The video version of this podcast can be found here:

·      https://youtu.be/vETTV_AmatY

The previous episode on AKI covering the diagnosis, investigations and recommendations on the use of contrast media can be found here:

·      https://youtu.be/k6amIFy84Bc

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE guideline on acute kidney injury, NG148, focusing on what is relevant to Primary Care only, covering the management recommendations by NICE, and the Primary Care flowchart on AKI by Barnsley Hospital NHS Trust and King’s College Hospital NHS Trust. You can find links to them in the description below.

If you have not already done so, I recommend that you check the previous episode on AKI covering the diagnosis, investigations and recommendations on the use of contrast media.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

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• Music provided by Audio Library Plus 
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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The links to the guidance covered in this episode can be found here:

Acute kidney injury: prevention, detection and management (NG148):

·      https://www.nice.org.uk/guidance/ng148

The 1-page visual summary on assessing the risk of acute kidney injury in adults having iodine-based contrast media: outpatient, non-urgent inpatient and community settings:

·      https://www.nice.org.uk/guidance/ng148/resources/visual-summary-pdf-13551376429

The algorithm for early identification of acute kidney injury, endorsed by NHS England:

·      https://www.england.nhs.uk/akiprogramme/aki-algorithm/

The Management of acute kidney injury in adults in Primary Care by Barnsley Hospital NHS Trust:

·      https://best.barnsleyccg.nhs.uk/media/hruaaymn/best-december-2015-barnsley-aki-primary-careguidance-pathway.pdf?form=MG0AV3

The Adult Acute Kidney Injury Care Pathway for Primary Care by King’s College Hospital NHS Trust:

·      https://www.kch.nhs.uk/wp-content/uploads/2023/01/mi-169.2-adult-acute-kidney-injury-care-pathway.pdf

A calculator for the National Early Warning Score (NEWS):

·      https://www.mdcalc.com/calc/1873/national-early-warning-score-news

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE recommendations on the management of acute kidney injury, focusing on what is relevant in Primary Care only. We will also cover the Primary Care flowchart on AKI by Barnsley Hospital NHS Trust and King’s College Hospital NHS Trust. You can find links to them in the episode description. If you have not already done so, I recommend that you check the previous episode on AKI covering the diagnosis, investigations and recommendations on the use of contrast media.

Right, let’s jump into it.

What management does NICE recommend?

Well, managing acute kidney injury in primary care settings is generally limited, as it often requires specialised hospital monitoring and treatment. We are also likely to feel apprehensive keeping these patients in Primary Care, given the severity of some causes of AKI, such as sepsis, or some of its complications, such as acidosis and hyperkalaemia. Although NICE does not spell out which cases can potentially be managed in Primary Care, some other guidelines do provide us with some guidance, stating that primary care management can be justified, particularly for lower-risk cases. I have looked at the guidelines on the management of AKI by Barnsley Hospital and King’s College Hospital and we will go through them a little later.

But for now, let’s stick to the NICE guideline.

In terms of pharmacological management:

·      We will not offer low-dose dopamine

·      We will not routinely offer loop diuretics but 

·      We will consider loop diuretics for treating fluid overload or oedema while:

• awaiting renal replacement therapy or
• while renal function is recovering and the patient is not receiving renal replacement therapy 

In terms of relieving urological obstruction, we will refer these patients to a urologist. We will do so as an emergency if there is:

• pyonephrosis
• an obstructed solitary kidney
• bilateral upper urinary tract obstruction or
• complications of acute kidney injury caused by urological obstruction. 

We will refer to nephrology those who need dialysis, but we will not refer those with a clear cause for the acute kidney injury if the condition is responding to medical management, unless they have a renal transplant. 

We will monitor creatinine after AKI, basing the frequency of monitoring on the renal function at the time of discharge. We will refer to a nephrologist if eGFR is 30 or less post AKI recovery. 

We will refer to a paediatric nephrologist anyone under 18 years who, after AKI, have hypertension, impaired renal function or 1+ or greater proteinuria on dipstick testing. 

Right, that is the end of the NICE guideline summary.

Let’s now review the guidance provided by King’s College Hospital and Barnsley Hospital. Since both pathways are quite similar, I’ll primarily focus on the flowchart from Barnsley Hospital NHS Trust, because it is better to navigate clinical cases but I’ll be sure to highlight any supplementary details from King’s College Hospital along the way.

Right, so, we start with the flowchart by Barnsley Hospital.

And, if we get an AKI Alert

Then we have to look at the stage of the AKI that we are dealing with, so, as promised, let’s look at them. We have:

Stage 1: which is when creatinine rises by between 1.5 and 1.9 times from normal baseline. King’s College hospital also includes here a rise of creatinine by 26µmol/L within 48 hours, which is in keeping with NICE recommendations.

Stage 2: is when creatinine rises by between 2 and 2.9 times from normal baseline and

Stage 3: is when creatinine rises by 3 or more times from normal baseline. King’s College hospital also includes here when creatinine rises to 354µmol/L or more.

Then we see that Stage 3 AKI will require admission to hospital,

But admission to hospital will also be needed in a number of other cases. Let’s go through the list:

So, not only stage 3 AKI but also

If the patient is Clinically Unwell, with suspected sepsis and/or has a high NEWS score. Remember that NEWS stands for National Early Warning Score, which is used to assess the severity of a patient's condition, especially in cases of sepsis or other acute illnesses. If you are not familiar with it, I have put the link for a NEWS calculator in the episode description.

We will also admit to hospital patients with any AKI stage with no clear cause

Or if there is inadequate response to initial treatment

A possible diagnosis that may need specialist treatment:

For example, AKI with suspicion of urinary tract obstruction or intrinsic renal disease,

Pregnancy

Urinalysis shows both ≥2+ Blood AND Protein, although here King’s College recommends admission if urinalysis shows either ≥2+ Blood or Protein in absence of UTI.

Systemic symptoms (for example arthralgia, rash, epistaxis, haemoptysis) (when we will think of glomerulonephritis, vasculitis, interstitial nephritis, and myeloma)

We will also admit if there are AKI Complications: like hyperkalaemia (with a K>6.0mmol/L), fluid overload, or uraemia

Also, if there is prior CKD stage 4 or 5, that is, an eGFR of below 30

And a renal transplant with any AKI

And so, in all these cases, we will refer to the medical team, considering discussion with nephrology or urology depending on the clinical presentation.

And therefore, the implication is that AKI stages 1 and 2 can potentially be managed in Primary Care.

So, in these cases, we will ask ourselves: Is the patient ACUTELY UNWELL? Are there AKI Complications? Is there a need for IV Fluids? Or worsening AKI? Or any other on-going Concerns?

And if the answer is yes, we will admit them to hospital.

But if the answer is no,

Then we should be able to manage them in the community.

For this, we will need Close follow-up, Early repeat of Creatinine and monitoring of Potassium (K+), carry out the process of STOP-AKI, which we will look at in a minute, and Review the patient Clinically within 24 to 48hrs (using the rapid response team if necessary), Discussing with the Medical Team if there are On-going Concerns.

So, what do we need to do in respect of the STOP AKI process? Well, STOP AKI is a systematic approach where each letter in "STOP" represents a critical component of AKI management, aiming to reduce complications and support kidney recovery:

So, S is for SEPSIS: where we should Recognise and treat infection.

We will Do Urinalysis and if there is protein / leucocytes or nitrites we will send an MSU and start Antibiotics. King’s College Hospital recommends that if there is infection, we should not prescribe trimethoprim or nitrofurantoin because of increased risk of toxicity and, in the case of nitrofurantoin, reduced efficacy in AKI.

We should also Check FBC and, U&E at least every 48-72hrs until the patient is clinically stable

T is for TOXINS: we should hold nephrotoxic drugs like for example NSAIDS, ACE inhibitors, ARBs, Nitrofurantoin and Allopurinol

O is for OPTIMISE BP and Fluid state

-If the patient is dehydrated, we will encourage oral fluid intake

-If there is fluid overload we will refer to the medics

-If the patient is HYPOTENSIVE, we will obviously stop anti hypertensives and diuretics until the situation is stable

P is for PREVENT Harm: We will do a Drug Review and apply Sick day Rules, like, for example, Stop or Adjust the dose of

- Metformin (because of the risk of lactic acidosis)

- Proton pump inhibitors, which can worsen electrolyte imbalances

- Opiates (because they can accumulate during AKI)

- And in the cases of specialist drugs such as Sulphasalazine or Lithium, we will Discuss it with the relevant specialist.

Obviously, we will always aim to identify the AKI Cause, Thinking of Pre-renal causes, Intrinsic Renal disease and Obstructive causes. In this respect, King’s College emphasises the need to exclude a palpable bladder during examination and requesting an USS of the urinary tract in patients with Stage 2 AKI.

So that is it, a review of the management recommendations on AKI. If you have not already done so, please check the previous episode covering the diagnosis, and initial investigations of AKI.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.