2. Key facts about AKI 5 Facts about acute kidney injury (AKI), formerly known as "acute renal failure“ Up to 20% of hospital admissions have AKI Up to 25% of AKI is preventable Morbidity and mortality rises with AKI Severe AKI (stages 2 and 3) is one of the strongest predictors of mortality in hospitalised patients NCEPOD identified suboptimal care of AKI in 50% of national cases reviewed

4. Monitor patient. Maintain circulation. Minimise Kidney insults - Avoid Nephrotoxic drugs, use of contrast, surgery or high risk interventions HAI. Manage Acute Illness.

5. 7 Steps of AKI Management Bundle (4) Confirm Urgent senior review from your own team Assess fluid status Undertake full physiological observations (early warning score) Urine dip Stop nephrotoxic drugs Daily U&Es Consider renal ultrasound and urinary catheter

6. AKI Management Bundle (5) Step 1 Na 135 K 5.9 Ur 15.6 Creat 420 ICE “AKI Alert” (checking blood result) Confirm AKI & Stage the injury 1,2 or 3

7. AKI Management Bundle (6) Step 2 Urgent Senior Review You do not have to be as old a SpR to provide a sound advice …. 64% of cases not reviewed by senior within 12 hrs in recent audit

8. AKI Management Bundle (7) Step 3 Assess fluid status

11. AKI Management Bundle (8) Step 4 Monitor NEWS

12. AKI Management Bundle (9) Step 5 Urine dip Omitted in 58% cases in recent audit

13. AKI Management Bundle (10) Step 6 Remove ‘The usual suspects’ NSAIDS ACE I /ARBs Gentamicin Spironolactone X-ray contrast

14. AKI Management Bundle (11) Step 7 Monitor daily U&Es and urine output Omitted in 48% cases in recent audit

15. AKI Management Bundle Step 8 Consider ultrasound and urinary catheter (10)

16. AKI Management Bundle If AKI stage 2 or 3, or if anuric, or if not improving (12) Escalate Medical SpR Discuss with Consultant regarding nephrology YB or discuss with Renal SpR Critical Care outreach If NEWS unstable or urgent dialysis support required

17. AKI Management Bundle (13) General Therapeutic Guidance Do not routinely offer loop diuretics Consider loop diuretics for treating fluid overload or oedema while awaiting renal replacement therapy or renal function is recovering without renal replacement therapy Do not offer low-dose dopamine to treat AKI

18. AKI Management Bundle Indication of Renal Replacement Therapy (14) Hyperkalaemia, metabolic acidosis, symptoms or complications of uraemia, fluid overload, pulmonary oedema decision to start RRT should be based on the condition of patient as a whole and not on isolated urea, creatinine or potassium value If RRT is indicated, nephrologist or critical care specialist should discuss the treatment with the patient or family/carer before starting treatment

19. AKI Management Bundle (12) Indications for Nephrology Opinion Do not routinely refer If clear cause is known AKI is responding promptly to treatment Refer/discuss ASAP if any of the following present Vasculitis, glomerulonephritis, tubulo-interstitial nephritis or myeloma AKI with no clear cause or inadequate response to treatment complications associated with AKI Refer immediately only if meeting criteria for RRT Refer / discuss all cases if AKI Stage 3 CKD 4 or 5 Previous renal transplant Doubt of benefit of RRT due to co-morbidities

20. Complications Prevent / Manage Complications HyperKalaemia Acidosis Pulmonary oedema Reduced Conscious level