Monday, 15 June 2009

Adding insult to injury

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Acute Kidney Injury study identifies systematic failings in the management of Acute Kidney Injury (AKI). The enquiry comments that “AKI is common, overlooked, poorly assessed and, when eventually recognised, mismanaged”.

Recognition and management of AKI must be linked to the care of the acutely ill patient. It was disappointing to read that the NICE guidance on acutely ill patients is not routinely being applied. Regular checks on biochemistry, administration of IV fluids and fluid balance measurements need to be built into basic management plans.

Acute Kidney Injury in numbers

  • AKI affects between 5-20% of hospitalised patients
  • AKI has a mortality between 19-83%
  • Only 50% of people with AKI receive a good standard of care
  • Between 14-22% of cases of AKI are avoidable
  • Clinical errors occur in over 30%
  • 24% of cases did not have an adequate senior review
  • 40% of hospitals cannot provide emergency nephrostomy

Depending on the definition, and therein lies one of the problems, AKI can affect up to 20% of all acute hospital admissions. Even a small rise in the serum creatinine of only 25 umols/l is associated with a significantly increased mortality whatever the underlying condition. AKI is reported to be associated with a mortality of between 20 and 80%! Would a systematic approach to identify and treat AKI earlier improve outcomes? We don’t yet have research studies that would unequivocally answer that question. But we do know from a range of epidemiological studies that in many cases of AKI there are errors of omission and commission early in management – particularly failure to maintain good fluid balance or withdraw potentially nephrotoxic drugs.

We now have an international classification for AKI. I am hopeful that it will allow intensivists, kidney clinicians, acute physicians, radiologists, surgeons and general practitioners to speak the same language. One of the difficulties of AKI is that it occurs in many settings from the community, to the emergency medical admissions unit, on surgical wards as well as in kidney units and intensive care units where we can offer dialysis.

In March this year NHS Kidney Care therefore brought together representatives and experts from all the clinical areas to start to develop an acute kidney injury initiative. The enthusiasm from all quarters was palpable. The Renal Association Clinical Practice Guidelines and Audit Measures published in June 2008 and GIFTASUP, the British consensus guidelines on intravenous fluid therapy for adult surgical patients, provide a sound basis for developing sound pathways of care for AKI. There is a need to agree definitions and a classification system; to begin to systematically collect data to provide information on incidence, associations and outcomes and a big need to demystify the condition and educate all clinicians, both trainees and practitioners, about AKI risk, fluid management and treatment.

Our NSF recommends that patients at risk of suffering from AKI should be identified promptly, with hospital services delivering high quality, clinically appropriate care in partnership with specialist teams. This provides us with the challenge of how to improve the quality of care for patients who develop AKI in the modern healthcare setting. NHS Kidney Care has made AKI a key priority. We will be working with the kidney community, the acute medicine community and critical care colleagues to clarify definitions and provide education and support to all other clinical teams and organisations to transform the services for and outcomes of AKI.

Read the report, responses to it and see powerpoint presentations on the NCEPOD website
Listen to the BMJ podcast by Jim Stewart (Consultant Physician and principle author of the NCEPOD report)