acute kidney injury and the implications for community and practice nurses claire stocks – sister,...

Acute Kidney Injury and the implications for

community and practice nurses

Claire Stocks – Sister, Cardiac Arrest Prevention Team, County Durham & Darlington Foundation Trust

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Disclaimer……..I’m no expert!

DateAcute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks

DateAcute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks | 3

Learning Outcomes

Define Acute Kidney Injury (AKI)

Discuss the potential causes of AKI

Top Tips for nurses


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)

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.


Aged 75 or over

Cardiac Disease

Liver Disease

Diabetes

Chronic Kidney Disease

Cancer

Acute insult from conditions such as Sepsis.

Patients susceptible to dehydration


Risk of AKI

Causes…..

Pre Renal

Most common cause of AKIFlow disruption to the kidney

For example:Low blood pressureHeart FailureLow blood volume Blood flow

reduced


Causes….

Intrinsic

Damage to the kidney itself

For example:

Glomerulonephritis

Acute tubular Necrosis


Causes….

Post Renal

A consequence of urinary tract obstruction.For example:Blocked catheterRenal calculi Bladder tumours


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.


Top Tips for Nurses regarding Acute Kidney Injury

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.


1) Maintain a healthy blood pressure.



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.



3) Medication review is essential.UK Renal Pharmacy Group – AKI Medicines Optimisation Toolkit (March 2012)

Consider Acute Nephrotoxic Drug Action

Contrast MediaAce InhibitorsNSAID’sDiureticsARB’s

Be aware of other drugs excreted by the kidneys such as Metformin, Opioids, Some antibiotics, Digoxin & Lithium.


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.



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.


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


For further information regarding Acute Kidney Injury please see the Think

Kidneys Websitewww.thinkkidneys.nhs.uk

How to find out moreKaren ThomasThink Kidneys Programme ManagerUK Renal [email protected] WallaceThink Kidneys Programme CoordinatorUK Renal [email protected]

Julie SlevinThink Kidneys Programme Development OfficerUK Renal Registry

M 07810560766 | E [email protected]

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Contact Think Kidneys

Richard FluckNational Clinical Director for RenalNHS [email protected]

Joan RussellHead of Patient SafetyNHS [email protected]

Ron CullenDirectorUK Renal [email protected]

www.linkedin.com/company/think-kidneys

www.twitter.com/ThinkKidneys

www.facebook.com/thinkkidneys

www.youtube.com/user/thinkkidneys

www.slideshare.net/ThinkKidneys

www.thinkkidneys.nhs.uk

DateAcute Kidney Injury National Programme | Implications for community & practice nurses | Claire Stocks

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acute kidney injury and the implications for community and practice nurses claire stocks – sister,...

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