Warning

Patient at risk of AKI

  • Known Chronic kidney disease (CKD)
  • Heart failure
  • Diabetes
  • Ischaemic heart disease
  • Malignancy
  • Liver disease
  • Nephrotoxic drugs
  • IV contrast
  • Urinary obstruction
Stage 1 AKI Stage 2 AKI Stage 3 AKI
ALERT
  • Cr increase >1.5 to 1.9 x from baseline
  • OR acute ↑ Cr >26micromol/L/48 hrs
  • OR UO <0.5ml/kg/hr for >6 hours
  • Cr increase >2 to 2.9 x from baseline
  • OR UO <0.5ml/kg/hour >12 hours
  • Cr increase >3 x from baseline
  • OR Cr >354 micromol/L
  • OR UO <0.3ml/kg/hr for 24hrs
  • OR anuric for 12 hrs
  • OR requires RRT irrespective of Cr
ASSESS

Clinical history

  • risk factors
  • accurate drug history

Examination

  • SEWS
  • volume status
  • Glasgow Coma Scale (GCS)
  • Respiratory status
  • Palpable bladder
  • Signs of sepsis
  • Signs of vasculitis
  • Urine output

Investigations

  • serial U&Es
  • HCO3, FBC, CRP, LFTs, calcium
  • Urine PCR if proteinuria MSSU
  • Chest X-ray
  • ECG

Consider

  • Renal USS
  • Sepsis screen
  • ABGs, lactate, CK amylase
  • Vasculitic screen if haematuria & proteinuria
  • Myeloma screen

As per Stage 1

AND 

  • Renal US within 24 hrs
  • Sepsis screen

As per Stage 2

AND 

  • Look for multiorgan failure
  • Chase Renal US
ACT
  • Correct hypovolaemia
  • Optimise blood pressure
  • Accurate fluid balance
  • Avoid nephrotoxins
  • Rx sepsis
  • Relieve obstruction
  • Dose adjustment of renally excreted medication

Consider:

  • Urinary catheter
  • Senior review & CVP

As per Stage 1

AND

  • Senior review
  • Catheterise, 1° urine volumes  

Consider:

  • CVP/cardiac monitoring
  • Referral to Renal Team
  • Dietician review
    Transfer to Level 2 care

As per Stage 2

AND

  • Senior review
  • Refer to Renal Team &
    transfer to Level 2 care
  • Cardiac monitoring  

Consider:

  • CVP insertion
  • Referral to Intensive Care Unit (ICU)

See: Hyperkalaemia guideline

Referrals to renal unit

Urgent In-Patient

  • High suspicion of rapidly progressive glomerulonephritis
  • Indication for dialysis*
  • Stage 3 AKI
  • Stage 2 AKI unresponsive to Rx after 24 to 48 hrs
  • Renal transplant patient admitted to hospital
  • Dialysis patient admitted to hospital

Urgent referrals: speak directly to renal consultant.
Renal referrals are usually seen by renal consultant covering ward 7C.

Renal secretaries extension: 6342

Possible Indications for urgent dialysis

  • Refractory hyperkaleamia
  • Ur >30 +/- Cr >500
  • Refractory volume overload
  • Refractory acidosis pH <= 7.1
  • Complications of uraemia
  • Severe poisoning

Editorial Information

Last reviewed: 22/11/2023

Next review date: 30/11/2026

Author(s): Renal Department .

Reviewer name(s): Dr N Joss, Consultant Nephrologist .

Document Id: TAM357

Related guidelines