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Acute kidney injury with suspected acute nephritis — MSRA MCQ

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HardNephrologyAcute kidney injury with suspected acute nephritisMSRA

A 34-year-old woman is reviewed urgently in general practice because of 5 days of reduced urine output, ankle swelling and dark urine. She had a serum creatinine of 64 micromol/L during a pre-employment assessment 4 days ago; today it is 105 micromol/L. She has had no vomiting, diarrhoea, fever, dysuria, loin pain or recent contrast exposure. She has not taken NSAIDs or started any new medicines. Her BP is 154/94 mmHg. She has mild bilateral ankle oedema but no raised JVP, pulmonary crackles, hypoxia, confusion, pericarditic chest pain or symptoms of hyperkalaemia. Urine dipstick shows blood 3+ and protein 3+, with negative nitrites and leucocytes; urine culture shows no significant growth. Potassium is 4.7 mmol/L and bicarbonate is 23 mmol/L. What is the most appropriate next management action?

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Correct answer: C — Discuss management with a nephrologist today, and within 24 hours of detecting the acute kidney injury

This patient has acute kidney injury (AKI): creatinine has risen by more than 50% within 7 days. The combination of AKI, hypertension, haematuria and substantial proteinuria without urinary infection or an alternative haemodynamic cause is concerning for acute nephritis or another glomerular process. NICE recommends discussion with nephrology as soon as possible and within 24 hours when AKI has a possible diagnosis that may require specialist treatment, including glomerulonephritis. A delay for repeat testing is inappropriate because the active urinary findings make uncomplicated transient pre-renal AKI unlikely. Urgent ultrasound is indicated when there is no identified cause of AKI or there is risk of urinary tract obstruction; here the nephritic presentation instead requires early specialist input, who may arrange imaging and serology in parallel. Furosemide is not routinely used to treat AKI and she has no pulmonary oedema or clinically significant fluid overload requiring this. Routine referral after ACR confirmation would be appropriate for stable proteinuria assessment, not AKI with a suspected glomerular disorder. Immediate renal replacement therapy referral is not indicated because she has no refractory hyperkalaemia, severe acidosis, uraemic complication or pulmonary oedema.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Identifying the cause(s) of acute kidney injury (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Referring to nephrology (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations