South West Cardiovascular Clinical
Network AKI Event
17 September 2015
1
Improving Outcomes in AKI
Leaflets
Pharmacists
Sick Day
Rules
Nurses
Education
GPs
Renal
View
Hospital
doctors
AKI programme in the South West
November
14
March 15
September
15
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
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
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
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
Identifying risk factors for
Acute Kidney Injury
Dr Steve Dickinson
Renal Consultant,
South West SCN AKI Clinical Lead
17 September 2015
What I’ll cover
•
• Study looking at AKI Risk Factors at Royal
Cornwall Hospital
Workstreams
Risk Factors
Risk Factors
• Modifiable
• Non- modifiable
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
•
•
•
•
•
•
•
•
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
Prevention of AKI
• 8 July 2015. Interim position statement
from the Think Kidneys Board
• Sick Day rules in patients at risk of AKI
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…
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.
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.
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.
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
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”
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.”
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
What I’ll cover
•
•
•
•
•
Aims
Methods
Results
Our AKI Risk Score
Questions/Comments
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)
Methods
• Prospective Observational Cohort Study
• Non consenting
• Data collection
• Acute Medical Take
• 3 days a week for 6 months
• Data collected
• Comorbidities
• Physiological data
• Laboratory results eg creatinine, FBC
Results
• 2520 patients
• 11.9% (n=301) had AKI
• 87.7% (n=264) Pre renal
Results
• Stage of AKI
Results
• Mortality Rate
30 day
Number of
patients
Number of
patients who
died
Mortality
No AKI
2178
125
5.70%
AKI
301
59
19.60%
Number of
patients
Number of
patients who
died
Mortality
No AKI
2178
172
7.90%
AKI
301
69
22.90%
60 day
P Value
Overall
Wallace et
al 2014
Mortality
No AKI
2.30%
AKI
21.40%
<0.001
P Value
<0.001
Results
Variable
On Admission
Number (%)
Odds Ratio
OR 95% CI
P value
Systolic BP <100
180 (8.1)
2.849
1.987 - 4.084
<0.001
Respiratory Rate ≥20
395 (17.7)
1.729
1.286 - 2.326
<0.001
Temperature ≥37.5
219 (9.8)
2.019
1.415 – 2.881
<0.001
Heart Rate ≥90bpm
807 (36.1)
1.603
1.242 – 2.086
<0.001
Age ≥75yrs
943 (42.2)
1.815
1.407 – 2.341
<0.001
Chronic Kidney Disease
249 (11.1)
4.931
3.646 – 6.668
<0.001
47 (2.1)
3.148
1.662 – 5.960
<0.001
Diabetes
423 (18.9)
1.865
1.400 – 2.485
<0.001
ACEiARBSpironolactone
630 (28.2)
1.733
1.332 – 2.254
<0.001
Liver Disease
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
Risk Score ROC
1.01
Sensitivity
0.81
4 Risk
Factors
Sens 92.3%
Spec 35.4%
PPV 39.0%
NPV 91.1%
0.61
3 Risk
Factors
Sens 77.8%
Spec 66.4%
PPV 29.5%
NPV 94.3%
0.41
0.21
5 Risk
Factors
Sens 97.9%
Spec 13.9%
PPV 48.1%
NPV 89.1%
0.01
0
0.1
0.2
0.3
0.4
0.5
0.6
-0.19
1-Specificity
0.7
0.8
0.9
1
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
Questions & Comments
South West Cardiovascular Clinical
Network AKI Event
17 September 2015
38
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
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
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
Thank you