GUIDELINE

Acutekidneyinjury(QS76)
NationalInstituteforHealthandCareExcellence(NICE)

Introduction
Thisqualitystandardcoverstheprevention,detectionandmanagementofnontraumaticacute
kidneyinjuryuptothepointofrenalreplacementtherapyinadults,youngpeopleandchildrenolder
than1month.Itdoesnotcoverthemanagementofacutekidneyinjuryinpeoplewithrenal
transplantsorinpregnantwomen,butdoesincludewhentoinvolvenephrologyservicesforpeople
withrenaltransplants.Formoreinformationseethetopicoverview
(https://www.nice.org.uk/guidance/qs76/documents).

Whythisqualitystandardisneeded
Acutekidneyinjuryoccurswhenthekidneyssuddenly(withinhoursordaysofnormalfunctioning)
stopworkingastheyshould.Itencompassesawidespectrumofinjurytothekidneys,notjust
'kidneyfailure'.Thekidneysneedacompetentcirculationfornormalfunction,soacutekidneyinjury
isafeatureofmanysevereillnessesasaresultofreducedbloodflow.Othercausesofacutekidney
injuryincludedehydration,somedrugs,severeinfections,blockageoftheurinarytractandthe
contrastmediumusedforsometypesofscan.
Acutekidneyinjuryisseenin1318%ofallpeopleadmittedtohospital,witholderadultsbeing
particularlyaffected.Thesepatientsareusuallyunderthecareofhealthcareprofessionalspractising
inspecialtiesotherthannephrology,whomaynotalwaysbefamiliarwiththebestcareforpatients
withacutekidneyinjury.However,studiessuggestthatacutekidneyinjuryisunderrecordedon
patients'notesandpossiblyunderrecognised.Arecentstudy(Kerretal.2014
(http://ndt.oxfordjournals.org/content/early/2014/04/17/ndt.gfu016.full)),basedonHospitalEpisodes
Statistics(HES)data2010/11,foundthatacutekidneyinjurywasrecordedin2.4%ofinpatient
admissions.Thesamestudyusedlaboratorydatatoestimatethatageandgenderstandardised
prevalenceestimatesmaybemorethan5timesashigh.
Thenumberofinpatientsaffectedbyacutekidneyinjurymeansthatithasamajorimpacton
healthcareresources.TheannualcostofinpatientcarerelatedtoacutekidneyinjuryinEnglandis
estimatedtobe1.02billion,whichisjustover1%oftheNHSbudget(Kerretal.2014
(http://ndt.oxfordjournals.org/content/early/2014/04/17/ndt.gfu016.full))andismorethanisspentonbreast
cancer,lungcancerandbowelcancercombined(HealthServiceJournal22April2014
(http://www.hsj.co.uk/news/warningissuedoverhospitalkidneydeaths/5070134.article)).

Inpatientmortalityfromacutekidneyinjuryvariesconsiderably,dependingonseverity,setting
(intensivecareornonintensivecare)andmanyotherpatientrelatedfactors.HESdatafrom2010/11
showthatpatientsdiedbeforedischargeinapproximately28%ofadmissionswhereacutekidney
injurywasrecorded.Becauseofitsfrequencyandtheassociatedmortalityrate,preventionor
ameliorationofacutekidneyinjurywouldpreventalargenumberofdeathsandsubstantiallyreduce
complicationsandtheirassociatedcosts.
Acutekidneyinjuryisincreasinglybeingseeninprimarycare,andsoitisimportanttoraise
awarenessoftheconditionamonghealthcareprofessionalsworkinginprimarycare.Itisalso
importantthatanyidentifiedcasesofacutekidneyinjuryaremanagedorreferredappropriately.
Upto30%ofcasesofacutekidneyinjurymaybepreventable(NationalConfidentialEnquiryintoPatient
OutcomeandDeath2009(http://www.ncepod.org.uk/2009aki.htm)),andriskassessmentandprevention,
earlyrecognitionandmanagementarekeyfactorsinpreventingdeathsandreducingcomplications.
Becausethereisnospecifictreatmentforacutekidneyinjury,managementismainlysupportive.
Thisinvolvestreatingthecauseandmanagingthesymptomsuntilthekidneysrecoverfromthe
injury,andincludesreferralforrenalreplacementtherapyifappropriate.
Thequalitystandardisexpectedtocontributetoimprovementsinthefollowingoutcomes:
Avoidabledeath(includingprimarycausesotherthanacutekidneyinjury).
Deteriorationtostages2and3inpeoplewithacutekidneyinjurystage1.
Thenumberofpeoplewhoneedacuterenalreplacementtherapy.
Prevalenceofchronickidneydisease.
Patientexperienceofhospitalcare.
Thenumberofpatientsafetyincidents.
Admissionstocriticalcare(anddialysis).
Lengthofhospitalstayforacutekidneyinjury.
Incidenceofacutekidneyinjury.
Complicationsassociatedwithacutekidneyinjury(forexample,hyperkalaemia,fluid
overload).

Howthisqualitystandardsupportsdeliveryofoutcomeframeworks
NICEqualitystandardsareaconcisesetofprioritisedstatementsdesignedtodrivemeasurable
qualityimprovementswithinaparticularareaofhealthorcare.Theyarederivedfromhighquality
guidance,suchasthatfromNICEorothersourcesaccreditedbyNICE.Thisqualitystandard,in

conjunctionwiththeguidanceonwhichitisbased,shouldcontributetotheimprovementsoutlined
inthefollowingoutcomesframeworkpublishedbytheDepartmentofHealth:
NHSOutcomesFramework201415(https://www.gov.uk/government/publications/nhsoutcomes
framework2014to2015)

Table1showstheoutcomes,overarchingindicatorsandimprovementareasfromtheframeworks
thatthequalitystandardcouldcontributetoachieving.
Table1NHSOutcomesFramework201415(https://www.gov.uk/government/publications/nhsoutcomes
framework2014to2015)

Domain

Overarchingindicatorsandimprovement
areas

1Preventingpeoplefromdyingprematurely

Overarchingindicator
1aPotentialYearsofLifeLost(PYLL)from
causesconsideredamenabletohealthcare
i)Adults,ii)Childrenandyoungpeople

2Enhancingqualityoflifeforpeoplewithlongterm Overarchingindicator
conditions
2Healthrelatedqualityoflifeforpeoplewith
longtermconditions
3Helpingpeopletorecoverfromepisodesofill
healthorfollowinginjury

Overarchingindicator
3bEmergencyreadmissionswithin30daysof
dischargefromhospital*
Improvementareas
Improvingoutcomesfromplanned
treatments
3.1Totalhealthgainasassessedbypatients
forelectiveprocedures
i)Hipreplacement,ii)Kneereplacement,iii)
Groinhernia,iv)Varicoseveins
Improvingrecoveryfrominjuriesand
trauma

3.3Survivalfrommajortrauma
4Ensuringthatpeoplehaveapositiveexperience
ofcare

Overarchingindicator
4bPatientexperienceofhospitalcare
Improvementareas
Improvinghospitals'responsivenessto
personalneeds
4.2Responsivenesstoinpatients'personal
needs
Improvingpeople'sexperienceofaccident
andemergencyservices
4.3PatientexperienceofA&Eservices

5Treatingandcaringforpeopleinasafe
environmentandprotectingthemfromavoidable
harm

Overarchingindicator
5aPatientsafetyincidentsreported
5bSafetyincidentsinvolvingsevereharmor
death
5cHospitaldeathsattributabletoproblemsin
care
Improvementareas
Reducingtheincidenceofavoidableharm
5.4Incidenceofmedicationerrorscausing
seriousharm
Deliveringsafecaretochildreninacute
settings
5.6Incidenceofharmtochildrendueto
'failuretomonitor'

Alignmentacrossthehealthandsocialcaresystem
*IndicatorsharedwithPublicHealthOutcomesFramework(PHOF)

Patientexperienceandsafetyissues
Ensuringthatcareissafeandthatpeoplehaveapositiveexperienceofcareisvitalinahighquality
service.Itisimportanttoconsiderthesefactorswhenplanninganddeliveringservicesrelevantto
acutekidneyinjury.
NICEhasdevelopedguidanceandanassociatedqualitystandardonpatientexperienceinadultNHS
services(seetheNICEpathwayonpatientexperienceinadultNHSservices
(http://pathways.nice.org.uk/pathways/patientexperienceinadultnhsservices)),whichshouldbeconsidered
alongsidethisqualitystandard.Theyspecifythatpeoplereceivingcareshouldbetreatedwith
dignity,haveopportunitiestodiscusstheirpreferences,andbesupportedtounderstandtheir
optionsandmakefullyinformeddecisions.Theyalsocovertheprovisionofinformationtopatients
andserviceusers.Qualitystatementsontheseaspectsofpatientexperiencearenotusuallyincluded
intopicspecificqualitystandards.However,recommendationsinthedevelopmentsource(s)for
qualitystandardsthatimpactonpatientexperienceandarespecifictothetopicareconsidered
duringqualitystatementdevelopment.

Coordinatedservices
Thequalitystandardforacutekidneyinjuryspecifiesthatservicesshouldbecommissionedfromand
coordinatedacrossallrelevantagenciesencompassingthewholeacutekidneyinjurycarepathway.A
personcentred,integratedapproachtoprovidingservicesisfundamentaltodeliveringhighquality
caretopeoplewithacutekidneyinjury.
TheHealthandSocialCareAct2012setsoutaclearexpectationthatthecaresystemshouldconsider
NICEqualitystandardsinplanninganddeliveringservices,aspartofageneraldutytosecure
continuousimprovementinquality.Commissionersandprovidersofhealthandsocialcareshould
refertothelibraryofNICEqualitystandardswhendesigninghighqualityservices.Otherquality
standardsthatshouldalsobeconsideredwhenchoosing,commissioningorprovidingahighquality
acutekidneyinjuryservicearelistedinrelatedNICEqualitystandards.
Trainingandcompetencies

Thequalitystandardshouldbereadinthecontextofnationalandlocalguidelinesontrainingand
competencies.Allhealthcareprofessionalsinvolvedinassessing,caringforandtreatingpeoplewith
acutekidneyinjuryshouldhavesufficientandappropriatetrainingandcompetenciestodeliverthe
actionsandinterventionsdescribedinthequalitystandard.Qualitystatementsonstafftrainingand
competencyarenotusuallyincludedinqualitystandards.However,recommendationsinthe
developmentsource(s)onspecifictypesoftrainingforthetopicthatexceedstandardprofessional
trainingareconsideredduringqualitystatementdevelopment.
Roleoffamiliesandcarers

Qualitystandardsrecognisetheimportantrolefamiliesandcarershaveinsupportingpeoplewith
acutekidneyinjury.Ifappropriate,healthcareprofessionalsshouldensurethatfamilymembersand
carersareinvolvedinthedecisionmakingprocessaboutinvestigations,treatmentandcare.

Listofqualitystatements
Statement1.Peoplewhoareatriskofacutekidneyinjuryaremadeawareofthepotentialcauses.
Statement2.Peoplewhopresentwithanillnesswithnoclearacutecomponentand1ormore

indicationsorriskfactorsforacutekidneyinjuryareassessedforthiscondition.
Statement3.Peopleinhospitalwhoareatriskofacutekidneyinjuryhavetheirserumcreatininelevel

andurineoutputmonitored.
Statement4.Peoplehaveaurinedipsticktestperformedassoonasacutekidneyinjuryissuspectedor

detected.
Statement5.Peoplewithacutekidneyinjuryhavethemanagementoftheirconditiondiscussedwitha

nephrologistassoonaspossible,andwithin24hoursofdetection,iftheyareatriskofintrinsicrenal
diseaseorhavestage3acutekidneyinjuryorarenaltransplant.
Statement6.Peoplewithacutekidneyinjurywhomeetthecriteriaforrenalreplacementtherapyare

referredimmediatelytoanephrologistorcriticalcarespecialist.

Qualitystatement1:Raisingawarenessinpeopleatrisk
Qualitystatement
Peoplewhoareatriskofacutekidneyinjuryaremadeawareofthepotentialcauses.

Rationale
Manypeoplewhodevelopacutekidneyinjuryarenotawareofthepotentialcausesandhowto
preventit.Acutekidneyinjurycanbepreventedbyeducatingpeopleabouttherisksandhowtostop
itfromdeveloping.Bettereducationdeliveredinprimarycaresettings,outpatientsettingsandon
dischargefromhospitalwillhelptoreducethenumberofpeopledevelopingacutekidneyinjury
outsidehospitalandthenumberbeingadmittedtohospitalwiththecondition.

Qualitymeasures
Structure

Evidenceoflocalarrangementstoensurethatpeoplewhoareatriskofacutekidneyinjuryaremade
awareofthepotentialcauses.
Datasource:Localdatacollection.
Process

Proportionofpeoplewhoareatriskofacutekidneyinjurywhoaremadeawareofthepotential
causes.
Numeratorthenumberinthedenominatorwhoaremadeawareofthepotentialcausesofacute
kidneyinjuryinadocumenteddiscussionwiththeirhealthcareprofessional.

Denominatorthenumberofpeoplewhoareatriskofacutekidneyinjury.
Datasource:Localdatacollection.
Outcome

Incidenceofacutekidneyinjury.
Datasource:Localdatacollection.

Whatthequalitystatementmeansforserviceproviders,healthcareprofessionals,and
commissioners
Serviceproviders(GPsanddistrictgeneralhospitals)ensurethatsystemsareinplaceforpeople
whoareatriskofacutekidneyinjurytobemadeawareofthepotentialcausesandstepsfor
preventioninadiscussionwiththeirhealthcareprofessional(thatalsoinvolvestheirparentsor
carers,ifappropriate).
Healthcareprofessionalsensurethattheydiscussthepotentialcausesofacutekidneyinjuryand
stepsforpreventionwithpeoplewhoareatrisk(andwiththeirparentsorcarers,ifappropriate).
Commissioners(clinicalcommissioninggroups)ensurethattheycommissionservicesin
whichpeoplewhoareatriskofacutekidneyinjuryaremadeawareofthepotentialcausesandsteps
forpreventioninadiscussionwiththeirhealthcareprofessional(thatalsoinvolvestheirparentsor
carers,ifappropriate).

Whatthequalitystatementmeansforpatients,serviceusersandcarers
Peoplewhoareatriskofacutekidneyinjuryaretoldabouttheriskinadiscussionwiththeir
healthcareprofessional,whichalsoinvolvestheirparentsorcarersifappropriate.Thediscussion
shouldcoverpossiblecausesofacutekidneyinjury(forexample,dehydrationcausedbydiarrhoea
andvomiting,andcertaindrugsthatcanaffectthekidney)andwhattheycandotoavoidit.

Sourceguidance
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(NICEguidelineCG169),

recommendation1.6.4.

Definitionsoftermsusedinthisqualitystatement
Peopleatriskofacutekidneyinjury

Peoplewhoareparticularlyatriskofdevelopingacutekidneyinjuryinthecommunity,andshould
havetheriskdiscussedwiththem,includethosewhohaveanyofthefollowing:
historyofacutekidneyinjury(determinedbythedischargesummaryfromaninpatient
episode,documentingthestageandcauseofacutekidneyinjury)
chronickidneydiseasewithanestimatedglomerularfiltrationrate(eGFR)oflessthan
60ml/min/1.73m2

neurologicalorcognitiveimpairmentordisability,whichmaymeanlimitedaccesstofluids
becauseofrelianceonacarer.
[ExpertopinionandNICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),
recommendation1.6.4]
Potentialcausesofacutekidneyinjury

Thepotentialcausesofacutekidneyinjuryincludeconditionsleadingtodehydration(forexample,
diarrhoeaandvomiting)anddrugsthathavenephrotoxicpotential(includingoverthecounter
NSAIDs[nonsteroidalantiinflammatorydrugs]).Healthcareprofessionalsshoulddiscussthese
causesandhowtoavoidthemwithpeoplewhoareatrisk(andtheirparentsorcarersifappropriate).
Thediscussionshouldincludetheimportanceofstayinghydrated,shouldbehadatleastonceand
shouldbedocumentedintheperson'snotes.[AdaptedfromNICEguidelineCG169
(http://www.nice.org.uk/guidance/cg169),recommendation1.6.4withexpertopinion]

Equalityanddiversityconsiderations
Youngage,neurologicalorcognitiveimpairmentordisabilitymayresultinlimitedaccesstofluids
andariskofdehydrationforsomepeoplebecauseoftheirrelianceonotherstomaintainadequate
fluidintake.Thismayincludefrailolderpeople,peoplewithdementiaincarehomesandpeoplewith
physicaldisabilities.Also,theriskofacutekidneyinjurymightincreaseforpeopleofMuslimfaith
duringperiodsoffastingiftheyhaveotherriskfactors(forexample,iftheyaretakingdiuretics).

Qualitystatement2:Identifyingacutekidneyinjuryinpeoplewithno
obviousacuteillness
Qualitystatement
Peoplewhopresentwithanillnesswithnoclearacutecomponentand1ormoreindicationsorrisk
factorsforacutekidneyinjuryareassessedforthiscondition.

Rationale
Peoplewithacutekidneyinjurymaypresentwithnoobvioussignsorsymptomsofthisconditionin
primaryorsecondarycaresettings.Earlyassessmentforacutekidneyinjurywhenmakingdecisions
abouttreatmentforpeoplewhoareatriskmaypreventdelaysintreatingthecondition,leadingto
improvedoutcomes.Itisimportantforhealthcareprofessionalstobeawareofwhenitisnecessary
toassesstheriskofacutekidneyinjurysothatadiagnosisisnotmissed.

Qualitymeasures
Structure

Evidenceoflocalarrangementstoensurethatpeoplewhopresentwithanillnesswithnoclearacute
componentand1ormoreindicationsorriskfactorsforacutekidneyinjuryareassessedforacute
kidneyinjury.
Datasource:Localdatacollection.
Process

Process

Proportionofpresentationsofillnesswithnoclearacutecomponentalongwith1ormoreindications
orriskfactorsforacutekidneyinjurywhereanassessmentforacutekidneyinjuryisdone.
Numeratorthenumberinthedenominatorwhereanassessmentforacutekidneyinjuryisdone.
Denominatorthenumberofpresentationsofillnesswithnoclearacutecomponentalongwith1or
moreindicationsorriskfactorsforacutekidneyinjury.
Datasource:Localdatacollection.
Outcome

Incidenceofacutekidneyinjury.
Datasource:Localdatacollection.

Whatthequalitystatementmeansforserviceproviders,healthcareprofessionals,and
commissioners
Serviceproviders(primaryandsecondarycareproviders)ensurethatpeoplewhopresentwithan
illnesswithnoclearacutecomponentand1ormoreindicationsorriskfactorsforacutekidney
injuryareassessedforacutekidneyinjury.
Healthcareprofessionalsconsiderandassessforacutekidneyinjuryinpeoplewhopresentwith
anillnesswithnoclearacutecomponentand1ormoreindicationsorriskfactorsforacutekidney
injury.
Commissioners(clinicalcommissioninggroups)ensurethattheycommissionservicesinwhich
peoplewhopresentwithanillnesswithnoclearacutecomponentand1ormoreindicationsorrisk
factorsforacutekidneyinjuryareassessedforacutekidneyinjury.

Whatthequalitystatementmeansforpatients,serviceusersandcarers
Peoplewhoaregenerallyunwellwithnoobviousrecentorsuddenillnessandwho
haveindicationsorriskfactorsforacutekidneyinjuryareassessedtoseewhetherthey
havethiscondition.Thisshouldincludebloodtestsandhavingtheirurinevolumemeasured,aswell
asreviewinganymedicationstheyaretaking.

Sourceguidance
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(NICEguidelineCG169),

recommendation1.1.4.

Definitionsoftermsusedinthisqualitystatement
Illnesswithnoclearacutecomponent

Apersonwithanillnesswithnoclearacutecomponentfeelsgenerallyunwell(forexample,tired
withperhapsnauseaorswellingofthelegs),andhasnoclearideaofwhentheillnessbegan,andno
clearsuddenacuteillness.[Expertopinion]
Indicationsorriskfactorsforacutekidneyinjuryinpeoplewithanillnesswithnoclearacutecomponent

Indicationsorriskfactorsforacutekidneyinjuryinpeoplewithanillnesswithnoclearacutecomponent

Thefollowingareindicationsorriskfactorsforacutekidneyinjuryinpeoplewithanillnesswithno
clearacutecomponent:
chronickidneydisease(especiallystage3B,4or5)orurologicaldisease
newonsetorsignificantworseningofurologicalsymptoms
symptomssuggestingcomplicationsofacutekidneyinjury
symptomsorsignsofamultisystemdiseaseaffectingthekidneysandotherorgansystems(for
example,signsorsymptomsofacutekidneyinjuryplusapurpuricrash).
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.1.4]
Assessmentforacutekidneyinjury

Clinicalassessmentforacutekidneyinjuryinvolvesdoingabloodtesttocheckserumcreatinine
levelsagainstapreviousresult,measuringurinevolumeandreviewingmedication.Thisassessment
canbeundertakeninaprimarycaresettingaswellasahospitalsetting,althoughthefrequencyof
bloodtestingmaybelessinaprimarycaresetting.[Expertopinion]

Equalityanddiversityconsiderations
Allpeoplepresentingwithnoobviousacuteillnesswhohaveindicationsorriskfactorsforacute
kidneyinjuryshouldbeassessedforapossiblediagnosis.Symptomssuggestingacutekidneyinjury
shouldnotbedismissedbasedonaperson'sageforexample,ignoringurologicalsymptomsin
olderpeople.Youngage,neurologicalorcognitiveimpairmentordisabilitymaymeanthatpeopleare
lessabletodescribetheirsymptoms,soitisimportantthathealthcareprofessionalslookoutfor
changesinbehaviourthatsuggestacutekidneyinjuryinthesegroups.

Qualitystatement3:Monitoringinhospitalforpeopleatrisk
Qualitystatement
Peopleinhospitalwhoareatriskofacutekidneyinjuryhavetheirserumcreatininelevelandurine
outputmonitored.

Rationale
Acutekidneyinjurycanbea'silent'conditionwithnoexternalsignsorsymptoms.Becausemany
episodesofacutekidneyinjuryarepreventable,identifyingpeoplewhoareatriskandmonitoring
theirclinicalconditionisimportant.Changesinserumcreatininelevelandurineoutputare
indicatorsofrisk,anditisimportantthatthesebiomarkersaremonitoredalongsidea'trackand
trigger'system.Recognisingandrespondingtothesechangeswillensureappropriateandquick
interventiontopreventacutekidneyinjurydeveloping.

Qualitymeasures
Structure

Structure

Evidenceoflocalarrangementstoensurethatpeopleinhospitalwhoareatriskofacutekidney
injuryhavetheirserumcreatininelevelandurineoutputmonitored.
Datasource:Localdatacollection.
Process

Proportionofadmissionstohospitalofpeoplewhoareatriskofacutekidneyinjurywhereserum
creatininelevelandurineoutputaremonitored.
Numeratorthenumberinthedenominatorwhereserumcreatininelevelandurineoutputare
monitored.
Denominatorthenumberofadmissionstohospitalofpeoplewhoareatriskofacutekidneyinjury.
Datasource:Localdatacollection.Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169/resources)
(NICEguidelineCG169),clinicalaudittooladults,standards5and6andclinicalaudittoolchildren,
standard2.
Outcome

Incidenceofacutekidneyinjury.
Datasource:Localdatacollection.

Whatthequalitystatementmeansforserviceproviders,healthcareprofessionals,and
commissioners
Serviceproviders(districtgeneralhospitals)ensurethatprotocolsareinplacefortrained
healthcareprofessionalstomonitortheserumcreatininelevelandurineoutputofpeopleinhospital
whoareatriskofacutekidneyinjuryalongsideatrackandtriggersystem,andtorespondtoany
changes.
Healthcareprofessionalsfollowlocalprotocolsformonitoringtheserumcreatinineleveland
urineoutputofpeopleinhospitalwhoareatriskofacutekidneyinjuryalongsideatrackandtrigger
system,andrespondtoanychanges.
Commissioners(clinicalcommissioninggroups)ensurethatsecondarycareprovidershave
protocolsinplacefortrainedhealthcareprofessionalstomonitortheserumcreatinineleveland
urineoutputofpeopleinhospitalwhoareatriskofacutekidneyinjuryalongsideatrackandtrigger
system,andtorespondtoanychanges.

Whatthequalitystatementmeansforpatients,serviceusersandcarers
Peopleinhospitalwhoareatriskofdevelopingacutekidneyinjuryshouldhaveblood
teststomeasurelevelsofcreatinine(asubstancethatindicateshowwelltheirkidneysareworking)
andhavetheirurinevolumemeasured.Healthcareprofessionalsshouldtakeactioniftheyfindany

changes.Thisshouldbedoneforpatientsinacutehospitalsandotherhospitalsettings(suchas
psychiatrichospitals).

Sourceguidance
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(NICEguidelineCG169),

recommendations1.2.2,1.2.6and1.3.2(keypriorityforimplementation).
TheRenalAssociation(2011)Acutekidneyinjury
(http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx)Guideline1.3definition,

epidemiologyandoutcomes.
Acutelyillpatientsinhospital(http://www.nice.org.uk/guidance/cg50)(NICEguidelineCG50),

recommendation1.6.

Definitionsoftermsusedinthisqualitystatement
Peopleinhospitalwhoareatriskofacutekidneyinjury

Adultsinhospitalatriskofacutekidneyinjuryincludethose:
whohavenonelectiveadmissions
whohaveanymajorplannedinterventions,suchasinterventionalradiologicalprocedures
(includingcoronaryangiography)andgrade3orgrade4surgery,neurosurgeryor
cardiovascularsurgery(seepreoperativetests(http://www.nice.org.uk/guidance/cg3)[NICEguideline
CG3]fordefinitionsofsurgerygrades).
[Expertopinion]
NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.1.1hasadetailedlistof

riskfactorsforacutekidneyinjuryinadultswithacuteillness.
Childrenandyoungpeopleinhospitalwithacuteillnessareatriskofacutekidneyinjuryifanyofthe
followingarelikelyorpresent:
chronickidneydisease
heartfailure
liverdisease
historyofacutekidneyinjury
oliguria(urineoutputlessthan0.5ml/kg/hour)
youngage,neurologicalorcognitiveimpairmentordisability,whichmaymeanlimitedaccess
tofluidsbecauseofrelianceonaparentorcarer

hypovolaemia
useofdrugswithnephrotoxicpotential(suchasNSAIDs[nonsteroidalantiinflammatory
drugs],aminoglycosides,ACE[angiotensinconvertingenzyme]inhibitors,ARBs[angiotensin
IIreceptorblockers]anddiuretics)withinthepastweek,especiallyifhypovolaemic
symptomsorhistoryofurologicalobstruction,orconditionsthatmayleadtoobstruction
sepsis
adeterioratingpaediatricearlywarningscore
severediarrhoea(childrenandyoungpeoplewithbloodydiarrhoeaareatparticularrisk)
symptomsorsignsofnephritis(suchasoedemaorhaematuria)
haematologicalmalignancy
hypotension.
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.1.2]
Monitoringofserumcreatininelevelandurineoutput

Physiological'trackandtrigger'systems(earlywarningscores)shouldbeusedtomonitoralladult
patientsinacutehospitalsettings.Theserumcreatininelevelandurineoutputshouldberecordedat
admissionorintheinitialassessmentandthenaspartofroutinemonitoring.
Measurementofserumcreatininewillvaryaccordingtoclinicalneed,butdailymeasurementis
typicalwhileapersonisacutelyilland/orinhospital.Serumcreatininelevelsshouldbecompared
withabaselinemeasurementtodetectchangesthatwouldtriggeraresponse.Detailsofbaseline
measurementsanddetectingacutekidneyinjurybasedonchangesinserumcreatininelevelcanbe
foundinNHSEngland'snationalalgorithm
(http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/akialgorithm/).
Frequencyofurineoutputmonitoringwillalsodependonclinicalcircumstances.Whenadultsareat
riskofacutekidneyinjury,systemsshouldbeinplacetorecogniseandrespondtooliguria(urine
outputoflessthan0.5ml/kg/hour).
Forchildrenandyoungpeople,physiologicalobservationsshouldberecordedatadmissionandthen
accordingtolocalprotocolsforgivenpaediatricearlywarningscores.
Thefrequencyofmonitoringforadults,childrenandyoungpeopleshouldincreaseifabnormal
physiologyisdetected.
[AdaptedfromNICEguidelineCG50(http://www.nice.org.uk/guidance/cg50)andNICEguidelineCG169
(http://www.nice.org.uk/guidance/cg169)]

Equalityanddiversityconsiderations

Equalityanddiversityconsiderations
Youngage,neurologicalorcognitiveimpairmentordisabilitymayresultinlimitedaccesstofluids
andariskofdehydrationforsomepeoplebecauseoftheirrelianceonotherstomaintainadequate
fluidintake.Thismayincludefrailolderpeople,peoplewithdementiaincarehomesandthosewith
physicaldisabilities.Also,theriskofacutekidneyinjurymightincreaseforpeopleofMuslimfaith
duringperiodsoffastingiftheyhaveotherriskfactors(forexample,iftheyaretakingdiuretics).

Qualitystatement4:Identifyingthecauseurinedipsticktest

[1]Risk,injury,failure,loss,endstagerenaldisease,(p)referstothepaediatricclassification.
[2]AcuteKidneyInjuryNetwork.
[3]Kidneydisease:improvingglobaloutcomes.

Qualitystatement
Peoplehaveaurinedipsticktestperformedassoonasacutekidneyinjuryissuspectedordetected.

Rationale
Understandingthecauseofacutekidneyinjurybytestingtheurineforbloodandproteinis
importantforguidingfurtherspecialisedinvestigationsandappropriatetreatments.Urinedipstick
testingisasimple,effectiveandinexpensivediagnostictesttoidentifyunderlyingconditionsthatcan
betreatedtoeitherpreventacutekidneyinjuryorreduceitsseverity,thusavoidingmoreserious
consequences.

Qualitymeasures
Structure

Evidenceoflocalarrangementstoensurethatpeoplehaveaurinedipsticktestperformedassoonas
acutekidneyinjuryissuspectedordetected.
Datasource:Localdatacollection.
Process

Proportionofpresentationswhereaurinedipsticktestisperformedwithin6hoursofacutekidney
injurybeingsuspectedordetected.
Numeratorthenumberinthedenominatorwhereaurinedipsticktestisperformedwithin6hours
ofacutekidneyinjurybeingsuspectedordetected.
Denominatorthenumberofpresentationsinwhichacutekidneyinjuryissuspectedordetected.
Datasource:Localdatacollection.
Outcome

Outcome

Preventingseriousconsequencesresultingfromnottreatingthecausesofacutekidneyinjury.
Datasource:Localdatacollection.

Whatthequalitystatementmeansforserviceproviders,healthcareprofessionals,and
commissioners
Serviceproviders(primaryandsecondarycareproviders)ensurethatprotocolsandclearreferral
pathwaysareinplaceforurinedipsticktestingtobecarriedoutassoonasacutekidneyinjuryis
suspectedordetected,andforappropriateresponsestoabnormalresults.
Healthcareprofessionalsperformurinedipsticktestingassoonasacutekidneyinjuryis
suspectedordetected,andknowwhenandhowtorespondtoabnormalresults.
Commissioners(clinicalcommissioninggroups)ensurethatprimaryandsecondarycare
providershaveprotocolsinplaceforurinedipsticktestingtobecarriedoutassoonasacutekidney
injuryissuspectedordetected,andforappropriateresponsestoabnormalresults.

Whatthequalitystatementmeansforpatients,serviceusersandcarers
Peoplewithsuspectedordetectedacutekidneyinjuryhavetheirurinetestedwitha
'dipstick'assoonaspossibletocheckforcausesofacutekidneyinjury.

Sourceguidance
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(NICEguidelineCG169),

recommendation1.4.2.

Definitionsoftermsusedinthisqualitystatement
Suspectedordetectedacutekidneyinjury

Symptomsorsignsofacutekidneyinjurycanvaryandincludepassinglessurinethannormal,
nauseaandsickness,poorappetite,swellingofthelegsorotherpartsofthebodyandbreathlessness
[NICEguidelineCG169,informationforthepublic
(http://www.nice.org.uk/guidance/cg169/informationforpublic)].
Acutekidneyinjuryisdetectedinlinewiththe(p)RIFLE[1] ,AKIN[2] orKDIGO[3] definitions,by
usinganyofthefollowingcriteria:
ariseinserumcreatinineof26micromol/litreorgreaterwithin48hours
a50%orgreaterriseinserumcreatinineknownorpresumedtohaveoccurredwithinthepast
7days
afallinurineoutputtolessthan0.5ml/kg/hourformorethan6hoursinadultsandmore
than8hoursinchildrenandyoungpeople

a25%orgreaterfallinestimatedglomerularfiltrationrate(eGFR)inchildrenandyoung
peoplewithinthepast7days.
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.3.1]
Anationalalgorithm(http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/akialgorithm/)that
standardisesthedefinitionofacutekidneyinjuryhasbeenagreedandendorsedbyNHSEngland.
Urinedipsticktest

Aurinedipstickteststheurinesampleforblood,protein,leukocytes,nitritesandglucose,andcan
helptodetermineanunderlyingcauseofacutekidneyinjury.Thetestshouldbedoneassoonas
possibleafteracutekidneyinjuryissuspectedordetected,andwithin6hoursatmost.
Catheterisationforthesakeofperformingthetestshouldbeavoided.Theresultsofthetestshould
bedocumentedandappropriateactiontakenwhenresultsareabnormal.Theinterpretationofurine
dipstickfindingsinachildwithacutekidneyinjuryshouldalwaysbeundertakenbyapaediatrician
orapaediatricnephrologist.[AdaptedfromNICEguidelineCG169
(http://www.nice.org.uk/guidance/cg169),fullguidelinewithexpertopinion]

Qualitystatement5:Discussionwithanephrologist

[4]Risk,injury,failure,loss,endstagerenaldisease,(p)referstothepaediatricclassification.
[5]AcuteKidneyInjuryNetwork.
[6]Kidneydisease:improvingglobaloutcomes.
[7]Wheretheriseisknown(basedonapriorbloodtest)orpresumed(basedonthepatienthistory)

tohaveoccurredwithin7days.

Qualitystatement
Peoplewithacutekidneyinjuryhavethemanagementoftheirconditiondiscussedwitha
nephrologistassoonaspossible,andwithin24hoursofdetection,iftheyareatriskofintrinsicrenal
diseaseorhavestage3acutekidneyinjuryorarenaltransplant.

Rationale
Inputfromnephrologiststothemanagementofacutekidneyinjuryisneededassoonaspossiblefor
peoplewhoareatriskoftheirconditionworseningorofadverseoutcomes.Thishelpstoensurethat
peoplegetthespecialistcaretheyneedtohelptheirconditionimproveandtopreventitfrom
deterioratingfurther.

Qualitymeasures
Structure

Evidenceoflocalarrangementstoensurethatpeoplewithacutekidneyinjurywhoareatriskof
intrinsicrenaldiseaseorhavestage3acutekidneyinjuryorarenaltransplanthavethemanagement
oftheirconditiondiscussedwithanephrologistassoonaspossibleandwithin24hoursofdetection.
Datasource:Localdatacollection.
Process

Proportionofpresentationsofpeoplewithacutekidneyinjurywhoareatriskofintrinsicrenal
diseaseorhavestage3acutekidneyinjuryorarenaltransplantwheremanagementisdiscussedwith
anephrologistwithin24hoursofdetection.
Numeratorthenumberinthedenominatorwheremanagementisdiscussedwithanephrologist
within24hoursofdetectionofacutekidneyinjury.
Denominatorthenumberofpresentationsofpeoplewithacutekidneyinjurywhoareatriskof
intrinsicrenaldiseaseorhavestage3acutekidneyinjuryorarenaltransplant.
Datasource:Localdatacollection.Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169/resources)
(NICEguidelineCG169)clinicalaudittooladults,standard9andclinicalaudittoolchildren,
standard5.
Outcomes

a)Mortalityfromacutekidneyinjury.
Datasource:Mortalitystatistics(http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Mortality+Rates)from
theOfficeforNationalStatistics.
b)Progressionofacutekidneyinjury.
Datasource:Localdatacollection.

Whatthequalitystatementmeansforserviceproviders,healthcareprofessionals,and
commissioners
Serviceproviders(districtgeneralhospitals)ensurethatthemanagementofacutekidneyinjury
forpeoplewhoareatriskofintrinsicrenaldiseaseorhavestage3acutekidneyinjuryorarenal
transplantisdiscussedwithanephrologistorpaediatricnephrologistassoonaspossible,andwithin
24hoursofdetection.
Healthcareprofessionalsdiscussthemanagementofacutekidneyinjuryforpeoplewhoareat
riskofintrinsicrenaldiseaseorhavestage3acutekidneyinjuryorarenaltransplantwitha
nephrologistorpaediatricnephrologistassoonaspossible,andwithin24hoursofdetection.
Commissioners(clinicalcommissioninggroups)ensurethatsecondarycareprovidershave
protocolsinplacesothatthemanagementofacutekidneyinjuryforpeoplewhoareatriskof
intrinsicrenaldiseaseorhavestage3acutekidneyinjuryorarenaltransplantisdiscussedwitha

nephrologistorpaediatricnephrologistassoonaspossible,andwithin24hoursofdetection.

Whatthequalitystatementmeansforpatients,serviceusersandcarers
Peoplewithacutekidneyinjurywhoareatriskofkidneydiseaseorhavestage3acute
kidneyinjuryorakidneytransplanthavetheirconditiondiscussedwithaspecialistassoonas
possible(within24hoursatmost),sothattheygettherighttreatment.

Sourceguidance
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(NICEguidelineCG169)

recommendation1.5.15.

Definitionsoftermsusedinthisqualitystatement
Peoplewithacutekidneyinjury

Acutekidneyinjuryisdetectedinlinewiththe(p)RIFLE[4] ,AKIN[5] orKDIGO[6] definitions,by

usinganyofthefollowingcriteria:
ariseinserumcreatinineof26micromol/litreorgreaterwithin48hours
a50%orgreaterriseinserumcreatinineknownorpresumedtohaveoccurredwithinthepast
7days
afallinurineoutputtolessthan0.5ml/kg/hourformorethan6hoursinadultsandmore
than8hoursinchildrenandyoungpeople
a25%orgreaterfallinestimatedglomerularfiltrationrate(eGFR)inchildrenandyoung
peoplewithinthepast7days.
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.3.1]
Anationalalgorithm(http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/akialgorithm/)that
standardisesthedefinitionofacutekidneyinjuryhasbeenagreedandendorsedbyNHSEngland.
Peoplewithacutekidneyinjurywhoareatriskofintrinsicrenaldisease

Peoplewithacutekidneyinjuryareatriskofintrinsicrenaldiseasewhenoneormoreofthe
followingispresent:
apossiblediagnosisthatmayneedspecialisttreatment(forexample,vasculitis,
glomerulonephritis,tubulointerstitialnephritisormyeloma)
acutekidneyinjurywithnoclearcause
inadequateresponsetotreatment
complicationsassociatedwithacutekidneyinjury
chronickidneydiseasestage4or5.

[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.5.15]
Peoplewhohavestage3acutekidneyinjury

Stage3acutekidneyinjuryisdefinedinthe(p)RIFLE[4] ,AKIN[5] orKDIGO[6] definitionsas:

eGFRdecreaseby75%orgreater
or200%orgreaterriseincreatininefrombaselinewithin7days[7]
orriseincreatinineto354micromol/litreorgreaterwithanacuteriseof44micromol/litreor
greater
orriseincreatinineto354micromol/litreorgreaterwithanacuteriseof26micromol/litreor
greaterwithin48hoursor50%orgreaterwithin7days
or(pRIFLEonly)eGFRlessthan35ml/min/1.73m2
oranyrequirementforrenalreplacementtherapy.
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),fullguideline,table36]

Qualitystatement6:Referralforrenalreplacementtherapy

[8]Risk,injury,failure,loss,endstagerenaldisease,(p)referstothepaediatricclassification.
[9]AcuteKidneyInjuryNetwork.
[10]Kidneydisease:improvingglobaloutcomes.

Qualitystatement
Peoplewithacutekidneyinjurywhomeetthecriteriaforrenalreplacementtherapyarereferred
immediatelytoanephrologistorcriticalcarespecialist.

Rationale
Itisimportanttoensurethatpeoplewithacutekidneyinjurywhoneedtreatmentreceiveitinthe
rightcaresetting(suchasanintensivecareunitorrenalunit)attherighttime,andthatdelaysin
treatmentthatputpeopleatriskareavoided.Thiscanbeachievedthroughimmediatereferral
supportedbyeffectivereferralandtransferprotocolsthatprioritisepeoplewiththegreatestneed.
Prompttreatmentofferspotentialbenefitsthatincludepreventingfurtherdeteriorationofrenal
function,improvingchancesofrenalrecovery,shorterhospitalstays,lowermortalityandbetter
longtermoutcomes.

Qualitymeasures

Qualitymeasures
Structure

Evidenceoflocalarrangementstoensurethatpeoplewithacutekidneyinjurywhomeetthecriteria
forrenalreplacementtherapyarereferredimmediatelytoanephrologistorcriticalcarespecialist
andtransferredaccordingtolocalprotocols.
Datasource:Localdatacollection.
Process

Proportionofpeoplewithacutekidneyinjurywhomeetthecriteriaforrenalreplacementtherapy
whoarereferredimmediatelytoanephrologistorcriticalcarespecialist.
Numeratorthenumberinthedenominatorwhoarereferredimmediatelytoanephrologistor
criticalcarespecialist.
Denominatorthenumberofpeoplewithacutekidneyinjurywhomeetthecriteriaforrenal
replacementtherapy.
Datasource:Localdatacollection.
Outcomes

a)Durationofrenalreplacementtherapyforacutekidneyinjury.
Datasource:Localdatacollection.
b)Mortalityfromacutekidneyinjury.
Datasource:Mortalitystatistics(http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Mortality+Rates)from
theOfficeforNationalStatistics.

Whatthequalitystatementmeansforserviceproviders,healthcareprofessionals,and
commissioners
Serviceproviders(districtgeneralhospitalsandspecialisedrenalcentres)ensurethatclear
referralpathwaysandtransferprotocolsareinplacefortheimmediatereferralofpeoplewithacute
kidneyinjurywhomeetthecriteriaforrenalreplacementtherapytoanephrologistorcriticalcare
specialist.
Healthcareprofessionalsimmediatelyreferpeoplewithacutekidneyinjurywhomeetthe
criteriaforrenalreplacementtherapytoanephrologistorcriticalcarespecialistandtransferthem
accordingtolocalprotocols.
Commissioners(clinicalcommissioninggroupsandNHSEngland)ensurethatsecondarycare
providershaveclearreferralpathwaysandtransferprotocolsinplacefortheimmediatereferralof
peoplewithacutekidneyinjurywhomeetthecriteriaforrenalreplacementtherapytoanephrologist

orcriticalcarespecialist.CommissionersshouldworkwithNHSEnglandwhennecessarytoensure
thatthereisenoughcapacitywithinspecialistnephrologyteamsforreferrals.

Whatthequalitystatementmeansforpatients,serviceusersandcarers
Peoplewithacutekidneyinjurywhoneedrenalreplacementtherapy(suchasdialysis)
arereferredimmediatelytospecialistservicessothatdelaysinhavingthetreatmentareavoided.

Sourceguidance
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(NICEguidelineCG169)

recommendation1.5.11.

Definitionsoftermsusedinthisqualitystatement
Peoplewithacutekidneyinjury

Acutekidneyinjuryisdetectedinlinewiththe(p)RIFLE[8] ,AKIN[9] orKDIGO[10] definitions,by

usinganyofthefollowingcriteria:
ariseinserumcreatinineof26micromol/litreorgreaterwithin48hours
a50%orgreaterriseinserumcreatinineknownorpresumedtohaveoccurredwithinthepast
7days
afallinurineoutputtolessthan0.5ml/kg/hourformorethan6hoursinadultsandmore
than8hoursinchildrenandyoungpeople
a25%orgreaterfallinestimatedglomerularfiltrationrate(eGFR)inchildrenandyoung
peoplewithinthepast7days.
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.3.1]
Anationalalgorithm(http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/akialgorithm/)that
standardisesthedefinitionofacutekidneyinjuryhasbeenagreedandendorsedbyNHSEngland.
Immediatereferral

Immediatereferralbyhealthcareprofessionalsisneededtoensuretimelyinitiationoftherapy.
Effectiveandtimelyreferralshouldbemadeusinglocallydevelopedreferralandtransferprotocols.
Theseprotocolsshouldbebasedonlocalphysiologicalearlywarningscores,whichincludeurine
outputandparametersfromtheNationalEarlyWarningScore(NEWS),toensurethatpeoplewho
meetthecriteriaforrenalreplacementtherapyareseenbyasuitablespecialistandthatthereis
appropriatetriageofpeoplewithacutekidneyinjury,includingthosearrivingfromotherhospitals.
[AdaptedfromTheRenalAssociationAcutekidneyinjuryguideline
(http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx)5.3withexpertopinion]
Criteriaforrenalreplacementtherapy

Ifanyofthefollowingarenotrespondingtomedicalmanagement:

hyperkalaemia
metabolicacidosis
symptomsorcomplicationsofuraemia(forexample,pericarditisorencephalopathy)
fluidoverload
pulmonaryoedema.
[NICEguidelineCG169(http://www.nice.org.uk/guidance/cg169),recommendation1.5.8]

Usingthequalitystandard
Qualitymeasures
Thequalitymeasuresaccompanyingthequalitystatementsaimtoimprovethestructure,process
andoutcomesofcareinareasidentifiedasneedingqualityimprovement.Theyarenotanewsetof
targetsormandatoryindicatorsforperformancemanagement.
Wehaveindicatedifcurrentnationalindicatorsexistthatcouldbeusedtomeasurethequality
statements.TheseincludeindicatorsdevelopedbytheHealthandSocialCareInformationCentre
throughitsIndicatorsforQualityImprovementProgramme(http://www.hscic.gov.uk/iqi).Ifthereisno
nationalindicatorthatcouldbeusedtomeasureaqualitystatement,thequalitymeasureshould
formthebasisforauditcriteriadevelopedandusedlocally.
SeeNICE'swhatmakesupaNICEqualitystandard?(http://www.nice.org.uk/Standardsand
Indicators/DevelopingNICEqualitystandards/NICEqualitystandardsFAQs)forfurtherinformation,
includingadviceonusingqualitymeasures.

Levelsofachievement
Expectedlevelsofachievementforqualitymeasuresarenotspecified.Qualitystandardsare
intendedtodriveupthequalityofcare,andsoachievementlevelsof100%shouldbeaspiredto(or
0%ifthequalitystatementstatesthatsomethingshouldnotbedone).However,NICErecognises
thatthismaynotalwaysbeappropriateinpractice,takingaccountofsafety,choiceandprofessional
judgement,andthereforedesiredlevelsofachievementshouldbedefinedlocally.

Usingothernationalguidanceandpolicydocuments
Othernationalguidanceandcurrentpolicydocumentshavebeenreferencedduringthedevelopment
ofthisqualitystandard.Itisimportantthatthequalitystandardisconsideredalongsidethe
documentslistedindevelopmentsources(http://www.nice.org.uk/guidance/qs76/chapter/development
sources).

Informationforthepublic

NICEhasproducedinformationforthepublic(http://www.nice.org.uk/guidance/QS76/InformationForPublic)
aboutthisqualitystandard.Patients,serviceusersandcarerscanuseittofindoutaboutthequality
ofcaretheyshouldexpecttoreceiveasabasisforaskingquestionsabouttheircare,andtohelp
makechoicesbetweenprovidersofsocialcareservices.

Diversity,equalityandlanguage
Duringthedevelopmentofthisqualitystandard,equalityissueshavebeenconsideredandequality
assessments(http://www.nice.org.uk/Guidance/QS76/Documents)areavailable.
Goodcommunicationbetweenhealthcareprofessionalsandpeoplewithacutekidneyinjury,and
theirfamiliesorcarers(ifappropriate),isessential.Treatment,careandsupport,andthe
informationgivenaboutit,shouldbebothageappropriateandculturallyappropriate.Itshouldalso
beaccessibletopeoplewithadditionalneedssuchasphysical,sensoryorlearningdisabilities,andto
peoplewhodonotspeakorreadEnglish.Peoplewithacutekidneyinjuryandtheirfamiliesorcarers
(ifappropriate)shouldhaveaccesstoaninterpreteroradvocateifneeded.
Commissionersandprovidersshouldaimtoachievethequalitystandardintheirlocalcontext,in
lightoftheirdutiestohavedueregardtotheneedtoeliminateunlawfuldiscrimination,advance
equalityofopportunityandfostergoodrelations.Nothinginthisqualitystandardshouldbe
interpretedinawaythatwouldbeinconsistentwithcompliancewiththoseduties.

Developmentsources
Furtherexplanationofthemethodologyusedcanbefoundinthequalitystandardsprocessguide
(http://www.nice.org.uk/standardsandindicators)ontheNICEwebsite.

Evidencesources
ThedocumentsbelowcontainrecommendationsfromNICEguidanceorotherNICEaccredited
recommendationsthatwereusedbytheQualityStandardsAdvisoryCommitteetodevelopthe
qualitystandardstatementsandmeasures.
Acutekidneyinjury(http://www.nice.org.uk/guidance/cg169)(2013)NICEguidelineCG169.
Acutekidneyinjury(http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx)(2011)The

RenalAssociation.
Acutelyillpatientsinhospital(http://www.nice.org.uk/guidance/cg50)(2007)NICEguidelineCG50.

Policycontext
Itisimportantthatthequalitystandardisconsideredalongsidecurrentpolicydocuments,including:

NationalConfidentialEnquiryintoPatientOutcomeandDeath(2009).Addinginsulttoinjury
(http://www.ncepod.org.uk/2009aki.htm).
DepartmentofHealth(2004).Nationalserviceframeworkforrenalservices.Chronickidneydisease,
acuterenalfailureandendoflifecare(https://www.gov.uk/government/publications/nationalservice
frameworkkidneydisease).

Definitionsanddatasourcesforthequalitymeasures
NHSEngland(2014)Acutekidneyinjuryalgorithm
(http://www.england.nhs.uk/ourwork/patientsafety/akiprogramme/akialgorithm/).

TheOfficeforNationalStatistics(2014)Mortalitystatistics
(http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Mortality+Rates).

RelatedNICEqualitystandards
Published
Renalreplacementtherapyservices(http://www.nice.org.uk/guidance/qs72)(2014)NICEquality

standard72.
Intravenousfluidtherapyinadultsinhospital(http://www.nice.org.uk/guidance/qs66)(2014)NICE

qualitystandard66.
PatientexperienceinadultNHSservices(http://www.nice.org.uk/guidance/qs15)(2012)NICEquality

standard15.
Chronickidneydisease(http://www.nice.org.uk/guidance/qs5)(2011)NICEqualitystandard5.

Futurequalitystandards
ThisqualitystandardhasbeendevelopedinthecontextofallqualitystandardsreferredtoNICE,
includingthefollowingtopicsscheduledforfuturedevelopment:
Intravenousfluidstherapyinchildren.
Renalstones.

QualityStandardsAdvisoryCommitteeandNICEprojectteam
QualityStandardsAdvisoryCommittee
ThisqualitystandardhasbeendevelopedbyQualityStandardsAdvisoryCommittee4.Membership
ofthiscommitteeisasfollows:
MissAlisonAllam
Laymember

DrHarryAllen
ConsultantOldAgePsychiatrist,ManchesterMentalHealthandSocialCareTrust
MrsClaireBeynon(memberuntilJune2014)
HeadofThresholdManagementandIndividualFundingRequests,NHSSouthWestCommissioning
SupportUnit
DrJoBibby
DirectorofStrategy,TheHealthFoundation
MrsJaneBradshaw
LeadNurseSpecialistinNeurology,NorfolkCommunityHealthandCare
DrAllisonDuggal
ConsultantinPublicHealth,PublicHealthEngland
MrTimFielding
ConsultantinPublicHealth,NorthLincolnshireCouncil
MrsFrancesGarraghan
LeadPharmacistforWomen'sHealth,CentralManchesterFoundationTrust
MrsZoeGoodacre
NetworkManager,SouthWalesCriticalCareNetwork
MrMalcolmGriffiths(ActingChairatpostconsultationmeeting)
ConsultantObstetricianandGynaecologist,LutonandDunstableUniversityHospitalNHS
FoundationTrust
DrJaneHanson
HeadofCancerNationalSpecialistAdvisoryGroupCoreTeam,CancerNationalSpecialistAdvisory
Group,NHSWales
MsNicolaHobbs
AssistantDirectorofQualityandContracting,NorthamptonshireCountyCouncil
MrRogerHughes
Laymember
MrJohnJolly
ChiefExecutiveOfficer,BlenheimCommunityDrugProject,London
DrDamienLongson(Chair)
ConsultantLiaisonPsychiatrist,ManchesterMentalHealthandSocialCareTrust

DrRubinMinhas
GPPrincipal,OakfieldHealthCentre,Kent
MrsJulieRigby
QualityImprovementProgrammeLead,StrategicClinicalNetworks,NHSEngland
MrAlasterRutherford
PrimaryCarePharmacist,NHSBathandNorthEastSomerset
MrMichaelVarrow
InformationandIntelligenceBusinessPartner,EssexCountyCouncil
MrJohnWalker
HeadofOperations,GreaterManchesterWestMentalHealthNHSFoundationTrust
Thefollowingspecialistmembersjoinedthecommitteetodevelopthisqualitystandard:
DrSarahHarding(membersinceMay)
GP,ParkEdgePractice,Leeds
MrsCoralHulse
NurseConsultant,MidCheshireHospitalsNHSFoundationTrust
DrAndrewLewington
ConsultantRenalPhysician,LeedsTeachingHospital
MsFionaLoud
Laymember
DrMarliesOstermann
ConsultantinCriticalCareandNephrology,Guy'sandStThomas'FoundationNHSTrust
DrMarkThomas
ConsultantNephrologist,HeartofEnglandFoundationTrust,Birmingham

NICEprojectteam
DylanJones
AssociateDirector
ShirleyCrawshaw
ConsultantClinicalAdviser
RachelNearyJones
ProgrammeManager

TonySmith
TechnicalAdviser
StacyWilkinson
LeadTechnicalAnalyst
AnthonyGildea
ProjectManager
JennyMills
Coordinator

Aboutthisqualitystandard
NICEqualitystandardsdescribehighpriorityareasforqualityimprovementinadefinedcareor
servicearea.Eachstandardconsistsofaprioritisedsetofspecific,conciseandmeasurable
statements.NICEqualitystandardsdrawonexistingNICEorNICEaccreditedguidancethat
providesanunderpinning,comprehensivesetofrecommendations,andaredesignedtosupportthe
measurementofimprovement.
ThemethodsandprocessesfordevelopingNICEqualitystandardsaredescribedinthequality
standardsprocessguide(http://www.nice.org.uk/standardsandindicators).
ThisqualitystandardhasbeenincorporatedintotheNICEpathwayonacutekidneyinjury
(http://pathways.nice.org.uk/pathways/acutekidneyinjury).
NICEproducesguidance,standardsandinformationoncommissioningandprovidinghighquality
healthcare,socialcare,andpublichealthservices.WehaveagreementstoprovidecertainNICE
servicestoWales,ScotlandandNorthernIreland.DecisionsonhowNICEguidanceandother
productsapplyinthosecountriesaremadebyministersintheWelshgovernment,Scottish
government,andNorthernIrelandExecutive.NICEguidanceorotherproductsmayinclude
referencestoorganisationsorpeopleresponsibleforcommissioningorprovidingcarethatmaybe
relevantonlytoEngland.
Copyright
NationalInstituteforHealthandCareExcellence2014.Allrightsreserved.NICEcopyright
materialcanbedownloadedforprivateresearchandstudy,andmaybereproducedforeducational
andnotforprofitpurposes.Noreproductionbyorforcommercialorganisations,orforcommercial
purposes,isallowedwithoutthewrittenpermissionofNICE.
ISBN:9781473108974

Copyright2016Elsevier,Inc.Allrightsreserved.