how do i use aki biomarkers? - irriv-international renal ... · how do i use aki biomarkers?...

How Do I Use AKI Biomarkers?

1

Lui G Forni

Consultant Intensivist & Nephrologist


Conflicts of InterestWHAT DECLARATION

Grants/research support/P.I. Ortho Clinical Diagnostics, SBRI Renal Technologies; Kidney Research UK

Employee Royal Surrey County Hospital NHS Foundation Trust

Consultation fees Baxter Gambro Renal

Honoraria Fresenius, Astute Medical, Ortho Clinical Diagnostics

Speakers bureau Fresenius, Astute Medical, Ortho Clinical Diagnostics

Company sponsored Astute Medical, Ortho Clinical Diagnostics

Stock shareholder None

Spouse/partner None

Scientific Advisory Board La Jolla Pharmaceuticals; GE; Medibeacon

Other


14%

30%

0%

10%

20%

30%

40%

50%

MI AKI

Myocardial Infarction(No AKI)

Acute Kidney Injury(No MI)

Mortality at One Year…..


AKI : A Broad Clinical Syndrome


Which Of Our Patients Are At Risk of AKI ?


Incidence and outcomes of acute kidney injury in intensive care units: A Veterans Administration study

Risk Related to Cause

CV Thakar et al,

Crit Care Med 2009


How Do We Risk Assess Our Patients For AKI?


•Risk Prediction Scores Exist But…

•Mostly Single Centre• ‘AKI’ Mortality 36-75%•Where Externally validated : performance poor…

What Role of Biomarkers of AKI?

Can We Improve Risk Prediction?


A Role For Biomarkers?

“The next towards personalized medicine would be a combination of biomarker assessment and an individualized prediction tool”


APS & Biomarker

NPV 97%


When Are Biomarkers Needed?

Risk AssessmentRecognitionDifferential DiagnosisTargeted InterventionPrognosis

Which Biomarkers Should Be Measured?

FunctionalDamageCombination

How Should Results Be Interpreted?

Single vs MultiplePPVNPV

How Should Data Be Used For Management?

Guide Timing & Nature of InterventionsImprove Process of CareRefine Clinical Data

Potential Use of AKI Biomarkers


How Are AKI Biomarkers Used?Clinical Use of [TIMP-2]•[IGFBP7] Biomarker Testing to

Assess Risk of Acute Kidney Injury in Critical Care: Guidance from an Expert Panel

Louis M. Guzzi1, Tobias Bergler2, Brian Binnall3, Daniel T. Engelman3, Lui Forni4,5, Michael J. Germain3, Eric Gluck6, Ivan Goecze2, Michael Joannidis7, Jay L. Koyner8, V. Seenu Reddy9, Thomas Rimmelé10, Claudio Ronco11, Julien Textoris10,12, Alexander Zarbock13, John A. Kellum14

• Methods: We invited a group of experts knowledgeable on the utility of this test for kidney injury to a panel discussion regarding the appropriate use of test. Specifically, we wanted to identify which patients would be appropriate for testing, how the results are interpreted, and what actions would be taken based on the results of the test. We used a modified Delphi method to prioritize specific populations for testing and actions based on biomarker test results. No attempt was made to evaluate the evidence in support of various actions however.

Critical Care Submitted


Protocols Ranked by Orders of Actions



Consensus statements for potential actions after positive and negative [TIMP-2] [IGFBP7] testing


How Do I Use Biomarkers?

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• GIM?• AMU?• PACU?• ICU?

Where to Implement?


•Why ICU?

• 55% Surgical

• Dedicated Staff

• Interest

• Used to embracing new technologies

• Used to POC testing



Post CVS Surgery

Post MajorSurgery

Shock

Post Cardiac Arrest

Sepsis Oliguria

Burns

Heart Failure

Who To Test?


And it’s a Problem in Surgery

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How Do I Use AKI Biomarkers? 23



All our Major Surgery Follows ERAS Pathways


Can Biomarkers Play a Role?


Post CVS Surgery

Post MajorSurgery

Shock

Post Cardiac Arrest

Sepsis Oliguria

Burns

Heart Failure

Who To Test?


Post Gynae Oncology Surgery

Oliguria

Who Do I Test?


QIP in Gynae-Oncology Surgery

• Previous Audit had revealed high rate of AKI

• NSAIDs used in pathway

• No guidance from ERAS regarding AKI

• Initial QIP testing NC at 4 hours post op in consecutive patients


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<0.3 0.3-2.0 >2.0

NC & AKI in Gynae-ONC Surgery

Nephrocheck



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<0.3 0.3-2.0 >2.0


Nephrocheck AKI


Mainly UO Criteria


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Nephrocheck AKI

? False Positive


When to Use Crystalloids, Colloids and Blood Products

“No Such Thing As A False Positive”


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<0.3 0.3-2.0 >2.0


Nephrocheck AKI

Sub-Clinical AKI



What Do I do with a

Positive Test?


What Do I do after positive and negative [TIMP-2] [IGFBP7] testing


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<0.3 0.3-2.0 >2.0


Nephrocheck AKI

Affected Pathway in

70%!



Word Is Spreading….

How Do I Use AKI Biomarkers?44

Why Are We Not Using Biomarkers Routinely?

How Can AKI Biomarkers Break Through the Glass

Ceiling?...

How Do I Use AKI Biomarkers?45

…It’s Called Evidence

Thanks For Your Attention….

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