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Acute kidney injury stage 3 due to hypovolaemia and medication-related renal hypoperfusion — MSRA MCQ

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Moderateall topics relevant for this examAcute kidney injury stage 3 due to hypovolaemia and medication-related renal hypoperfusionMSRA

A 72-year-old man is reviewed urgently after same-day blood tests requested for 3 days of profuse diarrhoea and vomiting. He has CKD G3a, type 2 diabetes mellitus and HFrEF. His regular medicines are ramipril, furosemide, spironolactone, metformin and dapagliflozin. He has also taken ibuprofen for back pain during this illness. He is thirsty and dizzy on standing but alert. His observations are: temperature 36.8°C, pulse 96 beats/minute, blood pressure 102/64 mmHg, respiratory rate 18 breaths/minute and oxygen saturation 97% on air. He reports passing approximately 300 mL of urine in the preceding 12 hours. His creatinine today is 306 micromol/L; his most recent stable creatinine, measured 6 weeks ago, was 96 micromol/L. Potassium is 5.3 mmol/L. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Arrange immediate hospital assessment and withhold medicines contributing to acute kidney injury pending transfer

Explanation lettering: B = shown as A · A = shown as B · D = shown as C · E = shown as D · C = shown as E

This man has acute kidney injury (AKI) stage 3: his creatinine has increased from 96 to 306 micromol/L, which is more than three times baseline. He also has oliguria, clinical hypovolaemia and several precipitants for AKI: diarrhoea and vomiting, CKD, heart failure, diabetes, ACE-inhibitor and diuretic therapy, an SGLT2 inhibitor, metformin, spironolactone, and recent NSAID exposure. Although he is not frankly shocked, an acutely unwell person in the community with an AKI warning stage 3 result requires immediate clinical review to consider hospital admission. Hospital assessment allows prompt assessment of volume status, ECG and serial potassium measurement, acid-base assessment, treatment of complications and investigation of the cause. A and C understate the severity: outpatient repeat testing may be appropriate in selected stable patients at risk of AKI or with less severe renal dysfunction, but not with stage 3 AKI. B appropriately identifies ramipril as contributory but delays necessary acute assessment; specialist nephrology referral is not the first community action. E is inappropriate because continued ACE-inhibitor/diuretic treatment and NSAID exposure may worsen hypovolaemic AKI; ultrasound is considered where obstruction is suspected but must not delay acute management.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (2019; amended 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE QS76: Acute kidney injury — Quality statement 4: Response to acute kidney injury warning stage 3 test result (Updated 23 March 2023) — https://www.nice.org.uk/guidance/qs76/chapter/Quality-statement-4-Response-to-acute-kidney-injury-warning-stage-3-test-result NICE NG28: Type 2 diabetes in adults: management — Person-centred medicine (2022; amended 2026) — https://www.nice.org.uk/guidance/ng28/chapter/Person-centred-medicine