Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Identifying acute kidney injury in patients with acute illness

  • Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in adults with acute illness if any of the following are likely or present:

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

    • heart failure

    • liver disease

    • diabetes

    • history of acute kidney injury

    • oliguria (urine output less than 0.5 ml/kg/hour)

    • neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer

    • hypovolaemia

    • use of drugs with nephrotoxic potential (such as non‑steroidal anti‑inflammatory drugs [NSAIDs], aminoglycosides, angiotensin‑converting enzyme [ACE] inhibitors, angiotensin II receptor antagonists [ARBs] and diuretics) within the past week, especially if hypovolaemic

    • use of iodinated contrast agents within the past week

    • symptoms or history of urological obstruction, or conditions that may lead to obstruction

    • sepsis

    • deteriorating early warning scores

    • age 65 years or over.

  • Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in children and young people with acute illness if any of the following are likely or present:

    • chronic kidney disease

    • heart failure

    • liver disease

    • history of acute kidney injury

    • oliguria (urine output less than 0.5 ml/kg/hour)

    • young age, neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a parent or carer

    • hypovolaemia

    • use of drugs with nephrotoxic potential (such as NSAIDs, aminoglycosides, ACE inhibitors, ARBs and diuretics) within the past week, especially if hypovolaemic

    • symptoms or history of urological obstruction, or conditions that may lead to obstruction

    • sepsis

    • a deteriorating paediatric early warning score

    • severe diarrhoea (children and young people with bloody diarrhoea are at particular risk)

    • symptoms or signs of nephritis (such as oedema or haematuria)

    • haematological malignancy

    • hypotension.

Assessing risk factors in adults having iodinated contrast agents

  • Before offering iodinated contrast agents to adults for emergency or non‑emergency imaging, assess their risk of acute kidney injury. Be aware that increased risk is associated with:

    • chronic kidney disease (adults with an eGFR less than 40 ml/min/1.73 m2 are at particular risk)

    • diabetes but only with chronic kidney disease (adults with an eGFR less than 40 ml/min/1.73 m2 are at particular risk)

    • heart failure

    • renal transplant

    • age 75 years or over

    • hypovolaemia

    • increasing volume of contrast agent

    • intra-arterial administration of contrast agent.

      Ensure that risk assessment does not delay emergency imaging.

Assessing risk factors in adults having surgery

  • Assess the risk of acute kidney injury in adults before surgery. Be aware that increased risk is associated with:

    • emergency surgery, especially when the patient has sepsis or hypovolaemia

    • intraperitoneal surgery

    • chronic kidney disease (adults with an eGFR less than 60 ml/min/1.73 m2 are at particular risk)

    • diabetes

    • heart failure

    • age 65 years or over

    • liver disease

    • use of drugs with nephrotoxic potential in the perioperative period (in particular, NSAIDs after surgery).

      Use the risk assessment to inform a clinical management plan.

Ongoing assessment of the condition of patients in hospital

  • When adults are at risk of acute kidney injury, ensure that systems are in place to recognise and respond to oliguria (urine output less than 0.5 ml/kg/hour) if the track and trigger system (early warning score) does not monitor urine output.

Detecting acute kidney injury

  • Monitor serum creatinine regularly[2] in all adults, children and young people with or at risk of acute kidney injury.

Identifying the cause(s) of acute kidney injury

  • Identify the cause(s) of acute kidney injury and record the details in the patient's notes.

Ultrasound

  • When adults, children and young people have no identified cause of their acute kidney injury or are at risk of urinary tract obstruction, offer urgent ultrasound of the urinary tract (to be performed within 24 hours of assessment).

Referring to nephrology

  • Discuss the management of acute kidney injury with a nephrologist or paediatric nephrologist as soon as possible and within 24 hours of detection when one or more of the following is present:

    • a possible diagnosis that may need specialist treatment (for example, vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma)

    • acute kidney injury with no clear cause

    • inadequate response to treatment

    • complications associated with acute kidney injury

    • stage 3 acute kidney injury (according to (p)RIFLE, AKIN or KDIGO criteria)

    • a renal transplant

    • chronic kidney disease stage 4 or 5.

Information and support for patients and carers

  • Give information about long-term treatment options, monitoring, self‑management and support to people who have had acute kidney injury (and/or their parent or carer, if appropriate) in collaboration with a multidisciplinary team appropriate to the person's individual needs.



[2] The GDG did not wish to define 'regularly' because this would vary according to clinical need but recognised that daily measurement was typical while in hospital.

  • National Institute for Health and Care Excellence (NICE)