Transcript Top Tips for Nurses regarding Acute Kidney Injury

Acute Kidney Injury and the
implications for community
and practice nurses
Claire Stocks – Sister, Cardiac Arrest Prevention Team,
County Durham & Darlington Foundation Trust
Disclaimer……..I’m no expert!
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Learning Outcomes
Define Acute Kidney Injury (AKI)
Discuss the potential causes of AKI
Top Tips for nurses
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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)
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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.
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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
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Causes…..
Pre Renal
Most common cause of AKI
Flow disruption to the kidney
For example:
Low blood pressure
Heart Failure
Low blood volume
Blood flow
reduced
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Causes….
Intrinsic
Damage to the kidney itself
For example:
Glomerulonephritis
Acute tubular Necrosis
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Causes….
Post Renal
A consequence of
urinary tract obstruction.
For example:
Blocked catheter
Renal calculi
Bladder tumours
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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.
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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.
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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.
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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.
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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.
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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.
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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) 2009. 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. 2012 Apr;7(4):533-40. doi: 10.2215/CJN.08970911. Epub 2012 Feb 23
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For further information regarding Acute
Kidney Injury please see the Think
Kidneys Website
www.thinkkidneys.nhs.uk
Contact Think Kidneys
How to find out more
Karen Thomas
Think Kidneys Programme Manager
UK Renal Registry
[email protected]
Richard Fluck
National Clinical Director for Renal
NHS England
[email protected]
Teresa Wallace
Think Kidneys Programme Coordinator
UK Renal Registry
[email protected]
Joan Russell
Head of Patient Safety
NHS England
[email protected]
Julie Slevin
Ron Cullen
Director
UK Renal Registry
[email protected]
Think Kidneys Programme Development
Officer
www.linkedin.com/company/thinkkidneys
www.twitter.com/ThinkKidneys
www.facebook.com/thinkkidneys
www.youtube.com/user/thinkkidneys
www.slideshare.net/ThinkKidneys
www.thinkkidneys.nhs.uk
UK Renal Registry
M 07810560766 | E
[email protected]
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