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Acute Kidney Injury - Coggle Diagram
Acute Kidney Injury
Risk factors
Chronic conditions such as heart failure, liver disease or diabetes
Neurological or cognitive impairment or disability
Symptoms or history of urological obstruction or conditions which may lead to obstruction.
Sepsis
Chronic kidney disease
Hypovolaemia
A history of acute kidney injury
Oliguria
People ages 65 years and over
Nephrotoxic drug use within the last week
Immunocompromise
Exposure to iodinated contrast agents within the past week
Toxins
Cancer and cancer therapy
Management
For possible underlying causes, including asking questions on: current symptoms, recent symptoms, history of CVD, symptoms of an inflammatory process, drug history, and Possibility of rhabdomyolysis.
For renal disease by performing urine dipstick testing for blood, protein, leucocytes, nitrites, and glucose - AKI with negative urinalysis usually indicates a pre-renal cause, Positive protein and blood indicators on urinalysis may suggest glomerular disease, increased white cells are non-specific but may suggest infection (most common) or interstitial nephritis and be aware that dipstick analysis of urine from people with catheters should be interpreted with caution.
Renal function and serum potassium level (to exclude hyperkalaemia).
The stage of acute kidney injury - in primary care creatinine level is the most readily available result.
Assess volume status: fluid intake and losses, peripheral perfusion, heart rate/blood pressure, jugular venous pressure, moistness of mucous membranes, skin turgor, changes in urination pattern, peripheral oedema and pulmonary crackles.
Arrange urgent admission - likely stage 3 AKI, underlying cause requiring urgent management, no identifiable cause, risk of urinary tract obstruction, sepsis, evidence of hypovolaemia, deterioration in the clinical condition or a complication of AKI.
Discuss the management of acute kidney injury with a nephrologist as soon as possible and within 24 hours of detection, when one or more of the following is present: stage 4 or 5 CKD, possible diagnosis requiring specialist treatment, inadequate response to treatment, renal transplant or other complications.
Stage 1 - if admission not required offer supportive measures advice on maintaing hydrations, consider stopping nephrotoxic medications or adjusting dose, monitor creatinine regularly and Reconsider the need to admit to hospital or discuss with a specialist if there is deterioration in the person's condition, or an inadequate response to treatment.
Follow up - are should become focused on monitoring and prevention of further episodes. Monitor serum creatinine. Ensure documented in notes. Review long term medications stopped during episode of AKI and offer written information.
Diagnosis
If no baseline creatinine value is available, it may be appropriate to repeat the creatinine measurement after 48–72 hours.
Take into consideration if the person has: CKD, recently treated with Trimethoprim, recently completed pregnancy.
Measure serum creatinine and compare to baseline and consider clinical context (in those that do not require urgent hospital admission)
If there is doubt whether a person with chronic kidney disease has worsening of their condition or has acute-on-chronic kidney disease, consider it to be acute and manage accordingly.
Detect AKI by using any of the following criteria: A rise in serum creatinine of 26 micromol/L or greater within 48 hours, A 50% or greater rise in serum creatinine (more than 1.5 times baseline) known or presumed to have occurred within the past 7 days, or A fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours.
When to suspect
Acute illness and any risk factors.
Illness with no clear acute component and any of the following: CKD, new onset or significant worsening of urological symptoms, symptoms/signs of a multi-system disease affecting the kidneys and other organ systems, symptoms suggesting presence of complications.
Symptoms/Signs: nausea, vomiting, diarrhoea, evidence of dehydration, reduced urine output or changes to urine colour, confusion, fatigue or drowsiness.
An acute kidney injury warning stage test result generated from electronic detection systems in a biochemistry laboratory. This flags up changes in creatinine levels suggestive of AKI for the person receiving the result in primary care. - Respond within an appropriate timescale.
Prevention
Discuss the risk of developing acute kidney injury, especially the risk associated with conditions leading to dehydration (for example diarrhoea and vomiting) and drugs with nephrotoxic potential.
Review regular medication and, if possible, avoid drugs that are potentially harmful to the kidneys. Advise the person to seek medical advice in the event of acute illness (for example diarrhoea or vomiting) to discuss temporarily stopping medications that may increase the risk of AKI such as angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and diuretics.
For those at risk use clinical judgement to decide the frequency of creatinine monitoring, taking into account the individual circumstances.
In all people with acute illness Consider admitting to hospital if the person is hypovolaemic and clinical judgement suggests they would benefit from intravenous fluids, especially if they are in an at risk group.
Definition: AKI is a term which covers a spectrum of injuries to the kidneys which can be caused by a number of different causes. It is a clinical syndrome rather than a biomedical diagnosis. The term 'acute kidney injury' has replaced the concept of acute renal failure as it more accurately describes that injury to the kidney can occur before function fails. It is characterized by a decline in renal excretory function over hours or days that can result in failure to maintain fluid, electrolyte, and acid-base homeostasis.