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Acute Kidney Injury Workshop: Aims & Objectives
1. To promote prompt recognition and consistent management of
AKI
2. To recognise aims and limitations of AKI electronic alerts (e-
alerts)
3. To ensure in-patient AKI episode details included within e-
discharges
What is Acute Kidney Injury?
• Abrupt loss of kidney function that develops within 7 days
• Previously called acute renal failure
Acutely Unwell Patient
↑ HR
↑ Temp
↑ CRP
Deteriorating Patient
Acute Kidney Injury
↓ Urine output
↑ Creatinine
↓ BP
AKI as a Patient Safety BarometerPresence of AKI often indicates presence of acute illness
Management of AKI = Good management of acutely unwell patient
• Common
• Indicates presence of severe acute illness
• Patient usually admitted for another problem
AKI a challenge for us all
• Causes harm and death
• Many are preventable
• Much can be done to minimise the impact of AKI
AKI a challenge for us all
• All health professionals should be have an awareness of AKI
AKI a challenge for us all
➢ 50% of junior doctors unable to define AKI
➢ 30% unable to name more than two risk factors for AKI
➢ 37% unable to name even one indication for renal referral
Muniraju et al. 2012
• NHS campaign to improve the care of people at risk of, or with, AKI
• Public awareness of kidney function and AKI is also poor meaning AKI occurring pre-admission is often recognised late
AKI a challenge for us all
1. AKI often recognised late by patients (and health care
professionals)
2. AKI commonly due to volume depletion, drugs, sepsis or a
combination of these problems
3. AKI associated with increased morbidity and costs
4. Most AKI can be managed with prompt simple interventions by
all health care professionals
AKI a challenge for us all
AKI: Consistent Management Across Northern Region
Table 1: Kidney Disease Improving Global Outcome (KDIGO) AKI Diagnosis and Staging
AKI Stage Serum creatinine criteria Urine output criteria
1 Creatinine rise ≥ 26 µmol/L within 48hrs OR Creatinine rise ≥ 1.5 - 1.9 x baseline creatinine
<0.5 mL/kg/hr for > 6 hrs
2 Creatinine rise ≥ 2 - 2.9 x baseline creatinine <0.5 mL/kg/hr for > 12 hrs
3 Creatinine rise ≥ 3 x baseline creatinine OR Creatinine rise ≥ 1.5 x baseline to ≥ 354 µmol/L OR Patient requiring dialysis due to AKI
<0.3 mL/kg/hr for > 24 hrs OR Anuria for 12 hrs
• AKI diagnosis & staging is based upon changes to either serum creatinine and / or urine output - assessed by clinician review and compared to defined international KDIGO AKI criteria (table 1)
• Baseline creatinine is considered as the usual creatinine for a patient prior to their current illness
• AKI e-alerts aim to expedite AKI recognition – but should be interpreted within clinical context and should not be relied upon to diagnose all AKI cases because:
1.AKI e-alerts still require clinicians to check blood results in order to see and verify alert.
2.AKI e-alerts rely upon a computer-derived baseline creatinine for each patient which may be an inaccurate baseline - as computer unable to ‘factor in’ clinical context of previous blood tests.
3.Urine output not assessed by e-alert system.
AKI: Confirming diagnosis & staging (& e-alert limitations)
What is an AKI warning stage alert?➢ AKI e-alerts reported if computer detects patient’s current serum creatinine
as a significant rise above computer-generated baseline creatinine for that patient
➢ Not an infallible system → False negatives & False Positives arise
➢ E-alerts stated as AKI stage 1, 2 or 3 depending on magnitude of creatinine rise
➢ AKI e-alert MAY indicate the presence of AKI – though this requires confirmation by clinician review of blood tests
➢ The presence of AKI may indicate patient clinical decline and should thus lead to prompt patient review +/- intervention
How are AKI e-alerts presented?
• This will depend upon pathology system used • WebICE patient demographic banner changes colour according to AKI Stage
AKI Nursing Core Care Plan
Links to AKI pathway & bundles from WebICE
How should you respond to e-alerts?
Acute Kidney Injury Workshop: e-Discharges & AKI
Rationale / Aims
•Clear plans for GP regarding medication
•Patients who sustain an AKI are at risk of CKD
•Patients who have sustained AKI may be at risk of further AKI
•2/3 patients who sustain AKI have already developed this by the time they are admitted to hospital, so preventative strategies have to include pre-hospital care
AKI details within e-discharges: AKI CQUIN 2015-2016• AKI CQUIN aims to improve discharge communication post AKI.
1. State highest AKI Stage sustained during hospital stay
2. State if medications reviewed / suspended on account of AKI
• If drugs suspended → should include advice if drugs to restart or
not
• If no drug changes → CQUIN mandates stating ‘no drugs changed
due to AKI’
3. State which blood tests required as part of AKI follow-up 1. If no bloods required → CQUIN mandates stating ‘no further
bloods required’
4. State when such blood tests should be undertaken