Scientific Day 19 th June 2014 11.00-15.00 Welcome 11.00 11.15 Dr - - PowerPoint PPT Presentation

Acute Kidney Injury (AKI) Scientific Day 19th June 2014 11.00-15.00

Welcome

11.00 – 11.15 Dr Andy Lewington Consultant Renal Physician/Honorary Associate Professor St James’s University Hospital, Leeds

The Cost of Ignoring Acute Kidney Injury

Dr Andy Lewington Consultant Renal Physician/Honorary Clinical Associate Professor Leeds Teaching Hospitals

Declaration of Interest

• AbbVie – Advisory Board for therapy for AKI
• AM Pharma – Advisory Board for therapy for

AKI

• Alere – honoraria for chairing meeting
• Bioporto – Advisory Board for NGAL
• Fresenius – Honoraria for lecture at ICS
• Baxter – Honoraria for lecturing on IV Fluids

Acute Kidney Injury The Scale of the Problem

<50% of AKI care considered good – poor assessment of risk factors 43% of post-admission AKI – unacceptable delay in recognition

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

£1.2 Billion

Changing Face of Medicine

Hospital Population

• 25% of general population aged >60 yrs
• >85-yrs age group will double in next 20 yrs
• 66% of patients admitted >65 yrs
• 25% of patients have dementia
• Patients >85 yrs account for 22% of bed days in

NHS

Hospital Population

• Many patients have

– Multiple co-morbidities – More complex management issues – Decreased functional reserve

• Cardiac
• Respiratory
• Kidney

– Polypharmacy – e-prescribing

Less Trainees

Lewington A, et al. Kidney Int 2013;84:457–67

$9,000,000,000/YR

1.2 million 300,000

people die in the US annually from AKI People per year get AKI during a hospital stay 5 22 Your length of stay in the hospital increases by

12.5 days (3.5 times)

if you get AKI

100,000 200,000 300,000 400,000 Prostate cancer Breast cancer Heart failure Diabetes AKI

More than breast cancer, prostate cancer, heart failure and diabetes, combined

20 40 60 80 100 0.3-0.4 0.5-0.9 1.0-1.9 >=2.0

unadjusted age adjusted multivariable

ODDS OF DEATH DEATH RATE/YR 3.5% ADMISSIONS

$7,500

(3 to 14,000) PER ADMISSION EXCESS HOSPITAL COSTS

Severity of AKI

Lewington A, et al. Kidney Int 2013;84:457–67

Think Functional Reserve !

50% loss of function before serum creatinine rises above the upper limit of normal

‘It is morally inexcusable that people – mostly young people – still die of untreated acute kidney failure.’ President Giuseppe Remuzzi

ISN 0 by 25 Initiative

This initiative has one clear and concise aim: that no one should die of untreated acute kidney failure in the poorest parts of Africa, Asia and South America by 2025

Projects Team Leaders Update May 26 2014

ISN AKI 0 by 25

Collate Existing Evidence

Nephrology cohorts (AKI, CKD, registries) Jorge Cerda* Marcello Tonelli* Non-renal cohorts (HIV, Malaria, Leptospirosis, CV disease, diabetes) Emmanuel Burdmann* Vivek Jha*

Create Prospective Data

Cross-sectional Global Snap shot

• f AKI

Ravi Mehta* Norbert Lameire* Longitudinal cohort studies Guillermo Garcia* Raul Lombardi*

Develop Education and

Training materials

Tool Kits for raising awareness

• f AKI

Fred Finkelstein* Andrew Lewington*

Pilot Implementation

Predefined setting with baseline data available Nathan Levin* John Feehally*

ISN “AKI 0 by 25”: Team Members

Develop Evidence for Global Burden of Disease Raise Awareness Implement Strategy

UK Approach to AKI

Clinical Practice Guideline for the Implementation of the Electronic Detection of AKI

• Meeting October 2013

– Chaired Donol O’Donoghue – Wide representation – 10 different professional bodies – accepted AKI algorithm

• ACB and small group of Nephrologist

– currently in draft format

• would like to circulate to group

Strippoli et al J Am Soc Nephrol 2004

• Nephrology has a poor record of RCTs – fewest of all internal medicine specialties
• 1.5% of publications were RCTs (3rd lowest)
• Quality of reporting is low

Outline of areas covered in CG169

• Identifying acute kidney injury in patients with acute illness*
• Investigating for acute kidney injury
• Identifying acute kidney injury in patients with no obvious acute illness
• Assessing risk factors in adults having iodinated contrast agents*
• Assessing risk factors in adults having surgery*
• Preventing acute kidney injury
• Ongoing assessment of the condition of patients in hospital*
• Preventing acute kidney injury in adults having iodinated contrast agents
• Monitoring and preventing deterioration in patients with or at high risk of acute kidney injury
• Detecting acute kidney injury*
• Identifying the cause(s) of acute kidney injury*
• Urinalysis
• Ultrasound*
• Managing acute kidney injury
• Relieving urological obstruction
• Pharmacological management
• Referring for renal replacement therapy
• Referring to nephrology*
• Information and support for patients and carers*

* Includes key priority for implementation (KPI)

Quality Standard

AKI quality standard being developed Concise set of statements designed to drive measurable quality improvements e.g Patients at risk of AKI who suffer acute illness should have their creatinine measured

9 months to implement

Risk of Chronic Kidney Disease AKI intimately linked with CKD Both injurous processes

Severity of AKI Leads to More CKD

10 20 30 40 50 60 70 80 90 1-yr pre during 1-3 mo post 3-12 mo post > 1 yr post

Mean eGFR Time Period

None R I F D AKI Severity During Admission

Opportunity

• Harmonise the measurement of AKI
• Characterise the epidemiology

– identify those at risk of AKI

• Data for major research

– attract big Pharma

• Collaborate to refine the methodology
• No other country able to achieve
• Bruce Molitorus

– ‘if you can shame the USA into trying to achieve this then so be it’

Caveats

• Not all NHS Trusts have the same method of measuring

creatinine

– enzymatic, Jaffe

• AKI defintion – algorithm will not detect all patients

with AKI

– importance of urine output (NEWS), clinical skill

• Not all patients with small rises in creatinine will have

AKI

– ascertainment

• E-detection systems will not determine the cause of

AKI

– syndrome

• E-detection systems will detect those with AKI already

developing – need to identify those at risk

‘Kidneys are for Life’

Thank You for Attending

The National Acute Kidney Injury Programme and the Role of the Detection Workstream

11.15 – 11.35 Dr Robert Hill Chair of the AKI Detection Workstream

47

Primary Aim

The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings.

48

The purpose of the National Programme is to deliver and implement a structure and tools within three years that will lead to a fall in the number of preventable episodes of AKI, and with that a reduction in deaths associated with AKI. It will lead work on the development of clinical tools, information and levers and prioritise patient empowerment. It will utilise commissioning pathways and other clinical networks. It will also establish local and national data collection and audit leading to further safety improvement and target research towards areas that require elucidation.

Programme Purpose

26/06/2014 49

RCPE Consensus Statement November 2012

• Identification of AKI in both primary and secondary care

should be facilitated through introduction of e-alert systems

• At present systems are being developed ad hoc
• A national group should be established to develop agreed

standards for e alert systems recognising the need for some system dependent local flexibility. Components of the system should include an agreed definition of AKI based on the KDIGO classification and a standardised methodology for derivation of baseline serum creatinine. We recommend use

• f an enzymatic serum creatinine assay with an IDMS

Traceable calibration to enable standardisation.

Consensus AKI Warning Algorithm Meeting July 2013

• Held at the invitation of the Association for Clinical

Biochemistry and Laboratory Medicine

• Nephrologists appointed by Richard Fluck renal CD at NHS

England

• Clinical Biochemistry representation from England Scotland

and Wales

• Lab Computer suppliers invited via a poll of ACB members
• The output of the meeting was a consensus algorithm that

was not identical to any of the algorithms in use at the time

LIMS level ‘result’ Patient management system Alert Response

Local systems

Message Master patient index Other data systems AKI Registry

Regional National

Research QI

Local Flexibility

• The AKI programme is intending to implement

the standardised AKI warning algorithm

• Local versions of an AKI warning algorithm

even when developed to accomodate limitations of the local Pathology computer system (LIMS) will not be compliant with the AKI Programme

• Local flexibility will be necessary to convert an

AKI warning into an alert (digital or analogue)

Issues with Implementation

• Older versions of LIMS systems may require a

major software (possibly hardware) upgrade

• Existing algorithms established locally may

contain innovations that should not be discarded.

• Concerns about validation of external

algorithms

Why does the AKI warning algorithm need to be standardised?

• Removes an important variable facilitating

comparative research (The RCPE Consensus Conference : We recommend audit and research to confirm that in addition to identification of AKI the use of e-alert systems improves outcomes)

• Allows co-ordinated stepwise improvement of

the AKI warning algorithm

Design principles for national programme

Measurement underpins evidence Simplify data flows Use to evidence change Global – Social, primary and secondary care – Multiprofessional with patients and across specialties – Inclusive Strategy not tactics

57

Safety alert (issued 9/6/14)

• Raises profile of AKI and the need to develop

systems to detect early and treat

• Gives laboratories a clear idea of what to

demand from their LIMS suppliers

Maintaining and modifying the algorithm

• A sub-group of the detection workstream will

consider suggestions for changing the algorithm and supervise future pilots

• Updates of the algorithm will be issued

infrequently (maximum frequency 1 year) to allow stepwise adoption by LIMS suppliers ad their clients.

The AKI Detection Workstream Programme - What it is not about

• Ignoring innovation
• Intransigence to change
• Neglecting existing good practice
• Imposing a Tertiary Care model

What the detection workstream is about

• Reducing variation in the detection of AKI

between Trusts

• Providing a firm basis for outcome research
• Providing information resources to enable

Trusts to implement the national AKI programme

• Continuous stepwise improvement of the AKI

algorithm in co-operation with LIMS providers

Moderated Poster Session

11.35 – 12.35

• Poster Group A – Robert Hill – Moderator
• Poster Group B – Nick Selby – Moderator
• Poster Group C – Mike Bosomworth – Moderator
• Poster Group D – Andy Lewington - Moderator

Lunch/Open Poster Viewing 12.30 – 13.15

Group Work

13.15 - 13.55 Instructions We have set a question for each of the 6 groups to answer. The question can be found in your

• group. You have 40 minutes to debate this

question in your group. Be prepared to provide a five minute highlight presentation to feedback to the whole group. You will find flipcharts and pens in your groups.

Group Question 1 How would you advise a hospital that is planning to implement an AKI detection system? Would this be different for hospitals with and without renal units on site? 2 How could a best practice recommendation for converting an AKI report into an alert be developed - what would it say and what are the different

• ptions?

3 Detection of AKI also incorporates 'case finding' to ensure blood tests are actually taken in at risk groups. How can you facilitate this in clinical practice in primary care, secondary care and care home settings? 4 As AKI detection becomes more widespread, how can we continue to share experiences, good practice and problems encountered on a national basis? 5 In the absence of an automatic alert system being present, how should an AKI test result be acknowledged by clinicians? How would the transition for labs telephoning clinical areas in hospitals with significant serum creatinine changes to an AKI risk report be handled? 6 For audit/research purposes, how should a baseline AKI detection rate be established before introducing the AKI detection algorithm? How would you design an audit for those hospitals who are yet to introduce the algorithm to measure the impact of its introduction?

Feedback from Group Work

13.55 – 14.30

• 5 minutes feedback from each group

Question & Answer Session

14.30 – 14.50 Panel members Dr Andy Lewington, Consultant Renal Physician, St James’s University Hospital, Leeds Dr Robert Hill, Chair of the Detection Workstream, AKI National Programme Dr Nick Selby, Co-Chair of the Detection Workstream, AKI National Programme

Closing remarks and next steps

14.50 – 15.00 Dr Robert Hill Chair of the AKI Detection Workstream