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PRACTICE COMMENT

'Nurses must be familiar with acute kidney injury guidelines'

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It is important that nurses learn about the principles of detecting and managing acute kidney failure, says Richard Fluck

Many years ago I became involved in the care of a young man who had been readmitted to hospital. A week before I saw him he had his appendix removed. The operation was successful although his blood pressure was a little on the low side during the operation. He returned to the general surgical ward to recover. He received painkillers and when he commented that he wasn’t passing much urine he was encouraged to drink. He was discharged home.

Two days later he was readmitted, unable to breathe. His lungs were full of fluid. He had acute kidney injury (AKI) and was admitted to intensive care. In total, 20 litres of fluid were removed from his lungs. He made a full recovery physically but for many years afterwards had nightmares about drowning.

It was all about the basics. On the surface he was low risk. He had low blood pressure and received drugs that could affect kidney function. No fluid chart was completed nor was his weight measured during his entire stay. No blood tests were taken after his operation. Had any one of those taken place a serious complication may not have become life threatening.

Of course, the challenge of detecting and managing AKI varies and nurses need to be aware of the escalation guidelines and processes in place for their work environment, be it a walk-in centre, a nursing home or a hospital ward. For most nurses, the Kidney Disease: Improving Global Outcomes definitions, as well as the national algorithm, may be new territory. But it’s important that nurses learn about the principles, because so often you are the first line of defence in prevention and early detection.

So, do you know who is at risk on your ward or among your caseload? What advice do you give to those patients? Someone may have inherent risk factors, such as complex drug regimens or pre-existing medical problems. A trigger event - an operation, an infection, sickness and vomiting - may then result in AKI. What should you do? To whom do you go to seek advice?

Laboratories in England will be producing AKI test results, based on the international classification, that may alert you to the possibility of AKI. But we mustn’t forget about fluid balance and urine output. The story I told would have been very different if an accurate measurement of both input and output had been in place. The challenge is to ensure we think about the kidneys in the same way that we think about the heart and blood pressure. Ask about urine output and act on that information.

There are perhaps 40,000 excess deaths associated with AKI in England every year - a high proportion of those may be preventable. So ’think kidneys’! Join the forum on the Think Kidneys website to learn more. Become part of the drive to reduce the avoidable harm that AKI brings.

Richard Fluck is national clinical director (renal) at NHS England, consultant renal physician at Derby Teaching Hospitals Foundation Trust and chair of the Think Kidneys Programme Board.

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  • Learn about AKI prevention and management here
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