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Overview

  • This Guidelines summary covers preventing, detecting and managing acute kidney injury in children, young people and adults. It aims to improve assessment and detection by non-specialists, and specifies when people should be referred to specialist services. This will improve early recognition and treatment, and reduce the risk of complications in people with acute kidney injury
  • This summary only covers recommendations for primary care. Please see the full guideline for a complete set of recommendations

Assessing risk of acute kidney injury

Identifying acute kidney injury in people with acute illness

  • Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in adults with acute illness if any of the following are likely or present:
    • chronic kidney disease (adults with an estimated glomerular filtration rate [eGFR] less than 60 ml/min/1.73m2 are at particular risk)
    • heart failure
    • liver disease
    • diabetes
    • history of acute kidney injury
    • oliguria (urine output less than 0.5 ml/kg/hour)
    • neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer
    • hypovolaemia
    • use of drugs that can cause or exacerbate kidney injury (such as non-steroidal anti-inflammatory drugs [NSAIDs], aminoglycosides, angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor antagonists [ARBs] and diuretics) within the past week, especially if hypovolaemic
    • use of iodine-based contrast media within the past week
    • symptoms or history of urological obstruction, or conditions that may lead to obstruction
    • sepsis
    • deteriorating early warning scores
    • age 65 years or over
  • Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in children and young people with acute illness if any of the following are likely or present:
    • chronic kidney disease
    • heart failure
    • liver disease
    • history of acute kidney injury
    • oliguria (urine output less than 0.5 ml/kg/hour)
    • young age, neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a parent or carer
    • hypovolaemia
    • use of drugs that can cause or exacerbate kidney injury (such as NSAIDs, aminoglycosides, ACE inhibitors, ARBs and diuretics) within the past week, especially if hypovolaemic
    • symptoms or history of urological obstruction, or conditions that may lead to obstruction
    • sepsis
    • a deteriorating paediatric early warning score severe diarrhoea (children and young people with bloody diarrhoea are at particular risk)
    • symptoms or signs of nephritis (such as oedema or haematuria)
    • haematological malignancy
    • hypotension

Identifying acute kidney injury in people with no obvious acute illness

  • Be aware that in adults, children and young people with chronic kidney disease and no obvious acute illness, a rise in serum creatinine may indicate acute kidney injury rather than a worsening of their chronic disease
  • Ensure that acute kidney injury is considered when an adult, child or young person presents with an illness with no clear acute component and has any of the following:
    • chronic kidney disease, especially stage 3B, 4 or 5, or urological disease
    • new onset or significant worsening of urological symptoms
    • symptoms suggesting complications of acute kidney injury
    • symptoms or signs of a multi-system disease affecting the kidneys and other organ systems (for example, signs or symptoms of acute kidney injury, plus a purpuric rash)

For information on assessing risk factors in adults having iodine-based contrast media or surgery, ongoing assessment of the condition of people in hospital, and preventing acute kidney injury in adults having iodine-based contrast media, see the full guideline.

Monitoring and preventing deterioration in people with or at high risk of acute kidney injury

  • Consider electronic clinical decision support systems (CDSS) to support clinical decision making and prescribing, but ensure they do not replace clinical judgement
  • When acquiring any new CDSS or systems for electronic prescribing, ensure that any systems considered:
    • can interact with laboratory systems
    • can recommend drug dosing and frequency
    • can store and update data on patient history and characteristics, including age, weight and renal replacement therapy
    • can include alerts that are mandatory for the healthcare professional to acknowledge and review
  • Seek advice from a pharmacist about optimising medicines and drug dosing in adults, children and young people with or at risk of acute kidney injury
  • Consider temporarily stopping ACE inhibitors and ARBs in adults, children and young people with diarrhoea, vomiting or sepsis until their clinical condition has improved and stabilised

Detecting acute kidney injury

  • Detect acute kidney injury, in line with the (p)RIFLE[A] AKIN[B] or KDIGO[C] definitions, by using any of the following criteria:
    • a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
    • a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
    • a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people
    • a 25% or greater fall in eGFR in children and young people within the past 7 days
  • Monitor serum creatinine regularly[D] in all adults, children and young people with or at risk of acute kidney injury

Identifying the cause(s) of acute kidney injury

  • Identify the cause(s) of acute kidney injury and record the details in the person’s notes

Urinalysis

  • Perform urine dipstick testing for blood, protein, leucocytes, nitrites and glucose in all people as soon as acute kidney injury is suspected or detected. Document the results and ensure that appropriate action is taken when results are abnormal
  • Think about a diagnosis of acute nephritis and referral to the nephrology team when an adult, child or young person with no obvious cause of acute kidney injury has urine dipstick results showing haematuria and proteinuria, without urinary tract infection or trauma due to catheterisation

Ultrasound

  • Do not routinely offer ultrasound of the urinary tract when the cause of the acute kidney injury has been identified
  • When pyonephrosis (infected and obstructed kidney[s]) is suspected in adults, children and young people with acute kidney injury, offer immediate ultrasound of the urinary tract (to be performed within 6 hours of assessment)
  • When adults, children and young people have no identified cause of their acute kidney injury or are at risk of urinary tract obstruction, offer urgent ultrasound of the urinary tract (to be performed within 24 hours of assessment)

Managing acute kidney injury

Relieving urological obstruction

  • Refer all adults, children and young people with upper tract urological obstruction to a urologist. Refer immediately when one or more of the following is present:
    • pyonephrosis
    • an obstructed solitary kidney
    • bilateral upper urinary tract obstruction
    • complications of acute kidney injury caused by urological obstruction
  • When nephrostomy or stenting is used to treat upper tract urological obstruction in adults, children and young people with acute kidney injury, carry it out as soon as possible and within 12 hours of diagnosis

Pharmacological management

  • Do not routinely offer loop diuretics to treat acute kidney injury
  • Consider loop diuretics for treating fluid overload or oedema while:
    • an adult, child or young person is awaiting renal replacement therapy or
    • renal function is recovering in an adult, child or young person not receiving renal replacement therapy
  • Do not offer low-dose dopamine to treat acute kidney injury

Referring for renal replacement therapy

  • Discuss any potential indications for renal replacement therapy with a nephrologist, paediatric nephrologist and/or critical care specialist immediately to ensure that the therapy is started as soon as needed
  • When an adult, child or young person has significant comorbidities, discuss with them and/or their parent or carer and within the multidisciplinary team whether renal replacement therapy would offer benefit. Follow the recommendations on shared decision making in the NICE guideline on patient experience in adult NHS services
  • Refer adults, children and young people immediately for renal replacement therapy if any of the following are not responding to medical management:
    • hyperkalaemia
    • metabolic acidosis
    • symptoms or complications of uraemia (for example, pericarditis or encephalopathy)
    • fluid overload
    • pulmonary oedema
  • Base the decision to start renal replacement therapy on the condition of the adult, child or young person as a whole and not on an isolated urea, creatinine or potassium value
  • When there are indications for renal replacement therapy, the nephrologist and/or critical care specialist should discuss the treatment with the adult, child or young person and/or their parent or carer as soon as possible and before starting treatment. Follow the recommendations on shared decision making in the NICE guideline on patient experience in adult NHS services

Referring to nephrology

  • Refer adults, children and young people with acute kidney injury to a nephrologist, paediatric nephrologist or critical care specialist immediately if they meet criteria for renal replacement therapy in the recommendation above
  • Do not refer adults, children or young people to a nephrologist or paediatric nephrologist when there is a clear cause for acute kidney injury and the condition is responding promptly to medical management, unless they have a renal transplant
  • Consider discussing management with a nephrologist or paediatric nephrologist when an adult, child or young person with severe illness might benefit from treatment, but there is uncertainty as to whether they are nearing the end of their life
  • Refer adults, children and young people in intensive care to a nephrology team when there is uncertainty about the cause of acute kidney injury or when specialist management of kidney injury might be needed
  • Discuss the management of acute kidney injury with a nephrologist or paediatric nephrologist as soon as possible and within 24 hours of detection when one or more of the following is present:
    • a possible diagnosis that may need specialist treatment (for example, vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma)
    • acute kidney injury with no clear cause
    • inadequate response to treatment
    • complications associated with acute kidney injury
    • stage 3 acute kidney injury (according to (p)RIFLE, AKIN or KDIGO criteria)
    • a renal transplant chronic kidney disease stage 4 or 5 (see Table 1)
  • Monitor[E] serum creatinine after an episode of acute kidney injury. Consider referral to a nephrologist or paediatric nephrologist when eGFR is 30 ml/min/1.73m2 or less in adults, children and young people who have recovered from an acute kidney injury
  • Consider referral to a paediatric nephrologist for children and young people who have recovered from an episode of acute kidney injury but have hypertension, impaired renal function or 1+ or greater proteinuria on dipstick testing of an early morning urine sample

Table 1: Stages of chronic kidney disease

StageeGFR (ml/min/1.73 m2)DescriptionQualifier
eGFR=estimated glomerular filtration rate

1

≥90

Kidney damage, normal or increased GFR

Kidney damage (presence of structural abnormalities and/or persistent haematuria, proteinuria or microalbuminuria) for ≥3 months

2

60–89

Kidney damage, mildly reduced GFR

3A

45–59

Moderately reduced GFR ± other evidence of kidney damage

GFR <60 ml/min for ≥3 months ± kidney damage

3B

30–44

4

15–29

Severely reduced GFR ± other evidence of kidney damage

5

<15

Established kidney failure

 

 

Footnotes

[A] Risk, Injury, Failure, Loss, End stage renal disease, (p) refers to the paediatric classification

[B] Acute Kidney Injury Network

[C] Kidney Disease: Improving Global Outcomes

[D] The 2013 guideline committee did not wish to define ‘regularly’ because this would vary according to clinical need but recognised that daily measurement was typical while in hospital

[E] The frequency of monitoring should be based on the stability and degree of renal function at the time of discharge

© NICE 2019. Acute kidney injury: prevention, detection and management. Available from: www.nice.org.uk/guidance/ng148. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

Published date: December 2019.