P30
Incidence of Community- Acquired Vs Hospital- Acquired Acute Kidney Injury in a District
General Hospital
Ramaswamy Diwakar, Adeniyi Yomi-Adeleke, Aisha Gohar, Katherine Richmond
Shrewsbury and Telford Hospitals NHS Trust
Introduction: Acute kidney injury (AKI) is a common problem in hospitalised patients. The
importance of early diagnosis and management of AKI in hospitalised patients has been highlighted
following the publication of the UK National Confidential Enquiry into Patient Outcome and Death,
AKI: Adding Insult to Injury report. However, relatively little is known about AKI acquired in the
community. AKI is associated with a high mortality. Hence any delay in its recognition or
management can potentially be associated with an even worse outcome. Early recognition of these
patients in the community before they are admitted via emergency portals may improve their clinical
outcome.
Aims: The objectives were to study the incidence among emergency hospital admissions of AKI
Stage 3, the precipitants and the outcomes including length of stay in the hospital and mortality. A
comparison of the incidence of community- acquired AKI stage 3 (CA-AKI) and hospital- acquired
AKI Stage 3 (HA-AKI) was undertaken.
Methods: This study was performed as part of the Acute Kidney Injury Audit of Outcomes and Care
Processes organised by NHS Kidney Care. In this study all patients with AKI stage 3 (AKI 3) were
identified manually using an algorithm based on KDIGO criteria. The study was performed over a
period of 6 months from August 2012 to January 2013. From this cohort 198 patients were randomly
selected for case notes review and further analysis.
Results: Using the algorithm, 427 patients were identified as having developed AKI 3 during the
study period. The incidence of AKI 3 was found to be 20 per 1000 emergency hospital admissions.
Among this cohort AKI was evident at admission in 70% (CA-AKI) and the other 30% developed
AKI subsequently (HA-AKI). Among the 198 patients randomly selected for case notes review , 194
were confirmed to have AKI 3 giving the algorithm a positive predictive value of 98% highlighting
the high degree of accuracy of the algorithm in identifying patients that meet the criteria. The
demographic characteristic of this group of 194 patients was 58% male, median age 75 years and 98%
white. The length of hospital stay in this group was 9 days (median). The commonest presumptive
causes of AKI were infection in 50% and hypovolaemia in 21%.
The in- hospital mortality was 35% and the total mortality at 1 month post diagnosis of AKI 3 was
39%. Of those who survived beyond 1 month 3% were on renal replacement therapy, 69% had
recovered renal function to baseline and 28% had evidence of incomplete recovery of renal function
compared to baseline.
Conclusion: The incidence of AKI 3 and the mortality and morbidity associated with AKI 3 was
high. Hence various aspects of AKI patient management including early recognition of AKI, early
recognition and management of risk factors and education of medical and nursing staff are being
looked at. A study is being undertaken to look at whether some of the AKI 3 are avoidable.
The incidence of CA-AKI was quite high (70%) in this cohort. A subsequent study of patients who
developed dialysis- requiring AKI showed a similar preponderance of CA-AKI (94%). This
preponderance of CA-AKI makes the early recognition of these patients in the community essential.
Given that the predominant cause of AKI was found to be infection and hypovolaemia, sick day rules
such as stopping ACE inhibitors may prevent some of these episodes of AKI.
The importance of a multidisciplinary approach to the prevention of AKI in the community cannot be
overstated and there is a clear role for of the GPs, district nurses and community pharmacists in
achieving early recognition of AKI, identification and modification of AKI risk factors. Discussions
are underway with CCGs to develop methods of early recognition of AKI and risk factors of AKI.
One such method is the AKI electronic- alert system, which is used in a number of hospitals around
the UK and has improved early AKI recognition and intervention in the AKI patient pathway for
inpatients. This can be adapted to aid early recognition of patients with AKI in the community.