People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Health professionals should follow our general guidelines for people delivering care:

Patient experience in adult NHS services

Babies, children and young people's experience of healthcare

Shared decision making

Medicines adherence

Medicines optimisation

Decision making and mental capacity

Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in adults with acute illness 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)

neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a 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 hypovolaemic

use of iodine-based contrast media within the past week

symptoms or history of urological obstruction, or conditions that may lead to obstruction

sepsis

deteriorating early warning scores

age 65 years or over. [2013]

Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in children and young people with acute illness if any of the following are likely or present:

chronic kidney disease

heart failure

liver disease

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 NSAIDs, aminoglycosides, ACE inhibitors, ARBs and diuretics) within the past week, especially if hypovolaemic

symptoms or history of urological obstruction, or conditions that may lead to obstruction

sepsis

a deteriorating paediatric early warning score

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. [2013]

Be aware that in adults, children and young people with chronic kidney disease and no obvious acute illness, a rise in serum creatinine may indicate acute kidney injury rather than a worsening of their chronic disease. [2013]

Ensure that acute kidney injury is considered when an adult, child or young person presents with an illness with no clear acute component and has any of the following:

chronic kidney disease, especially stage 3B, 4 or 5 as shown in table 1, or urological disease

new onset or significant worsening of urological symptoms

symptoms suggesting complications of acute kidney injury

symptoms or signs of a multi‑system disease affecting the kidneys and other organ systems (for example, signs or symptoms of acute kidney injury, plus a purpuric rash). [2013]

Discuss the benefits and risks of tests or treatments that use iodine-based contrast media with the person, and their family members and carers if appropriate. Follow the recommendations in the NICE guideline on shared decision making. [2024]

Be aware that there is a small but increased risk of acute kidney injury associated with an eGFR less than 30 ml/min/1.73 m2. [2024]

Do not delay the use of iodine-based contrast media in an emergency if the risk of delaying the contrast media is likely to be clinically significant. [2024]

Before requesting a non-urgent iodine-based contrast media CT scan, assess whether the person has pre-existing kidney disease. [2024]

If available, use an eGFR measurement from the past 6 months to support decision making about the use of iodine-based contrast media. If the person has been acutely unwell or clinically unstable since their last eGFR test, consider using a more recent eGFR. [2024]

If no eGFR is available from the past 6 months, ask the person, or their family members and carers if appropriate, the following screening questions:

do they have kidney disease or a kidney transplant?

have they seen or are waiting to see a kidney specialist, or a kidney surgeon or urologist?

do they have symptoms of acute illness likely to cause acute kidney injury such as diarrhoea, vomiting, fever, hypovolaemia, infection or difficulty passing urine? [2024]

If the screening questions indicate a history of kidney disease or acute illness to suggest that acute kidney injury is likely, consider an eGFR test to support decision making. [2024]

If the screening questions do not indicate a history of kidney disease and the person is clinically stable, consider proceeding with iodine-based contrast media CT scan without the need for further blood tests before the scan. [2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing risk factors in adults having iodine-based contrast media.

Full details of the evidence and the committee's discussion are in evidence review B: risk prediction tools and eGFR for the prediction of iodine-based contrast media-associated acute kidney injury.

Assess the risk of acute kidney injury in adults before surgery. Be aware that increased risk is associated with:

emergency surgery, especially when the person has sepsis or hypovolaemia

intraperitoneal surgery

chronic kidney disease (adults with an eGFR less than 60 ml/min/1.73 m2 are at particular risk)

diabetes

heart failure

age 65 years or over

liver disease

use of drugs that can cause or exacerbate kidney injury in the perioperative period (in particular, NSAIDs after surgery).Use the risk assessment to inform a clinical management plan. [2013]

Include the risks of developing acute kidney injury in the routine discussion of risks and benefits of surgery. Follow the recommendations in the NICE guideline on shared decision making. [2013]

Follow the recommendations in the NICE guideline on acutely ill adults in hospital on the use of track and trigger systems (early warning scores) to identify adults who are at risk of acute kidney injury because their clinical condition is deteriorating or is at risk of deteriorating. [2013]

When adults are at risk of acute kidney injury, ensure that systems are in place to recognise and respond to oliguria (urine output less than 0.5 ml/kg/hour) if the track and trigger system (early warning score) does not monitor urine output. [2013]

Consider using a paediatric early warning score to identify children and young people admitted to hospital who are at risk of acute kidney injury because their clinical condition is deteriorating or is at risk of deteriorating.

Record physiological observations at admission and then according to local protocols for given paediatric early warning scores.

Increase the frequency of observations if abnormal physiology is detected. [2013]

If using a paediatric early warning score, use one with multiple‑parameter or aggregate weighted scoring systems that allow a graded response and:

define the parameters to be measured and the frequency of observations

include a clear and explicit statement of the parameters, cut‑off points or scores that should trigger a response. [2013]

If using a paediatric early warning score, use one with multiple‑parameter or aggregate weighted scoring systems that measure:

heart rate

respiratory rate

systolic blood pressure

level of consciousness

oxygen saturation

temperature

capillary refill time. [2013]

When children and young people are at risk of acute kidney injury because of risk factors listed in the recommendation in the section on identifying acute kidney injury in people with acute illness:

measure urine output

record weight twice daily to determine fluid balance

measure urea, creatinine and electrolytes

think about measuring lactate, blood glucose and blood gases. [2013]

Encourage oral hydration before and after procedures using intravenous iodine-based contrast media in adults at increased risk of contrast-associated acute kidney injury (see the recommendation on increased risk in the section on assessing risk factors in adults having iodine-based contrast media). [2019]

For inpatients having iodine-based contrast media, consider intravenous volume expansion with either isotonic sodium bicarbonate or 0.9% sodium chloride if they are at particularly high risk, for example, if:

they have an eGFR less than 30 ml/min/1.73 m2

they have had a renal transplant

a large volume of contrast medium is being used (for example, higher than the standard diagnostic dose or repeat administration within 24 hours)

intra-arterial administration of contrast medium with first-pass renal exposure is being used.For more information on managing intravenous fluid therapy, see the NICE guideline on intravenous fluid therapy in adults in hospital. [2019]

Consider temporarily stopping ACE inhibitors and ARBs in adults having iodine-based contrast media if they have chronic kidney disease with an eGFR less than 30 ml/min/1.73 m2. [2013, amended 2024]

Discuss the person's care with a nephrology team before offering iodine-based contrast media to adults on renal replacement therapy, including people with a renal transplant, but do not delay emergency imaging for this. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on preventing acute kidney injury in adults having iodine-based contrast media.

Full details of the evidence and the committee's discussion are in evidence review A: preventing contrast-induced acute kidney injury.

Consider electronic clinical decision support systems (CDSS) to support clinical decision making and prescribing, but ensure they do not replace clinical judgement. [2013]

When acquiring any new CDSS or systems for electronic prescribing, ensure that any systems considered:

can interact with laboratory systems

can recommend drug dosing and frequency

can store and update data on patient history and characteristics, including age, weight and renal replacement therapy

can include alerts that are mandatory for the healthcare professional to acknowledge and review. [2013]

Seek advice from a pharmacist about optimising medicines and drug dosing in adults, children and young people with or at risk of acute kidney injury. [2013]

Consider temporarily stopping ACE inhibitors and ARBs in adults, children and young people with diarrhoea, vomiting or sepsis until their clinical condition has improved and stabilised. [2013]

Detect acute kidney injury, in line with the (p)RIFLE (paediatric Risk, Injury, Failure, Loss, End stage renal disease), AKIN (Acute Kidney Injury Network) or KDIGO (Kidney Disease: Improving Global Outcomes) definitions, by using any of the following criteria:

a rise in serum creatinine of 26 micromol/litre or greater within 48 hours

a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days (see also an algorithm for early identification of acute kidney injury, endorsed by NHS England)

a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people

a 25% or greater fall in eGFR in children and young people within the past 7 days. [2013]

Monitor serum creatinine regularly in all adults, children and young people with or at risk of acute kidney injury. Frequency of monitoring should vary according to clinical need, but daily measurement is typical while in hospital. [2013]

Identify the cause(s) of acute kidney injury and record the details in the person's notes. [2013]

Perform urine dipstick testing for blood, protein, leucocytes, nitrites and glucose in all people as soon as acute kidney injury is suspected or detected. Document the results and ensure that appropriate action is taken when results are abnormal. [2013]

Think about a diagnosis of acute nephritis and referral to the nephrology team when an adult, child or young person with no obvious cause of acute kidney injury has urine dipstick results showing haematuria and proteinuria, without urinary tract infection or trauma due to catheterisation. [2013]

Do not routinely offer ultrasound of the urinary tract when the cause of the acute kidney injury has been identified. [2013]

When pyonephrosis (infected and obstructed kidney[s]) is suspected in adults, children and young people with acute kidney injury, offer immediate ultrasound of the urinary tract (to be performed within 6 hours of assessment). [2013]

When adults, children and young people have no identified cause of their acute kidney injury or are at risk of urinary tract obstruction, offer urgent ultrasound of the urinary tract (to be performed within 24 hours of assessment). [2013]

Refer all adults, children and young people with upper tract urological obstruction to a urologist. Refer immediately when one or more of the following is present:

pyonephrosis

an obstructed solitary kidney

bilateral upper urinary tract obstruction

complications of acute kidney injury caused by urological obstruction. [2013]

When nephrostomy or stenting is used to treat upper tract urological obstruction in adults, children and young people with acute kidney injury, carry it out as soon as possible and within 12 hours of diagnosis. [2013]

Do not routinely offer loop diuretics to treat acute kidney injury. [2013]

Consider loop diuretics for treating fluid overload or oedema while:

an adult, child or young person is awaiting renal replacement therapy or

renal function is recovering in an adult, child or young person not receiving renal replacement therapy. [2013]

Do not offer low-dose dopamine to treat acute kidney injury. [2013]

Discuss any potential indications for renal replacement therapy with a nephrologist, paediatric nephrologist and/or critical care specialist immediately to ensure that the therapy is started as soon as needed. [2013]

When an adult, child or young person has significant comorbidities, discuss with them and/or their parent or carer and within the multidisciplinary team whether renal replacement therapy would offer benefit. Follow the recommendations in the NICE guideline on shared decision making. [2013]

Refer adults, children and young people immediately for renal replacement therapy if any of the following are not responding to medical management:

hyperkalaemia

metabolic acidosis

symptoms or complications of uraemia (for example, pericarditis or encephalopathy)

fluid overload

pulmonary oedema. [2013]

Base the decision to start renal replacement therapy on the condition of the adult, child or young person as a whole and not on an isolated urea, creatinine or potassium value. [2013]

When there are indications for renal replacement therapy, the nephrologist and/or critical care specialist should discuss the treatment with the adult, child or young person and/or their parent or carer as soon as possible and before starting treatment. Follow the recommendations in the NICE guideline on shared decision making. [2013]

Refer adults, children and young people with acute kidney injury to a nephrologist, paediatric nephrologist or critical care specialist immediately if they meet criteria for renal replacement therapy in recommendation 1.5.8. [2013]

Do not refer adults, children or young people to a nephrologist or paediatric nephrologist when there is a clear cause for acute kidney injury and the condition is responding promptly to medical management, unless they have a renal transplant. [2013]

Consider discussing management with a nephrologist or paediatric nephrologist when an adult, child or young person with severe illness might benefit from treatment, but there is uncertainty as to whether they are nearing the end of their life. [2013]

Refer adults, children and young people in intensive care to a nephrology team when there is uncertainty about the cause of acute kidney injury or when specialist management of kidney injury might be needed. [2013]

Discuss the management of acute kidney injury with a nephrologist or paediatric nephrologist as soon as possible and within 24 hours of detection when one or more of the following is present:

a possible diagnosis that may need specialist treatment (for example, vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma)

acute kidney injury with no clear cause

inadequate response to treatment

complications associated with acute kidney injury

stage 3 acute kidney injury (according to (p)RIFLE, AKIN or KDIGO criteria)

a renal transplant

chronic kidney disease stage 4 or 5 as shown in table 1. [2013]

Monitor serum creatinine after an episode of acute kidney injury. Base the frequency of monitoring on the stability and degree of renal function at the time of discharge. Consider referral to a nephrologist or paediatric nephrologist when eGFR is 30 ml/min/1.73 m2 or less in adults, children and young people who have recovered from an acute kidney injury. [2013]

Consider referral to a paediatric nephrologist for children and young people who have recovered from an episode of acute kidney injury but have hypertension, impaired renal function or 1+ or greater proteinuria on dipstick testing of an early morning urine sample. [2013]

Discuss immediate treatment options, monitoring, prognosis and support options as soon as possible with people with acute kidney injury and/or, if appropriate, their parent or carer. Follow the recommendations on patient views and preferences and shared decision making in the NICE guidelines on patient experience in adult NHS services, shared decision making and decision making and mental capacity. [2013]

Give information about long‑term treatment options, monitoring, self‑management and support to people who have had acute kidney injury (and/or their parent or carer, if appropriate) in collaboration with a multidisciplinary team appropriate to the person's individual needs. [2013]

Give information about future care to people needing renal replacement therapy after discharge following acute kidney injury. This should include information about the frequency and length of dialysis sessions and the preparation needed (such as having a fistula or peritoneal catheter). [2013]

Discuss the risk of developing acute kidney injury, particularly the risk associated with conditions leading to dehydration (for example, diarrhoea and vomiting) and drugs that can cause or exacerbate kidney injury (including over‑the‑counter NSAIDs), with people who are at risk of acute kidney injury, particularly those who have:

chronic kidney disease with an eGFR less than 60 ml/min/1.73 m2

neurological or cognitive impairment or disability, which may mean limited access to fluids because of reliance on a carer.Involve parents and carers in the discussion if appropriate. [2013]

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary.

First-pass renal exposure is when the contrast medium reaches the renal arteries in a relatively undiluted form, for example, through injection into the left heart, thoracic and suprarenal abdominal aorta, or the renal arteries.

≥90

Kidney damage, normal or increased GFR

Kidney damage (presence of structural abnormalities and/or persistent haematuria, proteinuria or microalbuminuria) for ≥3 months

60 to 89

Kidney damage, mildly reduced GFR

Kidney damage (presence of structural abnormalities and/or persistent haematuria, proteinuria or microalbuminuria) for ≥3 months

45 to 59

Moderately reduced GFR ± other evidence of kidney damage

GFR