The role of the Nephrologist in Acute Kidney Injury. Rebecca Brown Consultant Nephrologist Royal Liverpool University Hospital

Transcription

1 The role of the Nephrologist in Acute Kidney Injury Rebecca Brown Consultant Nephrologist Royal Liverpool University Hospital

2 Overview Impact of AKI Need for change Who needs a Nephrologist Are we making a difference?

3 S 50% of patients who developed AKI received poor care. Delay in recognising in-patient AKI 30% of cases inadequately investigated and managed 20% of post-admission AKI predictable and avoidable

4 Even small increase in Creatinine has significant impact on mortality >176.8 Change in serum Creatinine µmol/l Chertow G M et al. JASN 2005;16: by American Society of Nephrology

5 (750) (2400) (840) (480) (3720) = 744 deaths/year --> 148 avoidable??

6 Impact of AKI Increased Morbidity and Mortality Not just short term mortality Risk of CKD Dialysis dependence Increased length of stay Increased cost

7 Consequence of AKI Regional data: Renal Recovery from AKI Baseline and Discharge creatinine Cr µmol/l Baseline creatinine Referral creatinine Discharge creatinine Ahmed et al, Am society of neph (ASN) 2008 Clin nephrology 2012 S Ahmed, RLUH 2011

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

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10 AKI Huge problem previously under-recognised Alerts improve recognition, not outcome

11 AKI Epidemic e-alert

12 Audit 50 deaths primary diagnosis 46/50 confirmed AKI Mean age 79 AKI 36% had 3 or more significant comorbidities 20 (40%) had a cancer diagnosis 8(16%) had a diagnosis of dementia 10 patients admitted from a nursing home 2 out of hospital cardiac arrests

13 Results All 46 were admitted with AKI. Stage 1 n=12 (1 progressed to stage 2) Stage 2 n=10 (1 progressed to stage 3) Stage 3 n=24

14 Cause of death in 46 patients with AKI as primary diagnosis MALIGNANCY SEPSIS CARDIAC AKI OTHER NO DATA

15 AKI a window on physiological instability AKI causes avoidable mortality Or Insert condition here Severe or sub-optimally managed..causes avoidable mortality (with associated organ damage as evidenced by AKI)

16 Window of opportunity

17 AKI e-alerts: RLUH Monthly alerts Stage Stage 2 70 Stage 3 40 AKI alert on ICE AKI specialist nurse visit and implement care bundle

18 Admitting specialty

19 Responsibilities Risk Recognition Response Preventing avoidable AKI Good basic medical care

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21 AKI is not a diagnosis Expectations Make a diagnosis often multifactorial Optimise BP/Hydration Look carefully for sepsis Stop/avoid Nephrotoxins contrast studies? see contrast guidance Exclude obstruction Consider intrinsic disease Urine dipstick Those that don t respond will require further investigation - renal referral

22 Liano et al, Kidney International 1996 Aetiology AKI Prerenal 21% Acute tubular necrosis 45% Acute on chronic Kidney injury 13% Obstructive 10% Glomerulonephritis (primary & secondary) 3% Acute tubulo-interstitial nephritis 2% Vasculitis 1.5% Vascular 1% Other 3.5%

23 ACUTE KIDNEY INJURY EXPLAINED UNEXPLAINED Modify risk factors Restore normal physiology/ hydration Exclude obstruction Treat underlying illness Treat complications Medication review Urine dipstick USS Kidneys Renal screen Prompt renal referral YES RESPONDING NO Good urine output. Renal function improving. Minimise risks Frequent U+E Senior review HDU/ITU Renal review

24 Time is kidney Pre-renal AKI Post-renal AKI rapidly reversible if promptly rectified Intrinsic renal disease earlier detection improves outcome Delay increases risk of progression, complications and long-term sequelae

25 Who needs a renal screen In all not promptly responding WTU Ultrasound Myeloma screen Septic screen Vasculitis screen if clinical suspicion, active urinary sediment.

26 Who to refer to

27 Key findings A third of patients were referred to a nephrologist A fifth of referrals were delayed 20% of patients not referred should have been 69% of patients who were referred to nephrologists received good care

28 Renal Referral All stage 3 Exceptions palliative pathway Urgently if: complications of AKI Intrinsic renal disease / diagnosis requires specialist treatment

29 Renal Referral Renal Replacement Criteria Refer patients immediately if any of the following are not responding to medical management: Hyperkalaemia Metabolic acidosis Symptoms or complications of uraemia (for example pericarditis or encephalopathy) Fluid overload Pulmonary oedema

30 Ensuring safe and appropriate transfer

31 Case study 82 F blind, IHD, Hiatus hernia, recent Pneumonia GP ref to MAU 3/1/14 worsening renal function AKI stage 3 c/o dragging sensation on passing urine & urinary incontinence Tired

32 o/e p70 BP 139/70 No palpable bladder Diltiazem Omeprazole Levothyroxine Irbesartan Adcal d3 Aspirin Doxazosin GTN Stopped

33 Impression New kidney failure? Intrinsic renal disease Plan Renal screen USS Stop nephrotoxins Renal ref Catheter bladder scan

34 ARB stopped Renal screen sent SpR review Stop ARB Renal review ICE referral sent 3/12/13 (Friday) 20:12pm No phone call to SpR

35 Consultant review 4/12/13 Recheck U+E if stable rest of Ix as O/P Discharged

36 Renal function slightly better / stable No complications of AKI No USS done Not seen by renal team / no renal follow-up arranged

37 Referral via GP Seen on 9B day ward urgent USS arranged

38 ? Acute interstitial nephritis Omeprazole stopped Renal Biopsy Diltiazem Omeprazole Levothyroxine Irbesartan Adcal d3 Aspirin Doxazosin GTN

39 Outcome Commenced on prednisiolone Stopped due to adverse effects 137 egfr 36

40 Outcomes in AKI Total mortality =14/93(15%) AKI stage 2= 4/62 (6%) AKI stage 3= 10/31 (32%) Total (n=93) 30 % AKI Stage 2 (n=62) AKI Stage 3 (n=31) Full Recovery Partial Recovery Dialysis Dependent Death - AKI Related Death - AKI Not Related

41 Comparison with proof of concept audit Proof of concept Current Audit Senior r/v 89.5% 100% dipstick 26.1% 32% MEWS 99.2% 95.6% Medication review 96.7% 96.7% Referred to Neph 53% 93% Median Length of stay 15.5 days 11 days Mortality 37% 32% (stage 3)

42 AKI Mortality RLUH AKI (Primary Diag = N17.9) 12 Month Rolling In Hospital Mortality Rate (Deaths /1000 Discharges) % reduction in median Mortality p= AKI alert live AKI team Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15

43 AQUA measures

44 Summary Much of AKI is reversible if treated promptly AKI is not a diagnosis Knowing what caused the AKI allows appropriate treatment Alerts/bundles/AKI teams are making a difference

45 The role of the Nephrologist in AKI Investigation & management of AKI unresponsive to bundle measures Managing the complications of AKI / dialysis provision Managing CKD post AKI Education

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47 Questions