GGC Medicines


Adult Therapeutics Handbook

Management of Acute Kidney Injury (AKI)

Management of Acute Kidney Injury (AKI)

The following renal guidelines are also available on NHSGGC StaffNet:

  • Nephrotic syndrome
  • Patients receiving dialysis
  • Renal transplant recipients
  • Referral criteria to renal unit

See NHSGGC StaffNet / Clinical Info /Clinical Guideline Directory (link only active if accessing via NHS computer).

Table 1 – Stages of AKI

AKI stage Definition
I Rise in creatinine of ≥1.5–1.9 from baseline
II Rise in creatinine of ≥2–2.9 from baseline
III Rise in creatinine of ≥3 from baseline

Aetiology of AKI

This can be separated into pre-renal, renal and post-renal causes:

  • Pre-renal – hypotension, hypovolaemia, sepsis, drugs, contrast
  • Renal – glomerulonephritis (GN) and vasculitis
  • Post-renal – obstruction.

Assessment

If a patient has an AKI, consider RENAL:

Rule out sepsis

Exclude obstruction

Note urinalysis

Assess fluid balance

Look at drugs

Assessment / Monitoring

  • Ask about thirst and volume loss.
  • Check blood pressure, heart rate and urine output.
  • Assess for peripheral oedema, ascites and pulmonary oedema.
  • Check urinalysis and urinary protein:creatinine ratio.
  • If urinalysis positive for blood or protein then:
    • Request GN screen - ANCA, ANA, GBM, rheumatoid factor and C3/C4
    • In those aged >60 years also request serum electrophoresis, immunoglobulins and Bence-Jones protein.
    • Do virology testing (HCV, HBV, HIV)
  • Request renal tract ultrasound

Management

  • Management of pre-renal AKI focusses on optimisation of fluid balance and cardiovascular support.
  • If volume deplete, 5% glucose is not a suitable replacement fluid on its own. If a patient is well-filled and hypotensive, consider inotropes (seek senior advice).
  • Hyperkalaemia is a medical emergency and must be treated promptly.
  • Close attention should be paid to medication. Involve the clinical pharmacist or Medicines Information (see Appendix 6 for contact details).
  • For GN, specific treatment may be required. Discuss with the renal unit.
  • Renal obstruction always needs to be discussed with urology.
  • Dialysis - indications include resistant hyperkalaemia and fluid overload which is unresponsive to diuretics. 
  • Other indications for contacting the renal unit in AKI are stage 2 AKI that is not resolving after 24 / 48 hours and stage 3 AKI.  
  • If contract is necessary for any planned imaging and a patient has an AKI or CKD with an eGFR ≤30ml/minute/1.73m2 then:
    • the radiologist should be informed
    • consider administrating 1 litre of sodium chloride 0.9% 12 hours prior to and following the scan. Urgent and essential scans should not be delayed to allow fluid administration. 

Other Information

Poisoning as an indication for dialysis:

  • Consult TOXBASE (www.toxbase.org, password required) for up to date advice when managing all presentations of poisoning.
  • Many drug overdoses are capable of causing AKI, which may necessitate dialysis, however many drugs taken in overdose can be removed via dialysis even in the absence of AKI. 

 

Content last updated October 2019