Acute Kidney Injury - RCP London
Transcript of Acute Kidney Injury - RCP London
Better Medicine Better Health
Acute Kidney Injury
Everybody’s Business
Dr Russell Roberts
Consultant Nephrologist
Bradford Teaching Hospitals
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
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
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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
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
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
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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
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
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
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Tackling AKI in Bradford
Care bundle
Incremental approach
Tests of change
Feedback from users
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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
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Selby et al Late Breaking Trials, American Society of Nephrology Nov 2017
Tackling AKI – improved processes
of care
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Co
ntr
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S p e c ia lis t re fe r ra l
% o
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F lu id a s s e s m e n t p e r fo rm e d
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p < 0 .0 0 1
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R e n a l Im a g in g R e q u e s te d
% o
f A
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p = 0 .5 8
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U r in a ly s is p e r fo rm e d
% o
f A
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pa
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ntr
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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
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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
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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.