acute kidney injury - rcp london

Better Medicine Better Health

Acute Kidney Injury

Everybody’s Business

Dr Russell Roberts

Consultant Nephrologist

Bradford Teaching Hospitals


NCEPOD

Adding Insult to Injury

Before we go any further

What is Acute Kidney Injury?

Why not Acute Renal Failure any more?

Now we can get epidemiology

Number of AKI cases per week IP and

A&E

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

295

226

185

240 241 246 250235

80

74

64

5369

99 84

48

15

54

48

57

57

6063

50

Month

Number of AKI episodes per week IP and A&E

AKI 1 AKI 2 AKI 3

7

Winner of BUPA Foundation

‘Technology for Healthy Outcomes’

Award 2012 Selby NM et al. CJASN 2012; 7(4): 533

First hospital wide e-alert system

based on current criteria introduced in

Derby 2010

Resulted in widespread interest

across the UK in developing similar

systems

VARIATION

http://pixabay.com/en/smarties-confectionery-lenses-50838/

National Directive from NHS England

Why does AKI matter?

Mortality 10-80% depending upon the clinical

setting

Increased length of stay and use of critical care

bed.

Long term implications for survival and morbidity

It is often predictable and preventable

If 20% - 30% of AKI is preventable

28,000 – 42,000 preventable cases of AKI in English hospitals

each year based on HES

8,000 – 12,000 preventable AKI-related deaths each year

Prevention of 20% of cases would pay salaries and

overheads for 20 to 30 extra nurses in every acute Trust

Preventable AKI Preventable AKI

deaths

140,000 cases of AKI in English hospitals (HES)

AKI leads to CKD, even in ‘mild’ AKI

* * * *

*

Horne et al. EDTA 2016 (TO022 and TO025)

AKI Clinical: Tues 24th 1.15pm

p=0.02

Recurrent AKI

P<0.001

Albuminuria

Summary so far

AKI is common and often both predictable and

preventable

AKI is associated with significant mortality and

morbidity

AKI is costly and prolongs hospital stay

AKI leads to CKD


Renal

(10-15%)

Small vessel

disease

Toxins

Crystals

Myeloma

(Oxford Handbook of Nephrology and Hypertension 2006)

Post renal

(10%)

Obstruction

Prostate

Renal

Calculi

Pre renal

(40-70%)

Sepsis

Dehydration

Hypovolemia

Cardiac

failure

https://www.thinkkidneys.nhs.uk/

Traditional vs Roberts Classification of

AKI

Pre-renal, renal or post-renal

Interesting or boring

Classification of AKI

interesting Wegeners granulomatosis

Systemic lupus erythematosus

Polyartertis nodosa

Churg-strauss

Post streptococcal

Mesangio-capillary glomerulonephritis type II

Mixed essential cryoglobulinaemia

Light chain nephropathy

Acute fibrillary glomerulonephritis

Multiple myeloma

Hanta virus nephropathy

Henoch schonlien purpura

Haemolytic uraemic syndrome/TTP

Ig A nephropathy

C1q nephropathy

Microscopic polyangiitis

Dense deposit disease

Features of

interesting AKI

Urinalysis is positive

USS excludes

obstruction

Rare

You get the ‘turf’ to

renal

Boring AKI

Why do kidneys crash?

The kidneys receive > 20% of cardiac output

Think of your patients kidneys as a more sophisticated NEWS score AND defend

them from the consequences of a deteriorating patient/rising NEWS

But remember the urine dip and the scan

NICE Guidance

Investigate adults with acute illness for

possible AKI if

Non-modifiable risk

factors

Age, CKD, heart

failure, liver disease,

diabetes, previous

AKI, renal transplant,

disability restricting

access to fluids,

symptoms or risk of

obstruction

Modifiable risk factors

Hypovolaemia

Drugs

NSAID, ACE/ARB.

Diuretics, gentamycin

Recent x-ray contrast

Sepsis

Reduced NEWS score

Every emergency admission

Key Recommendation from NCEPOD

All emergency admissions should have U&E

checked on admission and at appropriate

intervals thereafter

All emergency admissions should have

urinalysis recorded

All emergency admissions should have a ‘senior

review’ within 12 hours of admission


a weekend case Day 1 MAU-

51, Hx of DM, HT, CABG, CKD, TIA

Admitted with ?chest infection (+/- pul oedema)

Aspirin, statin, insulin, metformin, irbesartan, bisopolol, perindopril, adalat, furosemide

Creat 242 (baseline 150-190), K+ 5.6, CRP 180

Somebody writes

‘mild hyperK+ and worse renal function’

Bloods day 2 creat 253, K+ 5.4

It is acknowledged that the creat has increased

ALL MEDICATIONS PRESCRIBED AND ADMINISTERED

Risk factors for AKI Age

Co-morbidity

Diabetes

Vascular

Previous CKD

Medication

Precipitating factors

Sepsis

Hypovolaemia

Medication

contrast

Day 3 not seen

Day 4 plan for bloods tomorrow, increase

furosemide

Day 5 creat 609, K+ 6.2

Results received 1500 by which time all

medicines given

BP at 0630 was 95/50

All hell breaks loose!

If we achieve nothing else, we must stop these scenarios

Royal Derby Hospital Clinical need

5-15% of hospital admissions, mortality ~25% and >35% in AKI3

High incidence, poor outcomes

No specific therapies

Variation in care

E-alerts for AKI

Intranet Guidelines

Streamlined nephrology

referral Care bundle

Education programme

The approach in Derby

What is a care bundle? How do they work?

…A structured method of improving

processes of care and patient

outcomes...

A small, straight-forward set of

evidence-based practices:

For a defined patient segment or

population

All or none approach: every patient,

every time

When implemented collectively,

improves outcomes beyond that

expected if implemented

individually. Resar R. IHI Innovation Series White Paper. 2012

How should AKI be managed? The role of Care Bundles

Impact on

standards of

basic care

Cases note audit of 306 pts.

132 cases baseline

156 cases post intervention 77 in 2012 audit, 79 in 2013 audit

Equal numbers in each AKI stage

Baseline 2012 2013 p value

Fluid balance assessed 36.4% 66.2% 79.7% p<0.001

Medication review 71.1% - 88.4% p<0.001

Renal imaging (AKI 2 & 3) 45.3% 54.2% 71.0% p<0.001

Nephrology referral (AKI

3)

37.8% 56.5% 78.9% p<0.001

Urinalysis performed 40.3% 57.1% 35.5% p=0.177

Kolhe NV, Packington R, Monaghan J, Selby NM. Nephron Clin Prac 2013

* * *

*p<0.001

Care Bundles work- evidence from Derby

Survival to hospital discharge linked to Care Bundle completion

Kolhe NV, et al. (2015) Impact of Compliance with a Care Bundle on Acute Kidney Injury Outcomes: A

Prospective Observational Study. PLOS ONE 10(7): e0132279. doi:10.1371/journal.pone.0132279

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132279

Selby and Kohle. Nephron Clinical Practice 2016. 134; 195-199

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0132279

Tackling acute kidney injury – a

multi-centre pragmatic clinical

trial

Partner organisations: Derby Hospitals (lead organisation)

Leeds Teaching Hospitals

Bradford NHS Foundation Trust

Frimley Park Hospital

Ashford and St Peters Hospital

Surrey Pathology Services

UK Renal Registry

NHS England

• Will test scalability of a complex intervention:

• AKI detection and alerting

• Education programme (hospital wide)

• Care bundle for AKI management

• Cluster randomised stepped wedge design

• Outcome measures:

• Implementation and qualitative evaluation

• Process measures

• Patient outcomes

www.tacklingaki.org @TacklingAki

• News just in – Tackling AKI Poster at ASN- late breaking trials

http://www.biomedcentral.com/1471-2288/6/54/figure/F1?highres=y

http://www.health.org.uk/

3 key interventions A laboratory AKI detection system with automatic alerts

An educational program to raise awareness and knowledge

among ALL clinical staff

An AKI Care Bundle

Tackling AKI in Bradford

Education

E-learning

Grand rounds, screen

savers, global emails

Guidelines

Foot patrol

CCOR


Tackling AKI in Bradford

Care bundle

Incremental approach

Tests of change

Feedback from users


Started with the Medical Admission Unit

Motivated clinical leadership

Most cases of AKI per month

Large ward, many staff

Staff rotation to other areas

QI Methodology- start small and spread

Now on the EPR

Reducing the risk of AKI

the Importance of Medicines

Management

Royal College of Physicians Consensus

conference 2012

‘all patients admitted non-electively into hospital

will require assessment of volume status,

urinalysis and a medicines review. ACE/ARB

and NSAIDS should be withheld pending

senior review within 12 hours’

www.rcpe.ac.uk/clincal-standards/

Tackling AKI Results

No effect on 30 day mortality

Improved processes of care

Reduced length of stay and reduced duration of

AKI

Increased recognition of AKI


Selby et al Late Breaking Trials, American Society of Nephrology Nov 2017

Tackling AKI – improved processes

of care


Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

A K I R e c o g n it io n

% o

f A

KI

pa

tie

nts

p < 0 .0 0 1

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

C a re b u n d le u s a g e

% o

f A

KI

pa

tie

nts

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

M e d ic a t io n re v ie w

% o

f A

KI

pa

tie

nts

p < 0 .0 0 1

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

S p e c ia lis t re fe r ra l

% o

f A

KI

pa

tie

nts

p = 0 .3 1

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

F lu id a s s e s m e n t p e r fo rm e d

% o

f A

KI

pa

tie

nts

p < 0 .0 0 1

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

R e n a l Im a g in g R e q u e s te d

% o

f A

KI

pa

tie

nts

p = 0 .5 8

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

U r in a ly s is p e r fo rm e d

% o

f A

KI

pa

tie

nts p < 0 .0 0 1

Co

ntr

ol

Inte

rven

t io

n

0

2 0

4 0

6 0

8 0

1 0 0

U re th ra l c a th e te r is a t io n fo r re a s o n s

o th e r th a n re lie f o f o b s tru c t io n

% o

f A

KI

pa

tie

nts

p =0 .3

Selby et al Late Breaking Trials, American Society of Nephrology

Nov 2017

Tackling AKI results – reduced

length of stay

Quantile regression analysis of

length of stay – significant

reduction of 0.7 days at 60th

percentile


Change in L

oS

(days)

Ch

an

ge

in L

oS

(da

ys)

Selby et al Late Breaking Trials, American Society of

Nephrology Nov 2017

Acute Kidney Injury – everybody’s

business

Common, deadly,

expensive

Often predictable and

preventable

Frequently iatrogenic

Amenable to simple,

low-cost interventions

Benefit from whole

systems approach

Early recognition and

intervention

acheivable

IT friendly Better Medicine Better Health

www.thinkkidneys.nhs.uk



NYGH Pathology Department

Stamp all Creatinine results of

135 or higher to alert staff at

NYGH of possible AKI.

On average we can have

10+ alerts daily at NYGH.

Any Questions?

acute kidney injury - rcp london

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