Risk factors for Acute Kidney Injury - SWCN

Risk factors for Acute Kidney Injury - SWCN

South West Cardiovascular Clinical Network AKI Event 17 September 2015 1 Improving Outcomes in AKI Leaflets Pharmacis ts Sick Day Rules

Nurse s Educatio n GPs Renal View Hospita l

doctors AKI programme in the South West November 14 March 15 September 15 Special thanks to

Rachel Levenson - CV Programme Manager, South West Strategic Clinical Network Rachel Gair - AKI Project Lead - SW SCN Susan Shears Network Assistant Michelle Roe CV Network Manager Aims of the day To share learning across the Network and provide links to the national AKI programme To share and celebrate the achievements across the SW regarding AKI

To bring together communities responsible for spreading this work further To raise awareness and support sustainability for the future First session Dr Fergus Caskey Medical Director UK Renal Registry Sally Bassett Southern Derbyshire CCG Dr Preetham Boddhana Renal consultant Gloucester Dr Mark Uniacke Renal consultant Wessex Dr Steve Dickinson Renal consultant Truro

Second session Anne Cole Regional manager SW centre for pharmacists post graduate education Claire Oates Senior Pharmacist, Renal Services NBT Dr Helen Condy-Young Clinical effectiveness Lead NDHCT Identifying risk factors for Acute Kidney Injury Dr Steve Dickinson Renal Consultant, South West SCN AKI Clinical Lead 17 September 2015

What Ill cover Study looking at AKI Risk Factors at Royal Cornwall Hospital Workstreams Risk Factors Risk Factors Modifiable Non- modifiable

Non-modifiable risk factors for AKI CKD age over 65

heart failure liver disease diabetes history of acute kidney injury renal transplant Conditions which mean limited access to fluids because of reliance on a carer Renal tract obstruction Modifiable risk factors for AKI hypovolaemia drugs which could be harmful to the patients kidneys within the past week especially if hypovolaemic:

non-steroidal anti-inflammatory drugs [NSAIDs] aminoglycosides angiotensin-converting enzyme [ACE] inhibitors angiotensin II receptor antagonists [ARBs] diuretics use of iodinated contrast agents within the past week sepsis deteriorating early warning scores

Prevention of AKI 8 July 2015. Interim position statement from the Think Kidneys Board Sick Day rules in patients at risk of AKI Sick day rules Although there is strong professional consensus that advice on sick day rules should be given, and this approach is advocated in the NICE AKI guideline.. the evidence that

provision of such advice reduces net harm is very weak Sick day rules, drawbacks Patients may consider that the potential harm outweighs the potential benefit and decide to stop taking the drug despite the absence of an acute illness. Patients may over-interpret the advice and stop their drug treatment during even minor illnesses.

Sick day rules, drawbacks Patients may not re-start their drug treatment on recovery. The drugs may not be titrated back to the previous evidence based levels even when there has been no evidence of AKI. Sick day rules, drawbacks People may self-manage inappropriately and not seek professional help at an appropriate

stage. Issues related to removing medication from dossette boxes. Sick day rules it is reasonable for clinicians to provide guidance on temporary cessation of medicines to patients deemed at high risk of AKI based on an individual risk assessment. formal evaluation needed Sick day rules These patients should be advised

that if they become acutely ill and are unable to maintain a good fluid intake they should contact their GP for advice as to whether they should hold the ACEi or ARB Risk scores There were 12 AKI risk tools for patients in the hospital but no published scores for predicting development of AKI in the community There is no universally accepted validated risk score for AKI for either primary or secondary care.

IDENTIFICATION OF RISK FACTORS FOR ACUTE KIDNEY INJURY (AKI) IN PATIENTS ADMITTED TO HOSPITAL AS A MEDICAL EMERGENCY: SINGLE CENTRE OBSERVATIONAL STUDY Steve Dickinson, Emma Thomas, Katie Wallace, Laura Kendall, William Pynsent, Joanne Palmer, Rob Parry What Ill cover

Aims Methods Results Our AKI Risk Score Questions/Comments Aims To identify risk factors for AKI To develop a risk score for AKI To compare against existing risk scores Finlay et al. (Clinical Medicine, 2013)

CRASHED. Ramasamy et al. (NDT, 2014) Drawz et al. (Renal Failure, 2008) Methods Prospective Observational Cohort Study Non consenting Data collection Acute Medical Take 3 days a week for 6 months Data collected Comorbidities Physiological data

Laboratory results eg creatinine, FBC Results 2520 patients 11.9% (n=301) had AKI 87.7% (n=264) Pre renal Results Stage of AKI Results Mortality Rate 30 day

Number of patients Number of patients who died Mortality No AKI 2178 125

5.70% AKI 301 59 19.60% Number of patients

Number of patients who died Mortality No AKI 2178 172 7.90%

AKI 301 69 22.90% 60 day P Value Wallace Overall et al 2014

Mortality <0.001 No AKI 2.30% AKI 21.40% P Value <0.001

Results Variable On Admission Number (%) Odds Ratio OR 95% CI P value 180 (8.1)

2.849 1.987 - 4.084 <0.001 395 (17.7) 1.729 1.286 - 2.326 <0.001

Temperature 37.5 219 (9.8) 2.019 1.415 2.881 <0.001 Heart Rate 90bpm 807 (36.1)

1.603 1.242 2.086 <0.001 Age 75yrs 943 (42.2) 1.815 1.407 2.341

<0.001 Chronic Kidney Disease 249 (11.1) 4.931 3.646 6.668 <0.001 47 (2.1)

3.148 1.662 5.960 <0.001 Diabetes 423 (18.9) 1.865 1.400 2.485

<0.001 ACEiARBSpironolactone 630 (28.2) 1.733 1.332 2.254 <0.001 Systolic BP <100 Respiratory Rate 20

Liver Disease Analysis: Risk Score

Systolic BP <100 Respiratory Rate 20 Temperature 37.5 Heart Rate 90bpm Age 75yrs Chronic Kidney Disease Liver Disease Diabetes ACEi / ARB / Spironolactone Each Factor Scores 1 point

Risk Score ROC 1.01 Sensitivity 0.81 4 Risk Factors Sens 92.3% Spec 35.4% PPV 39.0% NPV 91.1%

0.61 3 Risk Factors Sens 77.8% Spec 66.4% PPV 29.5% NPV 94.3% 0.41 0.21 5 Risk

Factors Sens 97.9% Spec 13.9% PPV 48.1% NPV 89.1% 0.01 0 0.1 0.2 0.3

0.4 0.5 0.6 -0.19 1-Specificity 0.7 0.8

0.9 1 Future work Further develop the Risk Score Validation of other Risk Scores Potential clinical applications Develop a score which could predict development of hospital acquired AKI To triage which patients should have renal team review Explore validity as a screening tool which

could be used in Primary care Questions & Comments South West Cardiovascular Clinical Network AKI Event 17 September 2015 38 Aims of the day To share learning across the Network and provide links to the national AKI programme To share and celebrate the achievements

across the SW regarding AKI To bring together communities responsible for spreading this work further To raise awareness and support sustainability for the future First session Dr Fergus Caskey Medical Director UK Renal Registry Sally Bassett Southern Derbyshire CCG Dr Preetham Boddhana Renal consultant Gloucester Dr Mark Uniacke Renal consultant Wessex Dr Steve Dickinson Renal consultant Truro

Second session Anne Cole Regional manager SW centre for pharmacists post graduate education Claire Oates Senior Pharmacist, Renal Services NBT Dr Helen Condy-Young Clinical effectiveness Lead NDHCT Thank you

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