Liverpool experience of Community AKI care

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1 Liverpool experience of Community AKI care Shahed Ahmed Consultant Nephrologist and Honorary Lecturer Royal Liverpool University Hospital

2 Is AKI really a problem? , deaths are year are associated with acute kidney injury. (NCEPOD 2009) Costs to the NHS estimated to be 1 billion per year. (Kerr et al 2014) Approximately 65% of Acute Kidney Injury Starts in the Community. (Selby et al 2012) 2009: No systemic approach in recogn and management of AKI Adapted from NHS England AKI we

3 AKI Care : A Holistic approach mmunity AKI care AKI Risk Identificati Post AKI Care Patient Recognis E- Alert Referral/ ephrology Response AKI Guidelin Care Bund AKI team A co-ordinated care to improve AKI outcome ed Ahmed, RLUH

4 Our Approach: RLUH - Integrated AKI service Community AKI project AKI guideline Education and Training Patient E-AKI alert Care Bundle/ AKI clinic Clinic 2013 Hospital AKI Team Outcome ed Ahmed, RLUH

5 utcome RLUH : Integrated AKI service hahed Ahmed, RLUH

6 AKI: the present a positive trend with many excellent innovative service developments Shahed Ahmed, RLUH

7 Key Issues 1 : High mortality rates in hospitalised patients with AKI In a UK hospital-wide population with AKI: mortality 23.6% p< p=0.28 In a UK hospital-wide population lby NM et al CJASN 2012; 7(4):

8 AKI and mortality.the discrepancy!

9 AKI : Mortality! Independent risk factor for mortality? Marker of gravity of underlying illness? Increased risk non renal complications? Distant effects of ischaemic AKI -> Inflammation 65 years or over. Sepsis Hypovolaemia Heart failure Liver disease Diabetes Post surgery Risk Factors for AKI Neurological or cognitive impairm Chronic kidney disease (egfr <45 Use of drugs with nephrotoxic potential urological obstruction

10 Key Issues 2: Community acquired AKI accounts for twothirds of cases. p< Selby NM et al CJASN 2012; 7(4): 533

11 Community AKI : The Challenges! GPs worry : What if I miss an alert (litigation?) Secondary Care /Tertiary care worry:.not another AKI (workload)!! OOH/ Weekend : Impact on UC 24 service? Blood test over W/E? Shahed Ahmed, RLUH

12 014 munity project RLUH Community AKI Pilot Project 35,000 GP patient population( approx.) RLUH Renal team supported community AKI service RLUH community AKI Guideline AKI nurse support (consultant led AKI service) 24 hour renal on call support Education and training support hed Ahmed, RLUH

13 LUH Community AKI Guideline

14 unity KI RLUH Community AKI guideline Confirmed AKI (think FLUID S) Fluid balance: Check for signs of dehydration and treat Low BP (check BP and if SBP³<110) - withhold anti-hypertensive Urine: dip test and microscopy. Check urine output. Catheterize if in retention Imaging: US Kidney If suspected urological obstruction Drugs and Toxins: -Stop NSAID. Withhold ACE Inhibitors (ACEI) and A2 receptor blockers(arb) - avoid nephrotoxic medications Sepsis: Look for signs of sepsis and treat accordingly

15 Community AKI pilot: 1 year data otal samples AKI alerts (1-3) 18, % Total Full recovery Partial recovery No recovery Mortality 1 year AKI % 43% 16% 26% AKI % 8% 23% 31% AKI3 7 43% 14% 43% 57% AKI 1 AKI 2 AKI 3 Full Recovery Partial Recovery No Recovery No Recovery Partial Recovery Full Recovery AKI 1 AKI 2 AKI 3 median age Deceased Survived Survived Deceased median age Shahed Ahmed, RLUH

16 Post AKI : 2 Key problems? A. Risk of developing CKD B. Mortality over next 12 months or, so Recovered AKI requiring temporary dialysis: Increased risk of coronary events, cardiovascular mortality and heart failure Wu et al J Am Soc Nephrol 25: (2014) Odutayo et al J Am Soc Nephrol 2016 Jun 13 How do you tackle this? Shahed Ahmed, RLUH

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18 plan Meyer analysis of 3-year survival rates in patients without (no CKD prior to AKI) and with prior (prior CKD to AKI) de novo CKD after AKI. Triverio P et al. Nephrol. Dial. Transplant. 2009;24: r [2009]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please nals.permissions@oxfordjournals.org

19 Renal Recovery from AKI : why early diagnosis is important! Cr µmol/l 100% 75% Kaplan-Meier survival estimates 50% 25% 0% analysis time (months) Baseline creatinine Referral creatinine Discharge creatinine Non AKI AKI Ahmed S et al. Am Society of Neph (ASN) 2008 Clin Nephrology 2012

20 AKI : post discharge plan Review BP and medication Restart antihypertensive Restart ACE-I, ARBs Monitor recovery CKD follow up Address CV risk, Hypertension, proteinuria Education Sick day rules Seeking medical advice early Referral to Nephrology

21 ork-up for AKI AKI Pre-renal Intrinsic Renal Post renal / Obstruction Tubulointerstitial Glomerular ATN AIN Pre-renal AKI and ischaemic ATN accounts for 75% causes of AKI ( i.e. volume depletion, systemic vasodilatation, Low BP etc.) S Ahmed, RLUH 2015

22 Electronic AKI alert ( community AKI alerts) Lab based alert : on Creatinine value change With Comparator Cr. Value KDIGO/AKIN classification Baseline / reference Cr value : Median Cr value in previous 365 days Without Comparator Cr Value - Report as abnormal result

23 AKI Alert Case : PL- 81 year old male. Known T2DM, HTN current issue : generally unwell, poor oral intake, looks dehydrated. On amlodipine, Furosemide.

24 Assessing a patient with AKI it AKI? compare with previous lab results if in doubt assume it is until oved otherwise story Events preceding illness i.e. pre renal causes Hydration status Urine output Obstructive symptoms Possible focus of infection Risk factors of AKI

25 Examination Pulse / BP / Resp. Urine output Hydration status Palpable bladder / loin tenderness Evidence of systemic illness Infective focus Medication History: NSAIDs ACE inhibitors /ARBs, Diuretics

26 Investigations U&E, HCO3, Ca+ profile, LFTs, FBC WTU +/- MSSU Urine ACR ==================================================== Myeloma screen Immunoglobulins / electrophoresis, Urine BJP Renal Screen ANCA, Anti GBM, ANA, dsdna, Complement Renal US

27 Management : KI think FLUID S Ensure adequately hydrated Correct hypotension fluid Exclude obstruction Stop / Avoid Nephrotoxins Treat underlying causes e.g. sepsis Monitor input/output Treat complications Renal referral /? Intrinsic renal disease

28 Renal referral :

29 MO- 74 year old male P/M/H: CVA, polyneuropathy, limited mobility Current Issue: D + V, lethargy, poor oral intake

30 LD: 65 year old lady P/M/H : T2DM on insulin, chronic pain Current issue; Dysuria, lethargy

31 se : 21 year old male: 6 weeks history of sore throat, dry ugh, aches and pains. Recent Rx for Tonsillitis BP 130/80, Cr 160, CRP 150 Urine: protein +++ blood C-ANCA +ve: High PR3 titre - Renal Biopsy: Crescentic GN - ENT disease- vasculitis lesion Dx: Vasculitis: Rx: -IV Cycl+ Pred - Plasma Exchange ext step:? O/P referral? Urgent Referral S Ahmed, RLUH 2017

32 AKI sick day rule!

33 Conclusion: There is Opportunity to improve AKI care Often marker of physiological instability and disease severity Modifiable outcome Raise awareness Consequences for patients? What are my responsibilities? Recognition and management (Promote good practice) Post AKI care ( AKI in community)

34 Prevention better than cure Identify those at risk (see NICE CG169) Minimise risk stop nephrotoxins, avoid contrast studies if possible, optimise hydration Post AKI care : Repeat U & Es, Medication review etc. Finally, Most AKI is not true renal disease. Kidneys are often the innocent bystander. Simple history and examination including urine dip, will often give the diagnosis.

35 Acknowledgement Charlotte Hill (Clinical Chemistry team, RLUH) Dr Chris Paterson ( GP, Liverpool) AKI team, RLUH Renal Unit

36 Thank you Any Question? Shahed Ahmed, RLUH