Excerpt

NICE’s original guideline on acute kidney injury was published in 2013. It was updated in 2019.

Acute kidney injury (AKI), previously called acute renal failure, has chiefly been described as a syndrome since World War 2. Traditionally ‘acute renal failure’ was regarded as a less common organ failure, with patients typically requiring dialysis and managed by nephrologists. This view has now been overturned. AKI encompasses a wide spectrum of injury to the kidneys, not just ‘kidney failure’. It is a common problem amongst hospitalised patients, in particular the elderly population whose numbers are increasing as people live longer. Such patients are usually under the care of doctors practicing in specialties other than nephrology. For normal function the kidneys require a competent circulation. Conversely, it is known that renal function is vulnerable to even relative or quite modest hypotension or hypovolaemia. Hence AKI is a feature of many severe illnesses. Although these illnesses may affect many organs, the simple process of monitoring urine output and/or creatinine permits detection of AKI.

There have long been concerns that clinicians may inadvertently contribute to the development of AKI, by their use of drugs that are harmful to the kidneys. However, in spite of its wider adoption in the UK from the 1970's, audit was not fully applied to AKI until the turn of the millennium. A seminal moment was the confidential enquiry into the deaths of a large group of adult patients with AKI, published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2009. This described systemic deficiencies in the care of patients who died of AKI including failures in AKI prevention, recognition, therapy and timely access to specialist services. Only 50% of these sick patients received ‘good’ care. It was clear that many adult specialties needed to greatly improve their recognition and management of AKI and redesign their services. There are also known and unacceptable variations in the recognition, assessment, initial treatment and usage of renal replacement therapy in AKI. Some 20-30% of cases of AKI are regarded partially or fully preventable. Even if only 20% of cases can be prevented or ameliorated, successful preventive measures would produce a large reduction in deaths, complications and costs due to AKI.

The NCEPOD report informed a referral from the Department of Health for NICE to develop its first guideline on AKI.

The guideline development process is defined by its scope, published after stakeholder consultation. Therefore, the guideline does not cover all aspects of AKI, only addressing areas within the scope.

Importantly these guidelines include paediatric acute kidney injury. The scope of the guideline focuses on identifying clinical and cost effective practice that might improve care and outcomes in intervention in the earlier parts of the disease process, including risk assessment and prevention, early recognition and treatment. It does not include evidence regarding aspects of dialysis beyond the decision on its initiation. NICE guidance does not aim to provide a ‘textbook’ of care for the area under consideration. Thus it is beyond the scope of the guideline to give detailed discussion of the more basic management of AKI causes such as hypovolaemia, sepsis, and nephrotoxins. Instead it aims to distil relevant evidence and use this to provide a set of recommendations. It is primarily aimed at generalist clinicians, who will care for the large majority of patients with AKI in a non-specialist hospital or primary care setting

Contents

• Guideline development group members
• 1. Introduction
• 2. Development of the guideline
  • 2.1. What is a NICE clinical guideline?
  • 2.2. Remit
  • 2.3. Who developed this guideline?
  • 2.4. What this guideline covers
  • 2.5. What this guideline does not cover
  • 2.6. Relationships between the guideline and other NICE guidance
• 3. Methods
  • 3.1. Developing the review questions and outcomes
  • 3.2. Searching for evidence
  • 3.3. Evidence of effectiveness
  • 3.4. Evidence of cost-effectiveness
  • 3.5. Developing recommendations
• 4. Guideline summary
  • 4.1. Algorithms
  • 4.2. Key priorities for implementation
  • 4.3. Full list of recommendations
  • 4.4. Key research recommendations
• 5. Assessing risk of acute kidney injury
  • 5.1. Assessing risk in adults
  • 5.2. Assessing risk in children and young people
• 6. Preventing acute kidney injury
  • 6.1. Early Warning Scores
  • 6.2. Preventing Contrast induced acute kidney injury
  • 6.3. Computerised decision tools
  • 6.4. Stopping ACEI/ARB therapy
• 7. Detecting acute kidney injury
  • 7.1. Definitions and staging of acute kidney injury using AKIN/RIFLE/pRIFLE/KDIGO
• 8. Identifying the cause of AKI
  • 8.1. Urinalysis
  • 8.2. Ultrasound
• 9. Managing acute kidney injury
  • 9.1. Relieving urological obstruction
  • 9.2. Pharmacological management
  • 9.3. Referring for renal replacement therapy
  • 9.4. Referring to nephrology
  • 9.5. Recommendations and link to evidence
• 10. Information and support for patients and carers
  • 10.1. Introduction
  • 10.2. Review question: what information and support do patients with acute kidney injury and their carers require?
  • 10.3. Clinical evidence
  • 10.4. Economic evidence
  • 10.5. Evidence statements
  • 10.6. Recommendations and link to evidence
• 11. Reference list
• 12. Stages of chronic kidney disease
• 13. Acronyms and abbreviations
• 14. Glossary
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Literature search strategies
  • Appendix E. Clinical article selection
  • Appendix F. Economic article selection
  • Appendix G. Clinical evidence tables
  • Appendix H. Forest plots
  • Appendix I. Excluded clinical studies
  • Appendix J. Excluded economic studies
  • Appendix K. Cost-effectiveness analysis – Fluid regimens for the prevention of Contrast Induced Acute Kidney Injury
  • Appendix L. Research recommendations
  • Appendix M. References

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.