Acute Kidney Injury (AKI)

Scientific Day

19th June 2014

11.00-15.00

Welcome

11.00 – 11.15

Dr Andy Lewington

Consultant Renal Physician/Honorary Associate Professor

St James’s University Hospital, Leeds

The Cost of Ignoring Acute Kidney Injury

Dr Andy Lewington

Consultant Renal Physician/Honorary Clinical Associate Professor

Leeds Teaching Hospitals

Declaration of Interest

• AbbVie – Advisory Board for therapy for AKI

• AM Pharma – Advisory Board for therapy for AKI

• Alere – honoraria for chairing meeting

• Bioporto – Advisory Board for NGAL

• Fresenius – Honoraria for lecture at ICS

• Baxter – Honoraria for lecturing on IV Fluids

Acute Kidney Injury

The Scale of the Problem

<50% of AKI care considered good – poor assessment of risk factors 43% of post-admission AKI – unacceptable delay in recognition

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

£1.2 Billion

Changing Face of Medicine

Hospital Population

• 25% of general population aged >60 yrs

• >85-yrs age group will double in next 20 yrs

• 66% of patients admitted >65 yrs

• 25% of patients have dementia

• Patients >85 yrs account for 22% of bed days in NHS

Hospital Population

• Many patients have

– Multiple co-morbidities

– More complex management issues

– Decreased functional reserve

• Cardiac

• Respiratory

• Kidney

– Polypharmacy – e-prescribing

Less Trainees

Lewington A, et al. Kidney Int 2013;84:457–67

$9,000,000,000/YR

1.2 million 300,000 people die in the US

annually from AKI

People per year get AKI during a hospital stay

5

22

Your length of stay in the hospital increases by

12.5 days (3.5 times) if you get AKI

0

100,000

200,000

300,000

400,000

Prostatecancer

Breastcancer

Heartfailure

Diabetes AKI

More than breast cancer, prostate cancer, heart

failure and diabetes, combined

0

20

40

60

80

100

0.3-0.4 0.5-0.9 1.0-1.9 >=2.0

unadjusted

age adjusted

multivariableODDS OF DEATH

DEATH RATE/YR

3.5% ADMISSIONS

$7,500 (3 to 14,000)

PER ADMISSION EXCESS HOSPITAL

COSTS

Severity of AKI

Lewington A, et al. Kidney Int 2013;84:457–67

Think

Functional Reserve ! 50% loss of function before

serum creatinine rises above the

upper limit of normal

‘It is morally inexcusable that people – mostly young people – still die of untreated acute kidney failure.’

President Giuseppe Remuzzi

ISN 0 by 25 Initiative

This initiative has one clear and concise aim: that no one should die of untreated acute kidney failure in the poorest parts of

Africa, Asia and South America by 2025

Projects Team Leaders Update

May 26 2014

ISN AKI 0 by 25

Co

llate

Exi

stin

g Ev

ide

nce

Nephrology cohorts (AKI, CKD, registries)

Jorge Cerda* Marcello Tonelli*

Non-renal cohorts (HIV, Malaria, Leptospirosis, CV disease, diabetes)

Emmanuel Burdmann* Vivek Jha*

Cre

ate

Pro

spec

tive

Dat

a

Cross-sectional Global Snap shot of AKI

Ravi Mehta* Norbert Lameire* Longitudinal cohort studies Guillermo Garcia*

Raul Lombardi*

Dev

elo

p E

du

cati

on

an

d

Trai

nin

g m

ater

ials

Tool Kits for raising awareness of AKI

Fred Finkelstein* Andrew Lewington*

Pilo

t Im

ple

me

nta

tio

n

Predefined setting with baseline data available

Nathan Levin* John Feehally*

ISN “AKI 0 by 25”: Team Members

Develop Evidence for

Global Burden of Disease

Raise

Awareness

Implement

Strategy

UK Approach to AKI

Clinical Practice Guideline for the Implementation of the Electronic

Detection of AKI

• Meeting October 2013

– Chaired Donol O’Donoghue

– Wide representation

– 10 different professional bodies

– accepted AKI algorithm

• ACB and small group of Nephrologist

– currently in draft format

• would like to circulate to group

Strippoli et al J Am Soc Nephrol 2004

• Nephrology has a poor record of RCTs – fewest of all internal medicine specialties

• 1.5% of publications were RCTs (3rd lowest)

• Quality of reporting is low

Outline of areas covered in CG169 • Identifying acute kidney injury in patients with acute illness*

• Investigating for acute kidney injury • Identifying acute kidney injury in patients with no obvious acute illness • Assessing risk factors in adults having iodinated contrast agents* • Assessing risk factors in adults having surgery* • Preventing acute kidney injury

• Ongoing assessment of the condition of patients in hospital* • Preventing acute kidney injury in adults having iodinated contrast agents • Monitoring and preventing deterioration in patients with or at high risk of acute kidney injury • Detecting acute kidney injury* • Identifying the cause(s) of acute kidney injury*

• Urinalysis

• Ultrasound* • Managing acute kidney injury

• Relieving urological obstruction • Pharmacological management • Referring for renal replacement therapy

• Referring to nephrology* • Information and support for patients and carers*

* Includes key priority for implementation (KPI)

Quality Standard

AKI quality standard being developed

Concise set of statements designed to drive measurable quality improvements

e.g Patients at risk of AKI who suffer acute illness should have their creatinine measured

9 months to implement

Risk of Chronic Kidney Disease AKI intimately linked with CKD

Both injurous processes

Severity of AKI Leads to More CKD

0

10

20

30

40

50

60

70

80

90

1-yr pre during 1-3 mo post 3-12 mo post > 1 yr post

Mean e

GF

R

Time Period

None

R

I

F

D

AKI Severity

During

Admission

Opportunity

• Harmonise the measurement of AKI • Characterise the epidemiology

– identify those at risk of AKI

• Data for major research – attract big Pharma

• Collaborate to refine the methodology

• No other country able to achieve • Bruce Molitorus

– ‘if you can shame the USA into trying to achieve this then so be it’

Caveats • Not all NHS Trusts have the same method of measuring

creatinine – enzymatic, Jaffe

• AKI defintion – algorithm will not detect all patients with AKI – importance of urine output (NEWS), clinical skill

• Not all patients with small rises in creatinine will have AKI – ascertainment

• E-detection systems will not determine the cause of AKI – syndrome

• E-detection systems will detect those with AKI already developing – need to identify those at risk

‘Kidneys are for Life’

Thank You for Attending

The National Acute Kidney Injury Programme and the Role of the Detection Workstream 11.15 – 11.35

Dr Robert Hill

Chair of the AKI Detection Workstream

47

Primary Aim

The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings.

48

The purpose of the National Programme is to deliver and implement a structure and tools within three years that will lead to a fall in the number of preventable episodes of AKI, and with that a reduction in deaths associated with AKI. It will lead work on the development of clinical tools, information and levers and prioritise patient empowerment. It will utilise commissioning pathways and other clinical networks. It will also establish local and national data collection and audit leading to further safety improvement and target research towards areas that require elucidation.

Programme Purpose

26/06/2014 49

RCPE Consensus Statement November 2012 • Identification of AKI in both primary and secondary care

should be facilitated through introduction of e-alert systems

• At present systems are being developed ad hoc

• A national group should be established to develop agreed standards for e alert systems recognising the need for some system dependent local flexibility. Components of the system should include an agreed definition of AKI based on the KDIGO classification and a standardised methodology for derivation of baseline serum creatinine. We recommend use of an enzymatic serum creatinine assay with an IDMS Traceable calibration to enable standardisation.

Consensus AKI Warning Algorithm Meeting July 2013

• Held at the invitation of the Association for Clinical Biochemistry and Laboratory Medicine

• Nephrologists appointed by Richard Fluck renal CD at NHS England

• Clinical Biochemistry representation from England Scotland and Wales

• Lab Computer suppliers invited via a poll of ACB members

• The output of the meeting was a consensus algorithm that was not identical to any of the algorithms in use at the time

LIMS level ‘result’ Patient

management system

Alert Response

Local systems

Message

Master patient index

Other data systems

AKI Registry

Regional National

Research

QI

Local Flexibility • The AKI programme is intending to implement

the standardised AKI warning algorithm

• Local versions of an AKI warning algorithm even when developed to accomodate limitations of the local Pathology computer system (LIMS) will not be compliant with the AKI Programme

• Local flexibility will be necessary to convert an AKI warning into an alert (digital or analogue)

Issues with Implementation

• Older versions of LIMS systems may require a major software (possibly hardware) upgrade

• Existing algorithms established locally may contain innovations that should not be discarded.

• Concerns about validation of external algorithms

Why does the AKI warning algorithm need to be standardised?

• Removes an important variable facilitating comparative research (The RCPE Consensus Conference : We recommend audit and research to confirm that in addition to identification of AKI the use of e-alert systems improves outcomes)

• Allows co-ordinated stepwise improvement of the AKI warning algorithm

Design principles for national programme

Measurement underpins evidence

Simplify data flows

Use to evidence change

Global

– Social, primary and secondary care

– Multiprofessional with patients and across specialties

– Inclusive

Strategy not tactics

57

Safety alert (issued 9/6/14)

• Raises profile of AKI and the need to develop systems to detect early and treat

• Gives laboratories a clear idea of what to demand from their LIMS suppliers

Maintaining and modifying the algorithm

• A sub-group of the detection workstream will consider suggestions for changing the algorithm and supervise future pilots

• Updates of the algorithm will be issued infrequently (maximum frequency 1 year) to allow stepwise adoption by LIMS suppliers ad their clients.

The AKI Detection Workstream Programme - What it is not about

• Ignoring innovation

• Intransigence to change

• Neglecting existing good practice

• Imposing a Tertiary Care model

What the detection workstream is about

• Reducing variation in the detection of AKI between Trusts

• Providing a firm basis for outcome research

• Providing information resources to enable Trusts to implement the national AKI programme

• Continuous stepwise improvement of the AKI algorithm in co-operation with LIMS providers

Moderated Poster Session

11.35 – 12.35

• Poster Group A – Robert Hill – Moderator

• Poster Group B – Nick Selby – Moderator

• Poster Group C – Mike Bosomworth – Moderator

• Poster Group D – Andy Lewington - Moderator

Lunch/Open Poster Viewing

12.30 – 13.15

Group Work

13.15 - 13.55

Instructions

We have set a question for each of the 6 groups to answer. The question can be found in your group. You have 40 minutes to debate this question in your group. Be prepared to provide a five minute highlight presentation to feedback to the whole group. You will find flipcharts and pens in your groups.

Group Question

1 How would you advise a hospital that is planning to implement an AKI detection system? Would this be different for hospitals with and without renal units on site?

2 How could a best practice recommendation for converting an AKI report into an alert be developed - what would it say and what are the different options?

3 Detection of AKI also incorporates 'case finding' to ensure blood tests are actually taken in at risk groups. How can you facilitate this in clinical practice in primary care, secondary care and care home settings?

4 As AKI detection becomes more widespread, how can we continue to share experiences, good practice and problems encountered on a national basis?

5 In the absence of an automatic alert system being present, how should an AKI test result be acknowledged by clinicians? How would the transition for labs telephoning clinical areas in hospitals with significant serum creatinine changes to an AKI risk report be handled?

6 For audit/research purposes, how should a baseline AKI detection rate be established before introducing the AKI detection algorithm? How would you design an audit for those hospitals who are yet to introduce the algorithm to measure the impact of its introduction?

Feedback from Group Work

13.55 – 14.30

• 5 minutes feedback from each group

Question & Answer Session

14.30 – 14.50

Panel members

Dr Andy Lewington, Consultant Renal Physician, St James’s University Hospital, Leeds

Dr Robert Hill, Chair of the Detection Workstream, AKI National Programme

Dr Nick Selby, Co-Chair of the Detection Workstream, AKI National Programme

Closing remarks and next steps

14.50 – 15.00

Dr Robert Hill

Chair of the AKI Detection Workstream