RENAL

ACUTE KIDNEY INJURY

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Identify acute kidney injury (AKI) from blood tests
Understand the classification criteria of AKI - pre-renal, intra-renal and post-renal
Recognise the most common causes of AKI presenting to secondary care
Understand the key investigations and initial management of AKI
Recognise indications for acute dialysis
Perform an appropriate review of medications for a patient with AKI (5^th year level)

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Phillipa Clery

Uploaded:

25th September 2019

Last updated:

25th September 2019

Resources needed for this session:

Pen, paper, blood results, patient, BNF

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

Hyperkalaemia and Hypokalaemia

Urinalysis

Activity 1: Interpreting Investigations

5 min

Ask the student(s) to look through the blood results of the patient with an AKI. If no results are available, use the examples below.

Discuss:

What are the key blood results used to define AKI?
What are the key clinical parameters used to define AKI?
How is AKI defined?

Discuss the KDIGO classification (opposite).

Example 1.

68y/o female. Previously fit and well, presented with gastroenteritis. She has been unable to keep any fluids down for 2 days.

Previous blood results: eGFR >90

Na 138

K 5.1

Ur 9.1

Cr 138

eGFR 77

Example 2.

55y/o male. Past medical history of type two diabetes mellitus, hypertension, benign prostatic hypertrophy, chronic kidney disease. Current medications include metformin, bisoprolol, amlodipine, tamsulosin, finasteride, ramipril, colecalciferol, omeprazole, atorvastatin.

Presented with 2 days’ history of abdominal pain, which didn’t improve with paracetamol or ibuprofen at home. He was admitted under the surgeons and had a CT with contrast which showed severe cholecystitis. He has been started on IV gentamicin.

Current observations: BP 109/80, HR 100, RR 15, Sats 96% OA, temp 38.5

Previous blood results: eGFR 60, Creatinine 129

Na 138

K 6.9

Ur 9.0

Cr 258

eGFR 42

Example 3.

78y/o female. Past medical history of heart failure, atrial fibrillation, two previous non-STEMIs, hypertension, osteoarthritis of her knee. Current medications include apixaban, aspirin, bisoprolol, candesartan, naproxen, omeprazole, spironolactone, laxido.

Presented with fall and long lie.

Previous blood results: eGFR 80, Creatinine 90

Na 130

K 3.3

Ur 7.3

Cr 180

eGFR 75

Activity 2: History Taking

15 min

Ask the student(s) to take a history from the patient with particular focus on determine to precipitating factors, the likely cause(s) of AKI and a full drug history.

Activity 3: Case-Based Discussion

10 min

Ask the student(s) to present the case of the patient they have just seen. Feedback on presentation style (max 1 min).

Discuss the classification of causes of AKI e.g. pre-renal, intra-renal and post-renal causes of AKI. Highlight which of these most commonly present to hospital, and which are quite rare. Ask students to identify the possible and if clear, the most likely factors contributing to AKI in the patient they have seen.

If more appropriate, use the scenarios above as a basis of discussion.

Activity 4: Investigations and Management

10 min

Allow students to review the notes of the patient they have just seen. If none are available, base discussions around one of the cases above. Consider the key elements of the patient's initial assessment and investigations.

Some prompts for discussion:

What is/was the patient's fluid status on presentaton? (Students 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?

Discuss initial management:

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?

Activity 5: Medication Review

10 min

Ask the student(s) to suggest medications that should be considered in AKI. Try to categorise them into medications that should be:

Stopped
Dose adjusted
Continued

Consider their mechanism of action and the justification for answers given above.

For final years, ask them to write a drug chart for the patient they have seen or using one of the examples above, omitting or dose reducing any medications as required. They may wish to use the BNF (use the QR code opposite to view on their phone) or the Renal Handbook.

Review this with the student and correct any mistakes.