Identifying and managing acute kidney injury
Intended for healthcare professionals
CPD    

Identifying and managing acute kidney injury

Christopher Stephen Clare Charge nurse, intensive care unit, Southmead Hospital, Bristol, England

Why you should read this article:
  • To enhance your knowledge of the pathophysiology, staging, and signs and symptoms of acute kidney injury

  • To familiarise yourself with treatments for acute kidney injury such as fluid management and renal replacement therapy

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Acute kidney injury, previously referred to as acute renal failure, is a common and often preventable condition that is seen in patients in acute and primary care settings. Nurses in both settings should be able to identify and assess patients at risk of acute kidney injury, and those with developing acute kidney injury, and understand the principles of clinical management. Early identification can assist in prevention of acute kidney injury, while supportive management and interventions can prevent further deterioration in patients diagnosed with the condition. This article describes acute kidney injury and outlines the pathophysiology, staging, and signs and symptoms. The author also describes the clinical management of patients with acute kidney injury and the long-term effects of the condition.

Nursing Standard. doi: 10.7748/ns.2022.e11938

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

ChrisSClare@googlemail.com

Conflict of interest

None declared

Clare CS (2022) Identifying and managing acute kidney injury. Nursing Standard. doi: 10.7748/ns.2022.e11938

Published online: 11 July 2022

Aims and intended learning outcomes

The aim of this article is to describe the presentation and clinical management of patients with acute kidney injury to enhance understanding and recognition of the condition among nurses in acute and primary care. After reading this article and completing the time out activities you should be able to:

  • Define acute kidney injury and describe its pathophysiology.

  • Discuss the long-term risk factors and clinical indicators of acute kidney injury.

  • Identify the signs and symptoms of developing acute kidney injury.

  • Discuss patient assessment in the context of prevention and/or early identification of acute kidney injury.

  • Describe the main elements of clinical management of patients with acute kidney injury.

  • Be aware of the potential long-term effects of acute kidney injury and the need for follow-up in the community.

Key points

  • Acute kidney injury is caused by various aetiologies that impair kidney function, such as hypoperfusion or infection, or direct injuries such as primary kidney disease or nephrotoxicity

  • Acute kidney injury can be identified through increased serum creatinine levels and reduced urine output, which emphasises the importance of monitoring urine output in the acutely unwell patient

  • The aim of management of a patient with acute kidney injury is to achieve haemodynamic stability, which will restore consistent kidney perfusion and limit further damage

  • Patients who experience acute kidney injury are at risk of developing chronic kidney disease, particularly if they have had repeated episodes

Introduction

Acute kidney injury, previously referred to as acute renal failure, is a broad clinical syndrome that ranges from mild kidney dysfunction to severe or life-threatening kidney impairment, described as a rapid-onset deterioration of kidney function. This deterioration can develop over hours or days and impairs the body’s ability to maintain homeostasis, electrolyte balance and acid-base balance (Kellum et al 2012). An episode of acute kidney injury can have long-term negative outcomes for patients, including chronic kidney disease and end-stage renal disease (O’Callaghan 2017).

Acute kidney injury is caused by various aetiologies that impair kidney function, such as hypoperfusion or infection, or direct injuries such as primary kidney disease or nephrotoxicity (Kellum et al 2012). It is a common condition seen in patients in acute and primary healthcare settings and, while harmful, is often avoidable and potentially reversible (Emmett et al 2017).

The condition is a significant burden on healthcare services globally. In the UK, acute kidney injury is present in 13-18% of all people admitted to hospital, with older people particularly susceptible, and costs the NHS an estimated £434-£620 million per year (National Institute for Health and Care Excellence (NICE) 2019). For low- and middle-income countries, it is estimated that acute kidney injury affects over 13 million people and contributes to 1.7 million deaths annually (Selby et al 2016).

Acute kidney injury is not restricted to adults and is a common condition in children admitted to hospital, particularly those who require critical care, and represents an independent risk factor for increased mortality and severe morbidity in this population (McCaffery et al 2017). Most cases start in the community; an estimated 60% of patients admitted to hospital with acute kidney injury have developed the condition at home (Emmett et al 2017).

There are many international and national guidelines on the management of patients with acute kidney injury. For example, the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines are the international standards of care for patients with this condition and aim to support healthcare practitioners to provide optimal evidence-based care for adults and children (Kellum et al 2012). In the UK, the NICE (2019) guideline on the identification, prevention and management of acute kidney injury supports the Renal Association clinical practice guidelines (Kanagasundaram et al 2019).

Alongside these guidelines, efforts have been made to raise public awareness of the condition. For example, the NHS Think Kidneys awareness programme (www.thinkkidneys.nhs.uk) provides evidence-based resources for healthcare professionals and the public. The International Society of Nephrology launched an initiative aimed at eliminating all preventable deaths from acute kidney injury to zero by 2025; the website (www.theisn.org/initiatives/the-0by25-initiative) provides information on how various countries are progressing with this target.

Because acute kidney injury can occur as a consequence of other health conditions or develop independently during an inpatient admission, patients may not be under the care of a renal specialist. Therefore, it is important that nurses working in acute and primary care can identify patients at risk of acute kidney injury, recognise the signs and symptoms of developing acute kidney injury and understand clinical management and treatment options to support positive patient outcomes.

Pathophysiology

The kidneys are a pair of bean-shaped organs located on the posterior wall of the abdominal cavity, each surrounded by a fibrous renal capsule to protect against trauma. The cortex – the outermost layer of the kidney – contains the glomeruli, proximal and distal convoluted tubules, and the first section of the collecting ducts (Waugh and Grant 2018). The medulla – the inner layer – contains the renal pyramids, which are separated by areas of darker connective tissue referred to as renal columns (Waugh and Grant 2018). Collectively, the glomeruli (tiny capilliaries), proximal and distal convoluted tubules, and the loops of Henle, are referred to as a nephron and comprise the functional components of the kidney that produce urine through filtration, selective reabsorption and secretions (Waugh and Grant 2018). The loops of Henle are u-shaped portions of the nephron that reabsorbs water, sodium and chloride from urine and are found in the cortex and medulla. Figure 1 shows the basic kidney structure.

Figure 1.

Basic kidney structure

ns.2022.e11938_0001.jpg

The primary function of the kidneys is to filter the waste products of metabolism from the blood and produce urine to excrete these products from the body. The kidneys receive around a quarter of the body’s cardiac output and in a healthy adult produce around 180L per day of glomerular filtrate, which is made up of water and metabolic waste. Around 95% of this filtrate is reabsorbed by the nephrons, while around 1.5-2L per day is excreted as urine (Waugh and Grant 2018).

The renal system has a significant role in the regulation of the body’s homeostatic state, performing several functions including (Waugh and Grant 2018):

  • Regulation of fluid and electrolyte balance.

  • Excretion of waste products such as urea, creatinine and uric acid, and toxic elements following the breakdown of drugs.

  • Regulation of acid-base balance.

  • Hormone secretion, for example renin and erythropoietin.

The kidneys are susceptible to damage because of the high concentration of toxins they are exposed to, while acute kidney injury can damage the cells of the renal tubule leading to tubular necrosis. Serum creatinine and urea are waste products of protein metabolism, which are formed in the liver and excreted almost exclusively in the kidneys and are used as biochemical markers of acute kidney injury (Waugh and Grant 2018).

To function effectively, the kidneys require a constant flow of oxygenated blood, sufficient blood pressure to drive the blood flow around the kidneys and an unobstructed urinary tract for drainage. In acute kidney injury, at least one of these three conditions is not met or there has been direct injury to the organ itself, for example as a consequence of a road traffic collision or fall, resulting in acute loss of kidney function (Leach 2014).

TIME OUT 1

Refresh your knowledge of the basic structure and function of the kidneys by explaining these to a colleague

Causes of acute kidney injury are classified as pre-renal, intra-renal (or intrinsic) or post-renal (O’Callaghan 2017). Figure 2 shows the classification of the causes of acute kidney injury.

Figure 2.

Classification of the causes of acute kidney injury

ns.2022.e11938_0002.jpg

Pre-renal acute kidney injury accounts for around 60% of diagnoses and relates to hypoperfusion of the kidney, for example through hypotension, hypovolaemia or renal artery occlusion (O’Callaghan 2017). Hypotension and hypoperfusion of the kidneys render them unable to autoregulate – that is, maintain constant blood flow and pressure – which can cause and exacerbate an existing acute kidney injury (Gameiro et al 2020).

Intra-renal causes include glomerular and tubular diseases, damage through direct injury or deformation of the kidney structures, for example due to primary kidney disease, ischaemic damage to the nephrons or through nephrotoxic medicines (O’Callaghan 2017).

Post-renal causes account for around 15% of incidences and refer to obstruction of the urinary tract, for example due to urinary tract tumours or urinary retention, resulting in back pressure on the kidneys, which inhibits glomerular filtration (O’Callaghan 2017).

The kidney is unable to create new nephrons and damaged nephrons have limited regenerative capacity, therefore timely recognition and intervention for patients with acute kidney injury is vital to preserve kidney function (Fine 2014).

TIME OUT 2

Reflect on a patient you have cared for with acute kidney injury. Was the cause classified as pre-renal, intra-renal or post-renal? What was the patient’s presentation in the context of these classifications?

Definition and staging of acute kidney injury

There are several algorithms that can be used to define and stage acute kidney injury, including the (paediatric) risk, injury, failure, loss, end-stage (RIFLE, p-RIFLE) and acute kidney injury network (AKIN) criteria (Lopes and Jorge 2013). However, the KDIGO guidelines (Kellum et al 2012), which are based on the RIFLE and AKIN criteria, provide an international common frame of reference for healthcare professionals to communicate the severity of acute kidney injury. The KDIGO guidelines define three stages of acute kidney injury using serum creatinine and urine output as markers. Table 1 lists the three stages of acute kidney injury.

Table 1.

Three stages of acute kidney injury

Stage Serum creatinine Urine output
1 1.5-1.9 times baseline*
or
≥ 0.3mg/dL (26.5µmol/L) increase
< 0.5mL/kg per hour for 6-12 hours
22-2.9 times baseline< 0.5mL/kg per hour for ≥ 12 hours
3 ≥ 3 times baseline
or
Increase in serum creatinine to ≥ 4 mg/dL (353.6 µmol/L)
or
Initiation of renal replacement therapy
or
Estimated glomerular filtration rate < 35 ml/min/1.73m for patients aged under 18 years
< 0.3 mL/kg per hour for ≥ 24 hours
or
Anuria ≥ 12 hours

*Known or presumed to have occurred in the past seven days ?Within the past 48 hours

(Kellum et al 2012)

Acute kidney injury can be identified through increased serum creatinine levels and reduced urine output, which emphasises the importance of monitoring urine output in the acutely unwell patient. Although serum creatinine is the accepted marker for acute kidney injury, it is acknowledged that it is not the most sensitive marker, hence the need for a dual approach to diagnosis (Selby et al 2016). Serum creatinine is used rather than the estimated glomerular filtration rate (e-GFR), which cannot be estimated accurately in patients with rapidly changing serum creatinine levels, such as those with acute kidney injury (Selby et al 2016).

Assessment of risk and prevention of acute kidney injury

Acute kidney injury is a complex, multifactorial syndrome and a single episode can be a result of several causes occurring at once. Up to 30% of all incidences of acute kidney injury are considered avoidable through early recognition of the risk of renal dysfunction, ensuring sufficient fluid repletion and avoidance of nephrotoxic medicines (Leach 2014). Therefore, it is essential to undertake a comprehensive assessment to identify patients at risk of acute kidney injury, to support diagnosis and thereby ensure early intervention to prevent further damage. NICE (2019) recommends that all patients scheduled to undergo surgery, those whose condition has deteriorated and those who require iodine-based contrast for imaging (intravascular iodine-based contrast agents can have a negative effect on kidney function) should be routinely assessed for risk of acute kidney injury.

Patient assessment

Treatment of the patient with acute kidney injury centres on supportive management and treating the cause of the condition, therefore assessment should include (Leach 2014):

  • Careful history taking of the patient’s presenting signs and symptoms and how the condition has progressed.

  • Identification of precipitating events, for example use of contrast for imaging (see contrast-induced acute kidney injury (CI-AKI) explained later in the article).

  • Medication review, to identify nephrotoxic medicines.

  • Full physical examination.

  • Hydration and elimination – this forms part of all holistic patient assessments and can alert nurses to patients at increased risk of acute kidney injury.

  • Fluid balance assessment.

  • Blood tests – to confirm acute kidney injury and to provide a baseline for ongoing monitoring. Patients with suspected acute kidney injury must have blood serum creatinine measured on admission, which must then be monitored.

  • Urine dipstick testing for blood, protein, leucocytes, nitrates and glucose – this should be undertaken in all patients with suspected acute kidney injury to screen for urinary tract infection. However, the presence of these elements are not confident markers of acute kidney injury (NICE 2019).

Table 2 summarises the long-term risk factors and acute indicators of acute kidney injury. For physiological assessment, the airway, breathing, circulation, disability, exposure (ABCDE), or other recognised examination tool, should be used (Smith and Bowden 2017).

Table 2.

Long-term risk factors and acute indicators of acute kidney injury

Long-term risk factors Acute risk factors
  • Chronic kidney disease and/or previous diagnosis of acute kidney injury

  • Age ≥ 65 years

  • Heart failure

  • Liver disease

  • Diabetes mellitus

  • History of, or currently taking, nephrotoxic medicines

  • Young age where hydration needs are met by carers

  • Neurological and/or cognitive defects where hydration needs are met by carers

  • Oliguria – urine output < 0.5 mL/kg per hour

  • Hypovolaemia

  • Recent administration of radio-contrast for imaging

  • Sepsis

  • Deteriorating vital signs

  • Symptoms, history or suspicion of urinary tract obstruction

(Adapted from McCaffery et al 2017, Gameiro et al 2020)

Computed tomography or ultrasound may be necessary depending on the suspected underlying causes, for example obstruction due to a tumour, and surgical referral may be required if there is a suspected physical defect or obstruction such as primary kidney disease or a tumour (Chávez-Iñiguez et al 2020). Patients with no identifiable underlying cause of acute kidney injury, and those admitted due to an existing nephrological condition, should be referred to nephrology teams (NICE 2019).

TIME OUT 3

How might you identify a patient with, or at risk of, acute kidney injury? What questions might you ask that could reveal long-term risk factors and/or acute indicators?

Prevention

Prevention of acute kidney injury in patients identified as being at risk can be achieved through monitoring fluid balance, encouraging oral fluid intake in those with a negative fluid balance since admission (unless the medical team has specified a negative fluid balance) and discussion with the multidisciplinary team. The multidisciplinary team can include dietitians to advise on addressing dietary concerns including fluid intake, pharmacists to identify and advise on changes to nephrotoxic medicines, and medical staff to consider alternative diagnoses.

Early identification and treatment of severe systemic infection using, for example the UK Sepsis Trust screening tools (Nutbeam and Daniels 2022), limits the risk of developing acute kidney injury. Similarly, the use of early warning systems such as National Early Warning Score 2 (Royal College of Physicians 2017) can enable nurses to identify deterioration in patients – an indicator of acute kidney injury – and communicate this to the multidisciplinary team (Gameiro et al 2020).

Signs and symptoms

Alongside reduced urine output and/or increased serum creatinine levels, there are generic signs and symptoms and clinical indicators of acute kidney injury as shown in Table 3. Nurses should be able to recognise these during assessment of a patient with suspected or confirmed acute kidney injury and refer them to the appropriate medical or nursing team.

Table 3.

Generic signs and symptoms and clinical indicators of acute kidney injury

Generic signs and symptoms Clinical indicators
  • Nausea, vomiting or abdominal pain

  • Thirst

  • Signs of dehydration, such as dry lips or tongue

  • General malaise, lethargy or feeling unwell

  • Confusion and drowsiness

  • Deteriorating vital signs

  • Electrolyte imbalance, for example increasing urea and/or serum creatinine levels

  • Fluid overload, for example symptoms of heart failure, pulmonary oedema

  • Local or systemic infection or sepsis

  • Urinary tract obstruction

(Adapted from Gameiro et al 2020)

TIME OUT 4

Using the ABCDE examination tool as a framework, what signs and symptoms and/or clinical indicators might be apparent in a patient with suspected acute kidney injury?

Contrast-induced acute kidney injury

CI-AKI occurs as a result of the use of contrast medium, usually iodine-based, for imaging and is a significant risk involved in imaging procedures (Ozkok and Ozkok 2017). Patients should be screened for risk of acute kidney injury before non-emergency imaging and alternative methods for obtaining diagnostic information should be explored if a risk is identified. Common strategies used to reduce the risk of CI-AKI include encouraging effective hydration and use of intravenous (IV) volume expansion before and after the imaging procedure, although there is little evidence to demonstrate the effectiveness of these strategies (Ozkok and Ozkok 2017).

Clinical management of the patient with acute kidney injury

The aim of management of a patient with acute kidney injury is to achieve haemodynamic stability, which will restore consistent kidney perfusion and limit further damage, as well as treating the underlying causes (O’Callaghan 2017).

Fluid management

For patients with an identifiable cause of fluid loss such as excessive haemorrhage, diarrhoea or vomiting, initial management should include reducing or preventing that loss through appropriate methods. For patients in whom fluid loss cannot be immediately stopped, fluid replacement should be used to match any fluid loss, and must be individualised and implemented with caution to avoid fluid overload (Ostermann et al 2019). The choice of IV fluid is dependent on the nature of fluid loss – for example, dehydration may result in loss of electrolytes as well as fluid – therefore patients may require crystalloid, colloid or blood product replacement (Kellum et al 2012).

Diuretics

In general, diuretics should not be used to treat acute kidney injury because these medicines can increase the severity of the condition and the risk of mortality (Kellum et al 2012). Encouraging increased urine production via diuretics can be harmful to already-damaged kidneys and further disrupt electrolyte levels (Hedge 2020). However, diuretics can sometimes be used with caution in the management of patients with fluid overload or hyperkalaemia (elevated potassium levels in the blood) (Hedge 2020).

Anti-hypotensive medicines

Anti-hypotensive medicines such as vasopressors, which cause vasoconstriction, and positive inotropic medicines, which increase heart contractility, may be required to achieve sufficient perfusion of the kidneys where fluid management is ineffective (Leach 2014). These medicines are delivered via continuous IV infusion to attain and sustain a target blood pressure to support the patient during management of the cause of the acute kidney injury or through recovery. Patients on continuous IV infusion of vasopressors or positive inotropic medicines require cardiovascular monitoring to ensure the target blood pressure is achieved without causing hypertension or hypotension, and to prevent other cardiovascular complications associated with these medicines such as cardiac arrhythmia or damage to small blood vessels. Therefore, this intervention would usually take place in a critical care setting (Leach 2014).

Medication review

Medicines are a precipitating factor in new and developing acute kidney injury in 20-40% of patients (Gameiro et al 2020). Certain medicines can induce or exacerbate acute kidney injury through nephrotoxicity, therefore patients may require dose adjustment, an alternative medicine or complete withdrawal of the medicine (Perazella 2019). Some of the most common medicines that should be avoided or may require dose adjustment in patients with acute kidney injury are shown in Box 1.

Box 1. Medicines that should be avoided or may require dose adjustment in patients with acute kidney injury

  • Angiotension II receptor blockers

  • Angiotension-converting enzyme inhibitors

  • Aminoglycoside antibiotics, for example gentamicin

  • Metformin hydrochloride

  • Non-steroidal anti-inflammatory drugs

  • Glycopeptise antibiotics, for example vancomycin

(Adapted from O’Callaghan 2017)

Biochemistry

Regular monitoring of electrolytes, acid-base balance, urea and serum creatinine should be undertaken as appropriate to the patient’s condition; as a minimum, patients should have daily blood tests (Kellum et al 2012). Advances in point-of-care testing mean some areas, such as critical care, can conduct regular monitoring of patients’ electrolyte levels to guide management.

Radio-contrast procedures

Not all patients with acute kidney injury require radio-contrast procedures, but for those who do, alternatives such as ultrasound should be considered to prevent the risk of CI-AKI (Ozkok and Ozkok 2017). If a radio-contrast procedure is required, medical staff should plan for the possibility of deteriorating acute kidney injury and nurses should be alert to the symptoms of deteriorating kidney function in these patients.

Renal replacement therapy

Patients with severe acute kidney injury such as stage three, or those who are critically unwell, may require extracorporeal renal replacement therapy (Richardson and Whatmore 2014). Extracorporeal renal replacement therapy is the process of removing or replacing fluid and solutes from the patient’s blood outside of their body, either continuously (haemofiltration) or in short sessions (haemodialysis).

Renal replacement therapy may also be required in patients who do not respond well to initial treatment or who have a life-threatening change or deterioration in their condition that would require organ support in critical care, for example fluid overload leading to pulmonary oedema, or hyperkalaemia resulting in cardiac arrest (Kellum et al 2012).

Intermittent haemodialysis and acute peritoneal dialysis may be used for patients with established end-stage renal disease; however, these interventions can place significant strain on the cardiovascular system. Continuous renal replacement therapy is the more common choice compared with intermittent therapy for those with acute kidney injury but who do not have end-stage renal disease, and is better tolerated by patients with cardiovascular disease irrespective of their underlying kidney function (Richardson and Whatmore 2014). Patients with end-stage renal failure may also be referred for continuous renal replacement therapy if it is decided that intermittent therapy will not be safe or will not adequately manage their acute kidney injury.

Nephrology referral

Routine referral to nephrology teams is not advised if the cause of acute kidney injury is identified and managed, and the patient is receiving safe and effective treatment (NICE 2019). However, NICE (2019) guidelines advise discussion with nephrology teams for patients with an uncertain cause of acute kidney injury, inadequate response to treatment, stage three acute kidney injury, those with renal transplants and those with stage four or five chronic kidney disease. Patients who may require renal replacement therapy must be referred to nephrology and critical care (NICE 2019).

TIME OUT 5

Clinical management of a patient with acute kidney injury aims to achieve haemodynamic stability, limit further damage and treat underlying causes. What interventions might be used to support clinical management?

Continuous renal replacement therapy in critical care

Several of the clinical management options for patients with acute kidney injury such as renal replacement therapies and IV antihypertensive medicines are labour-intensive and require constant review of the patient’s condition as well as specialist knowledge and equipment. In a ward environment this level of management is not always feasible, therefore some patients require transfer to critical care, particularly those who require continuous renal replacement therapy, which involves one-to-one nursing care, or anti-hypotensive infusions (Richardson and Whatmore 2014).

Continuous renal replacement therapy enables gradual, continuous removal of fluids and waste products in haemodynamically unstable patients and is a specialist, nurse-led intensive treatment (Richardson and Whatmore 2014). The aims of this treatment are to provide toxin clearance and fluid balance management, and management of electrolytes and acid-base balance. Patients who need continuous renal replacement therapy often require further cardiovascular support and may have dysfunction in other organs, for example respiratory failure requiring invasive ventilation. Therefore, critical care is the appropriate setting for such patients (Leach 2014). Box 2 lists the support that can be provided in critical care environments to patients with acute kidney injury.

Box 2. Support provided in critical care environments to patients with acute kidney injury

  • Multidisciplinary staff and multidisciplinary approach to management

  • Focused medicines management

  • Cardiovascular monitoring

  • Intensive fluid management and resuscitation

  • Monitoring of patients on intravenous inotrope and vasopressor infusions

  • Electrolyte monitoring and replacement

  • Continuous renal replacement therapy

  • Organ support, for example mechanical ventilation

(Adapted from Baid et al 2016)

Evaluation of clinical management in patients with acute kidney injury

Evaluation of the effectiveness of clinical management depends on the causes identified and the treatment provided. An acute episode of acute kidney injury is considered to be resolved when a patient produces urine output within normal parameters and their serum creatinine levels return to normal (Kellum et al 2012). Ongoing monitoring of biochemistry, urine output and physiological parameters during treatment will identify if the interventions have been effective and to what extent, as well as offering an early indication of whether further treatment options should be explored (O’Callaghan 2017). Improved physiological parameters, increased urine output, decreased serum creatinine to baseline levels and normalisation of other blood tests generally indicate that the acute kidney injury is resolving.

The underlying causes of the condition will have their own parameters that demonstrate improvement or deterioration, and nurses should be able to recognise condition-specific signs and symptoms (Gameiro et al 2020).

Long-term complications

Greater understanding of the effects of acute kidney injury has shown that resolution of acute illness does not remove the risk of further episodes or development of chronic kidney disease. Patients who experience acute kidney injury are at risk of developing chronic kidney disease, particularly if they have had repeated episodes, and significant injury can lead to end-stage renal disease and reliance on haemodialysis (Kellum et al 2012). Patients who experience acute kidney injury are also at risk of hospital re-admission within 90 days and at increased risk of further episodes of the condition (Royal College of General Practitioners (RCGP) 2022).

In the UK, general practice clinicians are expected to follow up patients who have had acute kidney injury after discharge from hospital to monitor and support the recovery of their kidney function (RCGP 2022). Important aspects of community care include the creation of a local register of patients who have had acute kidney injury to ensure primary care practitioners such as general practice nurse practitioners and community nurses can conduct effective medicines management and monitor patients’ kidney health. Nurses should also offer patients education on simple prevention strategies such as adequate hydration and lifestyle advice to improve their kidney health (RCGP 2022).

Conclusion

Acute kidney injury is a broad clinical syndrome that ranges from mild kidney dysfunction to severe or life-threatening kidney impairment. Following a diagnosis, patients are at risk of further episodes of acute illness and significant long-term effects such as chronic kidney disease, which may require them to commence haemodialysis. In many patients the condition can be identified at an early stage and progression can be prevented through proactive interventions such as monitoring fluid balance and encouraging oral fluid intake.

Effective management of patients with acute kidney injury can result in positive outcomes, however patients will require post-discharge follow-up in the community to support their recovery and to avoid further episodes. Nurses in acute and primary care settings are often the first clinicians to have contact with patients and are therefore well-placed to identify those at risk of acute kidney injury and those who have developing acute kidney injury. Nurses in both settings should, therefore, be able to identify and assess these patients and instigate or refer them for management and/or specialist intervention by nephrologists. Nurses can also support patient follow-up in the community.

TIME OUT 6

Identify how acute kidney injury applies to your practice and the requirements of your regulatory body

TIME OUT 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

References

  1. Baid H, Creed F, Hargreaves J ( Eds ) (2016) Oxford Handbook of Critical Care Nursing. Second edition. Oxford University Press, Oxford.
  2. Chávez-Iñiguez JS, Navarro-Gallardo GJ, Medina-González R et al (2020) Acute kidney injury caused by obstructive nephropathy. International Journal of Nephrology. doi: 10.1155/2020/8846622
  3. Emmett L, Tollitt J, McCorkindale S et al (2017) The evidence of acute kidney injury in the community and for primary care interventions. Nephron. 136, 3, 202-210. doi: 10.1159/000460266
  4. Fine LG (2014) Restoring the function of a diseased kidney via its microvasculature. Nephron Experimental Nephrology. 126, 2, 82-85. doi: 10.1159/000360672
  5. Gameiro J, Fonseca JA, Outerelo C et al (2020) Acute kidney injury: from diagnosis to prevention and treatment strategies. Journal of Clinical Medicine. 9, 6, 1704. doi: 10.3390/jcm9061704
  6. Hedge A (2020) Diuretics in acute kidney injury. Indian Journal of Critical Care Medicine. 24, Suppl 3, S98-S99. doi: 10.5005/jp-journals-10071-23406
  7. Kanagasundaram S, Ashley C, Bhojani S et al (2019) Clinical Practice Guideline Acute Kidney Injury (AKI). http://ukkidney.org/sites/renal.org/files/FINAL-AKI-Guideline.pdf (Last accessed: 21 June 2022.)
  8. Kellum JA, Lameire N, Aspelin P et al (2012) Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney International Supplements. 2, 1 , 1-138. doi: 10.1038/kisup.2012.1
  9. Leach R (2014) Critical Care Medicine at a Glance. Third edition. Wiley Blackwell, Chichester.
  10. Lopes JA, Jorge S (2013) The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review. Clinical Kidney Journal. 6, 1, 8-14. doi: 10.1093/ckj/sfs160
  11. McCaffery J, Dhakal AK, Milford DV et al (2017) Recent developments in the detection and management of acute kidney injury. Archives of Disease in Childhood. 102, 1, 91-96. doi: 10.1136/archdischild-2015-309381
  12. National Institute for Health and Care Excellence (2019) Acute Kidney Injury: Prevention, Detection and Management. NICE guideline No. 148. NICE, London.
  13. Nutbeam T, Daniels R (2022) Clinical Tools: Screening and Action Tools. http://sepsistrust.org/professional-resources/clinical-tools (Last accessed: 21 June 2022.)
  14. O’Callaghan C (2017) The Renal System at a Glance. Fourth Edition. Wiley Blackwell, Chichester.
  15. Ostermann M, Liu K, Kashani K (2019) Fluid management in acute kidney injury. Chest. 156, 3, 594-693. doi: 10.1016/j.chest.2019.04.004
  16. Ozkok S, Ozkok A (2017) Contrast-induced acute kidney injury: a review of practical points. World Journal of Nephrology. 6, 3, 86-99. doi: 10.5527/wjn.v6.i3.86
  17. Perazella MA (2019) Drug-induced acute kidney injury: diverse mechanisms of tubular injury. Current Opinion in Critical Care. 25, 6, 550-557. doi: 10.1097/MCC.0000000000000653
  18. Richardson A, Whatmore J (2014) Nursing essential principles: continuous renal replacement therapy. British Association of Critical Care Nurses. 20, 1, 8-15. doi: 10.1111/nicc.12120
  19. Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. http://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 (Last accessed: 21 June 2022.)
  20. Royal College of General Practitioners (2022) Acute Kidney Injury Toolkit. http://www.rcgp.org.uk/aki (Last accessed: 21 June 2022.)
  21. Selby NM, Fluck RJ, Kolhe NV et al (2016) International criteria for acute kidney injury: advantages and remaining challenges. PLOS Medicine. 13, 9, e1002122. doi: 10.1371/journal.pmed.1002122
  22. Smith D, Bowden T (2017) Using the ABCDE approach to assess the deteriorating patient. Nursing Standard. 32, 14, 51-63. doi: 10.7748/ns.2017.e11030
  23. Waugh A, Grant A (2018) Ross & Wilson Anatomy and Physiology in Health and Illness. 13th edition. Elsevier, Edinburgh.

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