1. Acute Kidney Injury and the implications for community and practice nurses
Claire Stocks – Sister, Cardiac Arrest Prevention Team, County Durham & Darlington Foundation Trust

2. Disclaimer……..I’m no expert!
Currently a sister on the CAP Team.
Previous Acute medicine and ITU outreach.
Lots of experience of AKI in acute setting.
More involved recently. Lead nurse AKI for the Trust.
Try to look at the simple things and what we can do to try and prevent further deterioration.
Wide variety of resources available through the think kidneys website.
Register your interest no spam just a newsletter.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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3. Learning Outcomes Define Acute Kidney Injury (AKI)
Discuss the potential causes of AKI
Top Tips for nurses
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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4. Costs to the NHS estimated to be £1 billion per year.
Is AKI really a problem?
100,000 deaths are year are associated with acute kidney injury. (NCEPOD 2009) ‘
Costs to the NHS estimated to be £1 billion per year.
(Kerr et al 2014)
Approximately 65% of Acute Kidney Injury Starts in the Community. (Selby et al 2012)
3202 AKI episodes in 2619 patients during the 9-month study period (5.4% of hospital admissions).
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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5. Acute Kidney Injury
Acute kidney injury (AKI) is the sudden and recent reduction in kidney function resulting in a inability to maintain fluid, electrolyte and acid base balance. AKI is a syndrome that usually occurs in the presence of other acute illness such as SEPSIS or HEART FAILURE. Diagnosis of AKI is based on either the urine output or the creatinine level (or both) AND clinical assessment, history, presentation.
Important to try and identify the cause of AKI as this will aid in the treatment.
AKI is diagnosed by creatinine levels according to the KDIGO guidance. NHS hospitals in England should now have a detection pathway in which these are electronically generated. But this does not take into account urine output or clinical assessment. It is a tool and is only as good as the person using it.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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6. Risk of AKI
Aged 75 or over Cardiac Disease Liver Disease Diabetes Chronic Kidney Disease Cancer Acute insult from conditions such as Sepsis. Patients susceptible to dehydration
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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7. Pre Renal Causes….. Most common cause of AKI
Flow disruption to the kidney
For example:
Low blood pressure
Heart Failure
Low blood volume
Blood flow reduced
- 77 year old
- Past medical history of COPD
- Admitted with infective exacerbation of COPD and D&V.
- Not taken anything orally for few days.
- Rapid breathing rate, sweating.
- Dark Urine
Pre renal cause – dehydration/infection – resulting in reduced blood pressure – and reduced renal perfusion. -
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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8. Intrinsic Causes…. Damage to the kidney itself For example:
Glomerulonephritis
Acute tubular Necrosis
- 47 year old
- Background of diabetes
- Presented with hypertension
- Haematuria & Protein in Urine.
Suspected intrinsic cause requires senior and possible specialist referral.
Important to rule out other causes first – intrinsic AKI is the rarest but does occur.
Further investigations may be required such as a kidney biopsy to confirm diagnosis.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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9. Post Renal Causes…. A consequence of urinary tract obstruction.
For example:
Blocked catheter
Renal calculi
Bladder tumours
-86 year old gentleman
-Long term catheter in-situ
-Recent UTI
-Presented with abdominal pain and reduced urine output via catheter
-Palpable bladder and severe pain on palpation.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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10. Treatment of AKI
Treatment of AKI is about identifying the cause and formulating a treatment plan to address this. Usually AKI requires fluid replacement. It is therefore essential that clinical assessment of fluid status has been completed. It a patient is hypotensive and hypovolaemic IV supplementary fluid will be required. Medications may need to be with held for a few days until the acute insult is recovering. A renal ultrasound should be considered. Fluid balance should be monitored alongside vital signs. Dipstick Urine and document the results in the patients medical record. Referral to renal teams may be indicated if the cause of AKI is unknown, or the patients AKI is severe or not responding to treatment, or the patient has had a renal transplant. Referrals to specialities should be senior clinician to senior clinician. Patients with life threatening complications (Acidosis, Pulmonary Oedema, Hyperkalaemia or uraemia should be referred to specialist services for possible renal replacement therapy. For further information regarding recognition and management of AKI see NICE CG169.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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11. Top Tips for Nurses regarding Acute Kidney Injury
1) Maintain a healthy blood pressure.
The kidneys play a pivotal role in the regulation of blood pressure through salt and water balance. Blood pressure that is too high or too low will ultimately lead to damage within the kidneys so its important to keep patients blood pressure within normal range. Pre-renal AKI is often due to hypo perfusion and low blood pressure. For any patients with low blood pressure they must be assessed and discussed with the GP as they may need escalation into hospital for treatment. Not all pre renal AKI is a consequence of dehydration. Worsening heart failure will reduce cardiac output thus resulting in a lower BP. Be aware of your patients who have established heart failure and ensure they are reviewed regularly by the GP. For further information regarding hypertension in adults see NICE CG127 Hypertension.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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12. Top Tips for Nurses regarding Acute Kidney Injury
2) Urinalysis might alert you to an intrinsic kidney problem.
Protein and blood should not filter through to the urine therefore if it is present on a urinalysis test this could indicate signs of renal disease.
If more than 3+ of protein or blood is present – discuss with your GP about what to do next.
Not just looking for infection.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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13. Top Tips for Nurses regarding Acute Kidney Injury
3) Medication review is essential.
UK Renal Pharmacy Group – AKI Medicines Optimisation Toolkit (March 2012)
Consider Acute Nephrotoxic Drug Action
Contrast Media
Ace Inhibitors
NSAID’s
Diuretics
ARB’s
Be aware of other drugs excreted by the kidneys such as Metformin, Opioids, Some antibiotics, Digoxin & Lithium.
If you patient has AKI or risk factors and they are unwell. Consider omitting these for a few days.
Discuss with the GP if unsure.
Remember if acute illness consider escalation into hospital.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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14. Top Tips for Nurses regarding Acute Kidney Injury
4) Hydration is key.
Dehydration is the underlying cause of many common conditions including: constipation; falls; urinary tract infections; pressure ulcers; malnutrition; incontinence; confusion and pre renal AKI.
The elderly are more prone to dehydration because as we age we lost the ability to recognise thirst. Other factors such as poor mobility and reduced confidence can also affect a patients desire to keep hydrated.
Elderly patients are likely to have more co-morbidities and poly pharmacy which could be attributed to worsening AKI. Education to patients and carers regarding hydration and medications is vital.
Some patients may need further support in staying hydrated. For example patients may need beakers instead or cups – or carer input to maintain fluid intake throughout the day. It could be as simple as set drink routines rather than relying on thirst alone.
Signs of dehydration include:
Thirst, sunken eyes, irritability, confusion, cool peripheries, low BP, Raised HR, headaches, reduced skin turgor, dry mucus membranes.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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15. Top Tips for Nurses regarding Acute Kidney Injury
5) Consider the Kidneys in everything you do.
The kidneys don’t usually complain.
The kidneys can lose up to 90% of their function before you may even begin to notice.
The kidneys are clever organs but need a good blood supply to work effectively.
Consider the kidneys in your daily visits.
Ask if your patient has passed urine?
Ask if they are well hydrated.
Consider if your patient has risk factors for AKI and whether further investigations such as monitoring of creatinine levels are required.
Consider if your patient has an acute insult that may warrant temporary cessation of medications.
Consider further review by GP.
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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16. Further Information
References: Kerr M, Bedford M, Matthews B, O’Donoghue D. The economic impact of acute kidney injury in England. Nephrol Dial Transplant (2014) 29: 1362–1368. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Acute Kidney Injury: Adding Insult to Injury. National Institute for Health and Care Excellence (NICE) 2013, Clinical guideline 169, Acute Kidney Injury. Selby NM, Crowley L, Fluck RJ, McIntyre CW, Monaghan J, Lawson N, Kolhe NV. Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients. Clin J Am Soc nephrol Apr;7(4): doi: /CJN Epub 2012 Feb 23
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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17. For further information regarding Acute Kidney Injury please see the Think Kidneys Website

18. Contact Think Kidneys How to find out more Karen Thomas
Think Kidneys Programme Manager
UK Renal Registry
Teresa Wallace
Think Kidneys Programme Coordinator
Julie Slevin
Think Kidneys Programme Development Officer
UK Renal Registry M | E
Richard Fluck National Clinical Director for Renal NHS England Joan Russell Head of Patient Safety Ron Cullen Director UK Renal Registry
kidneys
Acute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks
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