Acute Kidney Injury (AKI)

AKI is defined by KDIGO criteria: creatinine rise ≥26 μmol/L in 48h, or ≥1.5x baseline in 7 days, or UO <0.5ml/kg/hr for ≥6h. Staging guides management intensity. Pre-renal is the most common cause in surgical patients.

AKI Care Bundle

The pathway

1 · Stage the AKI

Stage 1: Cr ×1.5 baseline
Stage 2: Cr ×2
Stage 3: Cr ×3, or Cr >354, or anuric >12h, or RRT

2 · Assess volume status

JVP
Skin turgor
Mucous membranes
Postural BP
Fluid balance chart
Recent weight

3 · Identify and treat cause

Pre-renal (most common): hypovolaemia, hypotension, sepsis
Intrinsic: ATN, glomerulonephritis
Post-renal: obstruction (PR exam, USS bladder/kidneys)

4 · Fluid challenge

250–500ml crystalloid (Hartmann's preferred) if pre-renal/hypovolaemic. Reassess UO after each bolus.

5 · Review nephrotoxins

Stop NSAIDs immediately
Hold ACEi/ARBs
Review gentamicin (check levels)
Review contrast agents

6 · Catheterise

Hourly UO monitoring
Catheter also rules out urinary retention as a cause

7 · Monitor electrolytes

K+ twice daily minimum
ECG if K+ >5.5
Treat hyperkalaemia early

8 · Specialist referral

Renal review for Stage 2+
Nephrology urgently for K+ >6.5, pH <7.1, or fluid overload

Drugs

Drug	Dose	Route	Notes
Hartmann's solution	250–500ml	IV	Preferred over 0.9% NaCl in AKI. Reassess after each bolus.
Calcium gluconate 10%	30ml	IV	Membrane stabilisation in hyperkalaemia with ECG changes. Over 10 minutes (6.8mmol calcium, UKKA 2023).
Insulin (Actrapid) + Dextrose 50%	10 units + 50ml	IV	Shifts K+ into cells in 20–30 mins. BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours — hourly checks miss early hypoglycaemia. If pre-treatment BM <7.0, follow with 10% glucose 50ml/hr for 5 hours (UKKA 2026).
Sodium zirconium cyclosilicate	10g TDS (up to 72h)	Oral	Potassium binder. Replaced calcium resonium in the UKKA 2023 emergency algorithm. Adjunct only — never instead of calcium and insulin-dextrose.

When to escalate

K+ >6.5 mmol/L with ECG changes,pH <7.1 (severe acidosis),Fluid overload with pulmonary oedema,Uraemic encephalopathy or pericarditis,Oliguria despite adequate fluids (consider RRT),Stage 3 AKI

Reference: KDIGO AKI Guidelines 2012 / NICE AKI Quality Standard

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