SERVICE SPECIFICATION 8
Acute Kidney Injury (AKI) requiring
dialysis
Table of Contents
Page
1
Key Messages
2
2
Introduction & Background
2
3
Relevant Guidelines & Standards
3
4
Scope of Service
3
5
Interdependencies with other specialties & support services
5
6
Markers of Good Practice
5
7
Quality Measures & Audit Criteria
6
Appendices
1 Impact Statement
2
Consultation Record, Document History & Version Control
This document should be read in conjunction with the Common Themes
document which is relevant to all Renal Service Specifications.
AKI requiring dialysis
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1
Key Messages
 Severity of AKI varies from a relatively trivial component of
another illness, to a serious life threatening condition
 Audits in Wales (in 2012 and 2013) estimate the potential harm
and waste as:
o Over 2,500 deaths per annum
o 15,000 bed days
o £25.5m cost of extra length of stay/care
 NCEPOD AKI enquiry (2009), confined to patients who had died
with AKI, highlighted that 20% of cases of AKI developing in
hospital were predictable and avoidable, and that 50% of
patients received care that was considered to be less than good
(www.ncepod.org.uk/2009aki.htm)
2
Introduction and Background
This service specification is confined to patients receiving haemodialysis for AKI,
and patients receiving plasma exchange when delivered by a renal service.
It excludes AKI not requiring renal replacement therapy (RRT) and patients
treated with Continuous Veno-Venous Haemofiltration (CVVH) which is usually
delivered by critical care services for severely ill, unstable patients with multiorgan failure. Delivery of CVVH does not require on-site renal services, is now
standard treatment in nearly all level 3 critical care units, and is commissioned
from critical care services.
The prevalence of AKI amongst hospitalised patients in published series varies
from 2% to 4.9%. The incidence has more than doubled over the last 20 years,
and accounts for nearly 40,000 bed days a year. Of those patients with AKI so
severe that death would occur without RRT, approximately half are nursed in a
level 3 unit and receive CVVH. The other half are most often nursed in a level 1
or level 2 bed and virtually always receive intermittent Haemodialysis (HD).
Patients may move between treatment modalities depending on the clinical
situation. In situations where a prolonged period of RRT is required for AKI,
patients will require intermittent HD delivered by a renal service.
AKI has a high morbidity and mortality. Where AKI occurs in conjunction with
the failure of two or more organs in-hospital mortality is 50-70% in most
published series. Single organ failure requiring RRT has an in-hospital mortality
of about 10-20% in most series.
A significant number of patients who develop AKI will either not recover function
and require RRT for the rest of their lives or develop CKD leading to ERF.
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The Acute Kidney Injury Capacity Survey - England and Wales (March 2011)
surveyed the availability of renal and critical care beds. It highlighted the
challenges faced in managing AKI, including high levels of bed occupancy and
significant numbers of patients awaiting transfer for specialist management.
Plasma exchange is a treatment which requires many of the same skills as HD
to perform but involves using a dialysis-like machine to filter plasma from the
patient’s circulation replacing it with either donated plasma or an alternative
fluid. It is usually performed in the context of AKI for patients with
glomerulonephritis or an inflammatory renal condition. It is recognised that
many renal units will perform plasma exchange for other specialties such as
haematology or neurology and this is not specifically covered in this
specification.
3
Relevant Guidelines and Standards
Renal Association Clinical Practice Guidelines:
http://www.renal.org/Clinical/GuidelinesSection/Guidelines.aspx
KDIGO AKI guidelines 2012:
http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO-AKI-Suppl-Appendices-AF_March2012.pdf
Acute Kidney Injury Protocols and Guidelines:
Adapted with permission from the North Central London AKI Network Version
1.0 September 2011 http://www.londonaki.net/
4
Scope of Service
Patients with AKI require specialist management in order to manage them safely
and appropriately and maximise their chance of renal recovery.
Referrals / Guidelines
There should be:

local guidelines for referral to renal services,

IT flags to possible AKI to alert non-renal clinicians to the possible
diagnosis and point towards these guidelines, and

Clear guidance to local hospitals that do not have nephrology services
to ensure access to prompt, senior renal advice and clear written
guidelines to ensure safe transfer of patients to the renal service
Environment

All patients requiring acute AKI or PlEx for AKI should be nursed in a
renal ward. This may be a whole ward dedicated to nephrology or a
dedicated part of a general medical ward.
AKI requiring dialysis
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
The ward will usually have a dedicated RO plant to provide ultrapure
water for RRT but an alternative would be the use of portable RO
machines depending on the size of the service.

There should be a facility to “step up” patients from a non-renal ward
as well as accept “step down” patients from critical care who require
on-going HD
Staff
There should be:

an MDT with expertise in treating AKI

a lead Consultant, with junior medical staff who are training in
nephrology

24 hr access to expert renal advice

7 days per week renal specialist input

expertise in providing acute dialysis line placement 24 hrs per day as
well as the ability to deal with any complications arising from this

staff with the ability to perform HD available 24 hrs per day. In smaller
units, this may be as an on-call service from home.

nursing staff with expertise in caring for patients with AKI staffing the
ward at all times. If dialysis staff are not present 24 hrs per day, the
staff who are most be fully competent to recognise, assess and deal
with the complications which can arise in dialysis patients.

specialist dietetic input

access to staff who can provide cytotoxic treatments to patients with
acute glomerulonephritis. This may be by training of renal staff or by
arrangement with staff elsewhere in the hospital with this skill set.
Treatments

Provision of intermittent haemodialysis AKI including access to
emergency HD 24 hours per day

Provision of plasma exchange – this may not be available in all units
24 hours per day but via a well developed referral pathway where it is
not.

Provision to perform urgent renal biopsies Mon – Fri.
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5
Interdependencies with other specialties & support
services
Radiology

There will be access to renal ultrasound within 24 hours as a
minimum.

There will be access to expertise to place nephrostomies a minimum
seven days a week 09.00 to 17.00.

There will be access to fluoroscopy to place venous access catheters
five days a week 09.00 to 17.00 as a minimum
Laboratory services

Renal units will have urgent access to blood products, including
plasma and plasma products, 24 hours a day 7 days a week.

There will be access to process specialised tests, such as immunology
and specialty biochemistry, five days a week as a minimum but ideally
7 days per week.

There will be access to allow processing of renal biopsies five days a
week including the ability to report urgent biopsies.
Critical Care

6
Patients with AKI frequently need the services of critical care. There
must be a good working relationship between the renal team and
critical care to allow flow of patients in both directions as clinically
indicated.
Markers of Good Practice
 Clear communication guidance exists to ensure prompt access
to renal specialists to discuss cases
 A designated renal clinical lead working with the LHB AKI
Champion to help co-ordinate local policies; the multidisciplinary team managing patients with AKI; and AKI audit
 There is clinical expertise to deliver intermittent haemodialysis
24 hours a day 7 days a week
 Doctors in training have sufficient exposure to AKI to develop
appropriate competencies
 Vascular access can be provided in appropriate settings
including operating theatres, imaging and clean areas on renal
wards 24 hours a day.
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 Colocated, interdependent and related services are available
(see section 13)
7
Quality Measures and Audit Criteria
 The clinical lead or AKI Champion provide an annual report
showing progress towards the Markers of Good Practice and
plans for service improvement
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Appendix 1: Impact Statement
This would be a general statement of possible impact and/or a record of what
the impact on each provider is agreed to be. The value of such a statement in
this appendix will be reviewed during 2016 before a statement is included
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Appendix 2: Consultation Record, Document History & Version Control
Document Author:
Executive Lead:
Approved by:
Issue Date:
Review Date:
Document No:
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Insert Committee
To be obtained from Corporate Services
Manager or Corporate Governance Manager
Document History
Revision History
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No.
Summary of Changes
Updated to
version no.:
Date of next revision
Consultation
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Date of Issue
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Approvals
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Distribution – this document has been distributed to
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By
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AKI requiring dialysis
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