acute kidney injury (aki) alerts for primary care

Acute Kidney Injury (AKI)Alerts for Primary Care

Fiona DuthieST7 Renal/GIM

Overview

• AKI – what is it and why is it important• AKI in the community • Electronic alerts• Lothian involvement - SPSP National Collaborative on AKI• E-alerts: the experience in NHS Tayside• What resource already exists?• Discussion

NCEPOD 2009

• 22% of cases who developed AKI in hospital, avoidable

• Recognition of risk factors poor• 33% had inadequate investigations• 31% referred to nephrology• 21% delayed• 20% omitted

• Only 50% of patients had �good� care

Stage Serum Creatinine Urine Output

Stage 1 1.5-1.9 x baselineOr rise >26µmol/l

<0.5mls/kg/hr 6-12 hrs

Stage 2 2.0-2.9 x baseline <0.5mls/kg/hr for >12hrs

Stage 3 3.0 x baselineOr rise to >353µmol/lOr RRT

<0.3mls/kg/hr for 24rs Or anuria for >12hrs

RenalGlomerular• GlomerulonephritisTubular• Acute tubular injury (ATI)• rhabdomyolysis• myelomaInterstitial• Interstitial nephritis

Post-RenalCalculiProstateMalignancyUrethral strictureRetroperitoneal fibrosisIntra-abdominal hypertension

Pre-RenalHypovolaemia

Reduced effective circulating volume

Drugs

AKI is a syndrome

AKI

Lewington Kidney International 2013

AKI - Cause of Death

Selby Plos One2012

AKI and Chronic kidney disease (CKD)

Lakhmir NEJM 2014 371:58-66Molitoris J Clin Invest 2014;124(6)2355-2363

Risk factorsModifiable• Drugs• High-risk or emergency

procedures• Anaemia• Critical illness• Sepsis• Trauma• Cardiac surgery• Major non-cardiac surgery• (Radiocontrast media)• Fluid overload• Hydroxyethyl starch

Non-modifiable• Age• Male sex• Black race• CKD• Proteinuria• Hypertension• Diabetes mellitus• Cirrhosis• Ischaemic heart disease• COPD• Peripheral vascular disease• Malignancy

Serum creatinine result exists?

Previous result Within 0 � 365 days?

Index creatinine value Defined as

C1

If Result within 0 � 7 days

Then:

If Result within 8 � 365 days

Then:

Find lowest value

Define as RV1

Calculate RV ratio C1 / RV1

Find MEDIAN of results

Define as RV2

Calculate RV ratio C1 / RV2

Is higher RV ratio �����

Is higher RV ratio ���������������

Is higher RV ratio ��������������

ALERT! ?AKI 3

Alert! ?AKI 2

ALERT! ?AKI 1

Is higher RV ratio ����

Has change occurred Within 48hrs?

��������������� Report without alert

Report without alert. Send to authorisation Q

If creatinine has �������������� ����

In < 7 days. Consider requesting

repeat If CKD unlikely.

< RI? Flag low

Within RI? No flag

Flag High ?AKI ?CKD

Suggest Repeat Algorithm for detecting Acute

Kidney Injury (AKI) based on serum creatinine changes with time This algorithm relates to the NHS England patient safety alert: NHS/PSA/D/2014/010

RI =Population Reference Interval (Age and sex related if available)

RV = Reference value. Defined as: the creatinine value with which an index

creatinine value is compared

D = difference between current and lowest previous result within 48hrs

YES

NO YES

YES

NO

NO

NO YES

YES

YES

YES

YES

NO

NO

NO

NO

ULRI = upper limit of reference interval

Is age < 18 years? Serum creatinine > x3 ULRI?

Serum creatinine �����������

YES

YES

YES

YES

NO

NO

NO

Electronic alerts

Baseline creatinine:

1. Median creatinine 8-365 days pre index creatinine

2. Lowest level 0-7 days pre index creatinine

3. Lowest level 0-2 days pre measurement

E-alert – activeor passive

www.thinkkidneys.nhs.uk/aki/

Acute Kidney Injury (AKI)

What have you tested?• AKI e-alert via trak system • Protocol – posters and link to

online protocol with AKI alert result

• Canned text for electronic patient record (\AKI) to improve documentation

• Curently working on hydration –nursing handover

ACUTE KIDNEY INJURY PROTOCOL

Early Recognition of AKI (KDIGO criteria) Creatinine rise from baseline by ≥50% or 26.5µmol/l

and/or

Oliguria (urine output <0.5ml/kg/hr for ≥6hrs)

Assessment/Management Alert senior doctors early

1  Correct hypovolaemia •  Use small fluid boluses (250ml) of

crystalloid initially •  Regularly reassess JVP, peripheral

perfusion, BP, urine output

2  Address hypotension •  Once euvolaemic consider CVP monitoring

+/- vasopressors - early critical care referral

3  Manage hyperkalaemia •  See separate protocol 4  Review drugs •  Stop nephrotoxins •  Stop antihypertensives if BP low •  Review all drug dosages in renal

impairment

5  Urinary tract ultrasound •  Look for obstruction/abnormal renal tract

Nephrology Referral Refer to Renal SpR if:

•  Clinical suspicion of intrinsic renal disease (even if mild AKI)

Proteinuria +/- haematuria Absence of clear precipitant of AKI Systemic symptoms/signs suggestive of vasculitis eg rash, arthropathy, pulmonary infiltrates •  Progressive renal impairment •  Refractory hyperkalaemia

(≥ 6.5 mmol/L) •  Refractory acidosis

(H+≥ 60 nmol/L) •  Refractory pulmonary oedema •  Renal transplant •  Background CKD 4/5

RIE Tel: 07816 174294

Consider potential causes

•  Sepsis •  Hypoperfusion Cardiac/liver failure Haemorrhage Dehydration

•  Nephrotoxins Drugs Contrast

•  Renal disease e.g. Myeloma, rhabdomyolysis, glomerulonephritis

•  Obstruction

R e q u i r e d a c t i o n s 1.  Senior review 2.  Updated renal function 3.  Fluid balance assessment 4.  Drug chart review 5.  Urine dip (+/- protein:creatinine ratio) 6.  Check acid/base (TCO2/H+/pH) 7.  Urinary tract ultrasound

\AKI

AKIStage: 1/2/3Contributingfactorsandworkingdiagnosis: Sepsis: Yes/NoVolumestatus: Hypovolaemia/Euvolaemia/HypervolaemiaUrinalysis: Urinaryobstruction(arrangeimaging): Yes/NoFluidsprescribed: Yes/No/NotindicatedFluidbalancerequested: Yes/NoRepeatbloodsordered: Yes/NoMedRec(nephrotoxins,metforminetc): Yes/NoOtherplans:

AKI in Secondary Care

AKI trak alerts

www.edren.org

AKI in Secondary Care

• Care of the Elderly, General Medicine, Orthopaedics (RIE)• AMU, Stroke (WGH)• Aim to release Lothian-wide later in the year in secondary care

0

10

20

30

40

50

60

70

80

Patie

nt da

ys

Month

Average LOS (in days) of patients who had at least one positive test for AKI | By discharge month | RIE Ward 202 | Jan 2017 to July 2018

Rule 1 - Point outside control limits

Rule 2 - Shift (8 + above CL)

Rule 2 - Shift (8 + below CL)

Rule 3 - Trend (6 + increasing)

Rule 3 - Trend (6 + decreasing)

Rule 4 - 2 of 3 in 3rd third

Rule 5 - 15 + in 1st third

UCL

LCL

Centre Line (running mean)

Target

Value

0

20

40

60

80

100

120

140

31/0

7/20

16

31/0

8/20

16

30/0

9/20

16

31/1

0/20

16

30/1

1/20

16

31/1

2/20

16

31/0

1/20

17

28/0

2/20

17

31/0

3/20

17

30/0

4/20

17

31/0

5/20

17

30/0

6/20

17

31/0

7/20

17

31/0

8/20

17

30/0

9/20

17

31/1

0/20

17

30/1

1/20

17

31/1

2/20

17

31/0

1/20

18

28/0

2/20

18

31/0

3/20

18

30/0

4/20

18

31/0

5/20

18

30/0

6/20

18

31/0

7/20

18

Patie

nt da

ys

Month

Total days in AKI for patients with all AKI alerts by month of first test - excluding patients who died in hospital | ward 202 | August 2016 - July 2018

Rule 1 - Point outside control limits

Rule 2 - Shift (8 + above CL)

Rule 2 - Shift (8 + below CL)

Rule 3 - Trend (6 + increasing)

Rule 3 - Trend (6 + decreasing)

Rule 4 - 2 of 3 in 3rd third

Rule 5 - 15 + in 1st third

UCL

LCL

Centre Line (running mean)

Target

Value

Lessons from secondary care:

• E-alert does nothing without education/guidance• And re-education!

• One size does not fit all• Review the patient, and re-review, and re-review• Concerns about balancing measures• Pulmonary oedema

• Patients’ concerns• Beware AKI 1

AKI in the community

AKI in the community

• 70% of AKI in hospital is community acquired• 0.4-1.4% of creatinine tests in primary care = AKI

• 46 practices in Salford, Apr-Aug 2016• 4 groups, 2x2 factorial design, education and e-alert• AKI 2 and 3 reported e-alerts and phoned• Primary outcomes: time from alert to repeat test or admission to hospital

• 1807 (0.8%) AKI – 391 Stage 2/3 in 251 patients• 78.4% AKI 1, 14.8% AKI 2, 6.9% AKI 3

Tollitt et al. Family Practice April 2018

Tollitt et al. Family Practice April 2018

Tollitt et al. Family Practice April 2018

Response time

Tollitt et al. Family Practice April 2018

Tayside experience

• Tayside population 400,000• April 2015 – e-alerts introduced in both primary and secondary care• Compared with 2012• Real-time alerts in lab reporting system – signposted to guide• Emails to ordering clinician AKI 2 and 3• Outcomes: time of repeat test, hospitalisation within 7 days

• 9781 in 12 months – 1460(14.9%) in primary care• 1167(79.9%) AKI 1, 181(12.4%) AKI 2, 112 (7.7%) AKI 3

Aiyegbusi et al. Clinical Kidney Journal 2018

Aiyegbusi et al. Clinical Kidney Journal 2018

Alert Levels

AKI 1

AKI 2

AKI 3

Dr Samira Bell, NHS Tayside

Link to AKI guidelines

Dr Samira Bell, NHS Tayside

Dr Samira Bell, NHS Tayside

Acute Kidney Injury

Best Practice Guidance: Responding to

AKI Warning Stage Test Results for Adults in Primary Care Publication date April 2016

www.thinkkidneys.nhs.uk/aki/

Table 1. Acute Kidney Injury: Recommended response times to AKI Warning Stage Test Results for Adults in Primary Care

AKI Warning Stage Test Result Clinical Context Within Which Blood Test Taken#

Confirm or refute automated AKI Test Result by If clinical context is unknown, then assume high pre-test probability until proven otherwise

comparing patient’s current creatinine within

LOW Pre-test Probability of AKI HIGH Pre-test Probability of AKI

clinical context against baseline creatinine

Stable Clinical Context Context of Acute Illness

AKI Warning Stage 1 Consider clinical review 72 hours of e-alert*

Consider clinical review 24 hours of e-alert*

Current creatinine ≥1.5 x baseline level

If AKI confirmed manage as per table 2 Likely Stage 1 AKI manage as per table 2

(or creatinine rise >26 mol/L 48 hrs)

AKI Warning Stage 2 Consider clinical review 24 hours of e-alert* Consider clinical review 6 hours of e-alert*

Current creatinine ≥2 x baseline level If AKI confirmed manage as per table 2 Likely Stage 2 AKI manage as per table 2

AKI Warning Stage 3 Consider clinical review 6 hours of e-alert*

Consider Immediate Admission*

Current creatinine ≥3 x baseline level

If AKI confirmed consider admission Likely Stage 3 AKI

(or creatinine 1.5 x baseline and >354 mol/L)

¥ UK Renal Association Clinical Practice Guidelines (2014) recommends emergency assessment and treatment of severe hyperkalaemia (K+≥6.5mmol/l) – http://bit.ly/hyperkalaemia-guidelines Refer to main guidance

document. The table is a guide to support an initial response to an AKI Warning Stage Test Result but clinical judgement must prevail. The table does not apply to children and young people (<18 years) or patients receiving end of life care. Acute Kidney Injury Best Practice Guidance: Responding to AKI Warning Stage Test Results for Adults in Primary Care 13

#Clinical Context

Why was the blood test taken? Routine chronic disease monitoring Drug monitoring Assessment of acute illness Creatinine rise within stable clinical context may reflect unstable CKD instead of AKI, especially if longer time period between current and baseline creatinine.

*AKI Risk Factors/Clinical Features Prompting Earlier Review Poor oral intake/urine output Evidence of hyperkalaemia, especially if moderate(K+ 6.0-6.4) or severe (K+ ≥ 6.5)¥ Known history of CKD stages 4 & 5 or history of kidney transplant Deficient Immunity Frail with co-morbidities (CKD, diabetes, heart failure, liver disease, neurological or

cognitive impairment) Past history of AKI Suspected intrinsic kidney disease Suspected urinary tract obstruction

www.thinkkidneys.nhs.uk/aki/

www.thinkkidneys.nhs.uk/aki/

Management in primary care

• Is it AKI? And is so, why?• Assess volume status- increase oral intake, stop diuretics if volume deplete• Consider obstruction• Consider intrinsic renal disease- urinalysis, history

• Review medications: consider stopping NSAIDs/ ACE inhibitors/ ARB• Treat sepsis (avoid trimethoprim)• Repeat U&Es in 24 hours

• If in doubt: Renal 07816 174294

Referral to Renal

• Any AKI 3• Suspicion of intrinsic renal disease eg myeloma, vasculitis• Renal transplants• Stage 4 or 5 CKD• Hyperkalaemia/acidosis/fluid overload

• If in doubt: Renal 07816 174294

Sick Day rules (avoid the term “nephrotoxins”)

Communication secondary to primary care

• Possible harms of AKI diagnosis• Drugs – when to restart• Readmissions with cardiac failure

• Tests – when to repeat (and what to do if abnormal)

• Ambulatory care/Day attenders• Hospital at home• Renal outpatient follow up

Summary

• AKI is common and the majority starts in the community • Syndrome; marker for sick patient – should prompt review• Associated with increased morbidity and mortality

• Primary care – opportunity for earlier detection and action• Improve care for patients

• Electronic alerts could be useful part of a tool to act early in primary care in Lothian• Support from secondary care essential

• There is resource available – one size does not fit all

Questions?

Fiona.duthie1@nhs.net

www.thinkkidneys.nhs.ukwww.londonaki.netwww.edren.org