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Clinical Practice GuidelinesRenal Replacement Therapy for Critically Unwell Adult Patients:Guidelines for best practice and service resilienceduring COVID-19Final version:Review date:8 October 202030 November 2020

AuthorsCo-chairsDr Jonathan MurrayConsultant Nephrologist, South Tees Hospitals NHS TrustDr Ganesh SuntharalingamIntensive Care Society & Consultant in Critical Care, London North West University HealthcareProfessor Paul CockwellConsultant Nephrologist, University Hospitals Birmingham NHS Foundation TrustLead authorsDr Jyoti BaharaniConsultant nephrologist, Birmingham Heartlands HospitalDr Mark DevonaldConsultant Nephrologist, Nottingham University Hospitals NHS TrustProfessor Lui ForniBoard member, Faculty of Intensive Care Medicine & Consultant Intensivist & Nephrologist, Royal Surrey County Hospital NHSFoundation TrustDr Richard GreenhowConsultant in adult critical care and renal medicine, Nottingham University Hospitals NHS TrustDr Marlies OstermannIntensive Care Society & Consultant in nephrology and critical care, Guys and St Thomas, LondonDr Andrew LewingtonConsultant nephrologist, Leeds Teaching Hospitals NHS TrustDr John R ProwleConsultant in Intensive Care & Renal Medicine, Barts Health NHS TrustBruno MafriciSpecialist Renal dietitian, Nottingham University Hospitals NHS TrustKaren WardBritish Dietetic Association & Specialist Critical Care Dietitian, Kings College Hospital, LondonDavid SapsfordConsultant Pharmacist Critical Care, Cambridge University Hospitals NHS Foundation TrustClare MorlidgePharmacist Advanced Lead Renal Medicine, East and North Hertfordshire NHS TrustReena MehtaUK Clinical Pharmacy Association & Pharmacy Team Leader, Critical Care, Kings College Hospital NHS Foundation TrustFraser HanksPrincipal pharmacist adult critical care, Guy's and St Thomas' NHS Foundation TrustAllie ThornleyClinical Lead and Matron for renal medicine, Oxford University Hospitals NHS Foundation TrustAlan HancockPatient representativeContributing authorsClaire MainCritical Care Manager/Specialist Nurse, Cardiff and Vale University Health BoardRia McMullenBritish Association of Critical Care Nurses & Critical Care Sister, Royal Berkshire NHS Foundation TrustDr Phanish MysoreConsultant nephrologist, Epsom & St Helier University Hospitals NHS TrustLinda ToveyCritical Care Renal Sister, Guy’s & St Thomas’ NHS Foundation TrustCharlotte TrumperAKI Network Lead & Clinical Governance Lead, Milton Keynes University HospitalDr Ricky BellConsultant in Critical Care and Renal Medicine, University Hospitals of Leicester NHS TrustElaine BowesSenior Clinical Nurse Specialist, Kings College Hospital NHS Foundation TrustRRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20202

Contributing authors (cont )Chris BrownChair, Society of Critical Care TechnologistsDr Katherine BullRenal & Academic Consultant, Oxford University Hospitals NHS Foundation TrustLynda CameronCritical Care Pharmacist, Guy's and St Thomas' NHS Foundation TrustDr David CresseyMedical Lead, North of England Critical Care Network & Consultant in Intensive Care Medicine and Anaesthetics, Freeman Hospital,NewcastleProfessor Andrew DavenportProfessor of Dialysis & ICU Nephrology, Royal Free LondonDr Paul DeanMedical Lead, Lancashire & South Cumbria Critical Care Network & Consultant in Intensive Care Medicine and Anaesthetics, EastLancashire Hospitals NHS TrustDr Ingi ElsayedConsultant in Critical Care and Renal Medicine, University Hospital of North MidlandsDr Andrew FergusonMedical Lead, Critical Care Network Northern Ireland & Consultant in Intensive Care Medicine, Belfast Health and Social Care TrustDr Isabel GonzalezChair, National Outreach Forum & Critical Care Consultant, South Tees Hospitals NHS Foundation TrustDr Matthew Graham-BrownConsultant nephrologist, University Hospitals of Leicester NHS TrustDr Donna HallCritical Care Lead & Consultant Anaesthetist, Royal Brompton and Harefield NHS Foundation TrustDr Alex HarrisonConsultant in Nephrology and Intensive Care Medicine, Brighton & Sussex University HospitalsClaire HorsfieldLead Nurse, Lancashire & South Cumbria Critical Care and Major Trauma Operational Delivery NetworkZain HussainSenior Pharmacist, Critical Care, Kings College Hospital NHS Foundation TrustOlivia KankaLead Renal Pharmacist, Cambridge University Hospitals NHS Foundation TrustClare MacEwanConsultant Nephrologist and Consultant in Critical Care, Oxford University Hospitals NHS Foundation TrustDr Emma MontgomeryConsultant Nephrologist, Freeman Hospital, NewcastleRoger MooreChair, Association of Renal Technologists, Royal Wolverhampton NHS TrustDr Babu MuthuswamyWales Critical Care and Trauma Network & Consultant in Intensive Care MedicineJulie PlattenChair, CC3N & Network Manager, North of England Critical Care Operational Delivery NetworkSara PriceRenal Dietetic Clinical Lead, University Hospitals BirminghamLaura RadfordSenior Pharmacist Critical Care, Cambridge University Hospitals NHS Foundation TrustReem SantosPrincipal Pharmacist Antimicrobial Stewardship and Infectious Diseases,Cambridge University Hospitals NHS Foundation TrustProfessor Nick SelbyProfessor of Renal Medicine, Royal Derby HospitalDr Amanda SkingleIntensive Care Specialist Trainee, Wrexham Maelor Hospital, WalesDr David SouthernWales Critical Care and Trauma Network & Consultant in Anaesthesia & Intensive CareDr Robert ThompsonScottish Intensive Care Society & Consultant in Anaesthesia and Intensive Care Medicine, Fife NHS BoardDr Olivia WorthingtonConsultant in Nephrology and Intensive Care Medicine, Aintree University HospitalDr Qihe XuSenior Lecturer in Renal Medicine, King's College LondonRRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20203

EndorsementsThe National Institute for Health and Care Excellence (NICE) has accredited the process used by the RenalAssociation to produce its Clinical Practice Guidelines. Accreditation is valid for 5 years from October 2020.More information on accreditation can be viewed at www.nice.org.uk/accreditationMethod used to arrive at a recommendationThe recommendations for the first draft of this guideline resulted from a collective decision reached byinformal discussion by the authors and, whenever necessary, with input from the Chair of the ClinicalPractice Guidelines Committee. If no agreement had been reached on the appropriate grading of arecommendation, a vote would have been held and the majority opinion carried. However this was notnecessary for this guideline.Conflicts of Interest StatementAll authors made declarations of interest in line with the policy in the Renal Association Clinical PracticeGuidelines Development Manual. Further details can be obtained on request from the Renal Association.NomenclatureThe term "Renal Replacement Therapy (RRT)" has been utilised within this guideline as this nomenclature isused routinely by healthcare professionals working within the United Kingdom. It should be noted howeverthat this term is interchangeable with the term "Kidney Replacement Therapy (KRT)", used internationally.1AcknowledgementsThe authors wish to thank many members of the clinical and patient community who have shared theirexperience and learning to help inform development of this guideline.References1. Nomenclature for kidney function and disease: report of a Kidney Disease: Improving GlobalOutcomes (KDIGO) Consensus Conference. Kidney International (2020) 97, .010RRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20204

ContentsIntroduction . 6Summary of Clinical Practice Guideline Recommendations . 9Summary of Audit Measures . 20Rationale for Clinical Practice Guidelines . 20Lay summary. 21Section I: Management of Patients Pre and Post Critical Care with23 COVID-19 Associated Acute KidneyInjury . 23Section II: Intra-critical care management of COVID-19 associated renal disease . 35Section III: Renal Replacement Therapy in critical care during routine and surge scenarios . 45Appendix I: Clinical Guidance for adult critical care units – Antimicrobial drug dosing in.different modalities of renal replacement therapy. 59RRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20205

IntroductionPurposeThe purpose of this guideline is to support implementation of the NHS England (NHSE) service specification,which describes the requirements for renal replacement therapy (RRT) as an interdependent service foradult critical care services.1 Accordingly, this guideline has been produced collaboratively by members of theRenal Association and British Renal Society, and Intensive Care Society, with patient review. The guidelinewill support critical care RRT resilience in the event of further Coronavirus Disease 2019 (COVID-19) surgesor similar emergency states.BackgroundSevere acute illness is often complicated by acute kidney injury (AKI) and patients with chronic kidneydisease (CKD) are at high risk of critical illness if they develop COVID-19. AKI is more common amongstpatients hospitalised with COVID-19 than in patients hospitalised due to other illness. Furthermore patientswith COVID-19-associated AKI (C19-AKI) sustain worse outcomes than those who develop AKI associatedwith other acute illnesses. Intensive Care National Audit and Research Centre (ICNARC) data indicates that1 in 4 patients admitted to critical care in the United Kingdom due to COVID-19 require RRT with up to 80%mortality amongst these patients, compared to 44% amongst those not treated with RRT. Amongstsurvivors, RRT is associated with a much longer mean duration of critical care bed occupancy (30 daysversus 9 days for those not requiring RRT).The COVID-19 pandemic revealed national shortages of reserve resources and facilities required to meetsurges in critical care RRT. Further COVID-19 surges or emergency states risk overwhelming adult criticalcare RRT capacity, representing a national patient safety risk.Although observational data indicates COVID-19 associated renal disease is associated with worse patientoutcomes, there is no published evidence to suggest C19-AKI should be managed differently to AKIassociated with other illnesses. Innovative and flexible cross-specialty working by renal and critical caremulti-professional teams helped to sustain RRT delivery in centres across the UK during the early stages ofthe COVID-19 pandemic. Such collaborative experience and learning also highlighted opportunities tooptimise and streamline routine care of critically unwell patients with renal failure, including in centreswithout on-site renal services.The recommendations in this guideline are configured to support the NHSE service specification for RRT forcritical care, including delivery of renal capability across the specified three tier renal model of critical careunits: units with fully integrated on-site renal support (tier 1), units with flexible on-site renal support (tier2), units with no on-site renal service (tier 3).1 There should be a particular focus on supporting tier 3 units.Aims of guideline1. Reduce variation in practice and promote quality of care for critically unwell patients who requireRRT, through supporting implementation of the NHSE service specification.2. Enable and sustain RRT resilience across all critical care units in the event of COVID-19 surges oremergency states, including in hospitals without on-site renal services (tier 3).3. Provide an inventory of RRT options and standards that together can be delivered and sustainedacross all UK critical care units, including those without on-site renal services.RRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20206

4. Ensure optimal continuous RRT delivery to minimise inefficient use or preventable loss ofconsumables and impact upon staff workload and capacity.5. Provide flexible management plans to ensure responsible use of resources during routinecircumstances and responsive capability and resilience during surge circumstances.6. Provide a training and competency framework for consistent delivery of safe and qualityintermittent RRT within critical care units, underpinned by robust governance between renal andcritical care services.7. Provide a management framework to limit and manage C19-AKI outside of critical care units,including measures to mitigate RRT demand and prevent avoidable critical care admission duringsurges.8. Provide a management framework to limit and manage C19-AKI within critical care units, includingdrug safety and optimal nutrition.9. Provide recommendations for management of patients with dialysis dependent end-stage kidneydisease (ESKD) with COVID-19.10. Provide a management framework for patients with COVID-19 associated kidney disease followingcritical care discharge, including safe and timely patient follow-up.11. Ensure prompt and quality care for patients with COVID-19 or other acute severe illness in order tolimit their risk of AKI and avoidable critical care admission12. Provide guidance for safe and timely care transitions for patients requiring inter hospital transferand / or between critical care, renal and non-renal wards.13. Promote and sustain regional cross-specialty collaborative working, training and audit, to optimiseand streamline multi-professional care of critically unwell patients with renal disease during routineand emergency circumstances.ScopeThis guideline is intended for use by healthcare professionals responsible for the care of adults at risk ofsevere acute illness, complicated by acute kidney injury (AKI) or end-state kidney disease (ESKD). It includesa focus upon critically unwell patients who may require RRT within Adult Critical Care services during COVID19 surges or similar emergencies. Adult Critical Care underpins all secondary and specialist adult servicesand incorporates both intensive and high dependency care units (ICU/HDU), stand alone or combined.Review of EvidenceThe literature was reviewed using multiple database searches, such as PubMed (1960-2020) and OvidMEDLINE (1946-2020) for all human studies published in English pertaining to COVID-19, Acute Kidney Injury(AKI), Renal or Kidney Replacement Therapy and Critical Care in adults. Websites searches included NationalInstitute for Health and Care Excellence (NICE) and the UK Renal Association.Currently published literature to guide management of COVID-19 associated renal disease is limited tosingle and multi-centre observational studies, expert opinion and databases reporting epidemiology andoutcome amongst different patient populations. COVID-19 related elements of this guideline have beendeveloped based upon such limited published evidence, alongside unpublished experience and learning todate from multi-professionals managing critically unwell patients with COVID-19 and renal disease acrosscentres in the United Kingdom. Recommendations regarding COVID-19 elements of this guideline will beupdated if significant additional evidence emerges.RRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20207

Format of the GuidelineTo facilitate user navigation, this guideline is presented as three main sections and two appendices. Section I: Pre and post critical care management of COVID-19 associated renal disease.Section II: Intra-critical care management of COVID-19 associated renal disease.Section III: Renal Replacement Therapy in critical care during routine and surge scenarios.Appendix I: Antimicrobial drug dosing for patients receiving RRT in critical care.The writing process followed the Renal Association Guideline development manual. The guideline comprisesof a series of guideline statements accompanied by supporting evidence and audit measures. Therecommendations in each guideline statement have been graded using the GRADE system2 in evaluating thestrength of each recommendation (1 strong, 2 weak) and quality of evidence (A high, B moderate, C low, D very low).The main guideline layout is aligned with the chapter structure used by the Intensive Care Society andFaculty of Intensive Care Medicine in the joint General Provision of Intensive Care Services (GPICS)framework for UK critical care.3 Thus both standards and recommendations are included within sections I, IIand III of the guideline, where:1. Standards are a summarised form of what the authors regard as currently accepted practice whichshould be consistently applied, and2. Recommendations are a forward-looking set of statements about what the authors think should now beimplemented.References1. NHS England Appendix to Adult Critical Care specification: Interdependent services – Renalreplacement therapy (final version due October -critical-care-services/2. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) workinggroup: https://www.gradeworkinggroup.org/3. Guidelines for the Provision of Intensive Care Services - Edition /GPICS 2nd Edition.aspxRRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20208

Summary of Clinical Practice Guideline RecommendationsSection I: Pre and post critical care management of COVID associated renal disease1. For management of patients with COVID-19 associated Acute Kidney Injury (C19-AKI) outside CriticalCare, we recommend:1.1 Risk factors for developing COVID-19 associated AKI (C19-AKI) are the same as those for patientsdeveloping AKI from other common causes. Patients at high risk of developing C19-AKI should beidentified at an early stage and measures instigated to reduce this risk. (1A)1.2 Patients who develop COVID-19 should have at least twice daily monitoring of their volume statusto avoid hypovolaemia. Kidney function should be monitored daily.(2B)1.3 Patients who develop C19-AKI have a very high mortality and therefore it is important for all NHSorganisations to have an early recognition and response system in place. (1B)1.4 Hypovolaemia is common in patients with COVID-19 and will exacerbate the hypercoagulable stateand organ injury including C19-AKI. Volume status must be optimised with the appropriate fluidresuscitation, which should be part of a protocol to restore circulating volume status andhaemodynamic stability. (1B)1.5 Hyperkalaemia is a medical emergency and should be treated as per local guidelines. Potassiumbinders (e.g. patiromer and sodium zirconium cyclosilicate (SZC)) can be considered alongsidestandard care for the emergency management of acute life-threatening hyperkalaemia if indicated.SZC has a faster onset of action and lowers potassium to a greater extent in the first 48 hours.Patiromer and SZC can both be continued if their use controls hyperkalaemia and there are no otherindications for emergent RRT. If there are delays in patients receiving RRT due to lack of capacity,potassium binders may be used for an extended period of time with senior medical review anddietitian involvement. (2C)1.6 A full medication review should be performed and appropriate adjustments made to drug doses.Pharmacist-led review is strongly recommended for medicine optimisation, including appropriatedosing, avoidance of drugs harmful to the kidneys in the setting of COVID-19 and advice onanticoagulation. (1A)1.7 Urinalysis should be performed on all patients with COVID-19 and results recorded. The presence ofblood and/or protein in the urine (active urinary sediment) is common in patients with COVID-19with or without C19-AKI and may indicate underlying kidney disease. Urinalysis should be repeatedfollowing the acute illness, no later than 3 months, and if the active urinary sediment persists arenal opinion is recommended. (2B)1.8 Rhabdomyolysis may complicate C19-AKI and a creatine kinase (CK) should be checked. Suchpatients should receive aggressive fluid resuscitation and regular volume status review based onlocal guidelines. (2B)RRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 20209

1.9 Malnutrition is an independent predictor of in hospital mortality in patients with AKI. Localprotocols to screen for malnutrition and to identify patients with AKI at risk of malnutrition shouldbe in place. Health care professionals caring for patients with AKI should consider early dieteticreferral where concerns about nutritional status exist. Patients at risk for poor outcomes and highermortality following infection with COVID -19, namely older adults and polymorbid individuals,should be checked for malnutrition through screening and assessment. (2B)1.10 Renal referral should be considered where diagnostic uncertainty lies as to the cause of AKI or AKI isworsening despite initial management. COVID-19 has been shown to be associated with some rarerforms of AKI. (1A)1.11 Local transfer criteria and clear transfer pathways must be developed and disseminated to allow thesafe inter hospital transfer of patients from non-specialist renal wards to specialised kidney units.This includes transfer from critical care units within a tier 3 centre when referring to tertiary renalunits. Criteria may reflect local provision where transfer to renal level 2 units may have criteria atvariance to those without. (2B)1.12 Referral to critical care (in tier 1-3 centres) or renal (in tier 1-2 centres) for renal replacementtherapy (RRT) When it is anticipated that patient will meet usual criteria for renal replacementtherapy (RRT). (1A)2. For management of patients with Chronic Kidney Disease (CKD) and End-Stage Kidney Disease (ESKD)outside of Critical Care, we recommend:2.1 Those responsible for in-patient care of patients with COVID-I9 should be aware that thedevelopment of AKI carries a grave prognosis and therefore early identification may mitigateworsening of AKI. Clinicians must be aware that patients with CKD are at higher risk of developingAKI. (1A)2.2 There is no evidence currently that the initial supportive management of C19-AKI is different frompatients with non C19-AKI. As such treatment should follow established guidelines. (1B)2.3 Renal advice should be sought promptly if the patient has established CKD Stage 4/5 (eGFR is 30ml/min/1.73 m2) or has ESKD and is receiving dialysis, especially in tier 3 centres. (1B)2.4 In patients with advanced CKD where dialysis is planned then NICE guideline [NG160] COVID-19(rapid guideline: dialysis service delivery) should be followed. Local transfer criteria and localnetworking must be developed to allow the safe transfer of patients. (1A)3. For management of patients with COVID-19 Associated Acute Kidney Injury (C19-AKI) Post Critical Care,we recommend:3.1 Local transfer criteria and local networking must be developed to allow the safe transfer of patients.(1B)3.2 Critical care discharge summary must include baseline kidney function prior to admission if known,medications prior to admission, AKI risk factors, cause(s) and severity (highest stage duringadmission), reason for critical care admission, treatment received, discharge kidney function ifRRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 202010

dialysis-independent and the emergent need for dialysis . Some critical care units routinely send ICUdischarge letters to Primary Care and this is particularly recommended as good practice in thesetting of AKI, as new or worsening chronic kidney disease may develop post hospital discharge. (1C)3.3 Ensuring the provision of optimal nutrition post ICU is an essential component to support successfullong-term rehabilitation. Ongoing nutritional input in the recovery phase should therefore beintegral to a patient’s multidisciplinary rehabilitation plan. (1B)3.4 Tier 3 units should seek renal advice in terms of vascular access for dialysis as well asrecommencement of regular medication. (1B)4. For management of patients with COVID-19 Associated Acute Kidney Injury (C19-AKI) post hospitaldischarge, we recommend:4.1 Hospital discharge summary must include the baseline kidney function prior to admission if known,medications prior to admission, a list of investigations performed, treatment received, cause of AKI,maximum stage, the need for dialysis (temporary / ongoing), discharge kidney function if dialysisindependent. (1B)4.2 There must be specific recommendations to the GP, patients, relatives and/or carers on the needfor immediate, post-discharge monitoring of kidney function, advice on medications that may havebeen implicated in the episode of C19-AKI (e.g. continued avoidance or advice on re-introduction).(1B)4.3 Hospital discharge summary should link to relevant local guidelines, advise on the need fordocumentation of the AKI in the primary care record and note the need for registration on theprimary care CKD register if residual CKD exists at the time of discharge. (1B)4.4 Formal post-discharge renal review should be arranged within 90 days for those with residual CKDstage G4 at hospital discharge or within 30 days for those with residual CKD stage G5 (non-dialysisrequiring) at hospital discharge. (1B)Section II: Intra-critical care management of COVID-19 associated renal disease5. For prevention and management of AKI in critically ill patients, we recommend:5.1 Prevention and management of AKI in critically ill patients with COVID-19 should follow the sameprinciples as stated for patients in non-critical care wards (as per pre and post critical care (PPCC)guidance, recommendations 1.1 to 1.4). (1A)5.2 Although there are some differences in pathogenesis between COVID-19 associated-AKI (C19-AKI)and critical illness-associated AKI, management is similar, and should follow NICE guidance whereappropriate. (1A)5.3 There is no direct evidence for optimal fluid resuscitation in COVID-19, though a euvolaemicstrategy is recommended (as per PPCC guidance, recommendation 1.4). (1C)RRT for Critically Unwell Adult Patients: Guidelines for best practice and service resilience during COVID-19 – 202011

5.4 COVID-19 is a new disease with a rapidly evolving understanding of best clinical management. ICUclinicians should note a significant rotation away from an ARDS-like “dry” approach to lungmanagement in favour of clinical euvolaemia. (1B)5.5 Pharmacist-led review is strongly recommended for medicine optimisation, including appropriatedosing, avoidance of drugs harmful to the kidneys in the setting of COVID-19 and also advice onanticoagulation (as per PPCC guidance, recommendation 1.6). (1B)5.6 Acute kidney injury (AKI) is detected by monitoring changes in serum creatinine or reductions inurine output and must be defined using Kidney Disease Improving Global Outcomes (KDIGO)definitions (serum creatinine and urine output criteria) to recognise AKI. (1A)5.7 The NHS England AKI warning algorithm will identify patients with changes in serum creatininesuggestive of AKI and will identify in real time potential cases of AKI. This should be integrated intocurrent IT systems. (1A)5.8 All critically ill patients should have urinalysis performed on admission to ICU using multi-signaldipsticks. The results of these tests should be documented in the patient’s recordscontemporaneously. Abnormal results are not infrequent in ICU patients. Patients with COVID-19and proteinuria and haematuria should be discussed promptly with nephrology. (1A)5.9 Urinary obstruction is no more common in patients with COVID-19 than in other critically illpatients. A renal US should be ordered according to existing guidance. (1A)5.10 Consider imaging alongside potential for increased radiology workload and spread of COVID-19infection. The latter can be mitigated by appropriate infection control precautions and should notdelay diagnosis of reversible pathology. (1B)5.11 It is very unlikely that a native renal biopsy will be required in COVID-19 patients with AKI on criticalcare. Any potential indications for a renal biopsy should be discussed with a nephrologist. (1A)6. For non-dialytic management of complications of AKI in Critical Care, we recommend:6.1 Fluid overload should be avoided. If it occurs, it should be managed with diuretics as long as thepatient is diuretic responsive and there are no other life-threatening complications which requireRRT. (1B)6.2 Consider bicarbonate (enteral or intravenous) if no contraindications and worsening metabolicacidosis due to AKI. This may reduce RRT requirement. (1A)6.3 Hyperkalaemia is a medical emergency and should be treated as per local guidelines. Potassiumbinders (e.g. patiromer and sodium zirconium cyclosilicate (SZC)) can be used alongside standard ofcare for the emergency managem

Laura Radford Senior Pharmacist Critical Care, Cambridge University Hospitals NHS Foundation Trust Reem Santos Principal Pharmacist Antimicrobial Stewardship and Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust Professor Nick Selby Professor of Renal Medicine, Royal Derby Hospital Dr Amanda Skingle