Acute kidney injury in COVID-19: a summary of NICE guideline

  • National Institute for Health and Care Excellence

  • curated by Dawn O'Shea
  • Clinical Guidance Summaries
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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.

General recommendations

  • 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

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:
  1. an increase in serum creatinine of ≥26 μmol/L in 48 hours,
  2. an increase of ≥50 per cent in serum creatinine in the past seven days, or
  3. 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.

Managing hyperkalaemia

  • 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:
  1. uncertainty about the cause;
  2. abnormal urinalysis results, which may be a sign of COVID‑19-induced kidney damage or other intrinsic renal disease;
  3. complex fluid management needs;
  4. AKI is worsening or not resolved after 48 hours; and
  5. usual indications for RRT.

Renal replacement therapy