Network AKI Event 17 September 2015 1 Improving Outcomes in AKI GPs Hospital doctors Pharmacists Nurses Leaflets Sick Day Rules Education Renal View AKI programme in the South West ID: 491451
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South West Cardiovascular Clinical Network AKI Event17 September 2015
1Slide2
Improving Outcomes in AKI
GPs
Hospital doctors
Pharmacists
Nurses
Leaflets
Sick Day Rules
Education
Renal ViewSlide3
AKI programme in the South WestSlide4
Special thanks toRachel Levenson -
CV Programme Manager,
South West Strategic Clinical Network
Rachel
Gair
-
AKI Project Lead - SW SCN
Susan Shears
– Network Assistant
Michelle Roe
– CV Network ManagerSlide5
Aims of the dayTo 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 Slide6
First sessionDr 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 Slide7
Second sessionAnne 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 Slide8Slide9
Identifying risk factors for Acute Kidney InjuryDr Steve DickinsonRenal Consultant,South West SCN AKI Clinical Lead
17 September 2015Slide10
What I’ll cover Study looking at AKI Risk Factors at Royal Cornwall HospitalSlide11
WorkstreamsSlide12
Risk FactorsSlide13
Risk FactorsModifiableNon- modifiableSlide14
Non-modifiable risk factors for AKICKDa
ge 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 obstructionSlide15
Modifiable risk factors for AKIhypovolaemia 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 Slide16
Prevention of AKI8 July 2015. Interim position statement from the Think Kidneys BoardSick Day rules in patients at risk of AKISlide17
Sick day rulesAlthough 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…Slide18
Sick day rules, drawbacksPatients 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. Slide19
Sick day rules, drawbacksPatients 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. Slide20
Sick day rules, drawbacksPeople may self-manage inappropriately and not seek professional help at an appropriate stage.
Issues related to removing medication from
dossette
boxes. Slide21
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 neededSlide22
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” Slide23
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
.”Slide24
IDENTIFICATION OF RISK FACTORS FOR ACUTE KIDNEY INJURY (AKI) IN PATIENTS ADMITTED TO HOSPITAL AS A MEDICAL EMERGENCY: SINGLE CENTRE OBSERVATIONAL STUDYSteve Dickinson
, Emma Thomas, Katie Wallace, Laura Kendall, William
Pynsent
, Joanne Palmer, Rob ParrySlide25
What I’ll coverAimsMethodsResultsOur AKI Risk ScoreQuestions/CommentsSlide26
AimsTo 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)Slide27
MethodsProspective Observational Cohort StudyNon consenting
Data collection
Acute Medical Take
3 days a week for 6
months
Data collected
Comorbidities
Physiological data
Laboratory results
eg
creatinine
, FBCSlide28
Results2520 patients11.9% (n=301) had AKI87.7% (n=264) Pre renalSlide29
ResultsStage of AKISlide30
ResultsMortality Rate30 day
Number of patients
Number of patients who
died
Mortality
P Value
No AKI
2178
125
5.70%
AKI
301
59
19.60%
<0.001
Overall
Wallace et al
2014 Mortality
No AKI
2.30%
AKI
21.40%
60 day
Number of patients
Number of patients who
died
Mortality
P Value
No AKI
2178
172
7.90%
AKI
301
69
22.90%
<0.001Slide31
ResultsVariable
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
Liver Disease
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
<0.001Slide32
Analysis: Risk ScoreSystolic BP <100Respiratory Rate ≥20Temperature ≥37.5
Heart Rate ≥90bpm
Age ≥75yrs
Chronic Kidney Disease
Liver Disease
Diabetes
ACEi
/ ARB / Spironolactone
Each Factor Scores 1 pointSlide33
3 Risk Factors
Sens 77.8%
Spec 66.4%
PPV 29.5%
NPV 94.3%
5 Risk Factors
Sens 97.9%
Spec 13.9%
PPV 48.1%
NPV 89.1%
4 Risk Factors
Sens 92.3%
Spec 35.4%
PPV 39.0%
NPV 91.1%
Risk Score ROCSlide34
Future workFurther develop the Risk ScoreValidation of other Risk ScoresPotential clinical applications
Develop a score which could predict development of hospital acquired AKITo triage which patients should have renal team review
Explore validity as a screening tool which could be used in Primary careSlide35
Questions & CommentsSlide36Slide37Slide38
South West Cardiovascular Clinical Network AKI Event17 September 2015
38Slide39
Aims of the dayTo 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 Slide40
First sessionDr 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 Slide41
Second sessionAnne 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 Slide42
Thank you