Groups at higher risk

• Pre-existing chronic kidney disease
• Single kidney
• Previous episode of AKI
• Age >65 yr
• Neurological or cognitive impairment or disability
  • possible limited access to fluids
• Sepsis
• Cardiac failure
• Atherosclerotic peripheral vascular disease
• Diabetes/cirrhosis/cancer

Causes

• Often multifactorial
• Pre-renal (perfusion)
  • volume depletion
  • hypotension, pump failure
  • sepsis
• Renal (organ)
  • established acute tubular necrosis - ischaemic or toxic
  • glomerulonephritis/vasculitis
  • tubulointerstitial nephritis
• Post-renal (obstructive)

• Fluid balance chart
• Start NEWS scoring to detect further deterioration at early point
• Adequate fluid replacement
• Write monitoring plan in notes and inform nursing staff

Review medication and adjust dose as needed

• Document review of all medications in those at risk of or with identified AKI in order to withhold medications which may adversely affect renal function
• As renal function changes and as renal support is initiated, altered or discontinued, undertake regular re-evaluation of drug dosing
• Where possible, avoid NSAIDs
• If BP low, reduce/omit antihypertensives
• Minimise risk of acute kidney injury associated with radiographic contrast media
  • see Contrast induced acute kidney injury guideline
• When prescribing diuretics/NSAIDs/ACE inhibitors/angiotensin-II receptor antagonists, inform patients about AKI risks
  • give patient leaflet

Low BP

• Volume status assessment
  • IV fluids
• Hold BP-lowering medication
• Consider vasopressors

Sepsis

Identify

• Suspected or confirmed infection
• Quick sequential organ failure assessment score (qSOFA) >2
• RR >22 breaths/min
• Systolic BP <100 mmHg
• GCS ≤13

Response

• See Sepsis management guideline

Risk factors in patients requiring surgery

• Emergency surgery, especially when associated with sepsis or hypovolaemia
• Intraperitoneal surgery
• Major joint surgery
• Assess baseline renal function in any at-risk group

Prevention

• Ensure adequate pre-operative hydration
  • encourage patients who are nil-by-mouth for planned anaesthesia to drink clear fluids until 2 hr before anaesthesia
• If pre-operative U&E required in patient undergoing major surgical procedures, repeat 24 hr post-operatively