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Acute Kidney Injury
Clinical Directors Forum
March 2010
Mark Brady
Clinical Advisor, Department of Health
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Acute Kidney Injury (AKI)
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NCEPOD findings and recommendations
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Challenge and opportunities for the renal community
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Current work
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Discussion
Findings
NCEPOD Findings &
Recommendations
Recommendations
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50% of cases with AKI documented as cause of death received
satisfactory or good care
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30% of cases inadequately investigated and managed
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20% of post-admission AKI is predictable and avoidable (or hospital
acquired AKI = HAAKI)
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All emergency admissions should have electrolytes checked on
admission and appropriately thereafter
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All acute admissions should receive adequate senior reviews, with
consultant review within 12 hours of admission
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Implementation of NICE guidance CG50
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AKI Key Facts
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AKI occurs in 18% of all hospital admissions, in a range of
settings, where acutely unwell patients are managed
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“Minor” degrees of kidney dysfunction are associated with
prolonged lengths of stay and increased mortality
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AKI is often treatable or reversible using basic clinical tests
and steps
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Quality requirement of National Services Framework for
Renal Services (Part 2)
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AKI Challenges I
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Formal definition
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Defining, identifying and communicating population at risk
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Appropriate management of the acutely unwell
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NICE CG50
Robust data
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Post-operative AKI
AKI and critical care
Contrast induced nephropathy
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Education
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Service provision, systems and excellence
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AKI Opportunities I
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Increase awareness
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Establish formal inter-specialty relationships
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All acute admitting specialties
Renal
Radiology/Urology
Critical care
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Reduce unplanned renal replacement therapy, delayed and
dangerous transfers
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Offer safer better care for our patients
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Develop and agree suitable service contracts
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AKI Opportunities II – the QIPP
agenda
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Quality
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Innovation
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Prevention
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Productivity
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An opportunity to create a visionary service…………..
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AKI Opportunities III
Formulating the argument for nonnephrologists
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AKI is not primarily a renal issue
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Prevention will reduce:
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Renal leadership can help to establish this tenant
Local groups can reiterate this and implement best practice
CQUINS can incentivise
Proportion requiring RRT
Long term conditions (LTC) burden
 CVD
 CKD
Timely investigation and treatment will:
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Improve individual patient experiences and outcomes
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AKI Challenges II
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Determining true costs associated with AKI
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Determining quality indicators
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Achieving consciousness in healthcare professionals
equivalent to:
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VTE (venous thromboembolism)
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Blood Transfusion practice
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Current work
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Acute Kidney Injury Network 2007
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Renal Association AKI Guidelines 2008
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AKI Care Initiative (AKICI) Conference May 2009
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NCEPOD report June 2009
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Dept Health and NHS Kidney Care response
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Workshop October 2009
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Ministers response December 2009
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AKI delivery board inaugural meeting March 2010
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Current Work II
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National Imaging Board Guidelines
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Produced in February 2010
Examples of good practice
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North Central London
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West Yorkshire
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Acute Kidney Injury - The future
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Over to you………
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National AKI Board Deliverables
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Support tools for AKI
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Ensuring the integration of checks (MEWS, RCP)
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Drive on improvements in access to ultrasound scanning and nephrostomy
(National Ultrasound Steering Group)
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Bringing together kidney care and critical care networks to facilitate
agreement of care pathways, specialist support and transfer protocols
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Capacity surveys of specialist care to inform commissioning decisions
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AKI in all curricula
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Piloting data collection/ audit through extension of the Vascular Society of
Great Britain and Ireland’s National Vascular Database (NHS Kidney Care)
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Recommendations
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1. A national group is convened to work collaboratively enabling real
improvements in the prevention, detection and treatment of AKI
throughout the UK.
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2. An acceptable working definition for AKI is developed by performing
a multicentre study using different staging systems and correlated with
outcomes.
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3. Enzymatic serum creatinine assay should be implemented in all
biochemistry labs throughout the UK to ensure national comparability.
For patients admitted to different hospitals with different biochemistry
laboratories the development of shared databases should be created to
improve comparability between laboratories.
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4. An electronic alert biochemistry system should be developed which
is compliant with the AKI Map of Medicine.
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5. The National Vascular Database should be reviewed and updated to
ensure AKI data is collected and audited post surgery. The incidence
and outcome of AKI in patients undergoing vascular
surgery/interventional procedures will be captured routinely.
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Recommendations
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6. Further local AKI audits should be encouraged to assess the
incidence of AKI among other specialty patient groups.
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7. There must be a co-ordinated approach to improving both
undergraduate and postgraduate education for AKI. Core competencies
must be developed to improve the identification and management of
patients at risk of developing AKI, including the acutely ill patient (NICE
CG 50).
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8. District general hospitals (DGHs) without renal services should
develop links with local renal services and develop agreed care
pathways for patients who develop AKI, enabling optimisation of patient
care and efficient transfer of patients to a renal unit if appropriate.
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9. Identification of new and improved biomarkers allowing earlier
detection of AKI should be developed to improve the potential for
targeted therapeutic intervention.
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10. Renal units should work together locally with radiology and
cardiology departments to ensure shared guidelines are in place to
prevent contrast induced nephropathy.
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AKI definitions