Acute Kidney Injury (AKI) Scientific Day 19 th 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
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) <50% of AKI care considered good – poor assessment of risk factors 43% of post-admission AKI – unacceptable delay in recognition
£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
$7,500 Lewington A, et al. Kidney Int 2013;84:457 – 67 (3 to 14,000) PER ADMISSION $9,000,000,000/YR EXCESS HOSPITAL COSTS Your length of stay 3.5% ADMISSIONS in the hospital increases by 22 12.5 days 5 (3.5 times) if you get AKI People per year 1.2 million 300,000 get AKI during a hospital stay people die in the US 100 unadjusted annually from AKI 400,000 80 age adjusted 300,000 ODDS OF DEATH RATE/YR multivariable 60 200,000 DEATH 40 100,000 20 0 Prostate Breast Heart Diabetes AKI 0 cancer cancer failure 0.3-0.4 0.5-0.9 1.0-1.9 >=2.0 More than breast cancer, prostate cancer, heart Severity of AKI failure and diabetes, combined
Think Functional Reserve ! 50% loss of function before serum creatinine rises above the upper limit of normal
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 ‘It is morally inexcusable that people – mostly young people – still die of untreated acute kidney failure.’ President Giuseppe Remuzzi
ISN AKI 0 by 25 Projects Team Leaders Update May 26 2014
ISN “AKI 0 by 25”: Team Members Raise Implement Develop Evidence for Global Burden of Disease Awareness Strategy Nephrology cohorts Cross-sectional Tool Kits for Predefined (AKI, CKD, registries) Global Snap shot raising awareness setting with Collate Existing Evidence of AKI of AKI baseline data Jorge Cerda* Create Prospective Data available Ravi Mehta* Fred Finkelstein* Pilot Implementation Marcello Tonelli* Develop Education and Training materials Nathan Levin* Norbert Lameire * Andrew John Lewington* Non-renal cohorts Longitudinal Feehally* (HIV, Malaria, cohort studies Leptospirosis, CV Guillermo Garcia* disease, diabetes ) Raul Lombardi* Emmanuel Burdmann* Vivek Jha*
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 (3 rd 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
90 80 AKI Severity 70 During Admission 60 None Mean eGFR R 50 I F 40 D 30 20 10 0 1-yr pre during 1-3 mo post 3-12 mo post > 1 yr post Time Period
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
Primary Aim The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings. 47
Programme Purpose 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. 48
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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
Master patient Message index Regional Research National AKI Registry Patient management LIMS level ‘result’ system QI Local systems Other data systems Response Alert
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)
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