Acute Kidney Injury (AKI)
NICE AKI Quality Standards
NICE have published an updated set of quality standards for Acute Kidney Injury (AKI). The standard covers the prevention, detection and management of non traumatic AKI up to the point of renal replacement therapy in all patients with the exception of renal transplant recipients and pregnant women. To view the standard in full, please click here.
There is also a new website created specifically on AKI https://www.thinkkidneys.nhs.uk/
AKI Alerts to be released into Primary Care on 14 November
York Teaching Hospitals NHS Trust have advised the introduction of reporting of warning stage test results for acute kidney injury arriving in general practice, via GP IT systems, will go live on 14 November 2016. This is a development from NHS England as a result of a new national algorithm being developed and implemented in pathology labs across the country.
The impact for practices is relatively small in that a practice can expect to receive one or two alerts per GP per month in their practice – however, the impact for patients is great.
Being made aware sooner of raised serum creatinine blood results which indicate impaired kidney function, means that acute kidney injury can be detected and treated sooner with an improved outcome for the patient.
Recognising this change will present a challenge for practices, Think Kidneys has created a series of resources for primary care.
The development of these resources has been led by GPs in the team and a range of experts to ensure they provide the latest and best information for tackling acute kidney injury. The resources include good practice guidance in publications and easy to use materials and are all available here.
The nationally agreed algorithm to identify patients with rises in creatinine, which may satisfy the criteria for AKI, has been in place in York Hospital for hospital patients almost the past year. 60% of AKI starts in the community and at the direction of NHS England the alerts are to be rolled out locally on 14 November.
AKI Warning; possible AKI stage 1. There is a rise of more than 26 umol/L within 48hrs or a rise of > 1.5x the baseline. This warning will appear on routine blood results send back to the practice for the requesting doctor to manage.
AKI Warning; possible AKI stage 2. There is a rise in creatinine of more than 2x previous baseline values. This warning will be phoned through to the practice for action.
AKI Warning; possible AKI stage 3. There is a rise in creatinine of more than 3x previous baseline values. This warning will be phoned through to the practice for action.
These warnings do not mean that AKI is necessarily the diagnosis.
The changes should be in the context of acute illness and not in relation to up titration of heart failure medicines or the use of trimethoprim which can give a pseudo AKI due to effects on tubular resorption of creatinine.
What action needs to be taken?
It is important to assess the patient within 6 hours for suspected AKI stages 2 and 3. This may be by telephone if appropriate.
It is also important to be aware of potassium levels when deciding if admission is required.
Think Cause? Think sepsis, hypotension commonly with D and V, obstruction and renal parenchymal disease (rare but significant in young people with haematuria).
Think Medication? Think medications which may exacerbate AKI, NSAID, diuretics, and all antihypertensive medications. Think medications which accumulate and cause harm in AKI such as metformin,opiates, gabapentin and NOAC. Think about any new medications which could have caused the AKI. Is it safe to discontinue these medications until the patient improves?
Think Fluids? Are they thirsty? Are they able to increase their fluid intake? Are they loosing excess fluids? When did they last past urine? Can this be corrected at home?
Think Review? Do they need admission? What is the potassium level? Is the situation improving? Do they have support at home? When do they need some more blood tests?
Think Kidneys? All this information and more is available on the Think Kidneys website. There is patient information for those people considered at high risk of AKI to help them ‘ to keep their kidneys safe’ and for those who may already have had AKI.
There is a free RCGP e-Learning module available for all members of the practice clinical team to use which is based around a clinical case and can be accessed on the RCGP website.