Assessment of a patient with an AKI

Question 1

What should be your initial approach?

Answer 1

Carry out an ABCDE approach.

Make sure you know al the renal affects of drugs that are being taken.

Within ‘C’, 1) Assess fluid volume status - Check BP, JVP, skin turgor, cap refill, urine output. 2) Check an urgent potassium venous blood specimen and an ECG to check for life threatening hyperkalaemia,

Question 2

What should you check for in particular in the history?

Answer 2

1) Risk factors, comorbities, ask about previous renal disease, recent fluid intake and losses, new drugs including chemotherapy,
2) SYSTEMIC features such as rash, fever, joint pain. Others - productive cough, haemoptysis, GU or GI symptoms

Question 3

What will the examination include?

Answer 3

Full examination.

Look for: Palpable bladder, palpable kidneys, abdominal / pelvic masses, renal bruits, rashes

Question 4

What bedside tests could you perform?

Answer 4

URINE DIP

Microscopy for casts, crystals and cells

Cultures for infection.

Consider Bence-Jones protein

Question 5

Which blood tests would you order?

Answer 5

FBC, U+Es, LFTs, Clotting, CK, ESR, CRP.

Consider ABG for acid base assessment.

Culture blood if infection suspected.

Blood film and renal immunology if systemic cause suspected: immunoglobulins and paraprotein electrophoresis, complement, antibodies.

Question 6

What imaging would you order?

Answer 6

Renal ultrasound can help detect obstruction and hydronephrosis, look for abnormalities such as small kidneys, cysts, masses, assess corticomedullary differentiation.

CTKUB for obstruction above prostate.

CXR if fluid overload

Question 7

How do you differentiate between chronic and acute damage?

Answer 7

USS kidneys - Small kidneys

Question 8

When do you refer to a nephrologist?

Answer 8

First always assess the patient and correct and pre and post renal complications as far as possible. Treat any urgent problems such as hyperkalaemia, pulmonary oedema.

Refer if:

1) Hyperkalameia in an oligoanuric patient,
2) hyperkalaemia or fluid overload unresponsive to treatment
3) Urea >40mmol / L +/- signs of uraemia
4) Patients with suspected glomerulonephritis or systemic disease
5) No obvious cause, creatinine >300 or rising >50micromol / 24hr

Question 9

What are the indications for renal transplant?

Answer 9

1) Refractory pulmonary oedema
2) Persistent hyperkalaemia (>7mmol/L)
3) Severe metabolic acidosis (pH >7.2 or base excess