Clinical Case Study: Recognising & Managing Acute Kidney Injury
Acute Kidney Injury — or AKI — is one of the most common preventable conditions we see on the wards. It often creeps in quietly: a slightly rising creatinine, a patient who hasn’t drunk enough, a medication that’s suddenly become too strong. Catch it early and most kidneys recover fully. Miss it and it can lead to dialysis, long‑term damage, or worse. This case study is all about spotting those quiet signs before they become emergencies.
📋 How to Use This Case Study
- Read through Arthur’s background and bedside story carefully — treat it as your handover.
- Write down your answers to all 4 questions before clicking anything. What would you do first? Who would you call?
- Click “Reveal Answer & Rationale” to compare your reasoning against evidence‑based practice.
Patient Background & Clinical Narrative
Patient: Arthur Hughes, 72 years old
Background: Admitted 3 days ago with fractured neck of femur after a fall. History of hypertension, Type 2 diabetes, long‑term ibuprofen for back pain. Nil‑by‑mouth before and after surgery; slow to re‑establish oral intake. Says he “just doesn’t feel thirsty.”
What You See: Fluid balance shows intake 1200 mL / 24 hr, output only 550 mL — steadily dropping. Urine dark and concentrated. He feels weak, nauseous, ankles puffy. Creatinine risen from 98 to 168 μmol/L in 48 hours — a 71% jump.
Assessment & Key Findings
- Fluid Intake: 1200 mL / 24 hr — below target
- Urine Output: 550 mL total ≈ 23 mL/hr (oliguria; aim ≥0.5 mL/kg/hr)
- Creatinine: 168 μmol/L (up from 98 — Stage 1 AKI)
- Urea: 9.2 mmol/L — elevated
- BP: 100/60 — below his usual baseline
- Weight/Oedema: +1.8 kg in 2 days; mild ankle swelling
- Medications: Ibuprofen, ACE inhibitor, metformin — all continued
AKI Stage: 1 — Early recognition = best chance of full recovery
Question 1: What Type of AKI & Causes?
Arthur’s kidneys are struggling. What are the three main contributing factors and which category of AKI does this represent?
Answer: This is prerenal AKI — reduced blood flow to the kidneys, not structural damage yet. The three causes:
- Dehydration / reduced intake — repeated NBM periods + poor thirst response
- Hypotension / poor perfusion — BP 100/60 below his baseline
- Nephrotoxic drugs — ibuprofen (NSAID) + ACE inhibitor both reduce kidney blood flow, especially when dehydrated
Rationale: Prerenal AKI is the most reversible type. NSAIDs block protective prostaglandins that keep kidney vessels open — in dehydration, this tips quickly. Stop the drugs + restore fluids = kidneys usually recover.
Guidance: NICE NG137 — Acute Kidney Injury: Prevention, Detection and Management.
Question 2: Immediate Nursing Actions
What do you do right now — before calling the doctor — to protect his kidneys?
Answer:
- Hold ibuprofen & ACE inhibitor — flag to prescriber immediately; you don’t need a new prescription to stop known nephrotoxins in an emergency
- Strict hourly fluid balance — record every mL in/out; aim 30–50 mL/kg/day as prescribed
- Push oral fluids if safe — or prepare for IV fluids if prescribed
- Monitor BP & HR — track perfusion; report falling BP
- Check bloods — urea, creatinine, potassium; report rising trends
Rationale: Every hour of continued dehydration or drug exposure increases risk of progression to Stage 2 or 3. Early intervention is the single biggest factor in recovery.
Question 3: Escalation — SBAR Handover
Call the medical team. Deliver your SBAR handover.
Question 4: Discharge — Three Key Messages
Arthur recovers well. What three things must he take home to prevent this happening again?
Answer:
- Stay hydrated — don’t wait until thirsty. Drink well when unwell, after surgery, in hot weather.
- Stop ibuprofen — switch to paracetamol. Tell every doctor/dentist “I’ve had kidney problems.” NSAIDs are dangerous long‑term.
- Follow‑up bloods — GP must monitor kidney function regularly. AKI recurs in 1 in 3 patients.
Rationale: Patients rarely remember everything under stress. Write these three points down for him to take home. Clear, simple education prevents readmission.