Acute Kidney Injury

1. Acute Kidney Injury Clinical Directors Forum March 2010 Mark Brady Clinical Advisor, Department of Health

2. Acute Kidney Injury (AKI) NCEPOD findings and recommendations Challenge and opportunities for the renal community Current work Discussion Preliminary analysis of hospital episodes data on inpatient activity shows a significant growth in the number of bed days categorised under the heading of acute renal failure between 2007/08 and 2008/09, and although this is subject to further analysis, it may point to an increase in the awareness and recognition Preliminary analysis of hospital episodes data on inpatient activity shows a significant growth in the number of bed days categorised under the heading of acute renal failure between 2007/08 and 2008/09, and although this is subject to further analysis, it may point to an increase in the awareness and recognition

3. NCEPOD Findings & Recommendations 50% of cases with AKI documented as cause of death received satisfactory or good care 30% of cases inadequately investigated and managed 20% of post-admission AKI is predictable and avoidable (or hospital acquired AKI = HAAKI) All emergency admissions should have electrolytes checked on admission and appropriately thereafter All acute admissions should receive adequate senior reviews, with consultant review within 12 hours of admission Implementation of NICE guidance CG50 NCEPOD report produced 11th June 2009. NICE CG50 National Confidential Enquiry into Patient Outcomes and Death, Funded by National Patient Safety Agency, Maintain and improve standards of care Weaknesses: Coded for �Acute Renal Failure�; Missed AKI?, 587/1518 case notes completed, Hospital mortality only outcome assessed, Few surgical patients NCEPOD report produced 11th June 2009. NICE CG50 National Confidential Enquiry into Patient Outcomes and Death, Funded by National Patient Safety Agency, Maintain and improve standards of care Weaknesses: Coded for �Acute Renal Failure�; Missed AKI?, 587/1518 case notes completed, Hospital mortality only outcome assessed, Few surgical patients

4. AKI Key Facts AKI occurs in 18% of all hospital admissions, in a range of settings, where acutely unwell patients are managed �Minor� degrees of kidney dysfunction are associated with prolonged lengths of stay and increased mortality AKI is often treatable or reversible using basic clinical tests and steps Quality requirement of National Services Framework for Renal Services (Part 2) Not key component of NSF; quality requirement (26�mol/L rise in serum creatinine correlates with 4x increased mortality, Chertow et al, JASN 16:3365, 2005)) AKI audits � more data; part 2 renal NSF. Formal definition awaited for AKI � check dates etc. Historically, studies of AKI have estimated an incidence of 3-7% in hospitalised patients; However two recent studies using the RIFLE staging system identified 20% and 18% of patients admitted to medical centres in USA and Japan respectively as having evidence of AKI. Figures for rates of AKI in Intensive Care Units (ICUs) are 35-85%. The incidence for patients with AKI requiring RRT is 1% for patients admitted to hospital and 5-15 % for those in ICU.Not key component of NSF; quality requirement (26�mol/L rise in serum creatinine correlates with 4x increased mortality, Chertow et al, JASN 16:3365, 2005)) AKI audits � more data; part 2 renal NSF. Formal definition awaited for AKI � check dates etc. Historically, studies of AKI have estimated an incidence of 3-7% in hospitalised patients; However two recent studies using the RIFLE staging system identified 20% and 18% of patients admitted to medical centres in USA and Japan respectively as having evidence of AKI. Figures for rates of AKI in Intensive Care Units (ICUs) are 35-85%. The incidence for patients with AKI requiring RRT is 1% for patients admitted to hospital and 5-15 % for those in ICU.

5. AKI Challenges I Formal definition Defining, identifying and communicating population at risk Appropriate management of the acutely unwell NICE CG50 Robust data Post-operative AKI AKI and critical care Contrast induced nephropathy Education Service provision, systems and excellence Summer 2010 and KDIGO; separate documents on AKI definition. Primary and Secondary care information exchange. CG50 issued July 2007. Education � all levels and start early � Newcastle survey. Would hope for simple definition but implementation of ideal care not simple.Summer 2010 and KDIGO; separate documents on AKI definition. Primary and Secondary care information exchange. CG50 issued July 2007. Education � all levels and start early � Newcastle survey. Would hope for simple definition but implementation of ideal care not simple.

6. AKI Opportunities I Increase awareness Establish formal inter-specialty relationships All acute admitting specialties Renal Radiology/Urology Critical care Reduce unplanned renal replacement therapy, delayed and dangerous transfers Offer safer better care for our patients Develop and agree suitable service contracts Prof Burn. Cost of level 3 beds and in particular to step down Remuneration. Prof Burn. Cost of level 3 beds and in particular to step down Remuneration.

7. AKI Opportunities II � the QIPP agenda Quality Innovation Prevention Productivity An opportunity to create a visionary service����.. HOW WE DEMONSTRATE BUSINESS CASE TO AID IMPLEMENTING BEST SERVICE Quality = service, education, leadership we provide. Innovation = making the right way of managing AKI the easy thing to do Prevention = not simply education of colleagues but patients/community teams. Using information technology or existing avenues. Productivity = many views; ultimately done correctly would result in less work for the renal team but more importantly save money for the NHSHOW WE DEMONSTRATE BUSINESS CASE TO AID IMPLEMENTING BEST SERVICE Quality = service, education, leadership we provide. Innovation = making the right way of managing AKI the easy thing to do Prevention = not simply education of colleagues but patients/community teams. Using information technology or existing avenues. Productivity = many views; ultimately done correctly would result in less work for the renal team but more importantly save money for the NHS

8. AKI Opportunities III Formulating the argument for non-nephrologists AKI is not primarily a renal issue Renal leadership can help to establish this tenant Local groups can reiterate this and implement best practice CQUINS can incentivise Prevention will reduce: Proportion requiring RRT Long term conditions (LTC) burden CVD CKD Timely investigation and treatment will: Improve individual patient experiences and outcomes

9. AKI Challenges II Determining true costs associated with AKI Determining quality indicators Achieving consciousness in healthcare professionals equivalent to: VTE (venous thromboembolism) Blood Transfusion practice MARKER FOR THE ACUTELY UNWELL Dasta (NDT 2008) et al. in a retrospective case�control study on 516 patients who underwent cardiac surgery. RIFLE�Risk patients had a 2.2-fold increase in mortality, a 1.8-fold increase in postoperative length of stay, and a 1.6-fold increase in total postoperative costs compared with controls. Median total postoperative costs were twice as high in the AKI group compared with the non-AKI control group (US$37,674 versus $18,463). These authors noted that mortality, rate of requirement for RRT, length of hospital stay, and costs increased progressively with increases in AKI severity as classified by the RIFLE criteria. Patients with even the smallest increases in serum creatinine had significantly worse outcomes and increased costs compared with matched controls. These results confirm findings from other researchers such as Chertow et al., who found that small increases in serum creatinine level of 26.5�35.4 �mol/l resulted in a mean unadjusted increase of $8,900 in total costs and an increase in mortality and length of stay in hospitalized patients.MARKER FOR THE ACUTELY UNWELL Dasta (NDT 2008) et al. in a retrospective case�control study on 516 patients who underwent cardiac surgery. RIFLE�Risk patients had a 2.2-fold increase in mortality, a 1.8-fold increase in postoperative length of stay, and a 1.6-fold increase in total postoperative costs compared with controls. Median total postoperative costs were twice as high in the AKI group compared with the non-AKI control group (US$37,674 versus $18,463). These authors noted that mortality, rate of requirement for RRT, length of hospital stay, and costs increased progressively with increases in AKI severity as classified by the RIFLE criteria. Patients with even the smallest increases in serum creatinine had significantly worse outcomes and increased costs compared with matched controls. These results confirm findings from other researchers such as Chertow et al., who found that small increases in serum creatinine level of 26.5�35.4 �mol/l resulted in a mean unadjusted increase of $8,900 in total costs and an increase in mortality and length of stay in hospitalized patients.

10. Acute Kidney Injury Network 2007 Renal Association AKI Guidelines 2008 AKI Care Initiative (AKICI) Conference May 2009 NCEPOD report June 2009 Dept Health and NHS Kidney Care response Workshop October 2009 Ministers response December 2009 AKI delivery board inaugural meeting March 2010 Current work

11. Current Work II National Imaging Board Guidelines Produced in February 2010 Examples of good practice North Central London West Yorkshire NCL- Royal free; Chris Laing WY � Andy LewingtonNCL- Royal free; Chris Laing WY � Andy Lewington

13. Acute Kidney Injury - The future Over to you��� We know what we want to achieve, what have we missed, We know what we want to achieve, what have we missed,

14. National AKI Board Deliverables Support tools for AKI Ensuring the integration of checks (MEWS, RCP) Drive on improvements in access to ultrasound scanning and nephrostomy (National Ultrasound Steering Group) Bringing together kidney care and critical care networks to facilitate agreement of care pathways, specialist support and transfer protocols Capacity surveys of specialist care to inform commissioning decisions AKI in all curricula Piloting data collection/ audit through extension of the Vascular Society of Great Britain and Ireland�s National Vascular Database (NHS Kidney Care) tools to support routine risk assessment for AKI on all emergency admissions, and to support decision making on recognition of AKI, with the Society for Acute Medicine taking a leading role � ensuring the integration of checks for AKI with the use of early warning scoring and response systems, including working with the Royal College of Physicians � a drive on improvements in access to ultrasound scanning and nephrostomy through the work of the National Ultrasound Steering Group (a sub-group of the National Imaging Board) � bringing together kidney care and critical care networks to facilitate agreement of care pathways, specialist support and transfer protocols � surveying the capacity of specialist care to inform commissioning decisions (recognising that there has been a 54.4% increase in the number of critical care beds in England between January 2000 and July 2009) � ensuring that AKI and relevant competencies3 are adequately represented in the curricula for multi-professional training, including for nurses, via the responsible training boards and Royal Colleges, and through the Department of Health-funded e-learning project for junior doctors � Piloting data collection/ audit through extension of the Vascular Society of Great Britain and Ireland�s National Vascular Database, funded through NHS Kidney Care. tools to support routine risk assessment for AKI on all emergency admissions, and to support decision making on recognition of AKI, with the Society for Acute Medicine taking a leading role � ensuring the integration of checks for AKI with the use of early warning scoring and response systems, including working with the Royal College of Physicians � a drive on improvements in access to ultrasound scanning and nephrostomy through the work of the National Ultrasound Steering Group (a sub-group of the National Imaging Board) � bringing together kidney care and critical care networks to facilitate agreement of care pathways, specialist support and transfer protocols � surveying the capacity of specialist care to inform commissioning decisions (recognising that there has been a 54.4% increase in the number of critical care beds in England between January 2000 and July 2009) � ensuring that AKI and relevant competencies3 are adequately represented in the curricula for multi-professional training, including for nurses, via the responsible training boards and Royal Colleges, and through the Department of Health-funded e-learning project for junior doctors � Piloting data collection/ audit through extension of the Vascular Society of Great Britain and Ireland�s National Vascular Database, funded through NHS Kidney Care.

15. Recommendations 1. A national group is convened to work collaboratively enabling real improvements in the prevention, detection and treatment of AKI throughout the UK. 2. An acceptable working definition for AKI is developed by performing a multicentre study using different staging systems and correlated with outcomes. 3. Enzymatic serum creatinine assay should be implemented in all biochemistry labs throughout the UK to ensure national comparability. For patients admitted to different hospitals with different biochemistry laboratories the development of shared databases should be created to improve comparability between laboratories. 4. An electronic alert biochemistry system should be developed which is compliant with the AKI Map of Medicine. 5. The National Vascular Database should be reviewed and updated to ensure AKI data is collected and audited post surgery. The incidence and outcome of AKI in patients undergoing vascular surgery/interventional procedures will be captured routinely.

16. Recommendations 6. Further local AKI audits should be encouraged to assess the incidence of AKI among other specialty patient groups. 7. There must be a co-ordinated approach to improving both undergraduate and postgraduate education for AKI. Core competencies must be developed to improve the identification and management of patients at risk of developing AKI, including the acutely ill patient (NICE CG 50). 8. District general hospitals (DGHs) without renal services should develop links with local renal services and develop agreed care pathways for patients who develop AKI, enabling optimisation of patient care and efficient transfer of patients to a renal unit if appropriate. 9. Identification of new and improved biomarkers allowing earlier detection of AKI should be developed to improve the potential for targeted therapeutic intervention. 10. Renal units should work together locally with radiology and cardiology departments to ensure shared guidelines are in place to prevent contrast induced nephropathy.

17. AKI definitions