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Recognition of Acute Kidney Injury in Acute Admission Pathway

Acute admission (including emergency surgery)

Risk assess for AKI as soon as possible:

Clinical Condition Factors:
  • Age 65 yrs or more - Adult having iodinated contrast agents - CKD
  • Cardiac Failure - Liver Disease - Diabetes
  • Vascular disease - Nephrotoxic Medications - Nephrotoxic
  • Pigments (bilirubin, myoglobin)
Acute Condition Factors:
Follow ‘STOP’
  • Sepsis and hypoperfusion
  • Toxicity (medications)
  • Obstruction
  • Parenchymal kidney disease

 

Set and record targets for BP, HR, SpO2, temp, RR, conscious level and
urine output (if catheterised) and frequency of observations

Monitor

  • Full set of physiological observations (at least 4 hourly)
  • Fluid balance (at least 4 hourly)
  • Take admission bloods (U&Es, FBC. ABG if patient condition requires)

Review of admission blood tests <3 hours Raised creatinine, acidosis, hypokalaemia? Pathology alert flag for acute kidney injury

Yes

Manage the acute illness/event

  • Review observations
  • Review monitoring frequency
  • Review ABCDE interventions
  • Consider urine catheter

Assess severity of Acute Kidney Injury

No

Continue to monitor and recheck bloods daily

Stage 1

Serum creatinine:

Increase of Serum
creatinine ≥ 26 μmol/
L OR increase from
baseline of
150-200%


Urine Output:
<0.5ml/kg/hr for 6
hours

Acute Kidney Injury not requiring
immediate Renal support

Follow Management of Acute Kidney Injury Pathway

Stage 2

Serum creatinine:

Increase of serum
creatinine from
baseline of
200-300%


Urine Output:
<0.5ml/kg/hr for 12
hours

Acute Kidney Injury not requiring
immediate Renal support

Follow Management of Acute Kidney Injury Pathway

 

Stage 3

Serum creatinine: Increase of Serum creatinine > 400 μmol/L OR
increase of >300% from baseline
Urine Output: <0.3ml/kg/hr for 12 hours OR anuric > 6 hrs

 

Is the patient single (renal) organ failure?

Yes

Immediately discuss the following patients with Renal Care at
LTHTr (01772 716565):
Creatinine >400 μmol/L or >3x baseline
Hyperkalaemia (>6.0mmol/L)

  • No ECG changes.
  • If K lowered to <6.0 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 <12 mmol/L. - Lactate > 4 mmol/L. Respiratory
  • Respiratory rate >11 and < 26/min.
  • Oxygen saturations >94% on not more than 45% oxygen.
  • If patient required acute CPAP must have been independent of this treatment for 24 hrs. 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.

No

Refer to Critical Care (Bleep 703) patients that meet risk criteria but are physiologically unstable:

  • Hyperkalaemia
  • Acidosis
  • Requiring >45% face mask oxygen to maintain Spo2 >94
  • Hypotensive after
    • fluid resuscitation
  • Reduced Conscious Level