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  3. Investigating acute kidney injury in primary care
Practice Rational Testing

Investigating acute kidney injury in primary care

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4007 (Published 27 June 2019) Cite this as: BMJ 2019;365:l4007
  1. Indre K Semogas, academic foundation year trainee1,
  2. Amy Davis, consultant radiologist2,
  3. Imran Rafi, general practitioner and honorary senior lecturer3,
  4. Christopher Anderson, consultant urologist and honorary senior lecturer3 4,
  5. Nicholas M P Annear, consultant in acute medicine and nephrology and honorary senior lecturer1 3 5
  1. 1Department of Acute Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
  2. 2Department of Radiology, Epsom & St Helier Hospital NHS Trust, London, UK
  3. 3Institute of Medical and Biomedical Education, St George's University of London, London, UK
  4. 4Department of Urology, St George's University Hospitals NHS Foundation Trust, London
  5. 5Department of Renal & Transplantation Medicine, St George's University Hospitals NHS Foundation Trust, London
  1. Correspondence to: N M P Annear nickannear{at}doctors.org.uk

What you need to know

  • Acute kidney injury (AKI) in the community is most commonly due to infections such as influenza or gastroenteritis, with associated fluid depletion, but 10% of community cases are due to obstructive uropathy

  • AKI is associated with longer inpatient admissions, increased risk of progression to chronic kidney disease (CKD), and higher in-hospital and long term mortality

  • After an episode of AKI, review patients in primary care to advise on appropriate management and reintroduction of any medications withheld during an AKI episode and to screen for CKD

A 65 year old obese man with diabetes, hypertension, osteoarthritis, and a two month history of persistent lower urinary tract symptoms attended his general practice with general malaise. Regular medications included metformin, gliclazide, ramipril, and ibuprofen. On examination, his blood pressure was 150/96 mm Hg. Digital rectal examination revealed a smooth enlarged prostate. Urine analysis showed 2+ proteinuria. Blood tests revealed a serum creatinine concentration of 160 µmol/L, compared with 78 µmol/L three weeks earlier; his prostate specific antigen (PSA) level had been 6 µg/L.

The problem

Acute kidney injury (AKI) is a syndrome characterised by a sudden decline in renal function. To standardise AKI classification, international guidelines were published in 2012 (table 1).1

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Table 1

KDIGO classification of acute kidney injury (AKI)1

Population incidence of AKI is as high as 0.2%,2 and between 8.4% and 17.6% among hospital inpatients.34 Around two thirds of AKI cases identified in hospital develop in the community before hospitalisation.5 AKI is associated with longer inpatient admissions, increased risk of progression to chronic kidney disease (CKD), and higher mortality (in hospital6 and long term).37 Prompt identification of AKI and early management initiated in primary care is central to improving outcomes.

Identifying AKI in primary care

AKI in the community is most commonly due to infections such as influenza or gastroenteritis, with associated fluid depletion.8 …

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