Dr Tamer Al-Sayed, Acute Physician, The Christie Hospital Geraldine Campbell, Nurse Clinician, The Christie Hospital

1. The Christie NHS Foundation Trust
Acute Kidney Injury in Oncology
Preventing Insult Reducing Injury
Supporting our Patients
Dr Tamer Al-Sayed MB ChB FRCP MRCP (Nephrology) SCE (Acute Medicine) PGCE (PG Medical Education)
GC (Medical Physiology & Cardiovascular/Advanced Renal Specialisation)
Consultant in Acute & Renal Medicine
Acute Kidney Injury Clinical Lead
Honorary Senior Lecturer, Department of Health & Medical
Sciences, The University of Manchester
Geraldine Campbell, Acute Oncology Nurse Clinician, MSc
Advanced Practice, BSc (Nursing), RGN
National Acute Oncology Conference
Manchester
07.03.2017

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Presentation
• Setting the scene – Interactive Clinical Vignette
• Nephrology at a glance!
• Background
• Our Experience
• Closing case
• Food for thought
• Questions & comments – Gerry Campbell

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Acute Kidney
Injury
• 1 in 5 acute admissions
• 2/3 community
• 30-40% preventable
• Average LOS  by 5 days
• Mortality up to 50%
• 10-15% left with CKD
• 5-10% require long term
dialysis
•  Risk of HACI, Pressure
ulcers, falls & delirium
• Worsens outcomes in
sepsis, surgery & cancer
therapy
The Silent Killer
Its Everyone’s Problem
 AKI is 100x more deadlythanMRSA,killingan estimated25,000peopleperyear
 TreatingAKI coststhe NHS more thanthecost of treatingallcases oflung cancerand
skin cancercombined,at £434-620millionpoundsperannum.

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Acute Kidney Injury (AKI) at The Christie
• The Christie NHS FT -
comprehensive cancer centre
• largest single site cancer centre in
Europe treating more than 44,000
patients a year
• 18 months ago, new Acute
medicine role appointed
“As a Consultant treating acutely
unwell patients, I have worked
with an expert team to develop
guidelines for staff and patients in
the treatment of acute kidney
injury (AKI)” Dr Al-Sayed

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One of just many…….
• 56 male
• Routine F/U
• Bowel cancer – ileostomy
• Single kidney
• Hypertensive
• ‘Twitchy’
• SCr >1,800 µmol/l!
• Recent imaging
• Recently prescribed pain killers
• High output stoma
• On Ramipril & diuretics
• Recent contrast CT scan
• Given NSAIDS
• Hypotensive
• Severely dehydrated
• Hypocalcemic
• Uremic
• Needed emergency CVVHF
• Recovered function
• Prolonged LOS
• CKD

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NCEPOD & NICE
• For Better, for worse? – 2008
• Adding insult to injury – AKI 2009
• A time to intervene – 2012
• Just say sepsis – 2015
• NICE AKI guidance 2012
• NICE IV Fluid guidance 2013
• NPSA June 2014 & August 2016
• NHS Think Kidneys

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Functions of the Kidneys
• Excretion of toxic products of body metabolism
• Drug handling
• Regulation of volume status & osmolality
• Maintenance of ionic composition of ICF/ECF
• Acid – Base homeostasis
• Activation of Vitamin D & bone mineralisation
• Haemoglobin production
• Blood pressure control in the long term
• Gluconeogenesis
• Immunogenic functions

10. The Christie NHS Foundation Trust
• Filters 180L/day
• Highest regional blood flow
per weight (~ 400g)
• Filters 1kg salt/day
• Very sophisticated filter
• Up to 2 million glomeruli
• Low vascular resistance

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REGIONAL BLOOD FLOW AND OXIGEN CONSUMPTION AT REST
Blood Flow
Oxygen
Consumption
Blood Flow A-VO2 Venous O2
% ml ml/mi
n
% cc cc/min O2 Cons. Content Content
C.O. min 100
gm
Total min 100
gm
(ml/cc) (ml/dl) (ml/dl)
1. Coronary 5 250 70 13 30 8.4 8 12.5 6.5
2. Cerebral 15 750 50 22 50 3.3 15 6.7 12.3
3. Splanchnic 25 1250 50 24 53 2.1 24 4.2 14.8
4. Renal 22 1100 400 7 15 5.5 73 1.4 17.6
5. Cutaneous 8 400 10 2 5 0.1 80 1.2 17.8
6. Muscular 17 850 2 27 60 0.2 14 7.1 11.9
7. Other regions 8 400 3 5 12 0.1 33 3.0 16.0
Total Systemic
Circ.
100 5000 7 100 225 3.2 22 4.5 14.5

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Risk factors for AKI
• Old age
• Intravascular volume depletion
• Cardiac failure
• Nephrotoxic medication
• Atherosclerotic disease
• Diabetics with proteinuria
• Underlying CKD
• Poor nutritional status
• Sepsis
• High contrast load
• Major surgery (vascular and non-vascular)
• Genetic susceptibility (HLA)

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Pharmacokinetic
Consequences of AKI

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Volume 380, No. 9843,
p756–766, 25 August 2012

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Etienne Macedo MD, PhD
and Ravindra L. Mehta MD
Critical Care Clinics, 2015-10-01,
Volume 31, Issue 4, Pages 773-784,
Copyright © 2015 Elsevier Inc.

24. The Christie NHS Foundation Trust
The Christie Experience
• From Execs to patients
• Evolving sophistication
• Alerts – community
• Live dashboards
• EPR documentation
• Data collection
• e-prescribing
• AQUA 2017
• National recognition – HSJ Nomination
• Outpatient work – medicine optimisation
• Link with Sepsis group

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AKI e-Alerts and Triggers

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Raising The Profile of AKI

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AKI dashboard

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AKI dashboard
- alerts by patient and stage

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AKI dashboard

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Telephone triage for patients with suspected AKI
DIARRHOEA
Initial Assessment
Always review last U&E results in patient electronic notes
Questions:
• What chemotherapy is the patient on and when was the last treatment/tablet?
• Are they receiving radiotherapy and when was their last treatment?
• Number of recent episodes?
• How often do the bowels usually move?
• How many stools a day is the patient passing or how much stoma output is there above normal amount?
• Are stools/stoma output formed, loose or watery? Any faecal incontinence or urgency? Nocturnal movements?
• Is there any abdominal pain e.g., cramping pains coming in waves?
• For how many days has the patient had diarrhoea? Is it interfering with activities of daily living?
• Are they able to eat and drink normally? Are they passing plenty of clear urine?
• Do they have any other chemotherapy related toxicities, e.g. mouth ulcers, N/V, red hands/feet, stomatitis, mucositis?
• Any recent antibiotics or recent hospital admissions?
• Have they taken any laxatives or anti-sickness medication or any anti-diarrhoeal medication in the last 24 hours? What?
Advice:
If taking Capecitabine chemotherapy follow the Capecitabine management protocol
DRUGS - NB. Has the patient had a platinum based chemotherapy?
Is the patient taking:
•NSAIDs e.g. Diclofenac, Ibuprofen
•ACE inhibitors e.g. Ramipril, Lisinopril.
NB if patient taking any of the above drugs advise to omit until management plan agreed

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VOMITING
Initial Assessment
Always review last U&E results in patient electronic notes
Questions:
•Frequency (number of episodes in last 24/48 hours) and nature of nausea with or without vomiting?
•Assess bowel movements; Any symptoms that suggest constipation? Any diarrhoea?
•What food and fluids have you been taking over last few days?
•Any signs of dehydration e.g. decreased urine output, fever, thirst, dry mucous membranes etc.
•What is the underlying cancer diagnosis?
•What is the extent of the disease? – e.g. known metastases to brain, bone, liver etc.
•What medication is the patient taking i.e. antiemetics and has there been any recent changes?
•Increasing abdominal pain?
Advice:
If taking Capecitabine chemotherapy follow the Capecitabine management protocol
DRUGS - NB. Has the patient had a platinum based chemotherapy?
Is the patient taking:
•NSAIDs eg Diclofenac, Ibuprofen
•ACE inhibitors eg Ramipril, Lisinopril.
NB if patient taking any of the above drugs advise to omit until management plan agreed
Review prescribed
antiemetic medication;
Assess patient compliance
Phone / review the patient
in 24 hours
As for grade 1
Advise to get GP review
consider changing antiemetic
including route of admin.
Phone / review the patient in
24 hours
If symptoms worsen or are
associated with other toxicities
consider admission.
Urgent review required or discuss with Acute
Physician on MAU.

35. The Christie NHS Foundation Trust
Time Oral Intake Running
Total
IV 1 IV 2/ Other Running
Total
Total
Intake
07: 00
08: 00
09: 00
10: 00
11: 00
12: 00
13: 00
14: 00
15: 00
16: 00
17: 00
18: 00
19: 00
20: 00
21: 00
22: 00
23: 00
24: 00
01: 00
02: 00
03: 00
04: 00
05: 00
06: 00
TOTAL
INTAKE
Urine Running
Total
Other Other Running
Total
Total
Output
TOTAL
OUTPUT
Balance from
previous day:
Cumulative
balance:
Weight:
Balance from
previous day:
Cumulative
balance:
Weight:
BALANCE
Developed by Katerina Pearson, OAU Sister

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Opportunities for AOON
• Expanding development of specific expertise
• AKI & IV Fluid Stewardship
• Sepsis
• Critical Care
• Diabetes
• Surgical
• Early follow up reviews – admissions avoidance
• Patient education & empowerment
• Staff education – e-learning bytes
• Community engagement
• Research – biomarkers

37. The Christie NHS Foundation Trust
Key performance indicators – facets
of a care bundle
• Urine output
• Urinalysis
• Fluid balance
• IV fluid prescribing
• Treatment of sepsis – door to needle times
• Discontinuing toxic medications
• Hand over
• Data recording – audit & governance

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Final Case
• 35 female – CRC
• Multiple laparotomies
• Long term ureteric stents
• High output stoma
• Admitted AKI
• Diagnosis?
Pre-renal (dehydration) chronic obstructive uropathy

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Simple is Effective
 Pioneering in Cancer Care in the UK
 Innovative & Expert real time
cross disciplinary team
 The power of a culture shift
 A new tradition
 Medicines optimization
 Proactivity at the front door
 Maximising patient outcomes

45. The Christie NHS Foundation Trust
https://www.thinkkidneys.nhs.uk/aki/case-studies/acute-kidney-
injury-oncology-population-novel-quality-improvement-initiative/
Thank you
Questions?
Poster Exhibition