The acutely unwell patient with

diabetes; thinking kidneys in

primary care

Daniel Lasserson MA MD FRCP Edin MRCGPAssociate Professor and Senior Interface PhysicianCo-chair, Measurement Workstream, Think Kidneys Programme

86 years old, retired book keeper, lives alone after the death of her husband.

She has hypertension, type 2 diabetes, atrial fibrillation, previous falls with hip

fracture, osteo-arthritis and needs carers twice a week to help her with

shopping and some housework.

Feeling ‘not right’ for several days. ‘Muddled’ at times. Seen by her GP who

visits her at home on a Monday. Seen by Out of Hours GP on Saturday night.

Found fallen at home by carers the following Tuesday. Ambulance takes her to

a community based ambulatory care centre.

A patient journey – Mrs C

Early presentations of disease on a background of

normality

Lack of access to diagnostics

‘Reverse triage’ in acute illness

‘In hours’ and ‘Out of hours’

Acute illness in primary care

Rapid decline in renal function

Usual functions of the kidney are impaired

electrolyte balance

fluid balance

acid base balance

Usually due to another illness and pre-existing risk

factor

What is acute kidney injury (AKI)?

At the ambulatory care unit, she describes deteriorating mobility and is now

unable to mobilise without assistance. She wants to go home.

Her usual creatinine is around 112 micromol/L . Her point of care creatinine

test shows a creatinine of 382 (> 3 times her usual creatinine) - this is stage 3

acute kidney injury.

After discussion with the on call renal team, she is admitted to an elderly care

ward for multidisciplinary assessment and treatment with renal input.

A patient journey – Mrs C

Measuring the scale of AKI in primary care

Barton et al Nephron 2015;130:175-181

Who gets AKI in primary care?

Oke et al BMJ Open 2015;5:e009459

Are we doing enough blood tests?

Is AKI increasing in primary care?

Home or hospital?

Barton et al Nephron 2015;130:175-181

Hobbs et al BMC Nephrology 2014;15:206

Home or hospital? The next 2 years

Treated for infection, medications altered, renal function improved. She had an

episode of confusion on the ward. Desperate to go home.

She was discharged from hospital early with daily review coordinated by the

ambulatory care unit with an increase in her care package. As her strength and

confidence returned she needed less care in the following months.

Primary care team aware of her AKI risk and the non-specific presentation ‘just

not right’

A patient journey – Mrs C

Acute ambulatory care unit embedded in a local community,

outside of an acute care setting

Nurses, physiotherapy, OT, social work, medics

Point of care diagnostics

Referrals from GPs, Out of Hours primary care, paramedics

AKI at the interface of primary and secondary care

Detecting AKI in Out of Hospital Settings

0 200 400 600 800 1000 1200 1400 16000

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400

600

800

1000

1200

1400

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Creatinine i-Stat V Lab (micromol/l)Line X=Y

Laboratory

i-Sta

t

Referrals with frailty syndromes….

Median age of 81 years, with 5 co-morbid conditions

18% have diabetes (majority type 2)

85% are living in their own home

AKI at the interface of primary and secondary care

What are the clinical features of AKI in the older patient?

General decline, reduced mobility

Falls

Confusion

20% of patients we see with diabetes have AKI

AKI at the interface of primary and secondary care

What does Mrs C’s journey tell us?

Non specific presentation of AKI

Importance of developing out of hospital diagnostics

vulnerable populations

appropriate reduction in threshold for testing

Identification of ‘at risk’ populations

‘Think Kidneys’ – Primary Care guidance

When to suspect AKI

Timely response

What to do next

Future Strategies for AKI

Future Strategies for AKI

The Think Kidneys Measurement Workstream

CCG area

rates of AKI

outcomes (recovery, mortality)

Learn from variation

Help commissioners

What have we changed?

The acutely unwell patient with

diabetes; thinking kidneys in primary

care

Daniel Lasserson MA MD FRCP Edin MRCGPAssociate Professor and Senior Interface PhysicianCo-chair, Measurement Workstream, Think Kidneys Programme