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Management of Acute Kidney Injury Pathway

Patient with Stage 1 or 2 Acute Kidney Injury

Complications of AKI?

Yes

Management of AKI
Complications
(Click on each for further information):

  • Hyperkalaemia (>6mmol/L)
  • Acidosis
  • Pulmonary Oedema
  • Reduced Conscious Level
  • Reduced Drug Clearance

Consider Critical Care Review (Bleep 703)

No

Follow Below

Investigation of AKI

  • Investigate the cause of all AKI unless
    multi-organ failure or obvious precipitant
  • Request ‘Renal Panel’ on CyberLab
  • Urine dipstick. If proteinuria is present
    perform urgent spot urine protein
    creatinine ratio (UPCR).
  • USS should be performed within 24 hours unless AKI cause is obvious or AKI
    is recovering. USS within 6 hours if
    obstruction is suspected.
  • Check liver function (hepatorenal),
    Venous Bicarbonate, CRP and CK
    (rhabdomyolysis). If platelets low do blood
    film/LDH/Bili/retics (HUS/TTP). If myeloma
    is suspected send a serum for
    electrophoresis (EPH) & Free Light
    Chains (SLCH).
  • If parenchymal kidney disease
    suspected check renal antibody screen

If Urinary Tract Obstruction on USS refer to Urology

If suspected Renal Parenchymal disease discuss with Renal Unit

Fluid therapy in AKI

  • Assess heart rate, blood pressure, jugular venous pressure, capillary refill (should be <3 secs), conscious level.
  • If hypovolaemic give bolus fluids (e.g. 250- 500mls) until volume replete with 1 hourly review of response.
  • Middle grade review if >2 litres Have been given and still oliguric.
  • If the patient is euvolaemic give maintenance fluids (estimated output plus 500mls).

Monitoring in AKI

  • Take arterial blood gas and lactate if venous bicarbonate is low or evidence of severe sepsis or hypoperfusion.
Follow Sepsis Pathway
  • Consider insertion of urinary
    catheter and measurement of
    hourly urine volumes.
  • Measure urea, creatinine, electrolytes and venous bicarbonate at least daily while creatinine rising.
  • Measure daily weights, keep
    a fluid chart and perform a
    minimum of 4 hourly
    observations.
  • Perform 4 hourly fluid
    assessments and check for
    signs of uraemia.

Contact Critical Care Outreach Team/Acute Response Team (ART) (Bleep 600) and parent team

AKI 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

  • Consider Urine Catheter
  • 2 hourly urine output (if catheterised)
  • 2 hourly observations
  • Repeat ABG, Creatinine and Electrolytes at 24 hours (sooner if patients condition worsens)

AKI Stage 2

Serum creatinine: Increase of
serum creatinine from baseline of
200-300%
Urine Output: <0.5ml/kg/hr for 12
hours

  • Urine Catheter
  • Hourly urine output
  • Hourly observations
  • Repeat ABG, Creatinine and
    electrolytes at 12 hours (sooner if
    patients condition worsens)
Senior review at < 6 hours

AKI 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

  • Urine Catheter
  • Hourly urine output
  • Hourly observations
  • Repeat ABG, Creatinine and electrolytes at 8 hours (sooner if patients condition worsens)
  • Senior review < 3 hours
Inform Critical Care/Renal Unit
of patient

Supportive AKI Care

  • Treat sepsis - in severe sepsis intravenous antibiotics should be administered within 1 hour of recognition. Follow Sepsis Pathway
Follow Sepsis Pathway
  • Stop NSAID/ACE/ARB/ metformin/K-sparing diuretics and review all drug dosages.
  • Give proton pump inhibitor and perform dietetic assessment.
  • Stop anti-hypertensives if relative hypotension. If hypovolaemic consider stopping diuretics.
  • Review other medications for risk of accumulation in renal impairment.
  • Avoid radiological contrast if possible. If given follow prophylaxis protocol.