Renal Referrals at UHB

Mark JeskyResearch Registrar

Background

• Renal referrals received from virtually all hospital specialties

• Increased emphasis in recognising acute kidney injury (AKI) and managing appropriately– Awareness of even mild AKI associated with

increased hospital stay and mortality• Traditionally, referrals recorded on ad-hoc basis– Auditing activity difficult

A Brave New Dawn

• From September 2010 referrals made on PICS health informatics system

Audit Questions

• Referral demographics

• For AKI referrals– AKI stage at referral– AKI stage at peak creatinine during admission– Length of stay by AKI stage– Survival

• discharge• 90 days

– Renal survival– Renal Follow-up

Demographics

• From mid September 2010 – mid July 2011• 623 episodes captured– (1 person may have more than one event)

Total No. Referrals No. Days Referrals / dayNumber /day (inc weekend) 623 314 2.0Number /day (exc weekend) 573 225 2.5

Referral by Day

Monday Tuesday Wednesday Thursday Friday Saturday Sunday0

20

40

60

80

100

120

140

Referral by time of day

0000 - 0559 0600 - 0759 0800 - 0959 1000 - 1159 1200 - 1359 1400 - 1559 1600 - 1759 1800 - 1959 2000 - 2159 2200 - 05590

20

40

60

80

100

120

140

160

180

41.7%

62.4%

Type of Referral by PICS

Acute Kidney Injury Chronic Kidney Disease On Haemodialysis Transplant Other0

50

100

150

200

250

300

Referral by Directorate

Genera

l Med

icine

Critical

Care

Cardiology

Genera

l Surge

ry an

d GI med

icine

Neuro

scien

ces Liver

Clinica

l Hae

matology

Urology

Oncology

Cardiothorac

ics

Trauma a

nd orthopae

dics

Vascular

Surge

ry ENT

Renal

(!)Burn

s

Plastic S

urgery

0

50

100

150

200

250

300

AKI data

• 332 AKI episodes– 310 episodes excluding solid organ transplantation

• AKI classificationStage Serum Creatinine criteria Urine Output Criteria

1 Increase in serum creatinine of ≥26.4 µmol/L or increase to 150-200% from baseline

< 0.5 ml/kg/ hr for more than 6 hours

2 Increase in serum creatinine to more than 200-300% from baseline

< 0.5 ml/kg/hr for more than 12 hours

3 Increase in serum creatinine to more than 300% from baseline or ≥354 µmol/L with an acute increase of at ≥44 µmol/L

< 0.3 ml/kg/hr for 24 hours or anuria for 12 hours

AKI data

• 332 AKI episodes– 310 episodes excluding solid organ transplantation

• 24 duplicate referrals (21 single admission, 3 two admissions)• 3 triplicate referrals (1 single admission, 2 two admissions)

• AKI classificationStage Serum Creatinine criteria Urine Output Criteria

1 Increase in serum creatinine of ≥26.4 µmol/L or increase to 150-200% from baseline

< 0.5 ml/kg/ hr for more than 6 hours

2 Increase in serum creatinine to more than 200-300% from baseline

< 0.5 ml/kg/hr for more than 12 hours

3 Increase in serum creatinine to more than 300% from baseline or ≥354 µmol/L with an acute increase of at ≥44 µmol/L

< 0.3 ml/kg/hr for 24 hours or anuria for 12 hours

AKI stage(duplicates from same admission removed)

At Referral At Worst

AKI unclassified 81(28.4%)

31(10.9%)

1 78(27.4%)

83(29.1%)

2 27(9.5%)

28(9.8%)

3 84(29.5%)

141(49.5%)

unknown 15(5.3%)

2(0.7%)

Outcomes by AKI stage(duplicates from same admission removed)

Length of Stay -All

daysMedian (IQR)

Length of Stay - alive to discharge daysMedian (IQR)

AKI unclassified 13 (6.5-21) 12 (6.75-21)

1 18 (11-42.5) 16 (9.5-35)

2 21.5 (10-44) 25 (11-49.5)

3 17 (10-37.75) 19 (10-44)

Outcomes by AKI stage(duplicates removed)

n

Died in Hospital

n (%)

90 day mortality

n (%)AKI unclassified 31 3

(9.7%)4(12.9%)

1 83 16(19.3%)

24(29.2%)

2 28 6(21.4%)

10(28.9%)

3 136 39(28.7%)

51(37.5%)

Renal Survival

• 51/285 required in-patient renal replacement therapy (RRT)– 17.9%

• 10 required on-going RRT post discharge

Renal Follow-up

• From last (UHB) renal function on PICS• Alive and eGFR <30– 62 / 285 (21.8%)– Of these 62,• 38 (61.3%) under renal follow up• 24 (38.7%) not under follow up

– 1 self discharge, 1 decreased mobility, 2 DNA

Summary

• Electronic referrals good way to capture data• Typically over 14 referrals a week • AKI associated with increased length of stay– Similar AKI 1-3

• Significant mortality (in hospital and beyond)• Not all patients being adequately followed up

Recommendations

• Increase awareness of increased LOS, mortality associated with all stages of AKI– Ensure prompt referral

• Appropriate individuals need to be followed up in renal clinics– Documentation of follow-up in notes– Ensure no loss to renal follow up

Acknowledgements

• Dr Rachel Plant• Dr Peter Hewins