Acute kidney injury — fluid prescription and medication review

PLAB 2 & PRES 3 · emergency · medium · 8 minutes

Candidate brief

You are an FY2 doctor/SHO on the acute medical unit. Mr Thomas Kelly, 67, was admitted following 4 days of diarrhoea, vomiting and poor oral intake. His blood tests show a significant deterioration in kidney function. Assess him, interpret the results, prescribe appropriate initial intravenous fluid, review his medication and explain the immediate management plan. Verbalise any additional investigations, monitoring or escalation you would arrange.

What examiners look for

Acute kidney injury is a rapid reduction in kidney function. It may be reversible when the underlying cause is identified and treated promptly. Creatinine has increased from 88 to 225 micromol/L: 225 ÷ 88 = approximately 2.6 This meets the creatinine criterion for AKI stage 2. Urine output below 0.5 mL/kg/hour for at least 12 hours also meets stage 2 criteria. Assess ABCDE, haemodynamic status, hydration, sepsis, bleeding, urinary obstruction, intrinsic renal disease and medication contributors. For hypovolaemia, prescribe a defined fluid bolus with the fluid type, volume, route, rate and review plan. Reassess after every bolus for response and fluid overload. Do not prescribe several litres automatically. Older patients and those with heart or kidney disease may require smaller or slower boluses and closer review. Review all prescribed, over-the-counter and herbal medicines. NSAIDs should be stopped in this scenario. Ramipril, metformin and empagliflozin should be temporarily withheld during significant dehydration and AKI. This does not mean they should be discontinued permanently. Empagliflozin should not be restarted until the patient is clinically stable, eating and drinking, and blood ketones are normal. Metformin requires recovery of renal function and dehydration before restarting. Monitor urine output, creatinine, potassium, bicarbonate, glucose, ketones and clinical fluid status. Seek renal or critical-care support for refractory hyperkalaemia or acidosis, pulmonary oedema, uraemic complications, anuria, severe AKI or failure to respond.

Guideline references

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