What are the management steps for a patient with Chronic Kidney Disease (CKD) who has experienced a bump or trauma?

Management of Trauma in Patients with Chronic Kidney Disease

In patients with CKD who experience trauma or a bump injury, immediate assessment of kidney function and implementation of nephroprotective measures are essential to prevent acute kidney injury and further deterioration of renal function.

Initial Assessment

• Immediately monitor eGFR, electrolytes (particularly potassium), and assess for signs of acute kidney injury 1
• Evaluate the extent of trauma and potential for rhabdomyolysis or crush injury
• Assess volume status through clinical examination and fluid balance monitoring 1
• Check for hematuria, proteinuria, and abnormal electrolyte levels which may indicate kidney damage 1

Immediate Management

Fluid Management

• Maintain optimal fluid status (euvolemia) to reduce the risk of AKI 1

• For minor trauma without signs of rhabdomyolysis:

  • Ensure adequate hydration with oral fluids if possible
  • Consider IV crystalloids (0.9% saline) if oral intake is inadequate

• For significant trauma with risk of rhabdomyolysis:

  • Administer IV crystalloids (0.9% saline) at 1-2 L in first hour, then adjust based on clinical response 1
  • Avoid potassium-containing balanced salt solutions (such as Lactated Ringer's) 1
  • Avoid starch-based fluids which may increase risk of AKI 1

Medication Management

• Review and temporarily discontinue potentially nephrotoxic medications 1:

  • NSAIDs
  • Certain antibiotics
  • ACE inhibitors/ARBs (consider temporary hold for 48-72 hours) 1
  • Metformin and SGLT2 inhibitors 1

• Adjust dosages of medications cleared by the kidneys based on current eGFR 1

• Monitor therapeutic drug levels for medications with narrow therapeutic windows 1

Monitoring Protocol

Laboratory Monitoring

• Measure serum creatinine, urea, and electrolytes every 24-48 hours or more frequently if clinically indicated 1
• Monitor CK levels if rhabdomyolysis is suspected
• Check acid-base status and lactate levels in severe trauma 1

Clinical Monitoring

• Use early warning scores (e.g., NEWS2) for deteriorating patients 1
• Monitor urine output hourly in severe trauma cases
• Assess for signs of volume overload or depletion

Special Considerations

For Severe Trauma/Crush Injury

• Consider early nephrology consultation
• If rhabdomyolysis is present:
  • More aggressive fluid resuscitation (3-6 L/day depending on clinical condition) 1
  • Monitor for compartment syndrome
  • Avoid bicarbonate administration unless severe acidosis is present 1
  • Avoid mannitol due to potential nephrotoxicity and limited evidence of benefit 1

For Patients on Dialysis

• Assess need for urgent dialysis if:
  • Hyperkalemia develops
  • Volume overload occurs
  • Severe acidosis develops
• Consider earlier initiation of renal replacement therapy compared to non-CKD patients 1

Follow-up Care

• Document a clear plan for restarting temporarily discontinued medications 1
• Arrange follow-up kidney function testing within 7-14 days after injury 1
• Monitor for development or progression of CKD after trauma 1
• Consider nephrology referral for patients with:
  • GFR <30 ml/min/1.73 m² 2
  • Significant albuminuria (≥300 mg/day) 2
  • Rapid decline in kidney function 2

Prevention of Complications

• Avoid contrast studies if possible; if necessary, use the lowest possible dose of contrast and ensure adequate hydration 1
• If gadolinium-based contrast is required for patients with GFR <30 ml/min/1.73 m², use American College of Radiology group II and III agents 1
• Implement thromboprophylaxis as appropriate, with dose adjustment based on kidney function
• Ensure drug stewardship through collaborative relationships with pharmacists 1

Remember that patients with CKD are at higher risk for complications following trauma, and early intervention to prevent acute kidney injury is critical for preserving kidney function and improving outcomes.