Acute Kidney Injury

Balancing acute medical management of acute kidney injury and hyperkalaemia versus medicines optimisation for long-term Cardio-Renal-Metabolic (CaReMe) diseases: a narrative review

Review Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Cardio-Renal-Metabolic (CaReMe) diseases, in the form of heart failure, chronic kidney disease and diabetes mellitus, justify prescription of multiple prognostically beneficial medications, specifically renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter-2 inhibitors. Use of these medications is complicated by association with adverse effects, particularly acute kidney injury and hyperkalaemia. Balancing risk and benefit is a common dilemma in acute medicine, with increasingly frequent and complex treatment decisions. Physicians should contemplate adjustments to medications within the context of not just acute illness but also long-term benefit. In the setting of hyperkalaemia, potassium-binding medications can be utilised. At hospital discharge optimisation of therapy can be achieved through clear safety netting advice, scheduled biochemical follow-up, and planned clinical review.

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Renal replacement and extracorporeal therapies in critical care: current and future directions

Review Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

There are a wide number of indications for extracorporeal therapies in the critical care environment. A common indication seen by the acute physician is continuous renal replacement therapy (CRRT) in a proportion of patients with acute kidney injury. It is therefore important that acute physicians have a sound understanding of the principles of CRRT in the acutely unwell patient. This review will outline the indications for its use, commonly used methods and anticoagulation considerations. It will discuss when to start and stop CRRT as well as describing potential treatment complications. This review will also discuss the role of therapeutic plasma exchange in critical care and novel extracorporeal therapies including blood purification in sepsis and carbon dioxide removal in acute respiratory distress syndrome and acute exacerbations of obstructive lung disease. Extracorporeal membrane oxygenation is outside of the scope of this article.

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Isolated paracetamol-induced acute kidney injury: a systematic review

Clinical Reviews, Volume 21, Issue 2, Pages 65-120 (2022)

Aim: We sought to characterise the syndrome of isolated paracetamol-induced acute kidney injury (AKI), whose incidence and mechanisms are poorly understood.
Methods: Using systematic review methodology, fifty-six papers relating to paracetamol-induced AKI were identified.
Results: 24 cases of isolated paracetamol-induced AKI were identified and compared to 87 identified cases of concurrent renal and hepatic injury.
Paracetamol-induced AKI became detectable 3-4 days after exposure; liver injury, where it occurred, preceded AKI detection by 1 day.
Risk factors affecting hepatotoxicity risk do not appear to influence isolated AKI, with no clear associated factors except younger age (mean 18.8 versus 33.1 years).
Conclusions: Isolated paracetamol-induced AKI appears commoner in younger patients. Paracetamol-induced AKI occurs late and may go undetected by current treatment guidelines.

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Overview of acute renal manifestations in cancer patients

Clinical Reviews, Volume 19, Issue 1, Pages 1 - 60 (2020)

Acute kidney injury is frequently encountered in patients with malignancy and is associated with prolonged hospitalization, significant morbidity, and increased mortality. Thorough evaluation is required to identify possible contributing factors, which may range from relatively easily reversible pre-renal causes to complex cancer-specific aetiologies. This review will serve as a practical guide for acute care physicians on the acute medical unit to the assessment and initial management of cancer patients presenting with acute kidney injury.

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Reduced kidney function at presentation in unselected acute emergency medical admissions: incidence, outcome and associated factors

Original Articles, Volume 18, Issue 3, Pages 137 – 204 (2019)

We sought to assess the impact of renal impairment on acute medical admissions and to identify potential contributory factors to admissions involving renal impairment at presentation. In a prospective cohort study, 29.5% of all acute medical emergency admissions had an eGFR < 60 ml/min/1.73m2 at presentation. Of these, 19.9 % had definite chronic kidney disease and 8.4 % had definite acute kidney injury. Detailed analysis of a random subset of patients with an eGFR <60ml/min/1.73m2 at presentation demonstrated that the major reasons for admission included falls, dehydration and fluid overload. 46% were on diuretics and 53% were on an ACEI or ARB or both. Gastrointestinal disturbance and recent medication changes were common and diuretic use persisted even with diarrhoea or vomiting.

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Management of Acute Admissions of Heart Failure Patients with Kidney Disease

Clinical Reviews, Volume 18, Issue 2, Pages 61 – 136 (2019)

Acute heart failure (HF) admissions are common. They are often associated with prolonged hospitalisations and poor outcomes. One-third of chronic HF patients also suffer from chronic kidney disease (CKD). Hence, acute admissions of HF with CKD are common and are associated with longer length of stay and increased mortality. Hyperkalaemia and acute on chronic renal impairment are important challenges in the management of these cases. Cautious introduction of high-dose diuretic therapy, followed by the re-commencement of renin-angiotensin-aldosterone (RAAS) inhibitors, improves length of stay, quality of life, and prognosis. During an admission on to the medical assessment unit careful monitoring and management of the patient’s clinical condition and biochemistry is essential.

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Alcohol-induced Rhabdomyolysis: A Disease With Potential Pitfalls

Case Reports, Volume 17, Issue 4, Pages 173 – 240 (2018)

Non-traumatic rhabdomyolysis induced by alcohol appears to cause serious clinical implications and could result in catastrophic consequences. We describe a patient who developed rhabdomyolysis following acute alcohol intoxication which led to severe kidney injury requiring dialysis therapy. This case also illuminates the fact that deranged liver function can result from a significant skeletal muscle injury in the absence of a concomitant liver pathology.

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A Catastrophic Consequence of Cramp

Case Reports, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

Quinine has long been used for the treatment of conditions such as malaria and leg cramps, and is also present at low levels in some beverages; however, it can cause serious side effects. We describe a patient who developed severe haemolysis, thrombocytopaenia, and acute kidney injury following the ingestion of a single dose of quinine. This case demonstrates the importance of awareness of such potentially life-threatening consequences of exposure to this agent.

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Acute kidney injury in kidney transplant patients

Review Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Managing kidney transplant patients in an acute medical unit can be challenging, as patients have a single functioning kidney, underlying chronic kidney disease, and are immunosuppressed. Transplant patients develop AKI for all usual reasons but the differential diagnosis is wider and includes specific problems, such as obstruction of a single functioning kidney, vascular thrombosis, rejection, drug toxicity and drug-induced thrombotic microangiopathy. Septic AKI is common but again, the differential diagnosis of sepsis is wider. Transplant patients are at higher risk of developing both community and opportunistic infections, especially in the first year after the transplant or after any increase in immunosuppressive medication. In addition, there is always a risk of rejection, especially in case of reduction of immunosuppressive medications. Therefore, any change in the immunosuppressive therapy should to be discussed with the transplant team to achieve an appropriate balance between avoiding rejection and preventing opportunistic infections.

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Improving recognition and management of acute kidney injury

Research Audit and Clinical Practice, Volume 13, Issue 3, Pages 101 - 148 (2014)

Abstract

Acute kidney injury (AKI) is currently suboptimally recognised and managed in the UK, despite its association with significant patient morbidity, mortality and consequent implications for healthcare economics. Our prospective study, performed in a large urban London hospital, demonstrated that the introduction of a specially designed care bundle can significantly improve documentation of baseline creatinine, assessment and optimisation of fluid status, performance of urine dip, withholding of nephrotoxic drugs, appropriate monitoring of urine output, prescription of renal drug doses, and appropriate consideration of a renal ultrasound and urinary protein-creatinine ratio. Improved compliance of appropriate investigations and initial treatments translated to decreased requirement for intensive care admission and a trend towards shorter length of stays.

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