NICE has produced guidance on the management of acute kidney injury (AKI) in adults hospitalised with known or suspected COVID-19. The guideline focuses on what AKI management steps need to stop or start during the COVID-19 pandemic.
The key recommendations are summarised below.
- Communicate with patients and support their mental well-being, signposting to support services where available.
- Minimise face-to-face contact.
- Advise patients to contact NHS 111 phoneline or website for advice on COVID‑19.
Health care workers
- Health care workers involved in the care of patients with known or suspected COVID‑19 should follow government guidance on infection prevention and control.
- If COVID‑19 is later diagnosed in a patient not isolated from admission or presentation, follow guidance on management of exposed healthcare workers and patients in hospital settings.
Assessing for AKI in suspected or confirmed COVID-19
- AKI may be common in COVID-19, but prevalence depends on clinical setting (31% of patients on ventilators and 4% not on ventilators have needed renal replacement therapy [RRT] for AKI).
- Causes of AKI in COVID-19 may include hypovolaemia, haemodynamic changes, viral kidney tubular injury, thrombotic vascular processes, glomerular pathology or rhabdomyolysis
- AKI may be associated with haematuria, proteinuria and abnormal serum electrolyte levels (both increased and decreased serum sodium and potassium).
Detecting and investigating AKI
- Detect AKI using NHS England's AKI algorithm or if there is any of the following:
- an increase in serum creatinine of ≥26 μmol/L in 48 hours,
- an increase of ≥50 per cent in serum creatinine in the past seven days, or
- a fall in urine output to
- Determine the preferred method of urinalysis locally during the COVID‑19 pandemic.
- Do imaging if urinary tract obstruction is suspected.
Treating AKI in patients with COVID ‑19
- Discuss the risks/benefits of treatment options with patients, including treatment escalation plans and advanced care planning where appropriate.
- Treatments being used to manage COVID‑19 may increase the risk for AKI.
- Fever and increased respiratory rate increase insensible fluid loss.
- There is an increased risk for coagulopathy. Follow UK guidance.
- Assess for AKI in all transferred or admitted patients.
- Review the use of medicines that can cause or worsen AKI, and stop these unless essential. Consult a pharmacist for advice about optimising treatments.
- Use an early warning score, e.g., NEWS2. Note: Royal College of General Practitioners says any increase in oxygen requirements should be escalated for clinical review and increased observations.
- Determine the preferred method of monitoring fluid status locally during the pandemic.
Managing fluid status
- Ensure patients have an intravenous fluid management plan that is reviewed daily.
- Do not routinely offer loop diuretics but consider them for treating fluid overload.
- Be aware of the risk for hyperkalaemia and manage according to local protocols.
- Patiromer and sodium zirconium cyclosilicate can be used as options alongside standard care for the emergency management of acute life-threatening hyperkalaemia.
Referring patients with suspected or confirmed COVID-19
- Refer patients with AKI if there is:
- uncertainty about the cause;
- abnormal urinalysis results, which may be a sign of COVID‑19-induced kidney damage or other intrinsic renal disease;
- complex fluid management needs;
- AKI is worsening or not resolved after 48 hours; and
- usual indications for RRT.
Renal replacement therapy
- There are anecdotal reports of RRT circuit clotting because of the increased risk for coagulopathy in COVID‑19.
- There is no evidence on anticoagulants for RRT in patients with COVID‑19.
- See NHS England's clinical guide on renal replacement therapy in critical care during the pandemic.
- See the Renal Association's set of COVID-19 resources, including protocols for RRT.