Features

Acute kidney injury: the common condition that’s often overlooked

When nurses stay alert to the signs of AKI and the importance of hydration, they optimise patient outcomes

When nurses stay alert to the signs of AKI and the importance of hydration, they optimise patient outcomes

  • Acute kidney injury can be prevented if the signs are spotted early and action taken quickly
  • People with underlying conditions, such as diabetes, hypertension or previously unrecognised kidney impairment are at risk, as are those who have undergone major surgery
  • How to spot early warning signs and the importance of monitoring fluid balance and hydration
Picture: iStock

For such a common condition, acute kidney injury (AKI) has had a low profile.

Although the condition is seen in as many as 18% of people admitted to hospita l, according to the National Institute for

...

When nurses stay alert to the signs of AKI and the importance of hydration, they optimise patient outcomes

  • Acute kidney injury can be prevented – if the signs are spotted early and action taken quickly
  • People with underlying conditions, such as diabetes, hypertension or previously unrecognised kidney impairment are at risk, as are those who have undergone major surgery
  • How to spot early warning signs and the importance of monitoring fluid balance and hydration
Picture: iStock

For such a common condition, acute kidney injury (AKI) has had a low profile.

Although the condition is seen in as many as 18% of people admitted to hospital, according to the National Institute for Health and Care Excellence, AKI flies under the radar.

Estimated annual cost of AKI to the NHS

The annual cost to the NHS is £620 million, suggests UK charity Kidney Care, while a 2014 study put the figure at more than £1 billion.

In AKI, kidney function worsens over a short period, in contrast to chronic kidney disease, which tends to develop over months or years.

It is commonly caused by infection or dehydration, follows surgery or is seen in association with another serious condition, such as sepsis.

Fiona Loud, Kidney Care UK policy director

‘Acute kidney injury is one of these things that tends to be a well-kept secret,’ explains Kidney Care UK policy director Fiona Loud.

Now, she wants nurses, and the public, to learn more about AKI.

‘It happens a lot, but doesn’t have the awareness that it should have.’

AKI is a condition that can be prevented, and – if the signs are spotted early and action taken quickly – lasting damage or even death can be avoided.

COVID-19 has also led to AKI in severely ill patients, many of whom have required treatment in intensive care.

Nurses in all clinical settings will see patients with AKI

The Association of Nephrology Nurses (ANN UK) is involved in developing a specialist multi-professional AKI group to improve understanding of the condition.

ANN UK board member Claire Main explains that AKI can be seen in any clinical setting and nurses’ focus should be on preventative measures.

‘Whether you’re in a care home or an emergency setting, you may well see people with kidney injury,’ she says.

‘A lot of it then is trying to educate people about those early warning signs of what might happen.’

Until March, Ms Main was lead nurse for renal services at Cardiff and Vale University Health Board and is now on secondment within the same organisation as interim manager of critical care and major trauma for South Wales.

‘Here in Cardiff we’ve been looking a lot at our outreach services and trying to raise awareness of how to recognise people who may be at risk of or exhibiting early signs of AKI.’

How to spot when a patient might have acute kidney injury

Symptoms of acute kidney injury (AKI) can include:

  • Nausea or vomiting
  • Diarrhoea
  • Confusion
  • Poor or concentrated urine output
  • Dehydration
  • Drowsiness

People at increased risk include those who:

  • Are 65 or older
  • Have a long-term disease such as diabetes, heart failure or liver disease
  • Already have a kidney problem such as chronic kidney disease
  • Are dehydrated
  • Take certain medications, including non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, blood pressure lowering drugs, or those that treat heart conditions
  • Have a severe infection or sepsis or who have lost a lot of blood or undergone surgery

The condition is usually diagnosed by checking the level of creatinine in the blood. Management varies but can include changing medication, rehydration, or, in more serious cases, haemodialysis.

Source: NHS: Acute kidney injury

Early intervention may be able to reverse harm

Ms Main says people with underlying conditions, such as diabetes, hypertension, or previously unrecognised kidney impairment are at risk.

People who have undergone major surgery, or who have had serious burns or anything that affects their fluid balance may also sustain damage to their kidneys, she adds.

‘A lot of things that happen with these patients may be reversible in the early stage.

‘That’s why we’re driving to ensure nurses are aware of early warning signs, making sure they’re keeping an eye on people’s fluid balance, and questioning hydration of patients, with a huge emphasis on sepsis and dehydration related to those kinds of things.’

Picture: iStock

Seemingly insignificant events can lead of AKI

AKI can sometimes result from things that seem quite inconsequential, such as prolonged vomiting or diarrhoea, leading to dehydration.

But healthcare professionals may be more likely to look for AKI after more ‘pronounced’ incidents, such as loss of blood volume after a big accident or hypertensive episodes after surgery, adds Ms Main.

‘Some of the signs of kidney injury are quite insidious – they’re not things that you would automatically link with your kidneys’

Claire Main, Cardiff and Vale University Health Board renal services lead nurse

‘You may be more thinking along the lines of checking people’s blood results and taking a close look, but often it is the smaller changes that lead to the problem.

‘Or sometimes drugs that we’re giving people for other reasons have an impact on kidney function, so it’s about being very mindful.’

The risk posed by a hospital stay

A key risk for AKI is a hospital stay, according to Ms Main.

‘The reason you’ve come into hospital might not on its own cause the AKI, but that, linked with changing medication, for example, or not being able to get access to drinks can lead to AKI. It’s multifactorial.’

Understanding more about the kidney and how many other parts of the body relate to it is important, she adds.

‘As a kidney nurse, you become really aware of how important kidneys are for so many different regulatory systems in your body.

‘But if you’re on a ward that’s orthopaedics or whatever, that’s obviously your primary focus and you may not be thinking about anything else alongside that.

‘It’s common, it’s harmful, and it can be prevented with swift intervention’

Fiona Loud, policy director, Kidney Care UK

‘Plus, some of the signs of kidney injury are quite insidious – they’re not things that you would automatically link with your kidneys: you might look a bit dehydrated, but you might just look a little bit confused or disorientated, and if you’re in hospital that can be put down to just being in hospital, a little bit of analgesia, recovery – all sorts of things.’

COVID-19 and acute kidney injury

Picture: iStock

Although COVID-19 was originally considered a respiratory illness, it quickly became evident patients were also experiencing acute kidney injury (AKI).

The Association of Nephrology Nurses UK has been working with the British Association of Critical Care Nurses (BACCN) to develop guidance on how to manage AKI in critical care units, particularly related to COVID-19.

Patients in intensive care units (ICU) with AKI often undergo a process called haemofiltration – a slower, ‘kinder’ form of dialysis – but this put pressure on resources, explains BACCN chair Nicki Credland.

‘We’ve had lots of patients who have needed haemofiltration to the point we ran out of haemofiltration equipment completely.

‘In some areas we were going back to doing old-fashioned peritoneal dialysis.’

A shift in approach to fluid management

South Wales critical care and major trauma interim manager Claire Main says there was a tendency early in the pandemic to be conservative with fluid management of people in ICU with COVID-19 to help their breathing.

But that had a harmful effect on their kidneys.

‘We started to change the management, and be a little less conservative with fluid management and more aggressive with helping with oxygen therapies, which changed the balance.’

Patient education and management of chronic disease

Making sure people who have recovered are armed with the knowledge to prevent or spot a recurrence is also vital.

‘It’s about reassuring people that if normally you are fit and well, and this was a first-line acute kidney injury, then hopefully everything has gone back and there’s no effect on your long-term kidney function.

‘But, if you’ve been really unwell, or potentially there’s some longer lasting damage, and you’ve moved into a chronic kidney disease, it’s then about helping them – alongside primary care colleagues – to make sure things are being monitored regularly.’

‘It’s common, it’s harmful, and it can be prevented with swift intervention’

‘Nurses play an absolutely vital role in being the eyes and ears for patients, who won’t necessarily know why they are feeling the way they do’

Fiona Loud

Part of this is ascertaining the cause of the AKI and ensuring action is taken accordingly.

Ms Main says non-steroidal anti-inflammatory drugs, (NSAIDs) like ibuprofen, are sometimes to blame.

‘It’s about working with other healthcare providers to make sure those medications are monitored or changed, or [finding] other ways for people to manage their conditions.’

Use of NSAIDs such as ibuprofen can be associated with AKI Picture: iStock

Follow-up in primary care

The fact they have had an AKI should be flagged on patients’ discharge profile, she adds.

‘It’s about making sure follow-up in primary care happens, but also advising patients to keep an eye on their fluid balance, their urine output, and if they notice anything – if they’re not able to drink properly, or they’re losing fluids, that they alert whoever is doing the follow-up to these issues.’

The National Institute for Health and Care Excellence (NICE) published updated guidance on AKI late last year.

The nursing team’s role in monitoring fluid intake and urine output

Kidney Care UK’s Fiona Loud was part of the team that drew up the original NICE guidance back in 2013.

‘Nurses play an absolutely vital role in being the eyes and ears for patients, who won’t necessarily know why they are feeling the way they do,’ says Ms Loud. ‘That’s the case in primary care and in secondary care and that’s why there are various tools and checklists for people to look out for.

‘It’s common, it’s harmful, and it can be prevented with swift intervention.

‘Nurses and healthcare assistants all have a job to watch fluid in and fluid out.

‘Noticing early, and being able to assess early, and being able to intervene is of course the right thing to do, because by the time people might need dialysis things have gone really quite a long way – the organs have begun to fail and recovery is harder.’

Resources available for patients and nursing professionals

Ms Loud points to resources, including those produced by Kidney Care UK – aimed at health professionals and patients and the public and the Think Kidneys campaign.

‘There’s some good guidance out there and there was a lot of nurse input.

‘Nursing teams play an important part in teaching others how to watch out for the simple things that can be done with medication or hydration, intervening quickly as and when necessary. AKI can be very harmful, but it can be addressed if caught early.

‘A lot of people don’t know about AKI – don’t let’s make it a well-kept secret.’


Jennifer Trueland is a health journalist

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to nursing standard.com and the Nursing Standard app
  • Monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs