RENAL

Identify a patient on the ward who has, or has recently recovered from, acute kidney injury. Look through the blood results of the patient with an AKI. If no results are available, use the examples below.

Try to answer the following questions:

• What are the key blood results used to define AKI?

• What are the key clinical parameters used to define AKI?

• How is AKI defined?

Review the KDIGO classification (see references below) to see how your answers compare.

A common way to classify causes is by:

• pre-renal

• intra-renal

• post-renal

Suggest three to five causes of AKI for each category above.

Highlight which of these most commonly present to hospital and which are quite rare. Highlight the most likely cause(s) in the patient you have seen.

If no patient is available, complete the task above using the example scenarios above.

Take a history from the patient with AKI, focusing on trying to identify precipitating factors, the likely cause(s) of AKI and a full drug history.

Review the patient's notes and attempt the following questions:

• What is/was the patient's fluid status on presentation? (You could practice a fluid assessment examination on the patient, if appropriate.)

• Why is it important to measure urine output?

• How is a urine dip helpful in cases of AKI? What did this patient's urine dip show and did it change management?

• Why is a VBG necessary in patients presenting with AKI? What did this patient's VBG show?

• Why is an ECG required in AKI?

• Why is an ultrasound scan needed in some cases of AKI?

Consider:

• What management has been started in this patient? What fluids (if any) have been given?

• What might be the indication(s) for catheterising patients with AKI?

• What is the relevance of potassium measurement? What is the treatment for hyperkalaemia?

• What are the indications for dialysis in severe AKI?

Suggest 10 medications that should be considered in AKI. Try to categorise them into medications that should be:

1. Stopped

2. Dose adjusted

Consider their mechanism of action and the justify your answers given above.

For final years: write a drug chart for the patient you have seen or using one of the examples above, omitting or dose reducing any medications as required. You may wish to use the BNF or the Renal Handbook.

Review this with a doctor or pharmacist and correct any mistakes.

If possible, observe or practice catheterisation of a patient.

If required, attempt to observe or attempt a VBG or ECG for a patient with AKI. Practice interpreting the result and discuss with one of the junior doctors.

Highlight three key things you have learned today. Summarise them on a post-it note and keep it somewhere you will find in a week or two.

Found this useful? Please leave some feedback.

1. KDIGO definition and AKI management guidelines: https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf

2. Renal association guidelines (incl RRT indications): http://www.renal.org/guidelines/modules/acute-kidney-injury#sthash.PaFAGMt3.dpbs

3. NICE management of AKI: https://cks.nice.org.uk/acute-kidney-injury#!scenario

4. BMJ Best Practice: https://bestpractice.bmj.com/topics/en-gb/83

5. Osmosis Youtube Videos: Really clear explanations of pre-renal, intra-renal and post-renal causes: https://binged.it/2OjvyBJ; https://binged.it/2Ofv4N1; https://binged.it/2OiuttN