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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