Quality statement 2: Identifying acute kidney injury in people admitted to hospital | Acute kidney injury | Quality standards

Quality statement

Children, young people and adults at risk of acute kidney injury who are admitted to hospital have their serum creatinine level monitored. [2014, updated 2023]

Rationale

Acute kidney injury is a clinical syndrome with multiple causes. People with acute kidney injury may have no external signs or symptoms, and their kidney function can deteriorate rapidly, so identifying people who are at risk and monitoring their clinical condition is important. Early assessment for acute kidney injury in people at risk who are admitted to hospital may prevent delays in providing effective care, leading to improved outcomes. Monitoring serum creatinine levels in people who are likely to need blood tests for other reasons is inexpensive and easy to do with rapidly available results.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

a) Proportion of hospital stays for children, young people and adults at risk of acute kidney injury in which serum creatinine level is measured on admission.

Numerator – the number in the denominator in which serum creatinine level is measured on admission.

Denominator – the number of hospital stays for children, young people and adults at risk of acute kidney injury.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

b) Proportion of hospital stays for children, young people and adults at risk of acute kidney injury in which serum creatinine level is rechecked following admission.

Numerator – the number in the denominator in which serum creatinine level is rechecked following admission.

Denominator – the number of hospital stays for children, young people and adults at risk of acute kidney injury.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

Outcome

Length of hospital stay with an episode of acute kidney injury.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records. NHS Digital's Hospital Episode Statistics includes length of stay.

What the quality statement means for different audiences

Service providers (hospitals) ensure that systems are in place for children, young people and adults at risk of acute kidney injury who are admitted to hospital to have their serum creatinine level measured on admission and rechecked at a frequency appropriate to their individual clinical need.

Healthcare professionals (such as doctors, nurses and pharmacists) measure the serum creatinine level in children, young people and adults at risk of acute kidney injury who are admitted to hospital and recheck it at a frequency appropriate to their individual clinical need.

Commissioners (integrated care boards) ensure that they commission services that monitor the serum creatinine level in children, young people and adults at risk of acute kidney injury who are admitted to hospital.

Children, young people and adults at risk of acute kidney injury who are admitted to hospital have a blood test when they are admitted to measure the amount of creatinine in their blood. This shows how well their kidneys are working. This is repeated during their stay so that healthcare professionals can take action if any changes are found.

Source guidance

Acute kidney injury: prevention, detection and management. NICE guideline NG148 (2019), recommendations 1.1.1, 1.1.2 and 1.3.2

Definitions of terms used in this quality statement

Children, young people and adults at risk of acute kidney injury who are admitted to hospital

Adults at risk of acute kidney injury who are admitted to hospital include those:

who have non‑elective admissions
who have any major planned interventions, such as interventional radiological procedures (including coronary angiography) and grade 3 or grade 4 surgery, neurosurgery or cardiovascular surgery (see NICE's guideline on routine preoperative tests for elective surgery for definitions of surgery grades).

[Expert opinion]

Additionally, people with acute illness in hospital are at risk of acute kidney injury if any of the following are likely or present:

chronic kidney disease (adults with an estimated glomerular filtration rate [eGFR] less than 60 ml/min/1.73 m² are at particular risk)
heart failure
liver disease
diabetes
history of acute kidney injury
oliguria (urine output less than 0.5 ml/kg/hour)
young age, neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a parent or carer
hypovolaemia
use of drugs that can cause or exacerbate kidney injury (such as non-steroidal anti-inflammatory drugs [NSAIDs], aminoglycosides, angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor antagonists [ARBs] and diuretics) within the past week, especially if the person is hypovolaemic. For further information on high-risk medicines, see Think Kidneys' guidelines on medicines optimisation for AKI, section 3.
use of iodine-based contrast media within the past week in adults
symptoms or history of urological obstruction, or conditions that may lead to obstruction
sepsis
deteriorating paediatric or adult early warning scores
age 65 years or over.

There is also a risk of acute kidney injury if any of the following are likely or present in children and young people with acute illness:

severe diarrhoea (children and young people with bloody diarrhoea are at particular risk)
symptoms or signs of nephritis (such as oedema or haematuria)
haematological malignancy
hypotension.

[NICE's guideline on acute kidney injury, recommendations 1.1.1 and 1.1.2]

Monitoring serum creatinine level

Monitor serum creatinine regularly using a blood test for all adults, children and young people at risk of acute kidney injury. Frequency of repeat monitoring should be tailored to individual clinical need. [Adapted from NICE's guideline on acute kidney injury, recommendation 1.3.2]

Clinical laboratories should use creatinine assays that are specific (for example, enzymatic assays) and zero-biased compared with isotope dilution mass spectrometry (IDMS). [NICE's guideline on chronic kidney disease, recommendation 1.1.2]

NHS England has mandated a national acute kidney injury algorithm which, when integrated within laboratory information management systems, identifies potential cases of acute kidney injury using laboratory data in real time and produces an acute kidney injury warning stage test result to inform clinical teams.