Raising awareness of acute kidney injury: ongoing strategies Dr Andrew Lewington BSc MEd MD FRCP Consultant Renal Physician Clinical Sub Dean Leeds Teaching Hospitals UK

Outline Definitions Why do we need to raise awareness? Who is the target audience? What attempts have been made so far? Where are the knowledge gaps? How do we continue to raise the awareness of acute kidney injury?

Definitions 3

Definitions and Outcomes small rises in serum creatinine (SCr) associated with  morbidity  mortality overall mortality ranges from 10% to 80% depends on underlying illness no change over the last 20 years AKI represents an independent risk factor ↑ mortality 4

Definition and Outcomes data supporting small changes in serum creatinine (SCr) having a significant effect on outcome explanation unclear risk of complications volume overload infection electrolyte disorders distant effects systemic condition 5 5 5

AKI – a systemic condition Functional and structural extra-renal organ injury occurs in AKI Potential mediators uraemic toxins cytokines leukocytes Scheel et al., Kidney Int 2008 6

Definitions advantages of universal definition using common language identify and compare epidemiology treatment efficacy outcomes earlier detection and treatment 7

Definitions International Guideline Group Kidney Diseases: Improving Global Outcomes Publication planned June 2011 in Kidney International www.kdigo.org 8

Definitions - KDIGO AKI is defined when serum creatinine rises by ≥ 26µmol/L within 48 hours or serum creatinine rises ≥ 1.5X the reference value which is known or presumed to have occurred within one week or urine output is < 0.5ml/kg/hr for >6 consecutive hours 9

Definitions - KDIGO after identifying a patient who meets the criteria for AKI the cause of AKI should be determined and staging of the severity performed staging can be performed using serum creatinine or urine output criteria patients should be staged according to the criteria that gives them the highest stage 10

AKI Staging - KDIGO AKI stage Serum Creatinine criteria Urine output criteria 1 ­ SCr increase ≥ 26 µmol/L within 48hrs or ­ SCr increase ≥ 1.5-2 X reference SCr within 1 week < 0.5 mL/kg/hr for 6 consecutive hrs 2 ­ SCr increase ≥ 2-3 X reference SCr within 1 week < 0.5 mL/kg/hr for 12 hr 3 ­ SCr increase ≥ 3 X reference SCr within 1 week SCr increase ≥ 354 µmol/L initiated on RRT (irrespective of stage at time of initiation) < 0.3 mL/kg/hr for 24 hr anuria for 12 hr 11 11 11

Raising awareness of acute kidney injury: ongoing strategies

Why do we need to raise awareness of AKI? AKI associated with an increase in Morbidity Mortality Cost AKI can occur in patients cared for in all other specialties AKI is a marker of vascular dysfunction Potential for prevention and earlier treatment Potential for earlier renal referral of primary renal disease e.g. vasculitis

Why do we need to raise awareness of AKI? Despite increased understanding within the renal community AKI is still under recognised by other healthcare specialists Not all hospitals have renal units Delays in recognition Delays in transfer Patient pathways required ? Patient follow up following episode of AKI

Why do we need to raise awareness of AKI? Patients at  risk of CKD An increased awareness of AKI may stimulate increased research opportunities Attract research groups Funding bodies Not a cunning plan for nephrologists to take over the NHS Needs to be collaborative effort

Who is the target audience? There is a need to widen the target audience Healthcare professionals Clinicians/nurses/pharmacists Hospital-based Community-based Academic researchers Potential for collaboration Patients Patients with pre-existing risk factors/previous episode of AKI Politicians Increased funding

What attempts have been made so far? Much work over the years Major interest in AKI in USA Growing interest elsewhere Clinical studies Basic research International/National conferences ASN, ISN, Renal Association etc Influential clinicians shaping Education Research Clinical service

What attempts have been made so far? International multispecialty groups Acute Dialysis Quality Initiative (ADQI) RIFLE definition Acute Kidney Injury Network (AKIN) Recent summit meeting San Diego Recommendations for clinical research

What attempts have been made so far? Guidelines International KDIGO National Renal Association UK 5th AKI clinical practice guideline Audit measures How to translate guidelines into practice ie implementation Collaboration AKI data set – James Medcalf

What attempts have been made so far? KDIGO AKI Guidelines Much anticipated Will provide a specific definition that can be used by all healthcare professionals An opportunity to provide a universal definition for both undergraduate and postgraduate trainees Need to embed in curricula Will help establish universal criteria for clinical research trials

Raising awareness of AKI in the UK National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) AKI study ‘Adding Insult to Injury’ Proposed by John Feehally Published in 2009 Presented last year at CRRT www.ncepod.org.uk

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Key findings 50% of AKI care considered good poor assessment of risk factors 43% of post-admission AKI - unacceptable delay in recognition 23

Key findings Poor recognition of acute illness hypovolaemia sepsis 24

Recommendations Improved education required surrounding Recognition and responding to the acutely ill patient Risk of AKI Precipitants Prevention Early management Appropriate referral 25

NCEPOD Failure to identify surgical patients with AKI related to the coding Further study investigating management of patients aged > 80 years who died within 30 days of surgery Proposed looking for episodes of AKI

(patients aged 80 or older who died within 30 days of a surgical procedure) 27

Acute kidney injury This is out of the 248 patients who developed AKI post admission

Acute kidney injury 29

Raising awareness of AKI in the UK Both NCEPOD studies have helped raise the awareness of AKI in the UK Questions surrounding AKI Management were posed in Parliament

Raising awareness of AKI in the UK Mr. Benyon: Question asked the Secretary of State for Health what steps he planned to take in response to each of the 8 recommendations in the NCEPOD report on AKI

Raising awareness of AKI in the UK Ann Keen: Answered The Department of Health will work with a range of national health service, professional, and patients' organisations at a national level to improve the Prevention Detection and Management of AKI

Raising awareness of AKI in the UK All NHS trusts sent the report and advised to audit patient care against the recommendations Proposals to National Institute of Health and Clinical Excellence (NICE) AKI guideline iv fluid guideline Wide range of stakeholders signed up to provide input - patients

Raising awareness of AKI in the UK Department of Health AKI Delivery Board Group of experts representing a range of specialties Medical and surgical societies Biochemistry Hospital managers General practitioners Pharmacists Nursing colleges Patient group representatives

AKI Delivery Board National AKI core competencies Framework of healthcare professionals developed by multi-professional group Renal physician (chair) Intensivist Acute Medics (vice president of the Royal College of Physicians) Surgical college representative Intensive care nursing representative Pharmacy college representatives

AKI Delivery Board National AKI core competencies Core competancies progress in complexity dependent upon status of healthcare professional Recording vital signs nurse/doctor Recognising patients at risk or with AKI Nurse/doctor/pharmacst Responding to patients at risk or with AKI Nurse/doctor/pharmacist Level of response is dependent upon the status of the healthcare professional

AKI Delivery Board AKI core competancies Final stages Submitted to Joint Specialty Committee for Internal Medicine Academy of Medical Royal Colleges Royal Nursing Colleges Royal College of Pharmacy

AKI Delivery Board National audit of AKI in acute medical admission units across UK Incidence Raise awareness

AKI Delivery Board National audit of NHS capacity to care for patients with AKI in HDU and ICU number of patients with a diagnosis of AKI in renal units HDU/ICU Outside hospitals awaiting transfer Aim to perform on World Kidney Day Survey monkey

AKI Capacity Survey for England

Research opportunities Potential benefits of raising the awareness of AKI collaborations with other specialties to identify incidence and effect of AKI on outcomes Clinical research Laboratory-based research AKI & Biomarker research is very attractive  number of grant applications

Research opportunities Renal Association conference 2011 Marked 40 AKI abstracts 2 sessions Clinical Basic research

Increasing patient awareness of AKI in the UK Patient involvement in AKI guideline development Patient education through Kidney Patient Association website Frequently asked questions Patient vignettes

Where are the knowledge gaps? Undergraduate and postgraduate level Requires input nationally and locally to be successful Needs to be made relevant to other specialties AKI as marker of acute patient illness

A suggestion Consider proposing acute kidney injury as the topic for a future World Kidney Day Being considered

Thank you