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Health and Care Excellent (NICE) suggests increased
awareness of AKI is necessary if any of the following
are likely or present:
• chronic kidney disease (adults with an estimated
glomerular filtration rate [eGFR] less than
60 ml/min/1.73 m2 are at particular risk)
• heart failure
• liver disease
• diabetes
• history of acute kidney injury
• oliguria (urine output less than 0.5 ml/kg/hour)
• neurological or cognitive impairment or disability,
which may mean limited access to fluids because of reliance on a carer
• hypovolaemia
• use of drugs with nephrotoxic potential (such as
nonsteroidal antiinflammatory drugs [NSAIDs],
aminoglycosides, angiotensinconverting enzyme
[ACE] inhibitors, angiotensin II receptor antagonists
[ARBs] and diuretics) within the past week, especially
if hypovolaemic
• use of iodinated contrast agents within the past week
• symptoms or history of urological obstruction, or
conditions that may lead to obstruction
• sepsis
• deteriorating early warning scores
The second reason why AKI is important is because it
is associated with excess death. Back in 2009, the National Confidential Enquiry into Patient Outcome and
Death (NCEPOD) AKI report found that in the UK
up to 100,000 deaths each year in hospital are associated with acute kidney injury and up to 30% could
be prevented with the right care and treatment. The
majority of AKI is caused by sepsis, poor hydration
and medication but other causes exist including renal
tract obstruction and intrinsic renal disease. AKI is associated with high mortality rates; from 8 to 18%, 22–
33%, and 32–36% mortality for patients with AKI
stages 1, 2, and 3 respectively, whilst in the absence of
AKI, mortality runs at 2%. Even in the absence of
death, AKI can have short-term and long-term health
issues for survivors including heart disease, chronic
kidney disease and risk for developing kidney failure.
Since the NCEPOD report, great strides have been
made in hospital AKI care, including the introduction
of AKI algorithms to detect AKI and national advice
on what an AKI bundle should include. There is
greater awareness of clinically recognised risk factors
for AKI, both modifiable (e.g. use of iodinated contrast, use of certain medications) and non-modifiable
(e.g. age, presence of chronic kidney disease) providing greater opportunity to prevent the development
of AKI with appropriate intervention. For example,
staff should be alert to AKI risk in individual patients
that may lead to increased clinical monitoring or a
change in treatment.
How do we detect AKI?
AKI is normally diagnosed by a blood test to measure
the level of creatinine in the blood. If the creatinine
level has doubled, then there is severe AKI and urgent treatment is normally necessary. If the creatinine
level has gone up by a lesser amount, then there may
need to be follow up checks in the next few days.
However, this is less of an emergency and may be
managed in primary care. AKI can also be detected
based upon a drop in urine production in hospitalised
people, but this is less common.
AKI in medico-legal cases
AKI is common and likely to occur in many medicolegal cases, although it may not be immediately obvious. Due to the ubiquitous nature of blood test
investigations including kidney function checks, both
in hospitalised patients and in the community, it is
likely that a closer review of these investigations will
identify kidney issues like AKI. This is important to
flag up as the occurence of AKI can have immediate
and long-term consequences for health and wellbeing.
Think Kidneys (https://www.thinkkidneys.nhs.uk) is a
national campaign raising awareness of the importance of kidneys for life and health, both AKI and
chronic kidney disease. It is important for medicolegal teams to equally have greater awareness of kidneys in their wide variety of cases and seek expert
consult where required.
Often people with AKI have no symptoms, or have
symptoms of the underlying cause that has caused
AKI (e.g. infection), but some complaints people may
have include:
• feeling sick or being sick
• diarrhoea
• dehydration
• peeing less than usual
• confusion
• drowsiness
References
• Improving global outcomes (KDIGO) acute kidney injury work group: KDIGO clinical practice guideline for
acute kidney injury. Kidney Int Suppl. 2012;2(1):1–138
Incidence and outcomes of AKI
AKI is an important medical problem because firstly it
is very common. Around 1 in 4 adult hospital admissions are associated with AKI, with 1 in 2 adult critical
care admissions being associated with AKI. Approximately a third of patients with AKI in hospital develop
their AKI episode during their stay in hospital, while
two-thirds of patients with AKI in hospital had AKI at
the time of admission.
EXPERT WITNESS JOURNAL
• Acute Kidney Injury (AKI) Algorithm; https://www.england.nhs.uk/akiprogramme/aki-algorithm/
• Wang HE, Muntner P, Chertow GM, Warnock DG.
Acute kidney injury and mortality in hospitalized patients.
Am J Nephrol. 2012;35(4):349–55
• Selby NM, Crowley L, Fluck RJ, McIntyre CW, Monaghan J, Lawson N, Kolhe NV. Use of electronic results reporting to diagnose and monitor AKI in hospitalized
patients. Clin J Am Soc Nephrol. 2012;7(4):533–40
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