REMEDY : BNSSG referral pathways

Acute Kidney Injury

Checked: 29-01-2018 by Rob.Adams Next Review: 29-01-2019

Summary

In the UK up to 100 000 deaths a year are associated with acute kidney injury. Up to 30% could be prevented with the right care and treatment. The NHS Think Kidneys AKI Program has been successful in raising awareness and driving improvements in management of this important condition.

From Monday 6th November 2017 the Biochemistry departments in UHB, NBT and Weston will begin reporting Acute Kidney Injury (AKI) warning stage results to primary care. Previously these results were available in ICE but not sent directly to GP systems. This development is part of a national programme to improve outcomes for patients with AKI by more reliably identifying them.

The renal physicians are available at North Bristol Trust and they have a web page for clinicians which has contact details and advice.

Principles of Management

Local Pathway

See the BNSSG & BaNES primary care pathways for AKI e-alerts in adult patients.

 

National Guidelines

The Think Kidneys website also has useful Guides for Primary care on recognition and management of AKI in primary care and when to refer:

Recommended response times and staging of AKI for adults in primary care

Recognising and responding to AKI for adults in primary care

Quick guide to potentially problematic drugs and actions to take in primary care

When to restart drugs after an episode of AKI

Patient Information

The website also has links to patient information including:

Leaflet for patients at risk of AKI

Leaflet for patients who have had AKI

 

Red Flags

Consider immediate review and admission if AKI warning Stage 3 particularly in the context of acute illness.

Consider admission if K+ is 6.5 or above.

AKI risk factors that should prompt earlier review include:

  • Poor oral intake/urine output

  • Evidence of hyperkalaemia, especially if moderate(K+ 6.0-6.4) or severe (K+ ≥ 6.5 - see above)

  • Known history of CKD stages 4 & 5 or history of kidney transplant

  • Deficient Immunity

  • Frail with co-morbidities (CKD, diabetes, heart failure, liver disease, neurological or cognitive impairment)

  • Past history of AKI

  • Suspected intrinsic kidney disease

  • Suspected urinary tract obstruction

Rapid access advice is also available from the SpR bleep (9578) via Southmead switchboard

Follow up

Coding

GPs should code an episode of AKI in the medical record. If a patient has an episode of AKI during a hospital stay then this is now highlighted on discharge summaries and should be coded appropriately.

Medication Review

Following identification of an episode of AKI it is recommended that a medication review should be undertaken within a month to ensure that any necessary medications are restarted where indicated or discontinued if indicated. At this review patients should also be advised about the use of OTC medication.

Guides to stopping and restarting drugs can be found in the primary care section of the Think Kidneys website.

Investigations and Monitoring

Not all patients will experience a return to full renal function after an episode of AKI. It is recommended that patients are reviewed after 3 months  to determine resolution, new onset or worsening  of pre-existing CKD. Patients should therefore have a follow up creatinine, eGFR, urine ACR and a blood pressure reading within  3 months of diagnosis.

Refer to CKD guidelines (Clinical Knowledge Summaries) to support management in primary care and get advice on when to refer.

Patient Information

Informing patients that they have had an episode of AKI and giving written information can help to minimise the risk of a future episode. Other information for patients is available on the Think Kidneys website