Friday, 8 May 2009

Acute Kidney Injury, hyperkalaemia and the safe use of insulin

Acute Kidney Injury (AKI) is gaining visibility. The move to a standard definition and staging system based on the rise in serum creatinine will, I hope, have the same demystifying effect that introducing systematic eGFR reporting has had for chronic kidney disease. One of the complications of AKI is hyperkalaemia or an increase in the serum potassium and my colleague Dr Rowan Hillson (NCD for Diabetes) drew my attention this week to the work of Professor David Cousins from the National Patient Safety Agency work has done on risks to patient safety from insulin therapy. Between 2003 and 2009 a total of 13,180 incidents were reported from the NHS in England and Wales. These included 9 deaths, 863 cases of severe or moderate harm and a number of these cases included the use of insulin in the treatment of hyperkalaemia. In one such case a letter from the prescribing doctor read out in Court said that he believed “one unit of insulin was equivalent to one millilitre”. “I have not received any previous instruction in handling of insulin”. In the National Patient Safety Agency report 3,417 cases involved giving the wrong dose, strength or frequency of insulin.

In Northern Ireland the Clinical Resource Efficiency Support Team (CREST), have produced an excellent guideline for the treatment of hyperkalaemia in adults. One of the clinical pearls in that document was “always consult with a senior doctor responsible for the patient with hyperkalaemia”. Damian Fogarty (Consultant Renal Physician, Belfast) tells me that the Northern Ireland team went further and produced a hyperkalaemia kit that is now present in every adult ward.

We are all awaiting the national confidential enquiry into Patient Outcome and Death report “Adding Insult to Injury” on Acute Kidney Injury; I don’t know what it will say about hyperkalaemia and its treatment but it has looked at the following areas:

· Diagnosis and recognition of AKI
· Recognition of risk factors associated with AKI
· Prevention of AKI
· Assessment of patients recognised as being in AKI
· Management of established AKI
· Recognition and management of complications of AKI
· Organisational factors for the management of AKI patients

The report is to be launched at at the Royal Society of medicine on Thursday 11 June and a place at the event can be booked here