fluid • Daily U&Es, additional checks following

surgery or invasive procedures • Patients identified as having AKI; “renal

profile”, allows monitoring of bicarbonate in addition to creatinine and electrolytes

The AKI Care Bundle is for AKI Management and should be included in the notes for Patients Identified as having AKI at any stage

GP AKI Guidelines

Urinalysis to find the cause

if the patient shows signs of being unwell, perform a urinalysis and send relevant samples to the labs

• Albumin creatinine ratio (ACR)

or

• Protein creatinine ratio (PCR)

Samples to Clinical Chemistry

If signs of infection, leukocytes and nitrates in the urine send:

• Micro, culture and sensitivity (MC&S)

To microbiology

If protein and or blood present in the urine send:

Reason….. High PCR can suggests glomerular disease MSU can confirm infection

Key Points to take away

• AKI Risk Factors! Prevent

• Urine output! Identify

• Creatinine blood tests! Identify

• Finding and treating the underlying cause in a timely manner! Early management prevents long term consequences

• Identify and Treat life threatening complications • Hydration! Prevent/treat

• Medication review! Prevent/treat

• Patients! Inform/empower

Links for further information related to Acute kidney Injury (AKI)

NICE eLearning for intravenous fluid therapy in adults in hospital (If you choose to do the NICE eLearning, you need to register to NICE before you can access) : • http://elearning.nice.org.uk/enrol/index.php?id=6 NICE eLearning for intravenous fluid therapy in adults in hospital – CG 174 2013 reviewed 2017: • https://www.nice.org.uk/guidance/cg174/chapter/1-recommendations STH AKI eLearning (nurses, pharmacist and doctors eLearning available – consider doing any or all of them. The introduction is the same for all but then more specific includes case studies): • https://sheffieldpalms.org/course/index.php?categoryid=178

NICE AKI guidance (there is also a more in depth AKI eLearning available from NICE) • https://www.nice.org.uk/guidance/cg169 “Think Kidneys” website (recourse for secondary community and primary care): • https://www.thinkkidneys.nhs.uk/aki/

Guidance for medicines optimisation in patients with AKI (“Think Kidneys” website): • https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/07/Medicines-optimisation-

toolkit-for-AKI-MAY17.pdf