AKI Pathway(Nottingham University Hospitals April 2015)

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  Does the patient have AKI? Check NOTIS to see if CKD Is the patient under active renal follow-up with CKD, renal transplant or haemodialysis/peritoneal dialysis? Consider referral to QMC AKI service (780-6809) if: -Complications* of AKI -Suspected intrinsic renal disease -Discharge advice required   Refer QMC renal consultant 1 Mon-Fri 9-5pm 2 Yes Yes *Complications of AKI: -K >6.0 -pH <7.2 -BIC <15 -pulmonary oedema -symptomatic uraemia -oligoanuria The following describes patient flow and referral pathway for patients with acute kidney injury and non-AKI patients (CKD, renal transplants, haemodialysis & peritoneal dialysis) who are known to nephrology: QMC Emergency Admissions Renal Patient Pathway Does the patient have  AKI stage 1? Yes Does the patient have  AKI stage 2 or 3? No No  Are there any of the following: 1. Complications *  of AKI? 2. Suspected vasculitis/intrinsic renal disease 3. Lactic acidosis 4. Related to drug overdose Refer to QMC AKI service 780-6809 Mon-Fri 9-5pm OOH refer to acute medicine and follow NUH AKI guideline No Yes For all patient with confirmed AKI: Please follow NUH AKI guidelines (  http://nuhnet/nuh_documents/Guidelines/Trust%20Wide/Trust%20Wide/1719.pdf)   1.Assess fluid status: rehydrate when necessary 2.Urinalysis 3.Review drugs, dosage and omit/stop nephrotoxic drugs 4.Exclude obstruction 5.Treat sepsis (follow sepsis bundle) 6.Repeat renal function within 24hrs Refer QMC renal consultant  1  Mon-Fri 9-5pm 2 Yes Notes: 1  Please refer to renal consultant rota on the intranet for QMC cover or via switchboard  2 For urgent out of hours refer to renal StR/cons on-call at NCH via switchboard 3 If discharging a patient with AKI stage 1 from ED please ensure this is documented on the discharge summary and appropriate follow-up advice is given to GP AKI pathway developed by Dr Bisset (Renal Consultant), Dr Coleman (ED Consultant) 11/11/14. review date 11/11/16  Stage SCr criteria   U/O criteria   1 1.5  – 1.9 x baseline OR ≥26  mol/L increase   <0.5mL/kg/h for 6  – 12 h   2 2.0  – 2.9 x baseline <0.5mL/kg/h for ≥12 h  3 3.0 x baseline OR Increase in SCr to ≥354  mol/L OR Initiation of RRT OR In patients <18 years, decrease in eGFR to <35 mL/min per 1.73 m 2   <0.3mL/kg/h for ≥24 h  OR anuria for ≥12 h   KDIGO AKI staging criteria AKI pathway developed by Dr Bisset (Renal Consultant), Dr Coleman (ED Consultant) 11/11/14. review date 11/11/16 Acute Kidney Injury (AKI)  –   Initial Management   All Emergency Admissions   Urinalysis   Creatinine   Obs   + EWS   Fluid balance chart   Escalate   (CCOT)   Repeat < 24 h Stage AKI   AKI 1   AKI 2   AKI 3   >4 Compare with baseline creat Monitor U/O and repeat creat at least daily until improvement Exclude obstruction (Renal U/S < 24 hours)  Stop/avoid nephrotoxins and review all drug dosing Treat hypovolaemia and sepsis , If abnormal   Nitrites or LE Blood+ Protein+ Creat   U/O   x1.5   -   2 baseline   x2   -   3 baseline   > x3 baseline   or creat   >300 with acute rise of 50   <0.5 ml/kg/h x 6 h   <0.5 ml/kg/h x 12 h   <0.3 ml/kg/h x 24 h or anuria   x 12 h  MSU Consider nephritis screen PCR Immediate AKI Screen   Suggestion for inclusion into GP letter: “Dear Dr, A patient registered to your practice has been discharged from the ED. During their assessment is was noted that they may have had either stage 1 AKI, or possibly new found CKD if no recent U&E was available to view: Urea was: Creatinine was: GFR was: *The last GFR was: on the xx/xx/xxxx *NO previous GFRs existed on NOTIS *Delete as appropriate NICE clinical guideline 182 recommends the following: In people with a new finding of reduced GFR, repeat the GFR within 2 weeks to exclude causes of acute deterioration of GFR  –  for example, acute kidney injury, starting new medications Take the following steps to identify the rate of progression of CKD: Obtain a minimum of 3 GFR estimations over a period of not less than 90 days. Monitor people for the development or progression of CKD for at least 2  – 3 years after acute kidney injury, even if serum creatinine has returned to baseline. If you have any queries please contact the QMC AKI team (M-F 0900- 1700) via the NUH switchboard 0115 9249924”   AKI pathway developed by Dr Bisset (Renal Consultant), Dr Coleman (ED Consultant) 11/11/14. review date 11/11/16
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