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![Page 1: Raising awareness of acute kidney injury: ongoing strategies Dr Andrew Lewington BSc MEd MD FRCP Consultant Renal Physician Clinical Sub Dean Leeds Teaching.](https://reader036.fdocuments.net/reader036/viewer/2022062423/56649d8b5503460f94a723d5/html5/thumbnails/1.jpg)
Raising awareness of acute kidney injury: ongoing
strategies
Dr Andrew Lewington BSc MEd MD FRCP
Consultant Renal Physician
Clinical Sub Dean
Leeds Teaching Hospitals UK
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Outline
• Definitions
• Why do we need to raise awareness?
• Who is the target audience?
• What attempts have been made so far?
• Where are the knowledge gaps?
• How do we continue to raise the awareness of acute kidney injury?
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Definitions
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Definitions and Outcomes
• small rises in serum creatinine (SCr) associated with– morbidity– mortality
• overall mortality ranges from 10% to 80%• depends on underlying illness• no change over the last 20 years
• AKI represents an independent risk factor• ↑ mortality
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Definition and Outcomes
• data supporting– small changes in serum creatinine (SCr) having a
significant effect on outcome
• explanation– unclear– risk of complications
• volume overload• infection• electrolyte disorders
– distant effects• systemic condition
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AKI – a systemic condition
Scheel et al., Kidney Int 2008
Functional and structural extra-renal organ injury occurs in AKI
Potential mediators •uraemic toxins •cytokines•leukocytes
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Definitions
• advantages of universal definition – using common language– identify and compare
• epidemiology• treatment efficacy• outcomes
– earlier detection and treatment
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Definitions
• International Guideline Group– Kidney Diseases: Improving Global Outcomes– Publication planned June 2011 in Kidney
International– www.kdigo.org
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Definitions - KDIGO
• AKI is defined when – serum creatinine rises by ≥ 26µmol/L within
48 hours or
– serum creatinine rises ≥ 1.5X the reference value which is known or presumed to have occurred within one week or
– urine output is < 0.5ml/kg/hr for >6 consecutive hours
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Definitions - KDIGO
• after identifying a patient who meets the criteria for AKI – the cause of AKI should be determined and – staging of the severity performed
• staging can be performed using– serum creatinine or– urine output criteria
• patients should be staged according to the criteria that gives them the highest stage
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AKI stage Serum Creatinine criteria Urine output criteria
1 SCr increase ≥ 26 µmol/L within 48hrs
or SCr increase ≥ 1.5-2 X
reference SCr within 1 week
< 0.5 mL/kg/hr for 6 consecutive hrs
2 SCr increase ≥ 2-3 X reference SCr within 1
week
< 0.5 mL/kg/hr for 12 hr
3 SCr increase ≥ 3 X reference SCr within 1 week
orSCr increase ≥ 354 µmol/L
orinitiated on RRT (irrespective
of stage at time of initiation)
< 0.3 mL/kg/hr for 24 hror
anuria for 12 hr
AKI Staging - KDIGO
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Raising awareness of acute kidney injury: ongoing strategies
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Why do we need to raise awareness of AKI?
• AKI associated with an increase in– Morbidity– Mortality– Cost
• AKI can occur in patients cared for in all other specialties– AKI is a marker of vascular dysfunction
• Potential for prevention and earlier treatment• Potential for earlier renal referral of primary renal
disease e.g. vasculitis
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Why do we need to raise awareness of AKI?
• Despite increased understanding within the renal community AKI is still under recognised by other healthcare specialists
• Not all hospitals have renal units– Delays in recognition– Delays in transfer– Patient pathways required– ? Patient follow up following episode of AKI
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Why do we need to raise awareness of AKI?
• Patients at risk of CKD
• An increased awareness of AKI may stimulate increased research opportunities– Attract research groups– Funding bodies
• Not a cunning plan for nephrologists to take over the NHS– Needs to be collaborative effort
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Who is the target audience?
• There is a need to widen the target audience– Healthcare professionals
• Clinicians/nurses/pharmacists– Hospital-based
– Community-based
– Academic researchers• Potential for collaboration
– Patients• Patients with pre-existing risk factors/previous episode of AKI
– Politicians • Increased funding
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What attempts have been made so far?
• Much work over the years– Major interest in AKI in USA
• Growing interest elsewhere
– Clinical studies– Basic research– International/National conferences
• ASN, ISN, Renal Association etc
– Influential clinicians shaping• Education• Research• Clinical service
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What attempts have been made so far?
– International multispecialty groups• Acute Dialysis Quality Initiative (ADQI)
– RIFLE definition
• Acute Kidney Injury Network (AKIN)– Recent summit meeting San Diego– Recommendations for clinical research
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What attempts have been made so far?
– Guidelines• International
– KDIGO
• National– Renal Association UK 5th AKI clinical practice guideline– Audit measures
• How to translate guidelines into practice ie implementation
– Collaboration– AKI data set – James Medcalf
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What attempts have been made so far?
• KDIGO AKI Guidelines– Much anticipated– Will provide a specific definition that can be
used by all healthcare professionals– An opportunity to provide a universal
definition for both undergraduate and postgraduate trainees
• Need to embed in curricula
– Will help establish universal criteria for clinical research trials
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Raising awareness of AKI in the UK
• National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) AKI study ‘Adding Insult to Injury’– Proposed by John Feehally– Published in 2009– Presented last year at CRRT– www.ncepod.org.uk
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Key findings
• 50% of AKI care considered good
• poor assessment of risk factors
• 43% of post-admission AKI - unacceptable delay in recognition
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Key findings
• Poor recognition of – acute illness
– hypovolaemia
– sepsis
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Recommendations
• Improved education required surrounding
Recognition and responding to the acutely ill
patient
Risk of AKI
Precipitants
Prevention
Early management
Appropriate referral
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NCEPOD
• Failure to identify surgical patients with AKI– related to the coding
• Further study investigating management of patients aged > 80 years who died within 30 days of surgery– Proposed looking for episodes of AKI
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(patients aged 80 or older who died within 30 days of a surgical procedure)
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Acute kidney injury
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Acute kidney injury
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Raising awareness of AKI in the UK
• Both NCEPOD studies have helped raise the awareness of AKI in the UK
• Questions surrounding AKI Management were posed in Parliament
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Raising awareness of AKI in the UK
• Mr. Benyon: Question– asked the Secretary of State for Health
what steps he planned to take in response to each of the 8 recommendations in the NCEPOD report on AKI
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Raising awareness of AKI in the UK
• Ann Keen: Answered– The Department of Health will work with a
range of national health service, professional, and patients' organisations at a national level to improve the
• Prevention• Detection and• Management of AKI
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Raising awareness of AKI in the UK
• All NHS trusts sent the report and advised to audit patient care against the recommendations
• Proposals to National Institute of Health and Clinical Excellence (NICE)– AKI guideline– iv fluid guideline
• Wide range of stakeholders signed up to provide input - patients
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Raising awareness of AKI in the UK
• Department of Health AKI Delivery Board– Group of experts representing a range of
specialties• Medical and surgical societies• Biochemistry• Hospital managers• General practitioners• Pharmacists• Nursing colleges• Patient group representatives
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AKI Delivery Board
• National AKI core competencies– Framework of healthcare professionals– developed by multi-professional group
• Renal physician (chair)• Intensivist• Acute Medics (vice president of the Royal College
of Physicians)• Surgical college representative• Intensive care nursing representative• Pharmacy college representatives
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AKI Delivery Board• National AKI core competencies
– Core competancies progress in complexity dependent upon status of healthcare professional
– Recording vital signs• nurse/doctor
– Recognising patients at risk or with AKI• Nurse/doctor/pharmacst
– Responding to patients at risk or with AKI• Nurse/doctor/pharmacist• Level of response is dependent upon the status of
the healthcare professional
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AKI Delivery Board
• AKI core competancies– Final stages– Submitted to
• Joint Specialty Committee for Internal Medicine• Academy of Medical Royal Colleges• Royal Nursing Colleges• Royal College of Pharmacy
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AKI Delivery Board
• National audit of AKI in acute medical admission units across UK – Incidence– Raise awareness
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AKI Delivery Board
• National audit of – NHS capacity to care for patients with AKI in
• HDU and ICU
– number of patients with a diagnosis of AKI in • renal units • HDU/ICU• Outside hospitals awaiting transfer
– Aim to perform on World Kidney Day• Survey monkey
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AKI Capacity Survey for England
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Research opportunities
• Potential benefits of raising the awareness of AKI– collaborations with other specialties to identify
incidence and effect of AKI on outcomes• Clinical research • Laboratory-based research
– AKI & Biomarker research is very attractive• number of grant applications
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Research opportunities
• Renal Association conference 2011– Marked 40 AKI abstracts– 2 sessions
• Clinical• Basic research
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Increasing patient awareness of AKI in the UK
• Patient involvement in AKI guideline development
• Patient education through Kidney Patient Association website– Frequently asked questions– Patient vignettes
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Where are the knowledge gaps?
• Undergraduate and postgraduate level
• Requires input nationally and locally to be successful
• Needs to be made relevant to other specialties– AKI as marker of acute patient illness
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A suggestion
• Consider proposing acute kidney injury as the topic for a future World Kidney Day– Being considered
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Thank you