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

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 Recommendations Findings

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)

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

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

7. AKI Opportunities II – the QIPP agenda • Quality • Innovation • Prevention • Productivity • An opportunity to create a visionary service…………..

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

10. Current work • 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

11. Current Work II • National Imaging Board Guidelines • Produced in February 2010 • Examples of good practice • North Central London • West Yorkshire

13. Acute Kidney Injury - The future • Over to you………

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)

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