Assessment for AKI
Evaluation of the Fluid status is the most important part of the assessment in these patients. This may not be easy, but it is done by combining history with examination, looking for evidence of dehydration; such as thirst, tachycardia, hypotension, as well as ruling out fluid overload.
A Creatine Kinase (CK) level should be sent and the threshold for sending a myeloma screen of serum protein electrophoresis and serum free light chains should be lowered. Other than that, the AKI should be investigated as usual. A urine dipstick should be performed and where there is evidence of proteinuria it should be quantified with a urine protein creatinine ratio. If there is proteinuria with haematuria then a renal screen should be considered. There may be concurrent urinary tract obstruction so this should be ruled out with imaging.
Management of AKI
If there is evidence suggesting that the patient is dehydrated then fluids should be given with the aim of returning the patient to a euvolaemic state. The response to fluids needs to be monitored closely during the admission.
If a patient is hypotensive and not responding to fluids then escalation to critical care for inotrope support should be considered when appropriate.
Medications should be carefully reviewed, with any medications that might be contributing to the AKI being held and dose adjustments for those medications that are significantly renally cleared.
Referral to nephrology should be considered when the AKI is not easily explained, when the AKI is worsening despite supportive treatment and in many cases when the patients AKI stage 3 when appropriate.
When appropriate dialysis is indicated when a patient has evidence of pulmonary oedema not responding to intravenous loop diuretics, hyperkalaemia or severe metabolic acidosis not responding to medical treatment.
It is important that following recovery from AKI the medications that were held are reviewed and where appropriate restarted. This is because readmission with fluid overload post-AKI admission is a significant problem.
General practitioners should be informed that a patient has had AKI and some of these patients will require nephrology follow.