Wednesday, 21 November 2012

Acute Kidney Injury in Edinburgh

The Royal College of Physicians of Edinburgh attracted a large and diverse audience to its UK Consensus Conference on Acute Kidney Injury (AKI) last weekend. Supported by NHS Kidney Care it examined three main themes in the management of AKI:

-         the role of fluids,
-         e-alerts,
-         biomarkers

All areas that are not covered in the NICE AKI Clinical Guideline due to be published for comment on World Kidney Day – 14th March 2013.

The consensus event was developed against the backdrop of the NCEPOD Report – Adding insult to injury  that showed widespread clinical failings, resulting in 50% of patients who died receiving an inadequate standard of care. Professor Sir Ian Gilmore, immediate, past President of the Royal College of Physicians of London and Professor John Feehally, President of the International Society of Nephrology, co-chaired the consensus panel that heard thoughtful presentations from colleagues across the UK and international experts. There were also some excellent posters describing a range of research studies and quality improvement projects in AKI from Scotland and England.

The key recommendations included:
-         doing the basics well; improving training and education of clinical teams, agreeing referral criteria for specialist input, and scoring systems that better defined patients at risk of AKI needs to be developed and validated for wider use;
-         A system of e-alerts, in which doctors receive automated instant messages advising them of abnormal biochemical results, indicating that their patient has evidence of AKI, should be implemented throughout the NHS. This will facilitate rapid treatment and medication adjustments. A national group should be established promptly to develop the standards for e-alerts; and
-         All hospitals must have fluid therapy guidelines that will aid resuscitation of patients, and identify the fluids that are most appropriate for replacement and maintenance.

Optimal care could save up to 12,000 lives a year and produce substantial savings. There are things that can be done now to put the NHS in a better place to effectively implement the NICE Clinical Guidelines on AKI when they come out early next year. E-alerts are not a quick fix. They need leadership to be accompanied by training, agreed cared bundles and clinical audit and leadership. Fluid therapy should be guided by repeated evaluation of volume status. Clinical assessment of volume status is difficult and there is no short cut for regular re-evaluation based on history, cumulative fluid balance, daily weights and clinical examination.
The consensus conference concluded that there are lots we know that we need to do now. A systematic approach to AKI as part of the risk assessment and management for all acutely unwell patients is required, but there are still a lot of unanswered questions across the whole spectrum of Acute Kidney Injury not least, in the three areas of biomarkers, e-alerts and fluid therapy. Improving basic care has to be our first priority – make 2013 the year of identifying and improving AKI in the NHS.

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