South West Cardiovascular Clinical Network AKI Event 17 September 2015

Improving Outcomes in AKI Leaflets Pharmacists Sick Day Rules Nurses Education GPs Hospital doctors Renal View

AKI programme in the South West November 14 March 15 September 15

Special thanks to Rachel Levenson - CV Programme Manager, South West Strategic Clinical Network Rachel Gair - AKI Project Lead - SW SCN Susan Shears – Network Assistant Michelle Roe – CV Network Manager

Aims of the day To share learning across the Network and provide links to the national AKI programme To share and celebrate the achievements across the SW regarding AKI To bring together communities responsible for spreading this work further To raise awareness and support sustainability for the future

First session Dr Fergus Caskey – Medical Director UK Renal Registry Sally Bassett – Southern Derbyshire CCG Dr Preetham Boddhana – Renal consultant Gloucester Dr Mark Uniacke – Renal consultant Wessex Dr Steve Dickinson – Renal consultant Truro

Second session Anne Cole – Regional manager SW centre for pharmacists post graduate education Claire Oates – Senior Pharmacist, Renal Services NBT Dr Helen Condy-Young – Clinical effectiveness Lead NDHCT

Identifying risk factors for Acute Kidney Injury Dr Steve Dickinson Renal Consultant, South West SCN AKI Clinical Lead 17 September 2015

What I’ll cover Study looking at AKI Risk Factors at Royal Cornwall Hospital

Workstreams

Risk Factors

Risk Factors Modifiable Non- modifiable

Non-modifiable risk factors for AKI CKD age over 65 heart failure liver disease diabetes history of acute kidney injury renal transplant Conditions which mean limited access to fluids because of reliance on a carer Renal tract obstruction

Modifiable risk factors for AKI hypovolaemia drugs which could be harmful to the patients kidneys within the past week especially if hypovolaemic: non-steroidal anti-inflammatory drugs [NSAIDs] aminoglycosides angiotensin-converting enzyme [ACE] inhibitors angiotensin II receptor antagonists [ARBs] diuretics use of iodinated contrast agents within the past week sepsis deteriorating early warning scores

Prevention of AKI 8 July 2015. Interim position statement from the Think Kidneys Board Sick Day rules in patients at risk of AKI

Sick day rules Although there is strong professional consensus that advice on sick day rules should be given, and this approach is advocated in the NICE AKI guideline.. the evidence that provision of such advice reduces net harm is very weak… The major evidence comes from observational studies and case series that demonstrate an association between receipt of ACEI, ARBs and NSAIDs, and a risk of AKI during acute illness (4, 5, 6). However, these studies may be confounded by indication. For example patients receive ACEIs or ARBs because they have a pre-existing condition - for example, heart failure with a poor cardiac output - that is independently associated with an increased risk of AKI.

Sick day rules, drawbacks Patients may consider that the potential harm outweighs the potential benefit and decide to stop taking the drug despite the absence of an acute illness. Patients may over-interpret the advice and stop their drug treatment during even minor illnesses.

Sick day rules, drawbacks Patients may not re-start their drug treatment on recovery. The drugs may not be titrated back to the previous evidence based levels even when there has been no evidence of AKI.

Sick day rules, drawbacks People may self-manage inappropriately and not seek professional help at an appropriate stage. Issues related to removing medication from dossette boxes.

Sick day rules …it is reasonable for clinicians to provide …guidance on temporary cessation of medicines to patients deemed at high risk of AKI based on an individual risk assessment. formal evaluation needed

Sick day rules “These patients should be advised that if they become acutely ill and are unable to maintain a good fluid intake they should contact their GP for advice as to whether they should hold the ACEi or ARB”

Risk scores “There were 12 AKI risk tools for patients in the hospital but no published scores for predicting development of AKI in the community There is no universally accepted validated risk score for AKI for either primary or secondary care.” The AKI risk workstream has performed a systematic review of published and unpublished literature on scores to predict the risk of AKI. The main aims were to find out which risk scores had already been developed, and whether they had been validated.

IDENTIFICATION OF RISK FACTORS FOR ACUTE KIDNEY INJURY (AKI) IN PATIENTS ADMITTED TO HOSPITAL AS A MEDICAL EMERGENCY: SINGLE CENTRE OBSERVATIONAL STUDY Steve Dickinson, Emma Thomas, Katie Wallace, Laura Kendall, William Pynsent, Joanne Palmer, Rob Parry

What I’ll cover Aims Methods Results Our AKI Risk Score Questions/Comments

Aims To identify risk factors for AKI To develop a risk score for AKI To compare against existing risk scores Finlay et al. (Clinical Medicine, 2013) CRASHED. Ramasamy et al. (NDT, 2014) Drawz et al. (Renal Failure, 2008)

Methods Prospective Observational Cohort Study Data collection Non consenting Data collection Acute Medical Take 3 days a week for 6 months Data collected Comorbidities Physiological data Laboratory results eg creatinine, FBC 3 days a week in 6 month period Patient notes – admissions proforma for comorbidities, observations Electronic records – blood results – later. Baseline creatinine – if available in last 12 months, if not upper limit of normal range in our trust.

Results 2520 patients 11.9% (n=301) had AKI 87.7% (n=264) Pre renal Stage - Of these AKIs

Results Stage of AKI

Results Mortality Rate 2178 125 5.70% 301 59 19.60% <0.001 Overall 30 day Number of patients Number of patients who died Mortality P Value No AKI 2178 125 5.70% AKI 301 59 19.60% <0.001 Overall Wallace et al 2014 Mortality No AKI 2.30% AKI 21.40% 60 day Number of patients Number of patients who died Mortality P Value No AKI 2178 172 7.90% AKI 301 69 22.90% <0.001

Results Variable On Admission Number (%) Odds Ratio OR 95% CI P value Systolic BP <100 180 (8.1) 2.849 1.987 - 4.084 <0.001 Respiratory Rate ≥20 395 (17.7) 1.729 1.286 - 2.326 Temperature ≥37.5 219 (9.8) 2.019 1.415 – 2.881 Heart Rate ≥90bpm 807 (36.1) 1.603 1.242 – 2.086 Age ≥75yrs 943 (42.2) 1.815 1.407 – 2.341 Chronic Kidney Disease 249 (11.1) 4.931 3.646 – 6.668 Liver Disease 47 (2.1) 3.148 1.662 – 5.960 Diabetes 423 (18.9) 1.865 1.400 – 2.485 ACEiARBSpironolactone 630 (28.2) 1.733 1.332 – 2.254

Analysis: Risk Score Systolic BP <100 Respiratory Rate ≥20 Temperature ≥37.5 Heart Rate ≥90bpm Age ≥75yrs Chronic Kidney Disease Liver Disease Diabetes ACEi / ARB / Spironolactone Each Factor Scores 1 point Renin–angiotensin–aldosterone system antagonist A drug that blocks or inhibits the renin–angiotensin–aldosterone system including angiotensin-converting enzyme (ACE) inhibitors, angiotensin‑receptor blockers (ARBs), direct renin inhibitors and aldosterone antagonists. Renin–angiotensin system antagonist A drug that blocks or inhibits the renin–angiotensin system including ACE inhibitors, ARBs and direct renin inhibitors. This group of drugs does not include aldosterone antagonists

Risk Score ROC 5 Risk Factors Sens 97.9% 4 Risk Factors Spec 13.9% PPV 48.1% NPV 89.1% 4 Risk Factors Sens 92.3% Spec 35.4% PPV 39.0% NPV 91.1% 3 Risk Factors Sens 77.8% Spec 66.4% PPV 29.5% NPV 94.3%

Future work Further develop the Risk Score Validation of other Risk Scores Potential clinical applications Develop a score which could predict development of hospital acquired AKI To triage which patients should have renal team review Explore validity as a screening tool which could be used in Primary care To compare against existing risk scores

Questions & Comments

South West Cardiovascular Clinical Network AKI Event 17 September 2015

Aims of the day To share learning across the Network and provide links to the national AKI programme To share and celebrate the achievements across the SW regarding AKI To bring together communities responsible for spreading this work further To raise awareness and support sustainability for the future

First session Dr Fergus Caskey – Medical Director UK Renal Registry Sally Bassett – Southern Derbyshire CCG Dr Preetham Boddhana – Renal consultant Gloucester Dr Mark Uniacke – Renal consultant Wessex Dr Steve Dickinson – Renal consultant Truro

Second session Anne Cole – Regional manager SW centre for pharmacists post graduate education Claire Oates – Senior Pharmacist, Renal Services NBT Dr Helen Condy-Young – Clinical effectiveness Lead NDHCT

Thank you