Acute Kidney Injury (AKI) is a serious condition that requires prompt recognition and appropriate management to prevent complications and improve patient outcomes. In this article, we will explore the primary, secondary, and tertiary levels of care for AKI. We will discuss the importance of a detailed history, physical examination, identification and correction of underlying causes, and the role of dialysis when necessary. Additionally, we will highlight red flags for urgent referral, indications for dialysis, and the importance of follow-up in AKI management.
In the primary care setting, a detailed history and physical examination play a crucial role in identifying potential causes of AKI. It is essential to identify and correct volume deficits, discontinue nephrotoxic agents, and address any bladder outlet obstruction. In specific cases, such as snakebite-induced AKI, the administration of anti-snake venom may be necessary. Identifying and managing complications such as hyperkalemia and pulmonary edema are important, and peritoneal dialysis (PD) may be considered when indicated. Timely referral to a higher level of care should be initiated once the patient has been stabilized.
At the secondary care level, a detailed evaluation should be conducted to identify and correct volume deficits, discontinue nephrotoxic agents, and manage electrolyte imbalances, including hyperkalemia and metabolic acidosis. Assessing and addressing urinary tract obstruction using imaging studies such as ultrasound or CT scan is essential. Comprehensive investigations should be performed to identify any underlying infections, and management of pregnancy-related complications should be considered when appropriate. Additionally, evaluating for underlying chronic kidney disease (CKD) and initiating dialysis (either PD or hemodialysis) may be necessary.
In tertiary care settings, a detailed evaluation similar to secondary care is conducted. Identifying and correcting volume deficits, discontinuing nephrotoxic agents, and managing urinary tract obstruction are key priorities. Furthermore, thorough investigations for infections and systemic diseases should be performed. Specific diagnostic tests, including imaging and genetic tests, may be required to determine the cause of AKI. Kidney biopsy may be performed to aid in diagnosis. Dialysis (PD or HD) remains an important intervention at this level of care.
Red Flags for Urgent Referral:
Certain situations warrant urgent referral for specialized care. These include indications for dialysis, unexplained AKI, involvement of other organs, sepsis, systemic diseases, and complicated pregnancies. Prompt recognition and referral in these cases are essential for optimal management and outcomes.
Follow-up of AKI:
After an episode of AKI, regular follow-up is crucial to monitor kidney function and identify any ongoing complications. If urine output is greater than 1L, creatinine levels are stable or decreasing, and no symptoms are present, dialysis may be discontinued. If AKI does not resolve within two weeks, further imaging such as contrast-enhanced CT scan (CECT) may be performed to exclude cortical necrosis, and kidney biopsy may be indicated based on clinical judgment. It is important to monitor serum creatinine and urine protein levels regularly and assess for systemic diseases throughout the patient's life.
Managing acute kidney injury requires a multidimensional approach across primary, secondary, and tertiary levels of care. Recognizing red flags, providing appropriate interventions, and ensuring regular follow-up are crucial for optimizing patient outcomes. By adhering to evidence-based guidelines and utilizing a comprehensive management strategy, healthcare professionals can effectively address acute kidney injury, minimize complications, and promote patient well-being.
Proper nutrition plays a vital role in managing chronic kidney disease (CKD). It is important to consider dietary modifications to support kidney function and overall health. While salt restriction to less than 5g per day is recommended, it is crucial not to restrict proteins unless there is documented high protein usage. Protein intake should be maintained at 0.6-0.8g per kilogram of body weight per day. Good sources of protein include dairy products and white meat, and a variety of lentils should be included in the diet.
In terms of potassium intake, low-potassium fruits and vegetables should be preferred, especially for individuals with an estimated glomerular filtration rate (eGFR) below 30 ml/min. Examples of low-potassium fruits and vegetables include apples, pineapples, papayas, pears, tangerines, watermelons, grapes, plums, cabbages, carrots, cauliflower, onions, radishes, peppers, chilies, eggplants, cucumbers, green beans, peas, rice, and bread. It is advised to avoid fruit juices, coconut water, and carbonated beverages.
For children with CKD, ensuring adequate protein intake appropriate for their age is crucial for their growth and development.
Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD) are significant health concerns that require proper management at various levels of care. From primary care to tertiary care, healthcare professionals play a vital role in identifying and addressing the underlying causes, managing complications, and initiating appropriate interventions. Recognizing red flags, following evidence-based guidelines, and providing comprehensive follow-up are essential for improving outcomes and enhancing the quality of life for patients with kidney diseases.
By implementing the recommended protocols and guidelines, healthcare providers can effectively manage AKI and CKD, reduce the risk of complications, and improve patient outcomes. Collaborative efforts between primary care physicians, specialists, and patients themselves are crucial for successful management and long-term kidney health.
*KIDNEY DISEASE: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int, Suppl. 2012; 2: 1–138
Department of Health Research, Ministry of Health and Family Welfare, Government of India, Standard Treatment Workflow (STW) for the Management of CHRONIC KIDNEY DISEASE (CKD), ICD-10-N18.3