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Acute kidney injury

A CPPE distance learning programme

DLP 176 September 2015

Acute kidney injuryA CPPE distance learning programme

Educational solutions for the NHS pharmacy workforce

© Copyright controller HMSO 2015

Acknowledgements

Lead writer

Dr Sue Shaw, advanced renal services pharmacist, Royal Derby Hospital

CPPE programme developer

Geraldine Flavell, regional manager

Project team

Muhammad Abid, primary care pharmacist, Birmingham South Central ClinicalCommissioning Group

Tariq Iqbal, community pharmacy technician

Harbinder Kaur, practice-based pharmacist, Dudley CCG

Dost Muhammed, community pharmacist

Huda Rida, hospital pharmacist, County Hospital Stafford

Matthew Shaw, deputy director, CPPE

Julie Slevin, programme development officer, Think Kidneys programme, UK Renal Registry

Annie Taylor, communications consultant to Think Kidneys programme

Karen Thomas, head of programmes, Think Kidneys programme, UK RenalRegistry

Reviewers

Aleli Akani, renal pharmacist, Royal Derby Hospital

Adrian Coleman, lead pharmacist for renal services, East Kent HospitalsUniversity NHS Foundation Trust and member of the UK Renal PharmacyGroup, AKI subgroup

Alan Green, academic pharmacist practitioner, University of Sunderland andGateshead Health NHS Foundation Trust and member of the UK RenalPharmacy Group, AKI subgroup

This learning programme was piloted nationally by the following pharmacists and pharmacy technicians: Jos Collins, Abdul Dodhy, Khurshid Hussain,Mohammad Mir, Natasha Ubhoo.

CPPE reviewers

Ceinwen Mannall, lead pharmacist, learning development

Michelle Styles, regional manager

Production

Outset Publishing Ltd, West Sussex

Published in September 2015 by the Centre for Pharmacy PostgraduateEducation, Manchester Pharmacy School, University of Manchester, Oxford Road, Manchester M13 9PT

www.cppe.ac.uk

Printed on FSC® certified paper stocks using vegetable-based inks.ii

Acute kidney injury

Contents

About CPPE distance learning programmes v

About this learning programme vii

Section 1 What is acute kidney injury? 11.1 Why acute kidney injury is important 1

1.2 Definition of acute kidney injury 3

Chronic kidney disease 4

1.3 Causes and risks factors for acute kidney injury 4

Risk factors for acute kidney injury 5

Triggers for acute kidney injury 5

Causes of acute kidney injury 5

1.4 Medicines optimisation and prevention 5

1.5 Management of acute kidney injury 6

1.6 Recognising acute kidney injury 6

Summary and intended outcomes 8

Suggested answers 8

Exercises 2, 4

Reflective questions 2, 7

Section 2 Talking about kidney health 92.1 A patient-centred approach 9

2.2 Talking about kidneys 9

What people know about their kidneys 10

2.3 Talking about acute kidney injury 12

Diet and salt advice 12

Sick day rules 12


Suggested answers 16

Exercises 10, 13, 14

Practice point 11

Reflective questions 14

Contents

iii

Section 3 Acute kidney injury and the role 18of the pharmacy teamCase study 1 Recognising and preventing acute kidney injury 18

Case study 2 Medicines use review in patients at risk of 20acute kidney injury

Case study 3 Medicines optimisation in patients at risk of 21acute kidney injury

Case study 4 Managing acute kidney injury 22

Case study 5 Discharge advice and patient information in 24acute kidney injury


Suggested answers 26

Section 4 Committing to action to prevent or 31manage acute kidney injury4.1 Community pharmacy 31

Over-the-counter advice and sales 31

Medicines use review and the new medicine service 32

Community pharmacy audit on hydration messages 33to prevent acute kidney injury

Distributing sick day rules leaflets 34

4.2 Primary care pharmacy 35

Audit 35

Sick day rules and primary care 35

Post discharge from hospital 36

4.3 Secondary care 37

Medicines reconciliation 37

Medicines optimisation 38

Discharge planning and patient information, 39including advice to the GP


Practice points 32-40

References 42

Index 44

Figures and tablesFigure 1 Acute kidney injury: some facts and figures 1

Figure 2 Understanding kidneys 11

Table 1 Stages of acute kidney injury 3

iv

Acute kidney injury

About CPPE distance learningprogrammes

About CPPEThe Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range oflearning opportunities in a variety of formats for pharmacy professionals from allsectors of practice. We are funded by Health Education England tooffer continuing professional development for all pharmacists and pharmacytechnicians providing NHS services in England. For further information about ourlearning portfolio, visit: www.cppe.ac.uk

We recognise that people have different levels of knowledge and not every CPPEprogramme is suitable for every pharmacist or pharmacy technician. We havecreated three categories of learning to cater for these differing needs:

The categories are:

Core learning (limited expectation of prior knowledge)

Application of knowledge (assumes prior learning)

Supporting specialisms (CPPE may not be the provider and willsignpost you to other appropriate learning providers).

This is a learning programme.

Continuing professional developmentYou can use this workshop programme to support your continuing professionaldevelopment (CPD). Consider what your learning needs are in this area. You canrecord your CPD online by visiting: www.uptodate.org.uk or use the CPDrecord sheets to plan and record the actions you have taken.

Activities

Exercises

We include exercises throughout this programme as a form of self-assessment. Usethem to test your knowledge and understanding of key learning points.

Practice points

Practice points are an opportunity for you to consider your practical approach tothe effective care of patients or the provision of a service. They are discreteactivities designed to help you to identify good practice, to think through the stepsrequired to implement new practice, and to consider the specific needs of yourlocal population.

We have designed the practice points in this programme to help you and yourteam to make links between the learning and your daily practice and to co-ordinatewith other healthcare professionals.

1 2 3

1

2

3

1

About C

PPE distance learning programm

es

v

Case studies

We base case studies on actual or simulated events. They are included to help youto interpret protocols, deal with uncertainties and weigh up the balance ofjudgements needed to arrive at a conclusion. We design the case studies to prepareyou for similar or related cases that you may face in your own practice.

Reflective questions

We have included reflective questions in this programme to give you anopportunity to reflect on what you already know, or on what you have read so far,to reinforce and extend your learning. Thinking about these questions will helpyou to meet the objectives of the programme.

Assessment As part of your learning for this programme, you may wish to undertake the e-challenge edition number 96, launched on 28 October 2015. To access this e-challenge after this date go to: www.cppe.ac.uk/e-challenge/archive#navTop

References and further readingYou can find references for all the books, articles, reports and websites mentionedin the text, together with a list of further reading to support your learning at theend of the programme. References are indicated in the text by a superscriptnumber (like this3).

Programme guardiansCPPE has a quality assurance process called programme guardians. A programmeguardian is a recognised expert in an area relevant to the content of a learningprogramme who reviews the programme every six to eight months. Following theregular programme guardian review we develop an update to inform you of anynecessary corrections, additions, deletions or further supporting materials. Werecommend that you check you have the most recent update if you are using aprogramme more than six months after its initial publication date.

Brand names and trademarks CPPE acknowledges the following brand names and registered trademarks whichare mentioned throughout the programme: LoSalt®

External websitesCPPE is not responsible for the content of any non-CPPE websites mentioned inthis programme or for the accuracy of any information to be found there.

DisclaimerCPPE recognises that local interpretation of national guidance may differ from theexamples used in this learning programme and you are advised to check with yourown relevant local guidelines. You are also advised to use this programme withother established reference sources. If you are reading this programme significantlyafter the date of initial publication you should refer to current published evidence.CPPE does not accept responsibility for any errors or omissions.

FeedbackWe hope you find this learning programme useful for your practice. Please help usto assess its value and effectiveness by emailing us at: [email protected]

Acute kidney injury

About this learning programme

Welcome to the CPPE distance learning programme: Acute kidney injury. Thislearning programme has been designed to give you an overview of acute kidneyinjury (AKI) and of the contribution that the pharmacy team can make to itsprevention.

By the time you’ve worked through the material you should feel confident aboutyour knowledge of acute kidney injury. Your confidence should enable you to dealsensitively and effectively with patients at risk of developing acute kidney injury.

The study time will depend on you, but we estimate that the reading and activitieswill take a total of four hours.

Target audienceThis programme is intended for pharmacists and pharmacy technicians working inany area of practice and we have highlighted a few specific examples below.

Community pharmacy team members are well placed to advise people aboutkidney health and both notice and support people who may be at risk of acutekidney injury, whether in over-the-counter consultations or as part of prescriptionmedicines advice services.

Pharmacy professionals working in primary care can take opportunities toundertake medicines reviews and audits to support people at risk of acute kidneyinjury and can follow up patients after discharge from hospital.

Hospital pharmacists and pharmacy technicians can ensure medicinesoptimisation for patients in hospital in order to preserve kidney health or manageacute kidney injury.

Working through this programmeThe programme is divided into four sections. Depending on your own level ofknowledge or interest, you do not need to work through each section, or in theorder provided. Although we have selected and presented information andexercises which we think will be of interest to you in whichever sector of pharmacyyou work, you may enjoy reading the references and further resources to which wesignpost you, to broaden your knowledge, understanding and skills further.

We have designed the programme for self-study, but as you progress through thesections it will be essential for you to talk through some of the issues with yourstaff and colleagues.

About this learning program

me

vii

Aim

The aim of this learning programme is to update your knowledge about kidneyhealth and acute kidney injury and support you to use that knowledge with peopleand patients in your own sector of pharmacy to preserve kidney health and preventand manage acute kidney injury.

Learning objectives

You can use our programmes to support you in building the evidence that youneed for the different competency frameworks that apply across your career.These will include building evidence for your Foundation pharmacy framework(FPF), demonstrating development as your career progresses with the Knowledgeand skills framework (KSF) and supporting your progression through themembership stages of the Royal Pharmaceutical Society (RPS) Faculty.

As you work through the programme consider which competencies you aremeeting and the level at which you meet these. What extra steps could you take toextend your learning in these key areas?

After completing this distance learning programme, you should be able to:

� describe the underlying risk factors and triggers for acute kidney injury

� explain medicines optimisation as a strategy for the prevention and managementof acute kidney injury

� conduct patient-centred consultations as you discuss kidney health andprevention of acute kidney injury

� describe the role of the pharmacy team in acute kidney injury prevention andmanagement, including the use of sick day rules

� carry out a medicines use review for a patient who has recovered from acutekidney injury or provide appropriate information on discharge following acutekidney injury

� list three changes to practice that you could make to improve your approachrelated to the prevention and management of acute kidney injury

� make a pledge to implement one change in your practice and set yourself adeadline for this.

A note about web links

Where we think it will be helpful we have provided web links to take you directly toan article or specific part of a website. However, we are aware that web links canchange. If you have difficulty accessing any web links we provide, please go to theorganisation’s home page or your preferred internet search engine and useappropriate key words to search for the relevant item.

All the web links in this programme were accessed on 30 August 2015.

viii

Acute kidney injury

Up to deaths a year are associated with acute kidney injury 100,000

Up to of those deaths could be avoided 33%

people admitted to hospital as an emergency has acute kidney injury1 in 5

is the first health system in the world to tackle acute kidney injuryThe NHS

Over of acute kidney injury starts in the community 60%

The additional cost to the NHS of acute kidney injury is estimated at each year

£500 million2

Section 1What is acute kidney injury?

Learning objectives

On completion of this section you should be able to:


� explain medicines optimisation as a strategy for the prevention and management of acute kidney injury.

This section describes why having a good understanding of acute kidney injury isimportant to your area of practice and the people in your care. Acute kidney injuryis common, serious and harmful, but in many cases preventable. This section willexplain what acute kidney injury is, how it progresses and describes patient riskfactors, including medicines, and disease management.

1.1 Why acute kidney injury is importantFigure 1 shows some of the key facts and figures that demonstrate the challenge ofacute kidney injury.1

FIGURE 1 Acute kidney injury: some facts and figures

Acute kidney injury is not a disease itself but the result of underlying pathologyand a marker of an ‘unwell’ patient. Since it is insidious in nature, healthcareprofessionals need to be aware of it and be looking out for it in order to spot it.

Section 1 What is acute kidney injury?

1


Why do the facts and figures shown above matter to you in your practice?

Over 60 percent of cases of acute kidney injury start in the community. If you workin community pharmacy, how many of these have you noticed in your practice andwhat role did you play, or could you have played, in helping to prevent them?

One in five patients who are admitted to hospital as an emergency has acutekidney injury. If you work in hospital pharmacy, do you routinely ensure that renalfunction has been monitored for the new patients you see? What actions do youtake or could you take to identify these patients?

If two-thirds of cases of acute kidney injury start in the community, it follows thatthe remainder develop while the patient is in hospital. Hospital-acquired acutekidney injury may be caused, for example, by drug-induced nephrotoxicity,contrast-induced nephropathy and perioperative complications, and in some casescould be prevented by better monitoring and care of sick patients. This situationhighlights the importance for all healthcare professionals to be aware of the riskfactors and triggers for acute kidney injury.

Exercise 1Scan this code using the QR code reader on your smartphone ortablet device or visit: www.cppe.ac.uk/aki to hear a podcast inwhich a pharmacist talks about her mother, who developed acutekidney injury.

One of the areas we will explore in this learning programme is the simple actionyou can take to help prevent acute kidney injury as a pharmacy professionalworking in any sector. We will also discuss the role of the pharmacy team in themanagement of acute kidney injury when it does occur.

2

Acute kidney injury

One of the areas we will

explore in this learning

programme is the simple

action you can take to

help prevent acute kidney

injury as a pharmacy

professional working in

any sector.

1.2 Definition of acute kidney injuryFormerly known as acute renal failure, acute kidney injury describes a rapiddeterioration in a patient’s renal function over hours or days.2 Acute kidney injuryis characterised by reduced urine output and/or increased serum creatinine and isclassified into three stages, depending on the severity, using the KDIGO (kidneydisease: improving global outcomes) criteria.

Acute kidney injury is defined by any of the following:

� a rise in serum creatinine of 26 micromol/Litre or more within 48 hours

� a 50 percent or greater rise in serum creatinine from a baseline, known orpresumed to have occurred in the last seven days

� a fall in urine output to less than 0.5 mL/kg/hour for more than six hours inadults, or eight hours in children and young people

� a 25 percent or greater fall in eGFR in children and young people within the lastseven days.

TABLE 1 Stages of acute kidney injury

Stage Serum creatinine Urine output

1 Increase by greater than or equal to Less than 0.5 mL/kg/hour 26 micromol/Litre within 48 hours for 6-12 hours

OR1.5-1.9 times baseline

2 2-2.9 times baseline Less than 0.5 mL/kg/hour for 12 hours or more

3 3 times baseline Less than 0.3 mL/kg/hour

OR for 24 hours or more

Increase to greater than or equal to OR354 micromol/Litre No urine output for12 hours

OR or more

Decrease in eGFR to less than 35 mL/min/1.73m2 in children and young people

OR

Initiation of renal replacement therapy


3

Exercise 2

a) At what stage of acute kidney injury would an 80 kg adult with a serumcreatinine of 310 micromol/Litre be? Their baseline creatinine taken 48 hoursago was 100 micromol/Litre.

b) At what stage of acute kidney injury would a 70 kg adult with a urine output of 32 mL/hour for 14 hours be?

Turn to the end of the section for suggested answers.

All stages of acute kidney injury and even small increases in serum creatinine areassociated with worse outcomes for the already sick patient, including prolongedhospital stay and increased morbidity and mortality.3 Acute kidney injury has alsobeen linked to the development of chronic kidney disease.4

Chronic kidney disease

Chronic kidney disease is an abnormality of kidney function or structure that ispresent for more than three months.5 In chronic kidney disease, the kidneysgradually lose function over a longer period of time.

Many people, including healthcare professionals, may not understand thedifference between chronic kidney disease and acute kidney injury. Chronic kidneydisease has been the focus of health programmes in primary and secondary care inthe recent past as it is associated with poor cardiovascular health. Acute kidneyinjury has been poorly understood as it is characterised by a rapid decline inkidney function because of risks and triggers in a patient who is often already sickdue to infection or post-surgery.

1.3 Causes and risks factors for acute kidney injuryAs acute kidney injury occurs rapidly, and often in a patient who already has otherpresenting illnesses, it is very important to be aware of the risks and trigger factorswhich should alert all healthcare professionals to the possibility of acute kidneyinjury.

4

Acute kidney injury

Acute kidney injury has

been poorly understood as

it is characterised by a

rapid decline in kidney

function because of risks

and triggers in a patient

who is often already sick

due to infection or post-

surgery.

Risk factors for acute kidney injury

The most common underlying risk factors for acute kidney injury for a patientinclude:

� previous acute kidney injury

� pre-existing chronic kidney disease

� age – patients aged 65 years or over

� congestive cardiac failure

� atherosclerotic peripheral vascular disease

� diabetes

� liver disease.

If you do not have access to patient notes, for example, if you work in communitypharmacy, you may recognise patients with chronic kidney disease from themedicines they take, for example: alfacalcido; sodium bicarbonate; high dosefurosemide; phosphate binders, such as calcium carbonate, sevelamer andlanthanum. Patients with liver disease may be taking vitamin B or thiaminesupplements, or propanolol twice daily.

Triggers for acute kidney injury

Acute kidney injury has many different causes but usually occurs in patients withunderlying risk factors, alongside other serious illnesses or triggers.

Examples of serious illnesses or factors that may act as triggers for acute kidneyinjury include:

� sepsis or infections

� hypovolaemia (dehydration, bleeding)

� hypotension (for example, after a serious heart attack)

� certain medicines – this includes prescribed and over-the-counter medicines.

Causes of acute kidney injury

About 80 percent of cases of acute kidney injury are caused by pre-renal issuesand acute tubular necrosis, 10 percent are due to obstruction (post-renal) and 10 percent are due to intrinsic renal causes.6 These can be summarised as:

� pre-renal issues that cause reduced blood flow to the kidneys, including acutetubular necrosis; sepsis, infections, hypovolaemia and hypotension may allreduce renal blood flow

� post-renal due to obstruction to urine flow from the kidneys

� intrinsic renal causes due to damage to the functional tissues of the kidney.

1.4 Medicines optimisation and preventionMedicines are associated with all causes and types of acute kidney injury, eitherbecause of their nephrotoxic effect, or their potential to impair renal functionunder certain circumstances. Non-steroidal anti-inflammatory drugs (NSAIDs),angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin-IIreceptor blockers (ARBs) and diuretics may affect the kidney’s ability to respondto a reduced blood flow in a patient with underlying risk factors, such as chronickidney disease, and in conjunction with triggers, for example, hypovolaemia andacute illness.


5

About 80 percent of cases

of acute kidney injury are

caused by pre-renal issues

and acute tubular

necrosis, 10 percent are

due to obstruction

(post-renal) and

10 percent are due to

intrinsic renal causes.

The best way to manage acute kidney injury is to prevent it from developing byreducing pre-renal causes, including hypovolaemia and dehydration, in at-riskpatients. Continued use of medicines, such as NSAIDs, ACE inhibitors and ARBs,may further exacerbate an episode of acute kidney injury, so it is important tooptimise these in patients at risk of acute kidney injury.

There are three key steps to follow to reduce the risk of acute kidney injurythrough medicines optimisation:7

� avoid the use of nephrotoxic medicines, for example, avoid the use ofNSAIDs for patients with chronic kidney disease

� monitor renal function, for example, when medicines that may causedeterioration in renal function, such as ACE inhibitors, ARBs and diuretics, arestarted or their dose is increased

� reviewing medicines that may exacerbate acute kidney injury, for example,temporarily withholding ACE inhibitors, ARBs and NSAIDs if patients becomeacutely unwell.

1.5 Management of acute kidney injuryIf acute kidney injury does develop, there is no specific drug therapy for itstreatment. Management involves identifying and treating potential causes, forexample, infection, and optimising medicine choice and dosing. For patients withpre-renal acute kidney injury, the focus is on restoring circulating blood volume tooptimise haemodynamic status (blood pressure and cardiac output) withappropriate fluid therapy. Monitoring electrolyte balance and managing bloodpressure issues is a key component of care.

Pharmacy professionals have a key role to play in medicines optimisation in acutekidney injury. This role involves:

� reviewing medicines that can alter renal haemodynamics, for example,temporarily withholding ACE inhibitors, ARB, or NSAIDs

� reviewing or stopping medicines that are potentially nephrotoxic

� reviewing or stopping medicines with side-effects that could exacerbate acutekidney injury, for example, metformin, which may cause lactic acidosis, thusworsening the acute kidney injury.

Medicines are often implicated or contribute to the development of acute kidneyinjury, whether by affecting renal haemodynamics or by direct and indirectdamage8 and the pharmacy team can help to identify patients at risk andrecommend appropriate actions to minimise damage. It is also important for thepharmacy team to adjust the doses of medicines that are renally excreted and canaccumulate in renal impairment, for example, gabapentin.

1.6 Recognising acute kidney injuryIt is very difficult to recognise acute kidney injury, which is why the challenge ofraising awareness is so important.

In the early stages of acute kidney injury, there may be no symptoms. A possible warning sign may be that the person is not producing much urine,although this is not always the case. However, someone with acute kidney injurycan deteriorate quickly and suddenly experience nausea and vomiting, confusion,low or high blood pressure, abdominal pain, slight backache or oedema.

6

Acute kidney injury

Someone with acute

kidney injury can

deteriorate quickly and

suddenly experience

nausea and vomiting,

confusion, low or high

blood pressure, abdominal

pain, slight backache or

oedema.


What questions could you ask to determine if your patient is at risk of acute kidneyinjury?

How will you recognise acute kidney injury triggers in your at-risk patients?

What symptoms or signs will you look out for in your patients at risk of acute kidneyinjury, including new or worsening symptoms?

You may wish to create a checklist of patient, trigger and medicines risk factors foracute kidney injury that you will look out for. You will find more ideas for these laterin this programme.

If you work in the hospital setting it may be easier to recognise acute kidney injurythrough monitoring creatinine results. In March 2015 a national acute kidneyinjury detection algorithm for laboratory systems was implemented in the UK,which has led to the generation of electronic alerts for acute kidney injury (whichcan be accessed via the link below).9

www.thinkkidneys.nhs.uk/wp-content/uploads/2014/12/AKI-Warning-Algorithm-Best-Practice-Guidance-final-publication-0112141.pdf

There are plans for this system to be integrated into primary care.

The following sections will give you more information on the actions thepharmacy team can take to prevent acute kidney injury and support patients with,and following, acute kidney injury.


7

The following sections will

give you more information

on the actions the

pharmacy team can take

to prevent acute kidney

injury and support patients

with and following acute

kidney injury.

SummaryAcute kidney injury describes a rapid deterioration in a patient’s renal functionover hours or days. If a patient already has risk factors for acute kidney injury andfurther triggers occur, then it can result in acute kidney injury. Medicines areimplicated as one of the triggers for acute kidney injury and the pharmacy teamhas an essential role to play in advising patients and other healthcare professionalsto reduce this risk.

Intended outcomesBy the end of this section you should be able to: Can you?


� explain medicines optimisation as a strategy for the prevention and management of acute kidney injury.

Suggested answers

Exercise 2 (page 4)

a) At what stage of acute kidney injury would an 80 kg adult with a serumcreatinine of 310 micromol/Litre be? Their baseline creatinine taken 48 hours ago was 100 micromol/Litre.

Stage 3 – because serum creatinine is now three times the baseline.

b) At what stage of acute kidney injury would a 70 kg adult with a urine outputof 32 mL/hour for 14 hours be?

Stage 2 – because his/her urine output is 32/70 = 0.46 mL/kg/hour for 12 hours ormore.

8

Acute kidney injury

Section 2Talking about kidney health

Learning objective


� conduct patient-centred consultations as you discuss kidney healthand prevention of acute kidney injury.

This section discusses the importance of patient-centred consultations whendiscussing kidney health and preventing acute kidney injury. We look at whatpeople currently know about the role of the kidneys,10 the important functions ofthe kidneys, and how we can use this information to discuss kidney health andprevention of acute kidney injury with our patients and other healthcareprofessionals.

2.1 A patient-centred approach All pharmacy professionals were sent the CPPE distance learning programme,Consultation skills for pharmacy practice: taking a patient-centred approach in 2014.11

This is the self-study component of an extensive consultation skills six-step learning and development pathway that looks at the skills and techniquesyou can develop to support you in putting the patient at the centre of everyconsultation.

Taking a patient-centred approach reflects a shift from counselling a patient, totrue consultation, where the patient has as much of a role as you do. Both of youdevelop a shared agenda about what the patient’s needs and preferences are andtheir options for future action. The patient is a true partner in the discussion and isempowered to engage in their own planning and decision making.

Bear this in mind as you plan to engage your patients actively in maintaining theirkidney health.

2.2 Talking about kidneysThe kidney is responsible for homeostasis within the body and controlling many ofthe body’s normal functions. Maintaining kidney health is not only important inpreventing acute kidney injury but in balancing many other functions andpreventing the complications arising from these functions being disrupted.

Healthy kidneys:

� make urine to remove waste products, drugs and their metabolites

� control blood pressure by maintaining the renin-angiotensin system

� produce erythropoietin and red blood cells

� regulate calcium, phosphate and parathyroid hormone balance to help to keepbones healthy

� maintain fluid balance

� control the body’s chemical balance

� maintain metabolic acid-base balance in the body

� help keep the heart healthy.

Section 2 Talking about kidney health

9

Maintaining kidney health

is not only important in

preventing acute kidney

injury but in balancing

many other functions and

preventing the

complications arising from

these functions being

disrupted.

10

Acute kidney injury

Exercise 3What can go wrong if kidney function is reduced by acute kidney injury? Label thisbody with the consequences of each function failure.

Do not look at the answers at the end of this section until you have tried this foryourself.

The kidneys are vital organs that filter all the blood in the body up to 30 times aday. Healthy kidneys keep what is needed and get rid of what is not needed (waste,fluid, drugs and their metabolites) through urine. As we have already discussed,the kidneys have many other roles in maintaining normal body health, includingkeeping bones healthy, producing red blood cells and controlling blood pressure.

What people know about their kidneys

The kidneys require our attention to maintain their optimal function through ourlives. Figure 2 below gives an indication about the extent of people’s knowledgeabout their kidneys. The data is taken from an Ipsos MORI poll, commissioned bythe Think Kidneys programme in 2014.10

Only 12 percent of people interviewed thought their kidneys had a role in processing medicines

Only 50 percent of people know their kidneys make urine

Only 22 percent of participants thought medicines could affect kidney health

FIGURE 2 Understanding kidneys

There is a clear need for patients to understand kidney health and the critical rolethe kidneys have in our overall health. The results from the Ipsos MORI polldemonstrate that we have a long way to go in helping the public understand therole of their kidneys and their importance in excreting waste products andmedicines and maintaining fluid balance.10

Reading this, you may feel an urgent need to educate your patients and help themto know more about their kidneys and what they can do to protect them. However,your awareness of the importance of patient-centred consultations shouldencourage you to be cautious about passing on this information.

In the CPPE distance learning programme, Consultation skills for pharmacy practice:taking a patient-centred approach programme it states:11

‘In our eagerness to pass on our knowledge to the patient, it is easy to provide advicewithout sufficient consideration of the patient’s concerns, beliefs or aspects of their life thatmay impact on the way they manage their medicines or health.’

Practice pointHow and in what circumstances could you raise the topic of kidney health withyour patients?



11

The results from the Ipsos

MORI poll demonstrate

that we have a long way to

go in helping the public

understand the role of

their kidneys and their

importance in excreting

waste products and

medicines and maintaining

fluid balance.

2.3 Talking about acute kidney injuryNHS Choices is a helpful resource to support your discussions with patients.12 Itdescribes acute kidney injury as:

‘…sudden damage to the kidneys that causes them to stop working properly. It can rangefrom minor loss of kidney function to complete kidney failure’.

Dehydration in NHS Choices is described as occurring ‘when your body loses morefluids than you take in’.12 As water makes up over two-thirds of the healthy humanbody, when the normal water content of the body is reduced, it upsets the balanceof minerals (salts and sugar) in your body, which affects the way it functions.

Dehydration is usually caused by not drinking enough fluid, or by fluid that is lostand not replaced. Some of the early signs of dehydration include:

� feeling thirsty, dizzy or lightheaded

� a dry mouth, lips and eyes

� headache

� tiredness

� having dark coloured, strong smelling urine

� passing urine less often than usual.

Illness, such as persistent vomiting and diarrhoea, or sweating from a fever, cancontribute to dehydration. UK studies have tried to establish the recommendedamount that adults should drink, but since this varies depending on individualfactors, such as age, climate and physical activity, a good rule is for people to drinkenough so they are not thirsty for long periods and steadily increase their fluidintake when exercising and during hot weather.

For some people the amount of fluid they drink might be restricted, for example,for patients with heart failure or people undergoing dialysis.12 Other people maybecome dehydrated because they choose not to drink, for example, people,particularly women, with a urinary tract infection may not want to drink becauseurination is painful. Others with urinary incontinence may resist drinking if theyare to be away from home or a toilet for a while. Salford Clinical CommissioningGroup, a pathfinder site for acute kidney injury prevention activities, has recentlyaudited 30 admissions for community-acquired acute kidney injury Stage 2 and 3;preliminary data suggest that a significant number were associated with a recenturinary tract infection.13

Diet and salt advice

When talking to people about their kidneys it is likely they will ask about diet andsalt intake in particular. There is no specific advice about diet or salt intake forpatients with kidney disease. The general advice of reducing salt intake, as for allpatients with hypertension and cardiovascular disease, is appropriate here. It isworth noting that LoSalt has a high potassium content so is not appropriate forpatients with kidney disease, who tend to accumulate potassium even when on alow potassium diet. Following a healthy lifestyle of regular exercise, not smokingand having a balanced diet are also important for kidney health.

Sick day rules

The Drugs and Therapeutics Bulletin published details of the ‘sick day rules’, astrategy to help prevent acute kidney injury.14 The sick day rules recommend thatsome drugs (which have the potential to impair renal function and contribute tothe development of acute kidney injury) be temporarily withheld when avulnerable patient develops an intercurrent illness, such as diarrhoea, vomiting,fever or infection. The drugs to be considered include ACE inhibitors, ARBs,diuretics and NSAIDs.

12

Acute kidney injury

Some people may become

dehydrated because they

choose not to drink, for

example people,

particularly women, with a

urinary tract infection may

not want to drink because

urination is painful.

The Scottish Patient Safety Programme has launched a sick day rules card acrossScotland.15 This includes information on the medicines to be withheld, when torestart them, signs and symptoms of dehydration and how to seek furtherinformation.

The NICE acute kidney injury guideline (CG169) recommends:

‘consider temporarily stopping ACE inhibitors and ARBs in people with diarrhoea,vomiting or sepsis until their clinical condition has improved and stabilised’.2

Concern that withholding medicines may be detrimental in some cases has raised aquestion mark over the widespread implementation of sick day rules advice and asystematic review of the published evidence is underway. The current position16

(late July 2015) from the Think Kidneys board is that, pending the results of thatreview, clinicians should provide sick day rules guidance on temporary cessation ofmedicines to people deemed at high risk of acute kidney injury, based on anindividual risk assessment.

Pharmacists and their teams should communicate the risks of acute kidney injuryto patients with vomiting or diarrhoea, fever sweats or shaking, in whom they havenoted a number of risk factors or triggers, offer advice on hydration and advisewithholding risky medicines only until their acute illness is over (24-48 hours).

Some community pharmacists who piloted this programme expressed doubts overwhether they could advise a patient to withhold risky medicines without consultingtheir GP. The project team for this programme feels that if they follow the NICEacute kidney injury guideline (CG169)2 and advise patients taking ACE inhibitorsand ARBs not to take these medicines for 24-48 hours during a period of acuteillness, they would not be open to criticism but would in fact be improving patientoutcomes.

Exercise 4Scan this code using the QR code reader on your smartphone ortablet device or visit: https://soundcloud.com/bmjpodcasts/in-this-issue-april-2016?in=bmjpodcasts%2Fsets%2Fdtb-podcastto hear a podcast about the sick day rules. Listen until 4 minutes43 seconds.

Key tipWhen we are talking to patients who have had a diagnosis of acute kidneyinjury, it is also important to consider that they might be scared or confused asthey have been suddenly diagnosed with an acute illness. They may have beentold that they may need renal replacement therapy and they may be confuseddue to uraemic toxins, which can affect their cognitive ability.

Other useful reference sources

The patient website (http://patient.info) is another useful reference source.17

This website discusses acute kidney injury and includes information aboutmedicines that have risk factors with nephrotoxic potential, including NSAIDs,ACE inhibitors, ARBs, aminoglycosides and diuretics.

The Royal Pharmaceutical Society and CPPE have produced a medicinesoptimisation briefing for acute kidney injury which you may also find useful.18

This provides advice regarding kidney health, sick day rules and the importance ofrestarting medicines once illness resolves.


13

The Royal Pharmaceutical

Society and CPPE have

produced a medicines

optimisation briefing for

acute kidney injury which

you may also find useful.

This provides advice

regarding kidney health,

sick day rules and the

importance of restarting

medicines once illness

resolves.

https://soundcloud.com/bmjpodcasts/in-this-issue-april-2016?in=bmjpodcasts%2Fsets%2Fdtb-podcast

Reflective questionsNow that you have worked through this section you may want to consider how youwill make these discussions a part of your routine practice. Take this chance toconsider how you will respond to the following questions. Why not role play theseactivities with your pharmacy team?

1. How are you going to discuss with a patient who is taking ramipril that this drugwhich is good for their kidneys, might also increase their risk of acute kidneyinjury?

2. How are you going to tell your local GP or medical discharge team that you have advised a patient to withhold their irbesartan for 24 to 48 hours?


Exercise 5Summarise what you have learnt in this section by listing four pieces of advice youwill discuss with people who you think might be at risk, to help in the prevention ofacute kidney injury.

1.

2.

3.

4.


14

Acute kidney injury

SummaryIn this section we have shared some of the findings of the Ipsos MORI poll whichshow how little most people know about their kidneys. We have looked at theimportance of putting the patient at the centre of any consultation so that you canengage them actively in the management of their disease and explore the actionthey can take to prevent acute kidney injury.

You have had the chance to practise conversations with patients and prescribersand started to engage your whole pharmacy team. The next section explores howdifferent members of the team can make a difference to patient care.

Intended outcomeBy the end of this section you should be able to: Can you?

� conduct patient-centred consultations as you discuss kidney health and prevention of acute kidney injury.


15

A build-up of toxins or drugs, such as digoxin and gabapentin, occurs if waste products are not excreted in the urine.

The risk of cardiovascular disease is increased.

Blood pressure is affected if the renin-angiotensin is disturbed.

Ankle swelling and pulmonary oedema occur if there is too much fluid in the body.

Gout can occur if uric acid is not excreted.

Bone health can be compromised if calcium, phosphate and parathyroid hormone are altered.

Hyperkalaemia may occur if electrolyte balance is affected.

Metabolic acidosis may develop if the metabolic acid-base balance is compromised.

If kidneys cannot produce erythropoietin and red blood cells, anaemia may develop.

16

Acute kidney injury

Suggested answers

Exercise 3 (page 16)What can go wrong if kidney function is reduced by acute kidney injury?

The diagram below shows the consequences of each function failure.

Exercise 5 (page 14)Summarise what you have learnt in this section by listing four pieces of adviceyou will discuss with people who you think might be at risk, to help in theprevention of acute kidney injury.

We have suggested four key pieces of advice to help in the prevention of acutekidney injury in at-risk patients (you may have thought of others).

� Since the kidneys have many roles in maintaining health, it is important to lookafter your kidneys by drinking fluids to maintain your urine output.

� You may be at risk of acute kidney injury if you become acutely unwell, as aresult of infection or dehydration, for example, with vomiting, diarrhoea, hightemperatures or fevers, or if you are not able to drink normally.

� You should temporarily stop taking ACE inhibitors, ARBs, and/or NSAIDs, if youare at risk of acute kidney injury, but seek medical advice if your symptoms persist.

� You should avoid NSAIDs (including those purchased over-the-counter) if youare acutely unwell or dehydrated.


17

Practice point (page 11)How and in what circumstances could you raise the topic of kidney health withyour patients?

You could raise the topic of kidney health every time you:

� hear someone saying they are thirsty

� see someone drinking bottled water

� are consulted about sickness, diarrhoea or urinary tract infections

� hand over medicines that could cause or exacerbate acute kidney injury, such asNSAIDs, ACE inhibitors, ARBs and diuretics.

Engage in a patient-centred consultation if the patient shows an interest inknowing more and encourage them to feel empowered to take action forthemselves.

Reflective questions (page 14)Key points to consider

If you are not sure what to do here, please refer to the CPPE distance learningprogramme, Consultation skills for pharmacy practice: taking a patient-centredapproach.11

You will choose your own wording to raise these issues with your patients and GP/medical colleagues, but below we have suggested some key issues you mayhave considered.

1. How are you going to discuss with a patient who is taking ramipril that thisdrug which is good for their kidneys might also increase their risk of acutekidney injury?

For the patient:

� explore the patient’s views of taking ramipril

� discuss the evidence of the benefits of ramipril for kidney health

� discuss the risks and side-effects of ramipril

� discuss how to manage the potential risk of acute kidney injury with ramipril

� recognise that the patient will need time to think these issues through and invitethem to come and talk again.

2. How are you going to tell your local GP or medical discharge team that youhave advised a patient to withhold their irbesartan for 24 to 48 hours?

For the GP or medical team:

� explore the GP’s or medical team’s awareness of the national Acute KidneyInjury Programme (NHS England)(www.england.nhs.uk/ourwork/patientsafety/akiprogramme/) and adviceregarding sick day rules (the risks of acute kidney injury and the need totemporarily withhold medicines, such as ARBs and ACE inhibitors until functionbecomes normal or 48 hours after diarrhoea has stopped)16

� discuss your in-pharmacy approach to preventing the risks of acute kidney injury

� share techniques for embedding these recommendations into your pharmacypractice

� discuss how the GP/medical team want you to let them know when you havegiven advice to the patient.

18

Acute kidney injury

Section 3Acute kidney injury and the roleof the pharmacy team

Learning objectives


� describe the role of the pharmacy team in preventing and managing acute kidney injury, including the use of sick day rules

� carry out a medicines use review for a patient who has recoveredfrom acute kidney injury or provide appropriate information ondischarge following acute kidney injury.

In the first two sections of this programme we looked at why acute kidney injury isimportant and the actions you can take in order to make a difference to peoplewho are at risk of developing it, or to patients who have developed it. We alsolooked at the approaches you can take to make sure that the patient is at the centreof any discussions or decisions about their care.

In this section you will explore a series of case studies that will help you start toapply your learning. At the end of this section, we provide suggested answers sothat you can compare what you would do with the thoughts of our experts.

These case studies illustrate how the pharmacy team can help prevent and manageacute kidney injury. Depending on your area of practice, you may find some of thecase studies below more readily applicable than others, but you may find it usefulto work through all of them in order to gain an understanding of the issuesaffecting other pharmacy sectors.

Case study 1Recognising and preventing acute kidney injuryAn elderly lady calls into her local communitypharmacy to buy some loperamide. She introducesherself as Sylvia and tells the medicines counterassistant that she has had diarrhoea for the past 24 hours and has not been eating or drinking verywell. Since the pharmacist has asked his team tohighlight older people who may be dehydrated, the medicines counter assistantrefers this case to the pharmacy technician who notes from the dispensing recordsthat the patient is taking lisinopril 20 mg daily for hypertension. The pharmacytechnician follows the advice she has been given and consults the pharmacist, whodecides to speak to Sylvia about her risk of acute kidney injury.

This community pharmacy team has set up a good system for identifying patientsat risk of acute kidney injury which you might wish to consider implementing.Throughout the team, red flag alerts have been put in place to highlight thetriggers that are putting patients at risk of acute kidney injury.

What red flag alerts might you put in place for your medicines counter assistantsto use when they are using the WWHAM questions?

Which red flag alerts might you put in place for your pharmacy technicians touse when checking the patient’s medicines?

What advice could the pharmacist give to Sylvia to reduce her risk of developingacute kidney injury?


The patient calls back to the pharmacy the following week for a repeat prescriptionof her medicines and tells the pharmacist that she recovered from her diarrhoeawithin a couple of days and that she then started taking her lisinopril again. Sheexplains that she will use the advice the pharmacy team members have given herabout the health of her kidneys and withholding her medicines if she becomesdehydrated in the future and thanks them for all their help and advice. Thepharmacist was able to highlight this case to his team as an example of where theymay have prevented acute kidney injury.

Section 3 Acute kidney injury and the role of the pharm

acy team

19

20

Acute kidney injury

Case study 2Medicines use review in patients at riskof acute kidney injuryYou undertake a medicines use review with RobertBann, an elderly gentleman aged 82, who collectshis prescriptions from your pharmacy. He suffersfrom hypertension and occasional angina. Hiscurrent medicines include amlodipine 10 mg daily, aspirin 75 mg daily, ramipril 5 mg daily,allopurinol 300 mg daily, simvastatin 40 mg at night and occasionally he uses aglyceryl trinitrate (GTN) spray. He tells you that his ramipril was increased from 2.5 mg to 5 mg daily a couple of months ago but he does not remember havingany blood test checks since then. He took bendroflumethiazide for his hypertensionseveral years ago but this was stopped because he developed gout. He took acourse of colchicine and was then started on allopurinol. At that time he was toldthat he had chronic kidney disease Stage 3 which might have also contributed tohis gout.

What information would you discuss with Robert?


Case study 3Medicines optimisation in patients atrisk of acute kidney injuryMargaret is a 72-year-old lady who was admitted tothe medical admissions ward following a fall. Shewas found collapsed on the floor and confused. Itwas suspected that she was suffering from a urinarytract infection. Her daughter tells you she has notbeen drinking much over the last couple of days as itwas painful for her mum to pass urine. Margaret’smedical history includes irbesartan 300 mg daily,bisoprolol 10 mg daily and furosemide 80 mg daily for congestive cardiac failure(CCF). She has chronic kidney disease Stage 3 with proteinuria (G3A2). She alsotakes aspirin 75 mg daily and atorvastatin 20 mg at night. She previously tookfosinopril but developed a dry cough and so it was changed to irbesartan by herGP. Her blood pressure on admission is 96/60 and urgent U+Es have beenrequested. Margaret is in pain as she sprained her ankle during her fall and so sheis prescribed ibuprofen 400 mg, when required, by the junior doctor.

What factors could increase Margaret’s risk of developing acute kidney injury?

What advice would you give regarding Margaret’s medicines and her risk ofacute kidney injury?



acy team

21

Case study 4Managing acute kidney injuryJames is a 54-year-old man who weighs 95 kg. Hewas admitted to your surgical ward two days ago foran emergency appendectomy. He has type 2diabetes and receives metformin and insulin. He haschronic kidney disease Stage 3 with proteinuria(G3A3) for which he is taking ramipril 10 mg daily.

His latest serum creatinine taken preoperatively was146 micromol/Litre. He also takes omeprazole 20 mg when required for indigestion. Prior to hisemergency appendectomy he was given gentamicin 300 mg and metronidazole500 mg. During the operation he was found to have a perforated appendix andwas prescribed a five-day course of co-amoxiclav postoperatively.

You visit your ward to review James’ antibiotics and are told by the nursing staffthat he is now in a side room as he has developed Clostridium difficile. You checkhis U+Es and find his serum creatinine is now 210 micromol/Litre.

What risk factors does James have for developing acute kidney injury?

Has James developed hospital-acquired acute kidney injury?

What changes to his medicines would you recommend at this time?

22

Acute kidney injury

Below is a copy of the medicines listed on James’ discharge prescription.

This discharge prescription is written by the junior doctor relating to James’medicines.

What additional actions would you take regarding the transfer of information toprimary care and to ensure James has the information he needs?



acy team

23

Case study 5Discharge advice and patient information in acute kidney injuryAt the GP practice where you work as a practicepharmacist you see James who was dischargedfrom hospital five days ago following admissionfor an emergency appendectomy, after which hedeveloped acute kidney injury (see Case study 4).He would like some advice about which medicines he should be taking and isrequesting a repeat prescription.

You can see James’ discharge prescription at the end of the previous case.

What actions would you take regarding continuing or discontinuing James’medicines?


24

Acute kidney injury

SummaryIn this section we have provided case studies for you to work through whichexplore patients who might be at risk of acute kidney injury, the triggers thatfurther increase this risk and possible signs and symptoms of acute kidney injury.At the end of this section, we provide suggested answers for each case study anddiscuss the advice you might give patients to empower them to look after theirkidney health and help prevent acute kidney injury. These case studies highlightthe role the pharmacy team has in the prevention and management of acute kidneyinjury through medicines use review and medicines optimisation.

As you worked through the case studies you may have related them to patients youhave encountered in the course of your practice. There are many areas where thepharmacy team can make a difference to patient care and different steps that wecan take to do this. The next section considers these and asks you to commit tomaking a change.

Intended outcomesBy the end of this section you should be able to: Can you?

� describe the role of the pharmacy team in preventing and managing acute kidney injury, including the use of sick day rules

� carry out a medicines use review for a patient who has recovered from acute kidney injury, or provide appropriate information on discharge following acute kidney injury.


acy team

25

Suggested answers

Case study 1 (page 18)What red flag alerts might you put in place for your medicines counter assistantsto use when they are using the WWHAM questions?

Who?

Sylvia is at risk of acute kidney injury as she is elderly (ie, older than 65). Other riskgroups include people with chronic kidney disease, previous acute kidney injury,congestive cardiac failure, atherosclerotic peripheral vascular disease, diabetes orliver disease.

What?

Sylvia has had diarrhoea which may have put her at risk of dehydration – a triggerfor acute kidney disease. Other triggers include vomiting, infection, severehypotension, acute illness.

How long?

Sylvia has had diarrhoea for the past 24 hours and hasn’t been eating or drinkingvery well.

Action taken?

Sylvia is not currently drinking many fluids. You will want to advise her about thisand consider whether to sell her any rehydration fluids.

Medicines?

Sylvia is taking an ACE inhibitor. Other medicines which are red flag alerts foracute kidney injury include ARBs, NSAIDs and diuretics.

Which red flag alerts might you put in place for your pharmacy technicians touse when checking the patient’s medicines?

Sylvia is taking an ACE inhibitor. Other medicines which are red flag alerts foracute kidney include ARBs, NSAIDs and diuretics.

What advice could the pharmacist give to Sylvia to reduce her risk of developingacute kidney injury?

To prevent acute kidney injury, the pharmacist may wish to give advice about:

� rehydration

� recognising symptoms of dehydration

� withholding the ramipril for 24-48 hours

� seeing the GP if the diarrhoea has not resolved as this increases the risk ofacute kidney injury

� restarting her medicines if the diarrhoea does resolve after this time andremembering this advice for the future.

In your area there may be a leaflet that you wish to give out to remind patientsabout reducing their risk of acute kidney injury.

26

Acute kidney injury

Case study 2 (page 20)What information would you discuss with Robert?

You may wish to discuss with Robert:

� how he is getting on with his medicines, how he takes or uses them and anyproblems or concerns he has

� how the medicines are working and whether he is experiencing any side-effectsor unexpected effects

� adherence issues and missed doses

� any other medicines information he might need

� over-the-counter and complementary therapies

� issues identified, for example, drug interaction between amlodipine andsimvastatin; Robert may not have had his potassium and creatinine checkedsince increasing his ramipril dose; his kidney function should have been checkedas allopurinol is renally cleared (what is his current renal function and is thedose appropriate?)

� healthy lifestyle advice, for example, diet and nutrition (salt), smoking, physicalactivity, alcohol and weight management.

This healthy lifestyle advice will play an important role in cardiovascular health, butyou will also want to discuss kidney health and sick day rules relating to hisramipril.


acy team

27

Case study 3 (page 21)What factors could increase Margaret’s risk of developing acute kidney injury?

Margaret has chronic kidney disease and congestive cardiac failure and is takingan ARB. She is now acutely unwell with a urinary tract infection and is dehydratedand hypotensive. Furthermore, she has been prescribed an NSAID for pain.

What advice would you give regarding Margaret’s medicines and her risk ofacute kidney injury?

Your pharmacy team will probably be involved in performing medicinesreconciliation. Whose responsibility is this in your area of practice? In somehospitals, a standardised acute kidney injury risk assessment would be undertaken.Do you have this system in your hospital?

Since Margaret is at risk of acute kidney injury, the advice would be to withholdirbesartan for 24-48 hours until her urinary tract infection is treated, she hasreceived fluid replacement and her blood pressure has improved.

You should also ensure she has an assessment of her fluid status and, ifappropriate, the dose of furosemide should be withheld or reduced.

She should be advised to stop ibuprofen and change her pain relief. Paracetamolmay be enough but if opioids are required, as there is a risk of opioidsaccumulating, she should reduce the dose and increase the dose interval.

Her urinary tract infection should be treated, but you should consider thattrimethoprim may affect her creatinine and increase her potassium.

It may be appropriate to withhold her statin.

The bisoprolol should be withheld until her hypotension resolves and her heart rateshould be monitored.

Her U+Es should be monitored for acute kidney injury and hyperkalaemia and herfluid balance should also be monitored.

Her blood pressure should be monitored; this should improve with rehydration andresolution of her infection.

Her medicines should also be reviewed to determine her falls risk.

Case study 4 (page 22)What risk factors does James have for developing acute kidney injury?

James has chronic kidney disease and type 2 diabetes. He has undergone surgeryso it is important to check his fluid balance to ensure he has received appropriatefluids postoperatively and that he is not dehydrated.

Since he has diarrhoea related to his C. difficile this may have further contributedto his risk of dehydration. James was given gentamicin preoperatively which isnephrotoxic, so this may have increased his risk of acute kidney injury.

He was taking an ACE inhibitor preoperatively which will increase his risk of acutekidney injury, but usually this would have been withheld around the perioperativeperiod.

Has James developed hospital-acquired acute kidney injury?

Yes. James has acute kidney injury Stage 1 as his serum creatinine has risen by1.5-1.9 times baseline.

28

Acute kidney injury

What changes to his medicines would you recommend at this time?

Withhold metformin due to his risk of lactic acidosis during acute kidney injury.Insulin is metabolised by the kidneys so requirements for insulin are reduced whenrenal function is impaired. Monitor his blood glucose levels, especially as he ispostoperative and required insulin preoperatively.

A subcutaneous insulin infusion is the often the best way to control diabetes in anunstable situation like this.

If not already withheld due to surgery, withhold ramipril due to his acute kidneyinjury.

Change co-amoxiclav to an alternative antibiotic due to the risk of C. difficile.Avoid a combination of gentamicin and metronidazole as gentamicin isnephrotoxic and James has acute kidney injury. Piperacillin with tazobactam mightbe an alternative if James still requires treatment following his perforatedappendix. Remember that James has acute kidney injury so review the dose ofantibiotic that is newly prescribed and reduce this, if appropriate. Review the doseas his acute kidney injury resolves as it may need increasing again.

Similarly, review and reduce, then increase the dose, for any prescribed deep veinthrombosis (DVT)/pulmonary embolism prophylaxis.

Omeprazole may cause acute kidney injury by causing acute interstitial nephritis.19

It is unlikely to be the cause of his acute kidney injury in this case so would notneed stopping until other causes have been ruled out. However, James has C. difficile and proton pump inhibitors may contribute to this so would be stoppedfor this reason. Alginates or ranitidine might be alternatives if James still neededtreatment for his indigestion.

What additional actions would you take regarding transfer of information toprimary care and making sure James has the information he needs?

The discharge prescription should inform his GP:

� that James has developed acute kidney injury Stage 1

� whether his eGFR/ serum creatinine has returned to a reasonable baseline andwhether that represents recovery from acute kidney injury

� about follow-up advice for monitoring

� of any medicines withheld due to acute kidney injury and whether/when it isappropriate to restart these medicines following discharge from hospital.

Case study 5 goes on to discuss the specific medicines advice it would beappropriate to provide for his GP and the primary care team.

The pharmacy team will have a key role in discussing James’ medicine changeswith him. They should also discuss the sick day rules with him to prevent acutekidney injury from developing in the future.


acy team

29

Case study 5 (page 24)What actions would you take regarding continuing or discontinuing James’medicines?

Consider restarting metformin if his eGFR is greater than 30 mL/min/1.73m2, butwith caution unless it is over 45 mL/min/1.73m2.

Consider restarting ramipril if his serum creatinine and eGFR are returning to areasonable baseline and he is no longer hypotensive.

You may be confused as to why James’ omeprazole has been discontinued. Is itdue to his acute kidney injury, as taking omeprazole may result in acute kidneyinjury by causing acute interstitial nephritis,19 or is it due to C. difficile? If theomeprazole had caused acute kidney injury it would have been appropriate toinclude this information on his discharge prescription so that it could be recordedin his electronic record in primary care. Does James still require treatment for hisindigestion? An alginate or ranitidine might be suitable alternative treatments.

Recheck James’ U+Es one to two weeks after discharge if his serum creatinineand eGFR have not returned to baseline prior to discharge. Check his bloodpressure as he is taking ramipril.

Check if James had been made aware of the sick day rules while he was inhospital and if he could remember what he had been told. You are in a goodposition to reinforce this acute kidney injury prevention message now that Jameshas recovered from his surgery and acute illness. The sick day rules will apply forhis ramipril, but would also be appropriate for his metformin, due to the risk of itcausing lactic acidosis in acute kidney injury.

30

Acute kidney injury

Section 4Committing to action to preventor manage acute kidney injury

Learning objectives


� list three changes to practice that you could make to improve your approach related to the prevention and management of acute kidney injury

� make a pledge to implement one change in your practice and set yourself a deadline for this.

This section describes a range of approaches that you could take to put yourlearning into practice regarding the prevention and management of acute kidneyinjury. It draws together the knowledge and understanding that you have gained inworking through this programme and applied by working through the case studies.We have divided these potential actions into different sections relating to sectors ofpractice, but there is some overlap between them. Read through them all andconsider which of these changes you could make. We have suggested a pledge foreach sector of pharmacy.

4.1 Community pharmacyIf you work in community pharmacy you have a significant role to play in theprevention of acute kidney injury as you see patients every time they collect a newprescription. You can be involved in recognising people at risk of acute kidneyinjury when you provide over-the-counter advice, when you perform medicinesuse reviews and when you offer the new medicine service.

Your team members can discuss kidney health with people and help themunderstand how to avoid dehydration. You can review patients’ medicines andprovide advice, including for over-the-counter medicines such as NSAIDs. Each ofthese relies on the whole pharmacy team knowing the sick day rules and being ableto help your patients understand what action they should take and when.

Over-the-counter advice and sales

For this area of practice there are three main groups of customers who you wouldbe likely to target:

� customers who are purchasing over-the-counter NSAIDs

� customers asking for advice on sickness or diarrhoea

� customers seeking relief from a urinary tract infection.

All these groups need a consistent approach and engagement from all members ofyour pharmacy team. Each time someone makes a request in these areas, thepharmacy team member needs to identify whether they are at risk of acute kidneyinjury, or have renal disease.

Section 4 Com

mitting to action to prevent or m

anage acute kidney injury

31

Each time someone makes

an over-the-counter

request as outlined above,

the pharmacy team

member needs to identify

whether they are at risk of

acute kidney injury, or

have renal disease.

32

Acute kidney injury

What’s the challenge?

All members of your team need to understand:

� what acute kidney injury is and why it is important

� what questions they should ask and what action they should take based on theanswers they receive

� how to help patients avoid becoming dehydrated.

Practice pointIf you choose this challenge, how would you make sure that your pharmacy teamhad gained the required learning and were putting it into practice routinely?

Medicines use review and the new medicine service

This challenge is aimed at the pharmacist; whether it is the usual pharmacymanager or a locum pharmacist the need is for consistency in approach. Whenpatients at risk of renal disease are started on medicines that have the potential toimpair renal function and contribute to the development of acute kidney injury,your role is to make sure you can help them understand that these medicines willnot only help them (and in some cases protect the kidneys) but can, in somesituations, damage the kidneys. You need to be able to explain what to look out forand what action to take – as well as continuing to encourage them to be adherentwith their therapy. You should also be alert to patients who are receiving antibioticsfor urinary tract infections and ensure you advise them to keep well hydrated forthe sake of their kidneys.


All pharmacists working in your practice and offering these NHS services need toknow:

� what acute kidney injury is and why it is important that they take action tobenefit their patients

� how to identify patients with potential renal impairment and which medicinesare implicated in acute kidney injury

� the sick day rules to share with patients and be able to explain these to patientsin a clear and easy to understand manner.

The community pharmacy

team should be alert to

patients who are receiving

antibiotics for urinary tract

infections and ensure they

advise them to keep well

hydrated for the sake of

their kidneys.

Practice pointIf you choose this challenge, how would you make sure that all pharmacists hadundertaken the required learning and were putting this into practice routinely?

Community pharmacy audit on hydration messages to preventacute kidney injury

Each year community pharmacies are required to undertake two clinical audits aspart of the community pharmacy contractual framework; one of these is on a topicselected by NHS England and the other is on a topic selected by the pharmacycontractor.

A significant number of hospital admissions for community-acquired acute kidneyinjury Stages 2 and 3 appear to be associated with a recent urinary tract infection(personal communication). An audit has been developed to encourage communitypharmacists to target patients prescribed an antibacterial medicine for a urinarytract infection or wanting advice about urinary symptoms, with hydrationmessages to prevent dehydration and potential subsequent acute kidney injury.20

This links directly to the role of community pharmacists in reducing admissionsdue to acute kidney injury.

The audit has been developed by the NHS Specialist Pharmacy Services and willbe available nationally via the Pharmaceutical Services Negotiating Committee(PSNC) with data collection on PharmOutcomes.

www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/QIPP/Preventing/Community-Pharmacy-Audit-on-Hydration-Messages-to-Prevent-Acute-Kidney-Injury/

As well as helping your patients, the collation of data from the audit at a nationallevel will provide insight and evidence for the contribution of communitypharmacies in this important area.


You need to:

� commit to undertaking the audit on hydration messages for patients taking anantibacterial for a urinary tract infection or wanting advice about urinarysymptoms

� actively engage with this and make sure that all members of your team knowwhat is required and how to record the data accurately and completely.

Section 4 Com



33

An audit has been

developed to encourage

community pharmacists to

target patients prescribed

an antibacterial medicine

for a urinary tract

infection or wanting advice

about urinary symptoms,

with hydration messages

to prevent dehydration and

potential subsequent acute

kidney injury.

www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/QIPP/Preventing/Community-Pharmacy-Audit-on-Hydration-Messages-to-Prevent-Acute-Kidney-Injury/

34

Acute kidney injury

Practice pointIf you choose this challenge, how will you make sure that you act on the auditoutcomes?

The pledgeI will pledge to take part in the audit targeting all patients takingantibacterials for a urinary tract infection or wanting advice abouturinary symptoms, with hydration advice.

Distributing sick day rules leaflets

Working in community pharmacy you see people more often than any othermember of the healthcare team; every time they collect a prescription. Thischallenge asks you to make use of this opportunity and to provide a sick day rulesleaflet to every person who could be at risk of developing acute kidney injury, or istaking an ACE inhibitor or ARB.


All members of your team need to:

� know how to identify people who are at risk of developing acute kidney injuryand provide them with the sick day rules leaflet. Alternatively you mightprovide this information to all patients receiving ACE inhibitors or ARBs.

Sick day rules leaflets are usually developed locally. Why not ask your clinicalcommissioning group if they have stocks. Otherwise you could adapt one of the

cards or leaflets available online, like this one:

www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Primary%20Care/Medicine%20patient%20info%20leaflet.pdf

� know which people are at risk and be able to explain to them what the leaflet isabout

� invite people back to ask questions after they have read the leaflet and be able tooffer accurate advice on the action to take.

Practice pointIf you choose this challenge, how would you make sure that your team membersconsistently provide the leaflet to the right people?

This challenge asks

community pharmacy

team members to make

use of any opportunity to

provide a sick day rules

leaflet to every person who

could be at risk of

developing acute kidney

injury, or is taking an ACE

inhibitor or ARB.

www.scottishpatientsafetyprogramme.scot.nhs.uk/Media/Docs/Primary%20Care/Medicine%20patient%20info%20leaflet.pdf

Section 4 Com



35

4.2 Primary care pharmacyIf you work in primary care you will know that the primary care team has theopportunity to engage with patients in a formal healthcare setting and to discussmedicines during annual medication reviews. Primary care pharmacists andpharmacy technicians have the chance to talk directly with their colleagues withinpractices to share messages and to plan audits of at-risk patients. They canoptimise medicines, for example, reviewing the use of NSAIDs in patients withchronic kidney disease, providing prevention advice on sick day rules to patientsreceiving ACE inhibitors or ARBs, and supporting people who need extra helpafter discharge from hospital.

Audit

The primary care team has access to audit data to explore the number of patientswho are admitted with acute kidney injury and to investigate any impact on thisfollowing the introduction of sick day rules.


You need to be able to identify patients who are taking medicines that increase therisk of developing renal impairment who have not had a renal check for 12 months. These medicines may include ACE inhibitors, ARBs, spironolactone,ciclosporin, tacrolimus, lithium and diuretics.

Practice pointIf you choose this challenge, how will you engage your colleagues in the practiceso that they know what you are doing and why?

The pledgeI will conduct an audit of patients taking one or more of the following:ACE inhibitors, ARBs, spironolactone, ciclosporin, tacrolimus,lithium and diuretics, who have not had a renal check in the last 12 months and ensure that they are given a renal check within thenext three months.

Sick day rules and primary care

You are in a good position to be able to share information and advice about theright action to take when patients are at risk of developing acute kidney injury. Alsoyou can encourage people to seek advice from their community pharmacist,provide the sick day rules leaflet and discuss appropriate action on temporarilywithholding medicines when at risk of acute kidney injury.

Primary care pharmacists

and pharmacy technicians

have the chance to talk

directly with their

colleagues within practices

to share messages and to

plan audits of at-risk

patients.

Primary care pharmacy

team members can

encourage people to seek

advice from their

community pharmacist,

provide the sick day rules

leaflet and discuss

appropriate action on

temporarily withholding

medicines when at risk of

acute kidney injury.


You need to know:

� which of your patients are at risk of developing acute kidney injury and how toexplain to them what to do and when

� which laboratory results would give you supporting information and whataction it is appropriate to take.

Practice pointIf you choose this challenge, what approach will you take to prioritise the patientsthat you talk with first?

Post discharge from hospital

When patients are discharged from hospital, the discharge summary is sent to theirGP to keep their records up to date. You are in the right position to be able tointerpret any changes made to the patient’s medicines and consider what actionneeds to be taken to manage the risk of the patient developing acute kidney injuryand to control their other conditions. Medicines may have been stopped and needto be restarted, for example, antihypertensives.


You need to:

� know which medicines to look out for and the appropriate advice to offer

� check that medicines have been appropriately discontinued and follow up anymedicines that may need restarting.

36

Acute kidney injury

Primary care pharmacy

team members are in the

right position to be able to

interpret any changes

made to the patient’s

medicines and consider

what action needs to be

taken to manage the risk

of the patient developing

acute kidney injury and to

control their other

conditions.

Practice pointIf you choose this challenge, what approach will you take to make sure that youare routinely informed of patients who have been discharged from secondarycare?

4.3 Secondary careIf you work in hospital, you know that you are probably the only pharmacyprofessionals who are involved in the management of acute kidney injury, as wellas its prevention. Your role is medicines reconciliation and optimisation andplanning for patient discharge through advising GPs and offering patients theinformation they require.

Medicines reconciliation

Hospital pharmacy team members are some of the key professionals involved inreconciling patient’s medicines on admission. You find out which medicines thepatient is prescribed and discuss with them how and why they take them. Whenpatients are admitted with acute kidney injury, your role is to make sure that yougive the correct advice on which medicines should be prescribed and which shouldbe withheld.


You need to:

� recognise which medicines could put patients at risk of acute kidney injury

� talk with the patient to find out which of their medicines they take and whetherthey are aware of the sick day rules

� identify whether they are currently dehydrated or otherwise at risk of developingacute kidney injury

� be ready to make recommendations on withholding medicines to reduce the riskof acute kidney injury, if appropriate.

Section 4 Com



37

When patients are

admitted to hospital with

acute kidney injury, the

role of hospital pharmacy

team members is to make

sure that they give the

correct advice on which

medicines should be

prescribed and which

should be withheld.

38

Acute kidney injury

Practice pointIf you choose this challenge, how will you make sure that you ‘think kidneys’ foreach patient you see?

The pledgeI will ensure that I recognise the medicines which could put patientsat risk of acute kidney injury, talk with each patient to find outwhether they are aware of the sick day rules, identify whether they arecurrently dehydrated or otherwise at risk of developing acute kidneyinjury and be ready to make recommendations on withholdingmedicines to reduce the risk of acute kidney injury, if appropriate.

Medicines optimisation

As active members of the ward-based care team, you have the opportunity toreview patients’ renal function and to consider whether any of the medicines theyare taking could be putting them at risk of acute kidney injury. You can discuss thiswith the medical team and ensure that medicines are temporarily withheld whenappropriate to protect a patient’s renal function.


You need to:

� make sure that your medical and nursing colleagues know about the risks ofacute kidney injury and the sick day rules

� recognise the medical laboratory results which suggest that a patient isbecoming dehydrated or has acute kidney injury and recommend whichmedicines should be temporarily withheld

� ensure that the medicines are restarted when appropriate in order to protect thepatient’s long-term health.

As active members of the

ward-based care team,

hospital pharmacy team

members have the

opportunity to review

patients’ renal function

and to consider whether

any of the medicines they

are taking could be putting

them at risk of acute

kidney injury.

Section 4 Com



39

Practice pointIf you choose this challenge, how will you make sure that this approach is takenroutinely within your trust?

Discharge planning and patient information, including advice tothe GP

Patients’ medicines may be changed while they are in hospital and this can have animpact on their ongoing care and on their need to understand what action to taketo protect their kidneys. When patients are discharged, information can be lost ormiscommunicated and neither prescriber nor patient may understand why changeshave been made. If medicines have been withheld, it is important that this does notbecome a permanent discontinuation of essential therapy. Your role is to make surethat the prescriber in primary care receives useful and relevant information andthat the patient is a partner in their ongoing care.


You need to:

� make sure that you are able to contribute to a patient’s discharge letter andinclude relevant information about changes to their medicines

� clearly describe the sick day rules to the prescriber and explain why this isrelevant to the patient’s care

� discuss the sick day rules with the patient or their carers

� help patients and carers to understand why they should buy their medicinesfrom a pharmacy where the pharmacy team know about their therapy.

Practice pointIf you commit to this challenge, how will you make sure that your colleaguesunderstand why you are adding to discharge plans?

Hospital pharmacy team

members should make

sure that the prescriber in

primary care receives

useful and relevant

information and that the

patient is a partner in their

ongoing care.

Practice point: planning your challengeAt this stage you have read through a number of different potential areas whereyou can engage and make a difference to people at risk of developing acutekidney injury. We have covered some of the key areas that you would need to thinkabout for each of these and challenged you to think about key considerations. Youmay have decided on a different area where you can make a difference. Finally,we have suggested some challenges where you may feel moved to make a pledgeto improve patient care using your new knowledge of acute kidney injury.

In the box below, write down what you are going to commit to changing in yourpractice to improve your care for people at risk of developing acute kidney injury.

What will you need to do in order to make this change effective?

You may find it useful to think about which of your team members you need toshare your learning with, which of your colleagues you need to discuss this with andwhat other resources you need to have on hand.

When will you make this change to your practice?

How will you measure the outcome?

40

Acute kidney injury

SummaryThere are many steps that the pharmacy team can take to improve the care thatthey offer for people at risk of developing acute kidney injury, or who havedeveloped acute kidney injury. In this section we have explored some of these stepsand challenged you to commit to doing something differently in your routinepractice. You have selected an action that you are willing and able to commit to andhave developed an outline plan of how you are going to implement this.

Intended outcomesOn completion of this section you should be able to: Can you?

� list three changes to practice that you could make to improve your approach, related to the prevention and management of acute kidney injury

� make a pledge to implement one change in your practice and set yourself a deadline for this.

Section 4 Com



41

References

1. Think Kidneys website: www.thinkkidneys.nhs.uk

The Think Kidneys programme draws together existing good practice,resources, tools and education and aims to raise awareness of acute kidneyinjury among healthcare professionals. This NHS campaign aims to reduce therates of acute kidney injury and transform care for patients who experience it.

2. National Institute for Health and Care Excellence. CG169: Acute kidney injury:prevention, detection and management of acute kidney injury up to the point of renalreplacement therapy. London: NICE, 2013.

3. Chertow, GM et al. Journal of the American Society of Nephrology 2005; 16: 3365-3370.

4. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidneyinjury: a systematic review and meta-analysis. Kidney International 2012;81:442-448.

5. National Institute for Health and Care Excellence. CG182. Chronic kidneydisease: early identification and management of chronic kidney disease in adults inprimary and secondary care. London: NICE, 2014.

6. Shaw, S, Coleman, A and Selby, N. Acute kidney injury diagnosis, staging andprevention. Clinical Pharmacist 2012; 4: 98-102.

7. Shaw, S, Morlidge, C, Ashley, C and Selby, N. Acute kidney injury management.Clinical Pharmacist 2012; 4: 103-106.

8. McDaniel, BL and Bentley, ML. The role of medications and their managementin acute kidney injury. Integrated Pharmacy Research and Practice 2015; 4: 21-29.

9. Think Kidneys. Acute kidney injury warning algorithm: best practice guidance.December 2014. www.thinkkidneys.nhs.uk/wp-content/uploads/2014/12/AKI-Warning-Algorithm-Best-Practice-Guidance-final-publication-0112141.pdf

10. Selby, N et al. Do people ‘Think kidneys?’ a study of knowledge levels in the generalpopulation (on behalf of the NHS ‘Think Kidneys’ AKI Programme 2014).

11. CPPE. Consultation skills for pharmacy practice: taking a patient-centred approach.Manchester: CPPE; February 2014.

12. NHS Choices web page. Acute kidney injury. www.nhs.uk/conditions/acute-kidney-injury/pages/introduction.aspx

13. Salford Clinical Commissioning Group. Personal communication. 2015.

14. Sick day rules in kidney disease. Drugs and Therapeutics Bulletin 2015; 4: 317.

15. Scottish Patient Safety Programme. Medicine sick day rules card. 2015.www.scottishpatientsafetyprogramme.scot.nhs.uk/programmes/primary-care/medicine-sick-day-rules-card

16. Griffith K et al. ‘Sick day rules’ in patients at risk of acute kidney injury: aninterim position statement from the Think Kidneys Board. Version 6: 8 July 2015.www.thinkkidneys.nhs.uk/news/sick-day-rules-position-statement/

17. Patient web page. Acute kidney injury. www.patient.co.uk/doctor/acute-kidney-injury-pro

18. Royal Pharmaceutical Society and Centre for Pharmacy PostgraduateEducation. Medicines optimisation briefing: acute kidney injury (AKI). 2015.www.cppe.ac.uk/wizard/files/news%20attachments/aki_mo_briefing_final.pdf

42

Acute kidney injury

www.thinkkidneys.nhs.uk/wp-content/uploads/2014/12/AKI-Warning-Algorithm-Best-Practice-Guidance-final-publication-0112141.pdf

www.scottishpatientsafetyprogramme.scot.nhs.uk/programmes/primary-care/medicine-sick-day-rules-card

www.cppe.ac.uk/wizard/files/news%20attachments/aki_mo_briefing_final.pdf

19.Woods, D and Fonteles, MM. Interstitial nephritis caused by PPIs.Pharmaceutical Journal 2013; 290. www.pharmaceutical-journal.com/learning/learning-article/interstitial-nephritis-caused-by-ppis/11117189.article

20. East and South East England Specialist Pharmacy Services. Community pharmacy audit on hydration messages to prevent acute kidney injury. 3 September2015. (online only).www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/QIPP/Preventing/Community-Pharmacy-Audit-on-Hydration-Messages-to-Prevent-Acute-Kidney-Injury/

References

43

http://www.pharmaceutical-journal.com/learning/learning-article/interstitial-nephritis-caused-by-ppis/11117189.article

Mmedicines optimisation 38

medicines reconciliation 37

medicines use reviews 32

metformin 29, 30

Nnew medicine service 32non-steroidal anti-inflammatory drugs (NSAIDs) 5NSAIDs and sick day rules 12

Oomeprazole 29over-the-counter advice 31

Ppatient-centred consultations 9potassium intake 12primary care pharmacy, role of 35

Rramipril 27, 29, 30

Ssalt intake 12secondary care pharmacy team, role of 37sick day rules 12, 13, 34, 35spironolactone 35

Ttacrolimus 35

Uurinary tract infection 12, 28, 33

Index

AACE inhibitors and sick day rules 12

acute kidney injury, causes 5

acute kidney injury, definition 3

acute kidney injury, risk factors 5

acute kidney injury, stages 3

acute kidney injury, statistics 1

acute kidney injury, triggers 5

angiotensin converting enzyme (ACE) inhibitors 5,26, 35

angiotensin-II receptor blockers (ARBs) 5, 35

angiotensin-II receptor blockers (ARBs) and sick day rules 12

audit of hydration advice 33

Cchronic kidney disease, definition 4

ciclosporin 35

community pharmacy, role of 31-34

creatinine results, monitoring of 7

Ddehydration 12, 26, 32

diabetes 5, 28

diarrhoea 26

dietary advice 12

discharge planning 39

diuretics 5, 35

diuretics and sick day rules 12

Eexercise 12

Hhospital discharge 36

Kkidney health 9

Llifestyle advice 12, 27

lithium 35

liver disease 5

44

Acute kidney injury

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