South West Cardiovascular Clinical Network

Kidney workshop for

Primary Care 22 March 2016

Programme

• Acute Kidney Injury

– Dr Fergus Caskey, Medical Director UK Renal

Registry, Renal Consultant at North Bristol NHS Trust.

– Dr Kathryn Griffith, RCGP Clinical Champion for Kidney Care, Cardiovascular Lead for VoYCCG, GP

– Dr Steve Dickinson, SWSCN AKI Clinical Lead, Renal Consultant, Royal Cornwall Hospitals NHS Trust.

Programme

• Chronic Kidney Disease

– Dr Fergus Caskey, Medical Director UK Renal

Registry, Renal Consultant at North Bristol NHS Trust.

– Dr Anna Barton, Principal Biochemist, Royal Cornwall Hospitals Trust

– Dr Steve Dickinson, SWSCN AKI Clinical Lead, Renal Consultant, Royal Cornwall Hospitals NHS Trust.

Special thanks to

• Rachel Levenson - CV Programme Manager, South West Strategic Clinical Network

• Susan Shears – Network Assistant

• Michelle Roe – CV Network Manager

Objectives- AKI

• To be aware of the impact of AKI on patient safety

• To be aware of the 3 stages of AKI

• To be aware of the planned ‘switch on’ of AKI alerts to primary care

• To increase confidence of how to respond to an AKI alert

Objectives- CKD

• To learn about techniques to detect patients with deteriorating CKD

• To be aware of the implications of the NICE CKD guidelines from 2014

• To improve awareness of which patients can be managed in Primary Care

Specific questions…

• Please jot down any comments or specific AKI or CKD queries on the sticky notes

• We will attempt to answer them after the break!

South West AKI Support Tools for Primary care. I’ll cover…

• ‘Ten Top Tips’

• Primary Care Guidelines

• Prescribing – sick day rules for AKI

AKI extent in Primary Care

• Two thirds of AKI in hospital is present in patients on admission

• At RCHT we see ~350 patients each month with AKI

• Over 12 months 246,662 creatinine requests from Primary Care, 991 AKI i.e. 0.4% of requests*

* Barton et al. Nephron 2015; 130: 175-181

Ten Top Tips in AKI

• Accessible

• Simple

• Informative

Objectives

Objectives

Objectives

• AKI often indicates SICK ADULT

Objectives

Objectives

Objectives

Objectives

Primary Care Guidance- GPs

• AKI Guidelines

– National

– Local example

• Contrast Guidelines

• Medication Guidelines

Primary Care AKI Resources

• AKI patient leaflet

• Sick Day Guidance

• Secondary to Primary care patient handover i.e. AKI CQUIN on edischarge letter

www.thinkkidneys.nhs.uk

AKI resources for Primary Care

AKI in Primary Care Think Kidneys guidance

• Identifies risk factors

• Recommended response times to AKI alerts

• Advice on how to respond; cause, medication, fluid intake, clinical features prompting earlier review e.g. past history of AKI

AKI

• If no baseline creatinine value is available use normal range.

• AKI also is present if urine vol <0.5ml/Kg for 6 hours (measured by catheter output).

• If a patient receives regular haemodialysis or peritoneal dialysis then changes in creatinine will not reflect AKI. However, other abnormal electrolyte

results such as hyperkalaemia are still clinically relevant and need to be managed carefully.

Admit if:

• Clinically indicated eg sepsis • AKI stage 3 • Suspected obstruction • Suspected intrinsic renal disease with

• Urinalysis ≥1+ blood AND protein +/-Systemic symptoms eg. arthralgia, rash, bleeding

If unsure contact renal registrar or consultant via RCH switchboard.

Acute Kidney Injury Stages

Stage 3

↑Cr 3.0 x baseline known or presumed to have occurred within prior 7 days Or >354 micromol/L with ↑Cr >44 micromol/L in <24hrs Or in patients <18yrs ↓eGFR to <35

Stage 2

↑Cr 2.0-2.9 x baseline known or presumed to have occurred within prior 7 days

Stage 1

↑Cr 1.5-1.9 x baseline known or presumed to have occurred within prior 7 days Or ↑Cr >26 micromol/L in 48hrs

Acute kidney injury is a medical emergency

Trimethoprim

Trimethoprim can cause a mild rise in creatinine without a genuine drop in glomerular filtration rate. If the patient is unwell or has hyperkalaemia assume there is acute kidney

injury.

If not admitted

• Assess for cause of AKI and treat eg infection • Avoid/correct dehydration • Stop nephrotoxic drugs eg ACEi/ARB/diuretic/NSAID or new drugs especially PPI, antibiotics, allopurinol • Stop metformin(to avoid lactic acidosis). • If suspected intrinsic renal disease discuss with renal registrar or consultant via RCH switchboard. • Arrange early review and repeat creatinine and electrolytes . Repeat more urgently in more severe AKI-

generally 24hrs in Stage 3, 48-72 hrs in stage 1-2. If not improving phone the renal registrar or consultant via RCH switchboard.

Ongoing Management

• Has renal function fully recovered?- if not repeat creatinine after 2-4 weeks. If still not recovered to baseline repeat creatinine after 3 months and manage as per NICE CKD guidelines .

• Review need for ongoing use of nephrotoxic medications and consider alternatives. • If needed ACEi/ARB can usually be restarted once renal function is stable. Initiate at usual starting dose and

titrate monitoring creatinine 1 week after each dose increase. • After any AKI, monitor creatinine periodically for 2-3 years as per NICE guidance. • Inform patients on ACEi/ARB of sick day rules

Avoiding contrast nephrotoxicity

AKI CQUIN 2015/16

• Stage of AKI

• Evidence of a medicines review

• What blood tests are needed post discharge

• When the blood tests are needed

Medications and AKI

• Prevent development of AKI

– Through hypotension

– Direct action on the kidneys

• Limitation of complications of medication accumulation in AKI, e.g.

– Metformin

– Gliclazide

Prevention of AKI

• Sick Day Rules…

• Sick Day Guidance, version 8, Nov ‘15

Sick Day Guidance

• Although 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…

Sick Day Guidance, drawbacks

• Patients 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.

Sick Day Guidance, drawbacks

• Patients 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.

Sick Day Guidance, drawbacks

• People may self-manage inappropriately and not seek professional help at an appropriate stage.

• Issues related to removing medication from dossette boxes.

Sick Day Guidance

• …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 needed

Sick Day Guidance

• Advise patients 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 their antihypertensives (inc ACEi).

South West AKI Support Tools for Primary care

• ‘Ten Top Tips’

• Primary Care Guidelines

• Prescribing – sick day guidance for AKI

Questions & Comments