Tuesday, 20 October 2009

Acute Kidney Injury - on the agenda

Acute Kidney Injury (AKI) has until now been the poor relation of kidney care. The National Service Framework identified AKI, previously known as Acute Renal Failure (ARF) as a national priority and states:

People at risk of, or suffering from Acute Renal Failure are identified promptly, with hospital services delivering high quality, clinically appropriate care in partnership with specialist renal teams”.

An AKI care initiative conference was held at the Royal College of Physicians in March 2009 supported by NHS Kidney Care and a report of those proceedings has now been published with hard copies available from bdm@prolog.uk.com

Representatives from different specialist communities from around the UK were invited to share their own perspectives of AKI and how it impacts on patients managed in their speciality. The aims of the conference were for the delegates to work collaboratively in considering the following areas:

1. How to work towards a consensus definition of AKI.
2. How to prevent and detect AKI.
3. How to improve medical training curriculae for both undergraduate and postgraduate trainees and enable best practice management of AKI.
4. How to share datasets and codes to allow identification of quality markers to drive improvements and inform tariff development.

The conference recommended that:

1. A national group is convened to work collaboratively enabling real improvement in the prevention, detection and treatment of AKI throughout the UK.
2. An acceptable working definition of AKI is developed by performing a multi-centre study using different staging systems and correlating with outcomes.
3. Enzymatic serum creatinine assays should be implemented in all biochemistry labs throughout the UK to ensure national comparability. For patients is admitted to different hospitals with different biochemisty laboratories the development of shared databases should be created to improve comparability between laboratories
4. An electronic alert by biochemistry system should be developed which is compliant with the AKA Map of Medicine.
5. The national vascular database should be reviewed and updated to ensure AKA data is collected and audited post-surgery. The instances and outcome of AKI in patients undergoing vascular surgery/interventional procedures should be captured routinely.
6. Further local AKI audits should be encouraged to assess the incidence of AKI among other speciality patient groups.
7. There must be a coordinated approach to improve both undergraduate and postgraduate education for AKI. Core competencies must be developed to improve the identification and management of patients at risk of developing AKI , including the acutely ill patient (NICE Clinical Guideline 50).
8. District General Hospitals without renal services should develop links with local renal services and develop agreed care pathways for patients who develop AKI, enabling optimisation of patient care and efficient transfer of patients to a renal unit if appropriate.
9. Identification of new and improved biomarkers allowing early detection of AKI should be developed to improve the potential for targeted therapeutic intervention.
10. Renal units should work together locally with radiology and cardiology departments to ensure shared guidelines are in place to prevent contrast induced nephropathy.

Subsequently the National Confidential Enquiry into Patients Outcomes and Death (NCEPOD) AKI study was published and shows that only 50% of patients who died of AKI received satisfactory or good care. Delays were identified in the recognition of AKI particularly those who develop AKI after admission. The report has raised the importance of AKI throughout the NHS and will act as a catalyst to drive improvement in renal care.

Some of the individuals and organisations at the March Acute Kidney Injury Care Initiative Conference came back together a few days ago to help the Department of Health and NHS Kidney Care address the following questions:

1. How can you ensure that guidance/evidence relevant to AKI is implemented?
2. What do commissioners/Trusts need in order to ensure appropriate management of AKI?
3. How do you join up all relevant specialities to ensure AKI patients are treated effectively?
4. How do you ensure to and maintain awareness and capability for managing AKI.

AKI is a major issue for a range of communities in clinical medicine and has a significant impact on patient morbidity and mortality and on NHS resources. I am pleased that it is now being regarded as a systemic issue by those responsible for training, service delivery and quality. AKI is common, harmful and treatable. AKI affects up to 1 in 5 people admitted to hospital, and even modest changes in serum creatinine are associated with a 6.5 times increase in mortality.

All acute services have received a copy of the NCEPOD report and have been asked to review their approach to acutely unwell patients in the light of the findings. AKI is now be firmly on the agenda . I look forward to improvements in education, systems and care processes to support the prevention, early identification and treatment of AKI across the NHS, whatever the clinical or organisational setting.