1. Prospective audit October 2011-October 2012 Acute Kidney Injury at Dorset County Hospital renal unit Dominic Taylor ST4 Nephrology Dorset County Hospital

2. NCEPOD: Adding insult to Injury (2009) Only 50% of AKI care considered good Poor assessment of risk factors Appropriate investigations (Ultrasound, urine dip) not always performed Senior review within 12 hours recommended Renal referrals were delayed in 20% Timely, appropriate specialist advice and transfer needed.

3. Dorset County Hospital Nephrology service Large geographical area, population >850,000 ‘Outreach’ service and clinics at YDH, RBH and PGH

4. Aims Assess adequacy of care from Nephrology and non- Nephrology teams. Aim to implement guidelines to alter management and continuous re-audit.

5. Inclusion criteria October 2011- October 2012 Patients transferred to renal ward at DCH from other ward or hospital, with a diagnosis of AKI. Electronic and written notes review.

6. Demographics 51 patients 26 Male 25 Female Mean age at presentation 68 years (22-90) Median age 72 years

7. Referrals 26(51%) from within DCH 25 transferred from other hospitals 32(63%) from medical teams ReferrermedicalsurgicalITUTOTAL DCH175426 YDH3014 RBH54514 PGH6006 Salis1001 TOTAL3291051 9(18%) surgical 10(20%) ITU

8. Length of stay Mean LoS 7.5 days for medical patients at DCH Mean Length of stay 17 days

9. Risk Factors

10. Aetiology ‘Pre-renal' sepsis14 D&V/GI upset4 post-op3 GI bleed1 cardiorenal1‘Renal' Glomerulonephritis ANCA vasc7 Interstitial nephritis2 other vasculitis1 Systemic disease haemolysis/blackwater fever1 Myeloma3 Iatrogenic Post angio/contrast2 Vanc/Gent2 ACEi toxicity2 Ingestion NSAIDS2 Ethylene Glycol1 metabolic Rhabdomyolysis4 Hypercalcaemia1‘Post-renal' RPF/malignancy5 Retention2 Calculus2

11. Referring team management

12. Timing of Imaging

13. Referral and response Renal referral within 24 hours of AKI? Advice or review within 24 hours of referral? Transfer to renal unit within 48 hours of referral? %69100 72(85 excluding ITU on support)

14. Outcomes 34 received haemodialysis acutely 11 of these haemofiltered on ITU In-hospital death: 5 (10%) Death within 3 months: 10 (20%) 7 (14%) needed permanent RRT (all HD) DialysisDeath Baseline eGFR <60 significantly increased risk of permanent RRT ( χ 2 =0.00035) Baseline eGFR <60 significantly increased risk of death within 3 months ( χ 2 = 0.0004)

15. Summary Acute on CRF most common cause of AKI with poorer outcomes (death or long-term dialysis) 54% did not have renal tract imaging within 24 hours 20% patients did not have adequate fluid resuscitation 22% patients did not have nephrotoxic drugs discontinued 26% patients did not have consultant review within 12 hours of admission 29% patients did not have urine dip

16. Quick checklist to guide initial management for junior teams Applies to non medical teams and AKI occurring after admission Aim to pilot in DCH and re-audit for effectiveness. DCH AKI Checklist

17. AKI DEFINITION (Creatinine increased >26µmol/L in 48 hours Creatinine >1.5x known reference value or UOP <0.5ml/kg/hr last 6 hours) Check U&Es on every newly admitted patient In suspected AKI, find last recorded U&Es if available If AKI: Assess fluid status and replace fluid iv (Aim to restore blood pressure with saline. Plasmalyte contains potassium, avoid if ↑K + ) Examine for distended bladder (Especially in men; Bladder scan also useful; Catheterise if retention suspected) Perform urine dipstick (Nurses to record in medical proforma even if negative, nurses also to record patient weight) Stop nephrotoxic drugs (Specifically ACE inhibitors or ARBs, diuretics, other antihypertensives, NSAIDs) Check K + and treat medically if indicated (Check ABG; IV calcium gluconate 10 ml 10% followed by insulin-dextrose; do not use salbutamol) Monitor urine output (Catheter not always needed) Senior review asap; Consultant review within 12 hours Organise ultrasound to exclude obstruction (Within 24 hours) Try to establish the cause. Treat sepsis as per established guidelines. Escalate care if needed. Avoid iv contrast. If nephrotoxic antibiotics (Gentamicin) necessary, monitor carefully (see protocol) Refer to renal unit or discuss early. VTE prophylaxis with Clexane 20mg od if indicated. CHECKLIST FOR AKI PATIENTS ATTACH TO NOTES. TICK BOXES. MANAGEMENT PLAN IS NOT EXHAUSTIVE.

18. Acknowlegements Dr Jo Taylor, Consultant Nephrologist DCH Nephrology team, DCH