1. 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

2. 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?

3. Definitions 3

4. 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

5. 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

6. 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

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

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

9. 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

10. 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

11. AKI Staging - KDIGO AKI stage Serum Creatinine criteria
Urine output criteria 1
­ SCr increase ≥ 26 µmol/L within 48hrs or
­ SCr increase ≥ 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

12. Raising awareness of acute kidney injury: ongoing strategies

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 22

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

24. Key findings
Poor recognition of
acute illness
hypovolaemia
sepsis 24

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

26. 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

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

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

29. Acute kidney injury 29

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

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

39. 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

40. AKI Capacity Survey for England

41. 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

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

43. 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

44. 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

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

46. Thank you