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

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?

Definitions

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

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

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

Definitions

• advantages of universal definition – using common language– identify and compare

• epidemiology• treatment efficacy• outcomes

– earlier detection and treatment

Definitions

• International Guideline Group– Kidney Diseases: Improving Global Outcomes– Publication planned June 2011 in Kidney

International– www.kdigo.org

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

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

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

Raising awareness of acute kidney injury: ongoing strategies

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

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

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

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

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

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

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

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

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

Key findings

• 50% of AKI care considered good

• poor assessment of risk factors

• 43% of post-admission AKI - unacceptable delay in recognition

Key findings

• Poor recognition of – acute illness

– hypovolaemia

– sepsis

Recommendations

• Improved education required surrounding

Recognition and responding to the acutely ill

patient

Risk of AKI

Precipitants

Prevention

Early management

Appropriate referral

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

(patients aged 80 or older who died within 30 days of a surgical procedure)

Acute kidney injury

Acute kidney injury

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

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

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

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

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

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

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

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

AKI Delivery Board

• National audit of AKI in acute medical admission units across UK – Incidence– Raise awareness

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

AKI Capacity Survey for England

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

Research opportunities

• Renal Association conference 2011– Marked 40 AKI abstracts– 2 sessions

• Clinical• Basic research

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

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

A suggestion

• Consider proposing acute kidney injury as the topic for a future World Kidney Day– Being considered

Thank you