Management of AKI

Management of Acute Kidney Injury in Adults
Version 1.0
This guideline recognises and respects the right for all patients, their families and carers, to
be treated with honesty, privacy and dignity at all times.
Purpose: To advise and inform all hospital staff, patients and the wider community of the
hospitals overarching policy for the management of patients with AKI
For use by: All Clinical staff
This document is London AKI Network manual (2012), www.londonaki.net accessed on

compliant with/supports 3/09/2014.
compliance with:
National Institute For Clinical Excellence Clinical Guideline 169. Management
of AKI up the point of Renal Replacement Therapy (August 2013)
National Institute for Clinical Excellence Quality Standard on Management of

AKI (May 2014).
NHS England
This document New clinical guideline

supersedes:
Approved by: Initial approval by: Division 2 Governance Board (date)

Patient Safety & Clinical Effectiveness Group
Approval date: 17/06/2016
Notified to: Healthcare Governance Committee
Date Notified: 17/06/2016
Implementation date: 18/07/2016
Review date: 17/06/2017
In case of queries contact Consultant in Nephrology

Responsible Officer
Division/Department: Division 1 Acute and Emergency Medicine
Archive date ie date To be inserted by Information Governance Department when this document is
guideline no longer in superseded. This will be the same date as the implementation date of the new
force document.
Date document to be To be inserted Information Governance Department when this document

destroyed ie 10 years after superseded
archive date
Registered Document 1857 Page 1 of 20

Management of Acute Kidney Injury in Adults Guideline v 1.0 Implementation Date 18 July 2016
Version and Document Control:
Version Date of Change Description* Authors

Number Issue
0.1 01/2016 First Draft Dr Ande/ Dr Kitchen/Dr
Lewis/ RN Markose
1.0 Final Document
This is a Controlled Document
Printed copies of this document may not be up to date. Please check the hospital intranet
for the latest version and destroy all previous versions.
Hospital documents may be disclosed as required by the Freedom of Information Act 2000.
Sharing this Document with Third Parties
As part of the hospitals networking arrangements and sharing best practice, the hospital
supports the practice of sharing documents with other organisations. However, where the
hospital holds copyright to a document, the document or part thereof so shared must not be
used by any third party for its own commercial gain unless the hospital has given its express
permission and is entitled to charge a fee.
Release of any strategy, policy, procedure, guideline or other such material must be agreed
with the Lead Director or Deputy/Associate Director (for hospital-wide issues) or Division
/Departmental management Team (for Divisional or Departmental specific issues). Any
requests to share this document must be directed in the first instance to Dr Ande, Dr Lewis,
Dr Kitchen, RN Manju Markose Critical Care Outreach team.

CONTENTS
Page No
SECTION 1 - INTRODUCTION ..................................................................................... 4
1.1 Clinical Guideline statement and rationale .......................................................................... 4
1.2 Key Principles ...................................................................................................................... 4
1.3 Background Information ...................................................................................................... 4
1.4 Definitions ............................................................................................................................ 4
SECTION 2 - DUTIES AND RESPONSIBILITIES ......................................................... 5
SECTION 3 - ASSESSMENT OF ACUTE KIDNEY INJURY (AKI) ................................ 6

3. Assessment of AKI ............................................................................................................... 6
3.1 Identifying AKI in patients with acute illness ......................................................................... 6
3.2 Assessing risk factors in adults having iodinated contrast agents ....................................... 6
3.3 Assessing risk factors in adult patients having surgery ....................................................... 7
3.4 Identifying AKI ...................................................................................................................... 7
3.4.1 Identifying AKI in patients with acute illness ......................................................................... 7
3.4.2 Identifying AKI in patients with no obvious acute illness ...................................................... 8
3.5 Preventing AKI ..................................................................................................................... 8
3.5.1 Ongoing assessment of the condition of patients in hospital ............................................... 8
3.5.2 Preventing AKI in patients having iodinated contrast agents ............................................... 8
3.5.3 Monitoring and preventing deterioration in patients with or at high risk of AKI .................... 9
3.6 Detecting AKI ....................................................................................................................... 9
3.7 Identifying the cause(s) of AKI ............................................................................................. 9
3.8 Managing AKI ..................................................................................................................... 10
3.8.1 Pharmacological management .......................................................................................... 10
3.8.2 Referring for renal replacement therapy ............................................................................ 10
3.8.3 Referring to nephrology...................................................................................................... 10
3.9 Referring to the Critical Care unit ....................................................................................... 11
SECTION 4 - TRAINING & EDUCATION INCLUDING MAINTENANCE OF CLINICAL

COMPETENCE ............................................................................................................11
SECTION 5 - DEVELOPMENT AND IMPLEMENTATION INCLUDING

DISSEMINATION .........................................................................................................12
SECTION 6 - MONITORING COMPLIANCE & EFFECTIVENESS ..............................12
SECTION 7 - CONTROL OF DOCUMENTS INCLUDING ARCHIVING

ARRANGEMENTS .......................................................................................................13
SECTION 8 - SUPPORTING COMPLIANCE AND REFERENCES ..............................13
APPENDIX 1 - INVESTIGATE FOR AKI ......................................................................15

APPENDIX 2 - AKI CARE BUNDLE.............................................................................16
APPENDIX 3 - CONTRAST INDUCED NEUROPATHY (CIN) PROPHYLAXIS............17
APPENDIX 4 - RISK, PREVENTION AND RECOGNITION .........................................18
APPENDIX 5 - AKI COMPLICATIONS.........................................................................19
APPENDIX 6 - AKI CHECKLIST ..................................................................................20

SECTION 1 - INTRODUCTION
1.1 Clinical Guideline statement and rationale

Acute Kidney Injury (AKI) is a condition where there is partial or complete loss of
kidney function over hours or days (Academy of Medical Royal Colleges AKI
Competency Framework, 2010). However, Johnson and Gustin (2011) identified that
the impact is greater if the loss of kidney function last days rather than hours in terms
of renal function recovery and long term mortality. This guideline requires the
clinician to take responsibility for identifying patients with AKI or at risk of AKI and
initiating treatments in a timely fashion to attenuate its impact, promote recovery and
prevent from further progression of the disease (LAKIN 2010, Alkhatib et al 2009).
There have been concerns that suboptimal care may contribute to the development
of AKI. In 2009, the National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) described systemic deficiencies in the care of patients who died from AKI,
with only 50% receiving 'good' care. Other deficiencies in care included failures in
prevention, recognition, treatment and timely access to specialist services.
The recommendations in this guideline emphasise early intervention and the

importance of risk assessment and prevention, early recognition and treatment.
They aim to address known and unacceptable variations in recognition, assessment
and initial treatment. Prevention or amelioration of just 20% of cases of AKI would
prevent a large number of deaths and substantially reduce complications and their
associated costs (NICE 2013).
1.2 Key Principles

Risk assessment is essential
Institute AKI care bundle on all patients who are identified as having AKI
Ensure that AKI check list on clerking proforma is completed
1.3 Background Information

AKI is seen in 1318% of people admitted to hospital, with older patients and those
with other co-morbidities being particularly affected. Patients are usually under the
care of healthcare professionals practising in specialties other than nephrology. The
number of inpatients affected by AKI means that it has a major impact on healthcare
resources (such as Intensive care, RRT, longer duration of stay and progression of
disease to CKD).
1.4 Definitions
ABBREVIATION DEFINITION
ACEI Angiotensin-Converting Enzyme Inhibitors
AKI Acute Kidney Injury
ARB Angiotensin II Receptor Blockers
BP Blood Pressure
CCOT Critical Care Outreach Team
CKD Chronic Kidney Disease
CRP C Reactive Protein
eGFR estimated Glomerular Filtration Rate
MEWS Modified Early Warning Score

NCEPOD National Confidential Enquiry into Patient Outcome and Death
NICE National Institute for Health and Care Excellence
NSAIDs Non-steroidal anti-inflammatory drugs
RR Respiratory Rate
RRT Renal Replacement Therapy
Sr Cr Serum Creatinine
U Urea
SECTION 2 - DUTIES AND RESPONSIBILITIES
2.1 The responsible officers for this document are Dr Praveen Ande (Consultant
Nephrologist), Dr Robert Lewis (Consultant Anaesthetist), Dr Jessica Kitchen
(Consultant Acute Medicine, Nephrologist), and Manju Markose RN (Critical Care
Outreach Practitioner)
2.2 Patient Safety & Clinical Effectiveness Group will approve this document in
accordance with the Trust policy.
2.3 All Clinical Directors, Heads of Nursing/Midwifery Matrons, Ward Sisters/Charge

Nurses/Heads of Departments and other line managers
To be responsible for the implementation of, and compliance of this guideline in

the
To ensure that this guideline is accessible to staff members in the form of a paper
copy or through the intranet and update staff of changes to the guideline.
To clarify issues for any member of staff who does not understand any part of this
guideline or assist them in obtaining clarification from the document initiator as
required.
2.4 All Trust employees; bank, agency and locum staff; trainees; students and contracted
staff
To adhere to the guideline
To read and understand this guideline
To seek clarification from their line manager or the senior manager responsible
for the initiation and review of this guideline if unsure about any part of the
guideline or relevant document.
To be aware of the current version of this guideline and other documents and
how to access them

SECTION 3 - ASSESSMENT OF ACUTE KIDNEY INJURY (AKI)
Key related documents

Medication Policy for Healthcare Professionals policy
Monitoring Vital signs (MEWS) and intervention with acutely ill adult policy
Transfer of adult patients policy
Dignity and Respect Charter
Hyperkalaemia Algorithm by Resuscitation Council
3. Assessment of AKI
3.1 Identifying AKI in patients with acute illness

Assess patients who are admitted to hospital for AKI or at risk of developing AKI.
Ensure that AKI checklist on Emergency Assessment Proforma (Surgical and
Medical) is completed as appropriate (Appendix 6)
3.1.1 Routine Observations and MEWS

3.1.2 Full drug history recorded on drug chart/medical notes
3.1.3 Urinalysis
3.1.4 Baseline Creatinine, Urea and Electrolytes
3.1.5 Routine examination by the medical team to identify any physical abnormalities or
concerns prior to their intended procedure/investigation with specific attention to the
patients fluid volume status
3.1.6 Baseline Weight
3.1.7 eGFR calculated
3.1.8 Medication review and titrate for nephrotoxins and other medications as appropriate
3.1.9 Lying and standing BP
3.1.10 Assessment for requirements of either oral or IV fluid administration prior to
procedure/surgery
3.1.11 Discussion with the patients consultant with regards to plan of treatment
3.1.12 Daily monitoring of creatinine, electrolytes and weight
3.2 Assessing risk factors in adults having iodinated contrast agents

3.2.1 Investigate for CKD by measuring eGFR or by checking an eGFR result obtained
within the past 3 months prior to any Contrast given investigations (Appendix 3)
Emergency or non-emergency imaging, assess their risk of AKI. Be aware that

increased risk is associated with:
CKD (adults with an eGFR less than 40 ml/min/1.73 m2 are at particular risk)
Diabetes but only with CKD (adults with an eGFR less than 40 ml/min/1.73 m2
are at particular risk) [See Appendix 1and 4]
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.

3.2.2 Include the risks of developing AKI in the routine discussions of risks and benefits of
the imaging procedure.
3.3 Assessing risk factors in adult patients having surgery
3.3.1 Assess the risk of AKI in adult patients before surgery. Be aware that increased risk
is associated with:
Emergency surgery, especially when the patient has sepsis or hypovolaemia
Intra-peritoneal surgery
CKD (patients with an eGFR less than 60 ml/min/1.73 m2 are at particular risk)
[See Appendix 1]
Diabetes
Heart failure
Age 65 years or over
Liver disease
Use of drugs with nephrotoxic potential in the perioperative period
Use the risk factors identification form to inform the clinical management plan. (See
Appendix 2)
3.3.3 Include the risks of developing AKI in the routine discussion of risks and benefits of
surgery with the patient.
3.4 Identifying AKI
3.4.1 Identifying AKI in patients with acute illness

Investigate for AKI, by measuring serum creatinine and comparing with baseline, in
patients with acute illness if any of the following are likely or present:
CKD (adults with an estimated glomerular filtration rate [eGFR] less than 60
ml/min/1.73 m2 are at particular risk) [See Appendix 1]
Heart failure
Liver disease
Diabetes
History of AKI
Oliguria for more than 6 hours (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 NSAIDs, aminoglycosides,
ACEIs, ARBs and diuretics within the past week, especially if patient is
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 (MEWS)
Age 65 years or over.
Any patient identified as having AKI as an inpatient will follow the AKI checklist and
AKI care bundle Appendix 2. Once AKI is detected according to their serum
creatinine rise, each patient should be assessed on a daily basis and the multi-

disciplinary team should ensure that all crucial components of the AKI care bundle
are completed and any reasons for exemption clearly documented in the nursing or
medical notes.
3.4.2 Identifying AKI in patients with no obvious acute illness
3.4.2a Be aware that in adult patients with CKD and no obvious acute illness, a rise in serum
creatinine may indicate AKI rather than a worsening of their chronic disease.
3.4.2b Ensure that AKI is considered when an adult patient presents with an illness with no
clear acute component and has any of the following:
CKD, especially stage 3B, 4 or 5, or urological disease
new onset or significant worsening of urological symptoms
symptoms suggesting complications of AKI
Symptoms or signs of a multi-system disease affecting the kidneys and other
organ systems (for example: signs or symptoms of AKI, plus a purpuric rash).
Any patient identified as having AKI as an in-patient will follow the AKI care bundle as
shown in Appendix 2. Once AKI is detected according to their serum creatinine rise,
each patient should be assessed on a daily basis according to the care bundle and
the multi-disciplinary team should ensure that all crucial components of the AKI Care
bundle are completed and any reasons for exemption clearly documented in the
nursing or medical notes.
3.5 Preventing AKI
3.5.1 Ongoing assessment of the condition of patients in hospital
3.5.1a Follow the recommendations in Monitoring Vital Signs (MEWS) and Intervention with
the Acutely Ill Adult Policy (see the 'M' page of the Policies and Guidelines A-Z in
hospital intranet).
3.5.1b When adults are at risk of AKI, check and record full set of vital signs using i-POD
touch (e-Observations) and urine output with a frequency appropriate for the patients
condition.
3.5.1c Monitor Urine Output at least 4hrly if not catheterised and hourly if catheter present -
ensuring all outputs clearly documented on fluid balance charts and running totals
calculated. Escalate appropriately for every patient if oliguria detected for more than
3 hours.
3.5.1d Ensure the recommendations on AKI care bundle are instituted in all circumstances
3.5.1e Increase the frequency of observations if abnormal physiologies are detected and
inform CCOT team and medical team where appropriate (MEWS > 4).
3.5.2 Preventing AKI in patients having iodinated contrast agents
3.5.2a Offer intravenous volume expansion to patients having iodinated contrast agents if:
They are at increased risk of contrast-induced AKI because of risk factors, or if
they have an acute illness.
Offer IV fluids (eg Sodium Bicarbonate 1.26%) as per the guideline (Appendix 3).

3.5.2b Consider temporarily stopping ACE inhibitors and ARBs in patients having Iodinated
contrast agents if they have CKD with an eGFR less than 40 ml/min/1.73 m2. [See
Appendix 2]
3.5.2c Discuss care with the nephrology team before offering iodinated contrast agent to
patients with contraindications to intravenous fluids if:
they are at increased risk of contrast-induced AKI, or
they have an acute illness, or
they are on RRT.
3.5.3 Monitoring and preventing deterioration in patients with or at high risk of AKI
3.5.3a Seek advice from a Pharmacist about optimising medicines and drug dosing in adult
patients with or at risk of AKI.
3.5.3b Consider temporarily stopping ACE inhibitors and ARBs in patients with diarrhoea,
vomiting or sepsis until their clinical condition has improved and stabilised.
3.6 Detecting AKI
3.6.1 Detect AKI by using any of the following criteria:

a rise in serum creatinine of 26.5 micromole/litre or greater within 48 hours
a 50% or greater rise in serum creatinine known or presumed to have occurred
within the past 7 days
a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours
3.6.2 Monitor serum creatinine regularly in all patients with or at risk of AKI.
3.7 Identifying the cause(s) of AKI
3.7.1a Identify the cause(s) of AKI and record the details in the patient's notes.
3.7.1b Perform urine dipstick testing for blood, protein, leucocytes, nitrites and Glucose in all
patients as soon as AKI is suspected or detected. Document the results and ensure
that appropriate action is taken when results are abnormal.
3.7.1c Do not routinely offer ultrasound of the urinary tract when the cause of the AKI has
been identified.
3.7.1d When pylonephrosis (infected and obstructed kidney[s]) is suspected in patients with
AKI, offer immediate ultrasound of the urinary tract (to be performed within 12 hours
of assessment).
3.7.1e When patients have no identified cause of their AKI or are at risk of urinary tract
obstruction, offer urgent ultrasound of the urinary tract (to be performed within 24
hours of assessment).

3.8 Managing AKI
Any patient identified as having AKI as an inpatient will follow the AKI care bundle;
Appendix 2. Once AKI is detected according to the serum creatinine rise, each
patient should be assessed on a daily basis and the multi-disciplinary team should
ensure that all crucial components of the AKI care bundle are completed and any
reasons for exemption clearly documented in the nursing or medical notes.
3.8.1 Pharmacological management
3.8.1a Do not routinely offer loop diuretics to treat AKI.
3.8.1b Consider loop diuretics for treating fluid overload or oedema while awaiting RRT or
renal function is recovering in a patient not receiving RRT.
3.8.1c Do not offer low-dose dopamine to treat AKI.
3.8.2 Referring for renal replacement therapy
3.8.2a Discuss any potential indications for RRT with a Nephrologist and/or critical care
specialist immediately to ensure that the therapy is started as soon as needed.
3.8.2b When a patient has significant comorbidities, discuss with them/relatives and within
the multidisciplinary team whether RRT would offer benefit.
3.8.2c Refer patients immediately for RRT if any of the following are not responding to
medical management:
Hyperkalaemia
Metabolic acidosis
Symptoms or complications of uraemia (for example, pericarditis or
encephalopathy)
Fluid overload
Pulmonary oedema
3.8.2d Base the decision to start RRT on the condition of the patient as a whole and not on
an isolated urea, creatinine or potassium value.
3.8.2e When there are indications for RRT, the Nephrologist and/or Critical Care Specialist
should discuss the treatment with the patient / relative or carer as soon as possible
and before starting treatment.
3.8.3 Referring to nephrology
3.8.3a Refer patients with AKI to Nephrologist and/or Critical Care Specialist immediately if
they meet criteria for RRT therapy in recommendation.
3.8.3b Do not refer patients to a Nephrologist when there is a clear cause for AKI and the
condition is responding promptly to medical management, unless they have a renal
transplant.
3.8.3c Consider discussing management with Nephrologist when a patient with severe
illness might benefit from treatment, but there is uncertainty as to whether they are
nearing the end of their life.

3.8.3d Refer patients in intensive care to the nephrology team when there is uncertainty
about the cause of AKI or when specialist management of kidney injury might be
needed.
3.8.3e Discuss the management of AKI with a 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, tubule-interstitial nephritis or myeloma)
AKI with no clear cause
Inadequate response to treatment
Complications associated with AKI
Stage 3 AKI
a renal transplant
CKD stage 4 or 5
3.8.3f Monitor serum creatinine after an episode of AKI. Consider referral to a Nephrologist
when eGFR is 30 ml/min/1.73 m2 or less in patients who have recovered from an
AKI.
3.9 Referring to the Critical Care unit

Discuss with Critical Care Consultant (week days) or Special Registrar - Bleep
holder 055 (nights and weekends) about the patient if they are meeting the
criteria as specified in section 3.8.3
Liaise with CCOT (Bleep 732)
Transfer patient to Critical care unit as per the Trust Transfer policy.
SECTION 4 - TRAINING & EDUCATION INCLUDING MAINTENANCE OF

CLINICAL COMPETENCE
Education/ Staff Method of Responsibility for Timescale to

Training group/individual training/education training complete
Need (nominated person by training/competence
Division/ Department)
AKI care Medical staff Trust study days Nephrologist On going
bundle Medical meeting Consultant in Acute
E-learning Medicine
module Ward Sister/Charge
Nurse
AKI Care Nursing staff Induction days Ward sisters On going

bundle Midwives Ward based local
Pharmacists induction programme Ward Sisters/Charge On going
Renal nurses Critical care link nurse Nurses in collaboration
Nurse programme with CCOT
prescribers Internet
Community Trust email (monthly Pharmacy lead for Ongoing
nurses circular) education
Renal assistants The deteriorating
Healthcare patient simulation
assistants section

SECTION 5 - DEVELOPMENT AND IMPLEMENTATION INCLUDING
DISSEMINATION
5.1 Staff involved in the development and implementation of this guideline.

Praveen Ande, Consultant Nephrologist
Jessica Kitchen, Consultant in Emergency Medicine and Nephrology
Robert Lewis, Consultant Anaesthetist in Critical Care
Manju Markose, Critical Care Outreach Practitioner
The management of the AKI guideline will be introduced to the Trust using the
following methods:
Nursing and Midwifery Board

Trust study days
Medical meeting
Pharmacy meetings
Induction days
AKI awareness event
Critical care link nurse
Intranet (eg AKI app, Trust email )
The deteriorating patient study day
5.2 This guideline will be made available on the hospital intranet. All managers will be
asked to highlight this to all staff and attend teaching sessions as appropriate.
SECTION 6 - MONITORING COMPLIANCE & EFFECTIVENESS
Compliance to Monitoring Tools Responsibility Timescale

be measured (nominated person by
Directorate/Department)
AKI BUNDLE is Ward audit programme Medical Lead At 6 months and
instituted to all Audit of training records Matrons annually afterwards
patients at Risk/ Audit of clerking proforma Ward sisters
who developed
AKI
Fluid balance Ward audit programme Ward sisters/matrons 6 monthly

chart Audit of training records
Review of drug Pharmacy audit Renal Pharmacist/

charts Pharmacy team

SECTION 7 - CONTROL OF DOCUMENTS INCLUDING ARCHIVING
ARRANGEMENTS
7.1 Once approved by the Patient Safety & Clinical Effectiveness Group, the responsible
officer will forward this guideline to the Information Governance Department for a
document index registration number to be assigned and for the guideline to be
recorded onto the central hospital master index and central document library of
current documentation.
7.2 In order that this guideline adheres to the hospitals Records Management Policy, the
responsible officer will arrange for staff to be advised when this guideline is
superseded and for arranging for this version to be removed from the hospitals
intranet. They will also advise the Information Governance Department who will
ensure that this guideline is removed from the current index and library, archived and
retained for 10 years from the archive date.
SECTION 8 - SUPPORTING COMPLIANCE AND REFERENCES

NICE guidelines on AKI
London AKI Network Group
References
Academy of Medical Royal Colleges Acute Kidney Injury Competency Framework (2010)
[accessed online on 20/09/2014] www.aomrc.org.uk/9503-acute-kidneyinjury-a-competency-
framework.
Burgess, R. (2011), New Principles of best practice in clinical audit, 2ND edition, Radcliffe
Publishing Ltd
Care Quality Commission (2013), Leadership in Health care, accessed from

www.nationalarchives.gov.uk/doc/open-government-service-licence. Accessed on
30/12/2014.
Cerda,J.et al (2008),Epidemiology of Acute Kidney Injury. Clinical Journal of the American

Society of Nephrology 3(3). Pp 881-886
Davenport, A. (2010), Clinical guidelines for the protection of kidney function and prevention
of acute kidney injury in the intensive care unit: common sense rather than magic bullets?
European Resuscitation Council (2015), Hyperkalaemia Algorithm
Intensive Care Medicine. Volume 36, Issue 3, pp 379-380.
Department of Health (2009), NHS Kidney care.
Fallon, D. and Long, T. (2007), Ethics approval, ethical research and delusions of efficacy.
In Long, T. and Johnson, M (etal), Research Ethics in the real world: Issues and solutions for
Health and Social care, Churchill Livingston, London.

Hansen, M.K et al (2015), Acute Kidney Injury and Long term risk of cardiovascular events
after cardiac surgery: A population based cohort study. Journal Of Cardiothoracic and
Vascular Anaesthesia 29(3), pp 617-625
Hill, S.L. and Small, N. (2006) 'Differentiating between research audit and quality
improvement: Governance implications', Clinical Governance: An international Journal,
11(1), PP 98-106.
Kerr, M., Bedford, M., Matthews B, O. Donoghue,D. (2014). The economic impact of acute
kidney injury in England. Nephrology Dialysis Transplantation. April 21 2014.
London Acute Kidney Injury Network manual (2012), www.londonaki.net accessed on

3/09/2014.
National Institute of Health and Care Excellence (2013). Acute kidney injury: Prevention,
detection and management of acute kidney injury up to the point of renal replacement
therapy. Published in August 2013.
The National Enquiry in to Patient Outcomes and Death (2009), 'Adding insult in to injury'.
Neale, J. (2009), Research methods for health and social care, First Edition, Palgrave
Macmillan, United Kingdom.
Waikar, S.S., Liu, K.D., Chertow, G.M (2008) ,Diagnosis, epidemiology and outcomes of
acute kidney injury. Clinical Journal of American Society of Nephrology 3:844861.

APPENDICES
APPENDIX 1 - INVESTIGATE FOR AKI
Investigate for AKI, by measuring serum creatinine and comparing with baseline, in
patients with acute illness if any of the following are likely or present:
CKD (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 AKI
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.

APPENDIX 2 - AKI CARE BUNDLE

APPENDIX 3 - CONTRAST INDUCED NEUROPATHY (CIN) PROPHYLAXIS

APPENDIX 4 - RISK, PREVENTION AND RECOGNITION

APPENDIX 5 - AKI COMPLICATIONS

APPENDIX 6 - AKI CHECKLIST (on the back of emergency assessment proforma/clerking
proforma)
AKI Checklist
1. Seek cause
2. Assess fluid status
3. Review drug chart for nephrotoxic medicines
4. Consider Renal USS (within 24hrs if no obvious cause or obstruction likely)
5. Renal referral if Stage 3 AKI or not responding to treatment


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Management of Acute Kidney Injury in Adults

For use by: All Clinical staff

This document is London AKI Network manual (2012), www.londonaki.net accessed on

National Institute for Clinical Excellence Quality Standard on Management of

This document New clinical guideline

Approved by: Initial approval by: Division 2 Governance Board (date)

Approval date: 17/06/2016

Notified to: Healthcare Governance Committee

Date Notified: 17/06/2016

Implementation date: 18/07/2016

Review date: 17/06/2017

In case of queries contact Consultant in Nephrology

Division/Department: Division 1 Acute and Emergency Medicine

Date document to be To be inserted Information Governance Department when this document

Registered Document 1857 Page 1 of 20

Version Date of Change Description* Authors

This is a Controlled Document

Sharing this Document with Third Parties

Registered Document 1857 Page 2 of 20

SECTION 2 - DUTIES AND RESPONSIBILITIES ......................................................... 5

SECTION 3 - ASSESSMENT OF ACUTE KIDNEY INJURY (AKI) ................................ 6

SECTION 4 - TRAINING & EDUCATION INCLUDING MAINTENANCE OF CLINICAL

SECTION 5 - DEVELOPMENT AND IMPLEMENTATION INCLUDING

SECTION 6 - MONITORING COMPLIANCE & EFFECTIVENESS ..............................12

SECTION 7 - CONTROL OF DOCUMENTS INCLUDING ARCHIVING

SECTION 8 - SUPPORTING COMPLIANCE AND REFERENCES ..............................13

APPENDIX 1 - INVESTIGATE FOR AKI ......................................................................15

Registered Document 1857 Page 3 of 20

1.1 Clinical Guideline statement and rationale

The recommendations in this guideline emphasise early intervention and the

1.2 Key Principles

1.3 Background Information

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SECTION 2 - DUTIES AND RESPONSIBILITIES

2.3 All Clinical Directors, Heads of Nursing/Midwifery Matrons, Ward Sisters/Charge

To be responsible for the implementation of, and compliance of this guideline in

To read and understand this guideline

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Key related documents

3.1 Identifying AKI in patients with acute illness

3.1.1 Routine Observations and MEWS

3.2 Assessing risk factors in adults having iodinated contrast agents

Emergency or non-emergency imaging, assess their risk of AKI. Be aware that

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3.3 Assessing risk factors in adult patients having surgery

3.4 Identifying AKI

3.4.1 Identifying AKI in patients with acute illness

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3.4.2 Identifying AKI in patients with no obvious acute illness

3.5 Preventing AKI

3.5.1 Ongoing assessment of the condition of patients in hospital

3.5.2 Preventing AKI in patients having iodinated contrast agents

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3.6 Detecting AKI

3.6.1 Detect AKI by using any of the following criteria:

3.7 Identifying the cause(s) of AKI

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3.8.1 Pharmacological management

3.8.1a Do not routinely offer loop diuretics to treat AKI.

3.8.1c Do not offer low-dose dopamine to treat AKI.

3.8.2 Referring for renal replacement therapy

3.8.3 Referring to nephrology

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3.9 Referring to the Critical Care unit