Why AKI?Why AKI?

Dr Bill BartlettJoint Clinical Director

Diagnostics GroupNinewells Hospital & Medical School

NHS Tayside

Conflicts of Interest

None

AKI a Problem?

“Acute kidney injury is a major problem with profound consequences that has long been under- recognized,” “Our collective attention has been on chronic kidney disease, and rightfully so. However, we now know that acute kidney injury may be a precursor to CKD, and CKD can also lead to AKI.”

Dr. Bertram L. Kasiske, co-chair of KDIGO.http://www.kidney.org/news/newsroom/nr/aki_guidelines.cfm

Renal Association http://www.renal.org/clinical/guidelinessection/AcuteKidneyInjury.aspx

Acute kidney injury is common in hospitalised patients and has a poor prognosis: -

Studies indicate mortality ranging from 10%-80% – uncomplicated AKI, mortality rate 10%. – AKI + multi-organ failure mortality > 50% – RRT required mortality rate rises further to as high as 80%

“Acute kidney injury is no longer considered to be an innocent bystander merely reflecting co-existent pathologies. It has been demonstrated to be an independent risk factor for mortality”

NCEPOD ReportKey Findings

Avoidable in 20% of post admission cases Poor assessment of risk factors.Managed badly in 20% of cases.Care considered good in only 50% of cases.

How big a problem?

Hospital Episode Statistics 2010-2011Patients >18 years ICD-10 Codes N18 and N280: -

– 2.4% of admissions– Lab data suggest under reporting as estimates =13.25%

prevalence in East KentHospital AdmissionsIt is an issue in 1° and 2 ° careM Kerr National Clinical Director for Kidney Care DoHRCPE consensus conference.

How big a problem?Increased length of stay 10.54 days (95% CI 10.22 to 10.86)18% of critical care bed days 28.5% mortalityEstimated cost of acute admissions £424-768MCost of long term RRT post AKI £200M12000 avoidable deaths!

issuesRecognition

– Common serious issue in 1° and 2 ° care. Ubiquitous!– Assessment of risk and monitoring– Criteria needed for early identification of developing or developed AKI– Tools

Markers Creatinine/BiomarkersE-alertsFlags

Good Management– Understanding of pathophysiology and application of common sense– Sound clinical pathways with good flows of information and knowledge

NCEPODall emergency admissions should have a risk assessment for AKIall emergency admissions should have electrolytes checked on admission and appropriately thereafterpredictable avoidable AKI should not occurall acute admission should receive adequate senior reviews (consultant review within 12 hours) there should be sufficient critical care and renal beds to allow rapid step up care undergraduate medical training should include the recognition of the acutely ill patient and the prevention, diagnosis and management of AKI postgraduate training in all specialties should include training in the detection, prevention and management of AKI.

KDIGO Guidelines 2012Evaluation

– Diagnostic tools (urinary abnormalities, blood tests, biomarkers, imaging techniques)

– Clinical settings to consider (community, in-hospital, ICU, developing countries)– Limitations (age, adults > 18 years, specific infectious and/or nephrotoxic insults)

Prevention– Susceptible groups and risk factors (genetic, clinical, age, baseline eGFR)– General measures (volume status, hemodynamic monitoring, urine flow, renal

perfusion)– Pharmacologic interventions (diuretics, vasopressors, vasodilators, acetylcysteine)– Measures to consider in the use of drugs and procedures associated with AKI

Treatment and Prognosis– Non-dialytic (volume, anti-sepsis, ventilation, metabolic control, euglycemia)– Dialytic (type, dose, initiation, discontinuation, anticoagulants, access)– Scoring systems (recovery, mortality)– The interrelationship between AKI and CKD– Factors that determine general and renal recovery and outcome

KDIGO 2012KDIGO 2012

RCPE UK Consensus Conference 16-17th November 2102

Management of acute Kidney injury: the role of fluids, e-alerts and biomarkers.

Recognised KDIGO, and NICE in progress.Identified 3 areas requiring greater focus: -

Role of fluid therapy in AKIThe role of e-alerts based on KDIGO criteriaRole of Biomarkers

Scottish Approach

Opportunity through the Scottish Clinical Biochemistry Managed Diagnostic Network, ACB and SRA to develop an approach to this issue.Delivery and dissemination of knowledge, guidance, processes, and tools in a co-ordinated way across the patch.

WHY AKI?

" Recognizing that we have the kind of blood we have Recognizing that we have the kind of blood we have because we have the kind of kidneys we have, we must because we have the kind of kidneys we have, we must acknowledge that our kidneys constitute the major acknowledge that our kidneys constitute the major foundation of our philosophical freedom. Only because foundation of our philosophical freedom. Only because they work the way they do has it become possible for us to they work the way they do has it become possible for us to have bones, muscles, glands and brains. Superficially, it have bones, muscles, glands and brains. Superficially, it might be said that the function of the kidney is to make might be said that the function of the kidney is to make urine; but in a more considered view one can say that the urine; but in a more considered view one can say that the kidneys make the stuff of philosophy itself."kidneys make the stuff of philosophy itself."

From Homer Smith "From fish to philosopher" (1953)From Homer Smith "From fish to philosopher" (1953)