Raising awareness of acute kidney injury: ongoing strategies

1. 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

2. 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?

3. Definitions

4. 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

5. 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

6. AKI – a systemic condition • Functional and structural • extra-renal organ injury occurs in AKI • Potential mediators • uraemic toxins • cytokines • leukocytes Scheel et al., Kidney Int 2008

7. Definitions advantages of universal definition using common language identify and compare epidemiology treatment efficacy outcomes earlier detection and treatment

8. Definitions International Guideline Group Kidney Diseases: Improving Global Outcomes Publication planned June 2011 in Kidney International www.kdigo.org

9. 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

10. 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

11. AKI Staging - KDIGO

12. Raising awareness of acute kidney injury: ongoing strategies

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

23. Key findings 50% of AKI care considered good poor assessment of risk factors 43% of post-admission AKI - unacceptable delay in recognition

24. Key findings Poor recognition of acute illness hypovolaemia sepsis

25. Recommendations Improved education required surrounding Recognition and responding to the acutely ill patient Risk of AKI Precipitants Prevention Early management Appropriate referral

26. 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

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

28. Acute kidney injury

29. Acute kidney injury

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. AKI Delivery Board • National audit of AKI in acute medical admission units across UK • Incidence • Raise awareness

39. 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

40. AKI Capacity Survey for England

41. 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

42. Research opportunities • Renal Association conference 2011 • Marked 40 AKI abstracts • 2 sessions • Clinical • Basic research

43. 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

44. 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

45. A suggestion • Consider proposing acute kidney injury as the topic for a future World Kidney Day • Being considered

46. Thank you