So What Do We Do Now? Dr Donal O’Donoghue Dr Donal O Donoghue National Clinical Director for Kidney Care AKI Launch, NCEPOD RSM 11 June 2009
Acute Kidney Injury Acute Kidney Injury • Common • Common • Under recognised • Under recognised • Harmful • Avoidable • Treatable • Poorly Managed
Confused messages: Multiple terms g p Acute Renal Failure Acute on Chronic Renal Failure Acute Tubular Neorosis Oliguria Oliguria Creatinine Creatinine U Urea Anuria Anuria Acute Kidney Injury Acute Kidney Injury
C Conceptual Model for AKI t l M d l f AKI Complications Complications Complications Complications AKI Increased Increased Increased Increased Kidney Kidney Kidney Kidney ↓ GFR ↓ GFR Normal Normal Normal Normal Damage Damage Damage Damage GFR GFR Death Death Death Death risk risk risk risk failure failure failure failure Antecedents Intermediate Stage AKI Outcomes
Racking Up The Risk Racking Up The Risk 14 healthy elderly aged 67-78 Single dose of oral Diclofenac (50mg) or placebo With or without pre-treatment with Enalapril & BFZ 80 71(64-78) 71(64-78) 80 70 60(52-67) 59(52-66) 60(52-67) ( ) 70 59(52 66) 59(52-66) 60 ml/min) 60 48(40-55) 48(40-55) * * 50 50 * GFR (m 40 40 40 40 ** 30 30 *** 20 20 10 10 0 0 D/ACE/BFZ D/ACE/BFZ P P P/ACE/BFZ P/ACE/BFZ D D P P/ACE/BFZ D D/ACE/BFZ Juhlin et al, Eur J Heart Fail 2005;7:1049-1056
US National Hospital Discharge Survey • Projected 29,039,599 hospital admissions, 558,032 coded as ARF (1.92%) Without ARF With ARF Median age (yr) 58.0 73.0 Median LOS (d) 3.0 7.0 Death (%) 2.3 21.3 Liangos et al. CJASN ePress October 26, 2005
The Effect of ARF on Mortality The Effect of ARF on Mortality • 16,248 radiocontrast media procedures • 183 subjects with contrast-media associated ARF j • 174 paired subjects (age, procedure, baseline Cr) • Mortality • Mortality – 7% in those without renal failure – 34% in those with renal failure • After comorbidity adjustment renal failure y j conferred an odds ratio risk of dying of 5.5 Levy, Viscoli & Horwitz. Jama Levy, Viscoli & Horwitz. JAMA 1996;275:1489-94 1996;275:1489-94
Acute Kidney Injury and Costs • Consecutive sample of 19,982 adults • In 1237/9210 (13 4%) SCr ↑ by ≥ 44 µmol/L In 1237/9210 (13.4%) SCr ↑ by ≥ 44 µmol/L • 6.5x risk of death, 3.5d increased LOS Unadjusted Age and gender adjusted Multivariably adjusted Chertow et al. JASN 2005;16:3365-3370
ICNARC: ARF Length of Stay g y Days 35 35 17,326/276,731 (6.3%) ICU admissions 30 Mean age 63.2±15.6 yrs Mean age 63.2±15.6 yrs 25 ARF accounted for 9.4% of all bed days 20 20 Survivors 15 Deaths Deaths 10 5 5 0 ICU ICU all ll ICU ARF ICU ARF H Hospital All it l All H Hospital ARF it l ARF Kohle, Stevens, Crowe et al Critical Care
Rayner HC. Rayner HC. A model undergraduate core curriculum in adult renal medicine. Med Teacher 1995; 17:409–2. 36 month survival • CVP / fluid status 50 40 • Urinalysis 3 assmt 30 2 assmt 2 t % • Ultrasound 1 assmt 20 0 assmt 10 0 0
AKI in a UK DGH • 12 month prospective survey of ARF • Patients identified on a daily basis by computer y y p extract and assessed at the time of identification • Long-term follow up to determine survival Long term follow up to determine survival • Aims – Determine the epidemiology of ARF in East Kent Determine the epidemiology of ARF in East Kent – Evaluate the initial management of ARF – Determine what proportion of ARF is potentially D t i h t ti f ARF i t ti ll avoidable Stevens et al, QJ Med 2001;94:553-560
Community Acquired ARF Community Acquired ARF • 163/291 ARF present at time of admission • 45% were associated with intravascular volume depletion and/or hypotension p yp • 28% were associated with obstruction • 23% were associated with sepsis 23% i t d ith i • 23% were drug-related g Stevens et al, QJ Med 2001;94:553-560
Hospital Acquired ARF Hospital Acquired ARF • 125/291 ARF developed after admission • 55% were associated with intravascular volume depletion and/or hypotension p yp • 34% were drug-related • 29% were associated with sepsis 29% i t d ith i • 10% were associated with obstruction Stevens et al, QJ Med 2001;94:553-560
AKI in a UK DGH AKI in a UK DGH Definitely Avoidable ARF: 54 of 291 Definitely Avoidable ARF: 54 of 291 Potentially Avoidable ARF: 101 of 291 Probably Unavoidable ARF: 136 of 291 Stevens et al, QJ Med 2001;94:553-560
K Key Assessments: Age <70 A t A <70 10% 10% All 3 K All 3 Key Assessments A t 37% 37% 19% 19% 19% 2 of 3 Key Assessments 1 of 3 Key Assessments No Key Assessments 34% 34% 34% Stevens et al, QJ Med 2001;94:553-560
Key Assessments: Age ≥ 70 Key Assessments: Age ≥ 70 12% 12% 24% % 24% 24% All 3 Key Assessments All 3 K A t 2 of 3 Key Assessments 29% 29% 1 of 3 Key Assessments 35% No Key Assessments 35% Stevens et al, QJ Med 2001;94:553-560
Primary Instigating Factors for AKI Primary Instigating Factors for AKI Intravascular Surgery Intravascular Others Others volume volume Surgery Surgery Others Volume 5% 5% 11% depletion 11% Depletion 30 % 30% Infections Infections Infections Infections 12% 12% Cardiac Cardiac Cardiac Drugs 12% 12% Drugs 30% 30% Vijayan & Miller, Seminars in Nephrology 1998;18:523-32
eGFR = % Kidney Function SCr 120, eGFR 130 ml/min SCr 120, eGFR 30 ml/min
Knowledge is the enemy of disease Number of RCTs published in Nephrology and 12 other specialities in internal medicine 1996-2002 Strippoli et al. JASN 15:411-419, 2004
Responding to the NCEPOD Education AKI Report AKI Report Empowerment Encouragement N H S Kidney Integration Integration Risk Ri k Care Information Recognition Technology Rehabilitation Rehabilitation Information Systematic Reporting – Serial Serum Creatinine
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