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Acute kidney injury in hospital: COVID-19 rapid guideline summary

The purpose of NG175 is to help health professionals prevent, detect and manage acute kidney injury (AKI) in hospitalised adults with known or suspected COVID-19.

The guideline further states that this objective is necessary to improve outcomes in patients and to reduce the need for renal replacement therapy.

NG175 brings together existing national and international guidance and policies including NHS England’s speciality guide on acute kidney injury in hospitalised patients with COVID-19 and the clinical guide on renal replacement therapy options in critical care during the coronavirus pandemic.

Patient communication and minimising infection risk
NG175 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic to alleviate any anxieties or concerns they might have about the virus. NG175 recommends signposting patients to the relevant charities such as Kidney Care UK, and the National Kidney Federation which have patient information on COVID-19 or any appropriate local kidney patient organisations as well as the UK government guidance on the mental health and wellbeing aspects of COVID-19.

Minimising risks for patients and healthcare staff
NG175 advises that all healthcare workers involved in any aspect of patient contact and this will include those who are receiving, assessing and caring for patients who are known or suspected of having COVID-19, should follow the UK government guidance on infection prevention and control. In cases where COVID-19 is later diagnosed in a patient who was not initially isolated from admission, NG175 recommends that staff follow the UK government guidance on management of exposed healthcare workers and patients in hospital settings.

Treatment and care planning
NG175 discusses the importance of communicating with patients, their family and carers, the likely risks and benefits of any treatment options made for those with COVID-19. Such discussions will hopefully allow patients and/or their family and carers to make an informed decisions about treatment options and any escalation plans if required. NG175 suggests that staff utilise decision support tools if any are available and to fully record discussions and a the decisions which have been made.

The guideline also advises that staff ascertain whether patients had any specific advance care plans, especially if these involve “do not attempt cardiopulmonary resuscitation” decisions and that these are incorporated into care plans. NG175 directs staff to further resources to help with decision-making such as the British Medical Association, the Royal College of Physicians and the General Medical Council.

NG175 suggests that healthcare professionals monitor patients for the development or progression of chronic kidney disease for at least 2 to 3 years after acute kidney injury as per the NICE guideline on chronic kidney disease and signposts staff to the Think kidneys guidance which provides further advice on care after hospital discharge.

Assessing for AKI in patients with known or suspected COVID-19 infection
NG175 alerts healthcare professionals to the fact that AKI may be common in those with COVID-19, citing a recent Intensive Care National Audit report of those with COVID-19 which found that the incidence of AKI was about 31% for those on ventilators and 4% not on ventilation. In addition, AKI increases the risk of death and can develop either before or during hospital admission.

NG175 describes a long list of possible causes of AKI including hypovolaemia, haemodynamic changes, viral infection leading to kidney tubular injury, thrombotic vascular processes, glomerular pathology or rhabdomyolysis, haematuria, proteinuria and abnormal electrolyte levels.

The guidance also notes how the treatments for COVID-19 may also increase the risk of AKI (for example, diuretics) and that both fever, increased respiratory rate and dehydration can increase insensible fluid loss. There is also an increased risk of coagulopathy and NG175 directs healthcare staff to the Thrombosis UK’s practical guidance for the prevention of thrombosis in patients with COVID-19.

NG175 advises that an assessment for AKI should be undertaken for all admitted patients and that this should include:

  • Medical history and comorbidities (especially those associated with an increases risk of AKI such as chronic kidney disease, heart failure, liver disease diabetes, increased age)
  • Reviewing all medicines in conjunction with a pharmacist that could cause/worsen AKI. Seek further information from the Think Kidneys guidelines for medicine optimisation.
  • Fluid status should be assessed by clinical examination and fluid balance
  • Full blood count and urea and electrolytes

NG175 directs staff to a NICE guideline on acute kidney injury.

Continued assessment of patients for AKI while in hospital is recommended as is monitoring of electrolyte levels every 48 hours but more often if clinically indicated. Furthermore, early warning score systems such as NEWS2 should be used where the clinical condition is deteriorating or if sepsis is suspected.

Detecting and investigating AKI in patients with confirmed/suspected COVID-19
NG175 recommends that staff utilise NHS England’s AKI algorithm to help detect AKI. If not, the guideline suggests the following criteria:

  • An increase in serum creatinine of 26 micromole/litre or more in 48 hours
  • A 50% or more increase in serum creatinine, known or presumed to have occurred in the last 7 days
  • A fall in urine output to less than 0.5ml/kg/hour for more than 6 hours.

NG175 also suggests urinalysis for blood, protein and glucose to help identify possible causes of AKI. Imaging is also suggested if urinary tract obstruction is suspected.

Managing fluid status in patients with known/suspected COVID-19
NG175 advises that staff aim to achieve euvolaemia in all patients and where this is not possible either orally or enterally, patients should be given intravenous fluids, following NICE guidance on intravenous fluid therapy in adults. The choice of fluids should be based on biochemical results and fluid status as described in the composition of commonly used crystalloids in the NICE intravenous fluid guidance. Although NG175 advises against the use of loop diuretics, it suggests that these can be used to manage fluid overload.

Management of suspected hyperkalaemia in known/suspected COVID-19
NG175 alerts healthcare staff to the possibility of hyperkalaemia and suggests that potassium binders such as patiromer and sodium zirconium cyclosilicate can be used alongside standard care as described in the relevant NICE technology appraisal guides on patiromer and sodium zirconium cyclosilicate.

Referral in patients with suspected/conformed COVID-19
NG175 suggests that referral for specialist advice in patients with AKI is needed where:

  • There is diagnostic uncertainty about the cause of AKI
  • Where there are signs of COVID-19 induced kidney damage or intrinsic renal disease such as abnormal urinalysis results
  • Fluid management needs are complex
  • AKI has either worsened (despite management) or has not resolved after 48 hours
  • Patients require renal replacement therapy, particularly if there is no urine output including life-threatening hyperkalaemia, refractory fluid overload, severe metabolic acidosis.

In such cases, NG175 directs staff to the COVID-19 rapid guideline on critical care management.

Renal replacement therapy in patients with suspected/confirmed COVID-19
NG175 directs staff to NHS England’s clinical guide on renal replacement therapy during the coronavirus pandemic for patient options.

The guideline also points to The Renal Association’s set of COVID-19 resources because this includes renal replacement therapy protocols.

Finally, NG175 alerts staff to anecdotal reports of circuit clotting due to the greater coagulopathy risk in those with COVID-19 and suggests staff make use of NHS England’s clinical guide on renal replacement therapy options for advice on anticoagulant treatment options for such patients.

NG175 is available online and interested readers should check this version for further updates.

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