So What Do We Do Now? Dr Donal ODonoghue Dr Donal O Donoghue - - PowerPoint PPT Presentation

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
• Under recognised
• Common
• Under recognised
• Harmful
• Avoidable
• Treatable
• Poorly Managed

Confused messages: Multiple terms g p

Acute Renal Failure Acute on Chronic Acute Tubular Neorosis Renal Failure Oliguria Oliguria U Creatinine Urea Anuria Creatinine Acute Kidney Injury Anuria Acute Kidney Injury

C t l M d l f AKI Conceptual Model for AKI

Complications Complications Complications Complications

AKI

Death Death Death Death Normal Normal Normal Normal Increased Increased risk risk Increased Increased risk risk Kidney Kidney failure failure Kidney Kidney failure failure Damage Damage Damage Damage ↓ GFR GFR ↓ GFR GFR 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

59(52-66) 60(52-67) 71(64-78) 70 80

80 70

71(64-78) 60(52-67) 59(52-66)

48(40-55) 59(52 66) ( ) 40 50 60

ml/min)

* * *

60 50 40

48(40-55)

20 30 40

GFR (m

** ***

40 30 20

10

10

P P/ACE/BFZ D D/ACE/BFZ

P P/ACE/BFZ D D/ACE/BFZ

Juhlin et al, Eur J Heart Fail 2005;7:1049-1056 P P/ACE/BFZ D D/ACE/BFZ

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 1996;275:1489-94

Levy, Viscoli & Horwitz. JAMA 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

35

Days

30 35

17,326/276,731 (6.3%) ICU admissions Mean age 63.2±15.6 yrs

20 25

ARF accounted for 9.4% of all bed days Mean age 63.2±15.6 yrs

15 20

Survivors Deaths

5 10

Deaths

5 ICU ll ICU ARF H it l All H it l ARF ICU all ICU ARF Hospital All Hospital 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

• Urinalysis

30 40 3 assmt 2 t

• Ultrasound

20 % 2 assmt 1 assmt 0 assmt 10

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 D t i h t ti f ARF i t ti ll – Determine what proportion of ARF is potentially 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% i t d ith i

• 23% were associated with sepsis
• 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% i t d ith i

• 29% were associated with sepsis
• 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 A t A <70 Key Assessments: Age <70

10%

All 3 K A t 10%

37% 19%

All 3 Key Assessments 19% 37%

19%

2 of 3 Key Assessments 1 of 3 Key Assessments

34%

No Key Assessments 34%

Stevens et al, QJ Med 2001;94:553-560

34%

Key Assessments: Age ≥70 Key Assessments: Age ≥70

24% 12%

All 3 K A t 12% 24%

24%

All 3 Key Assessments %

29%

2 of 3 Key Assessments 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 volume Surgery Others

Intravascular Surgery

volume depletion 30% 5% Others 11% Infections

Volume Depletion 30 % Surgery 5% Others 11% Infections

Infections 12%

Infections 12%

Cardiac

Cardiac

Drugs 30% 12%

Cardiac 12% Drugs 30% Vijayan & Miller, Seminars in Nephrology 1998;18:523-32

eGFR = % Kidney Function

SCr 120, eGFR 30 ml/min SCr 120, eGFR 130 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

Education

the NCEPOD AKI Report

Empowerment Encouragement

AKI Report

N H S

Ri k

Kidney

Integration Risk Recognition Rehabilitation

Care

Integration Information Technology Rehabilitation Information

Systematic Reporting – Serial Serum Creatinine