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This page describes recognition and initial management of AKI for generalists. For specialist info, see AKI (specialist). Shortcut to this page:  bit.ly/aki-edren or edren.org/aki

 

ACUTE KIDNEY INJURY (AKI) PROTOCOL
Early Recognition (KDIGO criteria):
AKI 1: creatinine rise from baseline 1.5x or 26.5μmol/l, and/or oliguria (urine output <0.5ml/kg/hr for ≥6hrs)
AKI 2: rise of 2-3x baseline
AKI 3: rise of ≥3x baseline or 354μmol/l, or need for RRT

 

Consider potential causes

Sepsis
Hypoperfusion

  • Cardiac/liver failure
  • Haemorrhage
  • Dehydration

Drugs or contrast
Renal disease

  • e.g. Myeloma, rhabdomyolysis, glomerulonephritis

Obstruction

 

 

Assessment/Management

1. Correct hypovolaemia

  • Use small fluid boluses (250ml) of crystalloid initially (see fluid therapy)
  • Regularly reassess JVP, peripheral perfusion, BP, urine output

2. Address hypotension

  • If persistent once euvolaemic, consider CVP monitoring +/- vasopressors (HDU/ ITU?)

3. Manage hyperkalaemia

4. Review drugs

  • Stop any drugs which may contribute
  • Stop antihypertensives if BP low
  • Review all drug dosages in renal impairment

5. Urinary tract ultrasound

  • Consider if clinical suspicion of obstruction/abnormal renal tract

6. ALERT SENIOR STAFF EARLY

 

Required actions
1. Senior review
2. Updated renal function
3. Check historic renal function
4. Fluid balance assessment
5. Drug chart review
6. Urine dip (+/- protein:creatinine ratio)
7. Check acid/base (TCO2 /H+/pH)
8. Consider urinary tract ultrasound



 

Nephrology Referral

Consider specialist referral if:

  • Clinical suspicion of intrinsic renal disease (even if mild AKI)
    • Protenuria +/- haematuria
    • Absence of clear precipitant of AKI
    • Symptoms/signs suggestive of systemic disease
      e.g. rash, arthropathy, pulmonary infiltrates
  • Progressive renal impairment  
  • Refractory hyperkalaemia (≥ 6.5 mmol/L)
  • ≥ 60 nmol/L)+Refractory acidosis (H
  • Refractory pulmonary oedema
  • Renal transplant
  • Background CKD 4/5

 

AKI outcomes

AKI is a smoke alarm! It is associated with

  • Increased mortality
  • Longer hospital stay

But most patients don't die of renal failure. They die from their underlying condition.
And remember that too much fluid is a bad prognostic feature in AKI.

Further info

Fluid therapy - our page on the principles and practice

AKI (specialist) (specialist) - also has pointers to other sources of info, including for patients

 

 

 

 

 

Acknowledgements: Ailish Nimmo was the main author for this page, which was created in November 2017. Date last modified shown in footer.

Licensed under a Creative Commons LicenseCreative Commons Attribution 4.0 International License.

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This page last modified 08.12.2017 19:40 by ANT. edren and edrep are produced by the Renal Unit at the Royal Infirmary of Edinburgh and the University of Edinburgh. CAUTIONS and Contact us.