Acute Kidney Injury in the Context of COVID-19 (Dr Sarah Grieve May 2020)
- AKI is a clinical and biochemical syndrome reflecting abrupt kidney dysfunction
- AKI stage is determined by acute changes to serum creatinine and / or urine output
- AKI usually occurs secondary to acute illness ( commonly sepsis) Identifying underlying acute illness causing AKI is key to establishing primary diagnosis.
Key tables below
Full versions in RCGP AKI thumbnail link below (and link right)
Click on image below for link to full RCGP Toolkit
Click on image below to access “Think Kidneys” Website with patient and primary resources
Acute Kidney Injury (AKI) in the Community (Rachael Lee 2019)
AKI – a rapid reduction in kidney function resulting in a failure to maintain fluid, electrolyte and acid-base homoeostasis. Approximately 65% of AKI starts in the community
Definition of AKI – Kidney Disease: Improving Global Outcomes (KDIGO)
AKI Stage 1 – Rapid increase in serum creatinine increase > 1.5-2 from baseline ± oliguria
AKI Stage 2 – Rapid increase in serum creatinine increase 2-3 from baseline ± oliguria
AKI Stage 3 – Rapid increase in serum creatinine increase > 3 from baseline ± oliguria / anuria
Oliguria is often not a feature of AKI
The KDIGO definition does not state a time period. But AKI usually occurs over days / weeks
The NHS is the first health system in the world to attempt to tackle AKI with a system-wide approach.
- Up to 100,000 deaths each year in hospital are associated with AKI
- Up to 30% of those deaths could be prevented with the right treatment and care
- 1 in 5 people admitted to hospital as an emergency has AKI
- 15 million people in the UK live with long term conditions which are more prevalent in older people placing them at greater risk of AKI
- The annual cost of AKI-related inpatient care in England is estimated at £1 billion, just over 1% of the NHS budget
Distinguishing AKI and CKD
- Most patients with Acute Kidney Injury (AKI) look unwell, may have hyperkalaemia (potassium > 6.0 mmol/L), and usually need admission or rapid review according to the guidance above.
- Patients with CKD usually look well, and may have other complications of CKD (eg anaemia, low calcium, high PTH etc).
- If hyperkalaemic, they may also need admission or rapid review. AKI on CKD exists and can have a mixture of all these features, and should be managed as AKI.
AKI Prevention in Primary Care – Medicines Sick Day Card (Salford Sick Day Card)
The primary aim is prevention of AKI through education of the patients (making them aware of their higher risk), regular medicines management reviews and sick day guidance.
Use the Salford Sick Day Card for vulnerable patients (especially the elderly, with polypharmacy, and CKD).
This asks the patient to stop a range of drugs including Metformin, ACE/ARB, NSAIDs and diuretics for a few days if they are feeling unwell (especially septic, eg fever, gastroenteritis, UTI).
The will probably need to restart them 24-48 hours later, when better, and eating and drinking normally or consult their GP if unsure
UHCW Acute Kidney Injury (AKI) Service
Dr Krishna Appunu Consultant Nephrologist (Bleep 4474)
Rachael Lee Advanced Nurse Practitioner & Lead Nurse (Bleep 5009)
Charlotte Trumper Clinical Nurse Specialist (Bleep 5233)
Outlier Registrar Bleep 4134
The Acute Kidney Injury (AKI) Service provides a clinical review of in-patients at UHCW that flag via the CRRS alert system as having an AKI 1, 2 or 3.
The service works closely with the parent teams to identify the cause(s) of AKI and decide upon an appropriate management plan.
All patients with AKI 2 or AKI 3, that have been reviewed by either the Advanced Nurse Practitioner or Clinical Nurse Specialist during their inpatient stay, are invited to a post discharge clinic 2-3 weeks post discharge.
- Monitor the renal function to ensure AKI has resolved to baseline
- Organise any further investigation
- Educate patient about their AKI (to aim to reduce or prevent further AKI’s episodes)
Patients that have an AKI 3 or are too sick to manage in Primary Care should be referred through the GP Liaison Team (02476 966223 or Bleep 1424)
Information to send with referral
- Medical History – including recent bloods, urinalysis, MSU, ACR,PCR results
- Previous tests of renal function and the dates these were done
- Medications including recent prescriptions or alterations
- Examination findings
- Imaging results – i.e. CXR, USS KUB, Contrast procedures
- Recent surgery – dates & complications