1. South West Cardiovascular Clinical Network AKI Event 17 September 2015

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

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

4. 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

5. 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

6. 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

7. 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

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

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

11. Workstreams

12. Risk Factors

13. Risk Factors
Modifiable
Non- modifiable

14. 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

15. 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

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

17. 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.

18. 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.

19. 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.

20. 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.

21. 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

22. 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”

23. 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.

24. 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

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

26. 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)

27. 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.

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

29. Results
Stage of AKI

30. 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

31. Results Variable On Admission Number (%) Odds Ratio OR 95% CI P value
Systolic BP <100
180 (8.1)
2.849
<0.001
Respiratory Rate ≥20
395 (17.7)
1.729
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

32. 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

33. 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%

34. 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

35. Questions & Comments

38. South West Cardiovascular Clinical Network AKI Event 17 September 2015

39. 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

40. 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

41. 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

42. Thank you