Managing acute kidney injury

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/acute-kidney-injury
NICE Pathway last updated: 19 August 2020

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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1 Person with acute kidney injury

No additional information

2 Information and support

Discuss immediate treatment options, monitoring, prognosis and support options as soon as
possible with people with acute kidney injury and/or, if appropriate, their parent or carer. Follow
the recommendations on tailoring healthcare services for each patient and shared decision
making to enable adult patients to actively participate in their care in the NICE Pathway on
patient experience in adult NHS services.

Give information about long-term treatment options, monitoring, self-management and support
to people who have had acute kidney injury (and/or their parent or carer, if appropriate) in
collaboration with a multidisciplinary team appropriate to the person's individual needs.

3 Relieving urological obstruction

Refer all adults, children and young people with upper tract urological obstruction to a urologist.
Refer immediately when one or more of the following is present:

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

When nephrostomy or stenting is used to treat upper tract urological obstruction in adults,
children and young people with acute kidney injury, carry it out as soon as possible and within
12 hours of diagnosis.

Memokath-051 stent for ureteric obstruction

The following recommendations are from NICE medical technologies guidance on

Memokath-051 stent for ureteric obstruction.

The case for adopting Memokath-051 for treating ureteric obstruction is partially supported by
the evidence. The evidence is limited but suggests that in selected cases, Memokath-051 is

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effective at relieving ureteric obstruction and improving quality of life. When inserted by trained
clinicians (see section 4.8) and in appropriate patients (see below), Memokath-051 is
associated with equivalent success rates and a better patient experience compared with
double-J stents. Using Memokath-051 may also reduce the number of stent replacements
needed compared with using double-J stents.

Memokath-051 stents should be considered as an option in patients with:

malignant ureteric obstruction and anticipated medium- or long-term survival after

adjunctive therapy
benign ureteric obstruction who cannot have or do not want reconstructive surgery or
ureteric obstruction of any kind who cannot have or do not want a double-J stent, or for
whom repeat procedures are a particularly high risk.

The cost consequences of adopting Memokath-051 are uncertain. However, when used in
appropriate patients and by clinicians trained in its use, it may be cost neutral or cost saving
compared with standard treatment. Potential cost savings mainly come from fewer repeat
procedures with Memokath-051.

4 Pharmacological management

Do not routinely offer loop diuretics to treat acute kidney injury.

Consider loop diuretics for treating fluid overload or oedema while:

an adult, child or young person is awaiting renal replacement therapy or

renal function is recovering in an adult, child or young person not receiving renal
replacement therapy.

Do not offer low-dose dopamine to treat acute kidney injury.

5 Indications for renal replacement therapy

Refer adults, children and young people immediately for renal replacement therapy if any of the
following are not responding to medical management:

hyperkalaemia
metabolic acidosis
symptoms or complications of uraemia (for example, pericarditis or encephalopathy)

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fluid overload
pulmonary oedema.

Discuss any potential indications for renal replacement therapy with a nephrologist, paediatric
nephrologist and/or critical care specialist immediately to ensure that the therapy is started as
soon as needed.

When an adult, child or young person has significant comorbidities, discuss with them and/or
their parent or carer and within the multidisciplinary team whether renal replacement therapy
would offer benefit. Follow the recommendations on shared decision making to enable adult
patients to actively participate in their care in the NICE Pathway on patient experience in adult
NHS services.

Base the decision to start renal replacement therapy on the condition of the adult, child or young
person as a whole and not on an isolated urea, creatinine or potassium value.

When there are indications for renal replacement therapy, the nephrologist and/or critical care
specialist should discuss the treatment with the adult, child or young person and/or their parent
or carer as soon as possible and before starting treatment. Follow the recommendations on
shared decision making to enable adult patients to actively participate in their care in the NICE
Pathway on patient experience in adult NHS services.

Information about future care for people needing renal replacement therapy after
discharge

Give information about future care to people needing renal replacement therapy after discharge
following acute kidney injury. This should include information about the frequency and length of
dialysis sessions and the preparation needed (such as having a fistula or peritoneal catheter).

6 Referral to nephrology

Refer adults, children and young people with acute kidney injury to a nephrologist, paediatric
nephrologist or critical care specialist immediately if they have any of the indications for renal
replacement therapy [See page 4].

Refer adults, children and young people in intensive care to a nephrology team when there is
uncertainty about the cause of acute kidney injury or when specialist management of kidney
injury might be needed.

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Discuss the management of acute kidney injury with a nephrologist or paediatric nephrologist as
soon as possible and within 24 hours of detection when one or more of the following is present:

a possible diagnosis that may need specialist treatment (for example, vasculitis,
glomerulonephritis, tubulointerstitial nephritis or myeloma)
acute kidney injury with no clear cause
inadequate response to treatment
complications associated with acute kidney injury
stage 3 acute kidney injury (according to (p)RIFLE, AKIN or KDIGO criteria)
a renal transplant
chronic kidney disease stage 4 or 5 (see stages of chronic kidney disease [See page 8] for
more details).

Consider discussing management with a nephrologist or paediatric nephrologist when an adult,

child or young person with severe illness might benefit from treatment, but there is uncertainty
as to whether they are nearing the end of their life.

Do not refer adults, children or young people to a nephrologist or paediatric nephrologist when
there is a clear cause for acute kidney injury and the condition is responding promptly to
medical management, unless they have a renal transplant.

After an episode of acute kidney injury

Monitor serum creatinine after an episode of acute kidney injury (the frequency of monitoring
should be based on the stability and degree of renal function at the time of discharge). Consider
referral to a nephrologist or paediatric nephrologist when eGFR is 30 ml/min/1.73 m2 or less in
adults, children and young people who have recovered from an acute kidney injury.

Consider referral to a paediatric nephrologist for children and young people who have recovered
from an episode of acute kidney injury but have hypertension, impaired renal function or 1+ or
greater proteinuria on dipstick testing of an early morning urine sample.

Quality standards

The following quality statements are relevant to this part of the interactive flowchart.

5. Discussion with a nephrologist

6. Referral for renal replacement therapy

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7 Follow-up for person aged 18 or over

Monitor people for the development or progression of chronic kidney disease for at least 2–3
years after acute kidney injury, even if serum creatinine has returned to baseline.

Advise people who have had acute kidney injury that they are at increased risk of chronic
kidney disease developing or progressing.

See the NICE Pathways on chronic kidney disease and intrapartum care for women with kidney
disease.

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Stages of chronic kidney disease

eGFR
(ml/
Stage min/ Description Qualifier
1.73
m2)

Kidney damage,
1 ≥90 normal or increased
GFR Kidney damage (presence of structural
abnormalities and/or persistent haematuria,
proteinuria or microalbuminuria) for ≥3 months
Kidney damage, mildly
2 60–89
reduced GFR

3A 45–59 Moderately reduced

GFR ± other evidence
3B 30–44 of kidney damage

Severely reduced GFR GFR <60 ml/min for ≥3 months ± kidney damage
4 15–29 ± other evidence of
kidney damage

Established kidney
5 <15
failure

Glossary

Adult

(excluding pregnant woman)

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Adults

(excluding pregnant women)

AKIN

acute kidney injury network

Children

(excluding neonates less than 1 month old)

Child

(excluding neonate less than 1 month old)

eGFR

estimated glomerular filtration rate

KDIGO

kidney disease: improving global outcomes

(p)RIFLE

risk, injury, failure, loss, end stage renal disease; (p) refers to the paediatric classification

Sources

Acute kidney injury: prevention, detection and management (2019) NICE guideline NG148

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182

Memokath-051 stent for ureteric obstruction (2018) NICE medical technologies guidance 35

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Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to

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have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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