Acute Kidney Injury Workshop: Aims & Objectives

1. To promote prompt recognition and consistent management of

AKI

2. To recognise aims and limitations of AKI electronic alerts (e-

alerts)

3. To ensure in-patient AKI episode details included within e-

discharges

What is Acute Kidney Injury?

• Abrupt loss of kidney function that develops within 7 days

• Previously called acute renal failure

Acutely Unwell Patient

↑ HR

↑ Temp

↑ CRP

Deteriorating Patient

Acute Kidney Injury

↓ Urine output

↑ Creatinine

↓ BP

AKI as a Patient Safety BarometerPresence of AKI often indicates presence of acute illness

Management of AKI = Good management of acutely unwell patient

• Common

• Indicates presence of severe acute illness

• Patient usually admitted for another problem

AKI a challenge for us all

• Causes harm and death

• Many are preventable

• Much can be done to minimise the impact of AKI

AKI a challenge for us all

• All health professionals should be have an awareness of AKI

AKI a challenge for us all

➢ 50% of junior doctors unable to define AKI

➢ 30% unable to name more than two risk factors for AKI

➢ 37% unable to name even one indication for renal referral

Muniraju et al. 2012

• NHS campaign to improve the care of people at risk of, or with, AKI

• Public awareness of kidney function and AKI is also poor meaning AKI occurring pre-admission is often recognised late

AKI a challenge for us all

1. AKI often recognised late by patients (and health care

professionals)

2. AKI commonly due to volume depletion, drugs, sepsis or a

combination of these problems

3. AKI associated with increased morbidity and costs

4. Most AKI can be managed with prompt simple interventions by

all health care professionals

AKI a challenge for us all

AKI: Consistent Management Across Northern Region

Table 1: Kidney Disease Improving Global Outcome (KDIGO) AKI Diagnosis and Staging

AKI Stage Serum creatinine criteria Urine output criteria

1 Creatinine rise ≥ 26 µmol/L within 48hrs OR Creatinine rise ≥ 1.5 - 1.9 x baseline creatinine

<0.5 mL/kg/hr for > 6 hrs

2 Creatinine rise ≥ 2 - 2.9 x baseline creatinine <0.5 mL/kg/hr for > 12 hrs

3 Creatinine rise ≥ 3 x baseline creatinine OR Creatinine rise ≥ 1.5 x baseline to ≥ 354 µmol/L OR Patient requiring dialysis due to AKI

<0.3 mL/kg/hr for > 24 hrs OR Anuria for 12 hrs

• AKI diagnosis & staging is based upon changes to either serum creatinine and / or urine output - assessed by clinician review and compared to defined international KDIGO AKI criteria (table 1)

• Baseline creatinine is considered as the usual creatinine for a patient prior to their current illness

• AKI e-alerts aim to expedite AKI recognition – but should be interpreted within clinical context and should not be relied upon to diagnose all AKI cases because:

1.AKI e-alerts still require clinicians to check blood results in order to see and verify alert.

2.AKI e-alerts rely upon a computer-derived baseline creatinine for each patient which may be an inaccurate baseline - as computer unable to ‘factor in’ clinical context of previous blood tests.

3.Urine output not assessed by e-alert system.

AKI: Confirming diagnosis & staging (& e-alert limitations)

What is an AKI warning stage alert?➢ AKI e-alerts reported if computer detects patient’s current serum creatinine

as a significant rise above computer-generated baseline creatinine for that patient

➢ Not an infallible system → False negatives & False Positives arise

➢ E-alerts stated as AKI stage 1, 2 or 3 depending on magnitude of creatinine rise

➢ AKI e-alert MAY indicate the presence of AKI – though this requires confirmation by clinician review of blood tests

➢ The presence of AKI may indicate patient clinical decline and should thus lead to prompt patient review +/- intervention

How are AKI e-alerts presented?

• This will depend upon pathology system used • WebICE patient demographic banner changes colour according to AKI Stage

AKI Nursing Core Care Plan

Links to AKI pathway & bundles from WebICE

How should you respond to e-alerts?

Acute Kidney Injury Workshop: e-Discharges & AKI

Rationale / Aims

•Clear plans for GP regarding medication

•Patients who sustain an AKI are at risk of CKD

•Patients who have sustained AKI may be at risk of further AKI

•2/3 patients who sustain AKI have already developed this by the time they are admitted to hospital, so preventative strategies have to include pre-hospital care

AKI details within e-discharges: AKI CQUIN 2015-2016• AKI CQUIN aims to improve discharge communication post AKI.

1. State highest AKI Stage sustained during hospital stay

2. State if medications reviewed / suspended on account of AKI

• If drugs suspended → should include advice if drugs to restart or

not

• If no drug changes → CQUIN mandates stating ‘no drugs changed

due to AKI’

3. State which blood tests required as part of AKI follow-up 1. If no bloods required → CQUIN mandates stating ‘no further

bloods required’

4. State when such blood tests should be undertaken

thomasdoris@nhs.net