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Improving the prevention, recognition and
management of AKI: the ‘Think Kidneys’
initiative
Charlie Tomson - @CharlieTomson; charles.tomson@nhs.net
Chair, Intervention Workstream, NHS England ‘Think Kidneys’
RCPSG meeting 18.03.2016; 1335-1410
No conflicts of interest to declare
2
Think Kidneys: programme objectives
The primary aim of the National Programme is to ensure avoidable
harm related to AKI is prevented in all care settings.
It will aim to do this by ensuring that:
A variety of tools and interventions are developed and implemented to
support the prevention, early detection, treatment and enhanced recovery
of patients with AKI
Patients who develop AKI are appropriately managed to reduce further
deterioration, long term disability and death
Appropriate education and training programmes are developed for all health
professionals based on best available evidence.
| 3
| 4
Hydration Theme
Expert
ReferenceGroup
Algorithm
Sub-Group
NHS England Patient
Safety Steering Group
UK Renal Registry
Risk
workstream
Education
workstream
Detection
workstream
Intervention
workstream
Implementation
workstream
Measurement
workstream
Acute Kidney Injury
National Programme Board
Workstreams
Risk: identify patients at risk
Education: develop educational resources for public, patients, professionals
Detection: automated laboratory generation of AKI warning stage test
results
Measurement: national AKI registry linked to UKRR/HES/ONS, supporting
local regional and national QI
Intervention: appropriate clinical management of AKI (1o and 2o care)
Implementation: using commissioning and other quality levers
Hydration
RISK: Communities at risk of AKI
Secondary care:
Any acute illness; frail, elderly; CKD; heart failure; liver disease; diabetes
mellitus (esp if albuminuric); neurological or cognitive impairment
Primary care:
Diabetes mellitus; CKD; dementia; heart failure; frail, elderly; psychiatric
disease; children with CKD; patients with cancer
https://www.thinkkidneys.nhs.uk/wp-content/uploads/2015/07/Communities-at-risk-of-developing-AKI-Think-
Kidneys-010715.pdf
RISK: Example: adults having surgery
Non-modifiable risk factors:
Age>=65y; eGFR<60; kidney transplant; Diabetes mellitus; Heart failure; Liver disease
Previous episode of AKI
Emergency surgery
Intraperitoneal surgery
Modifiable risk factors:
Use of drugs that could be harmful to kidney function eg NSAIDs
EDUCATION
Infographic
GP educational resources (with RCGP)
Undergraduate curriculum
Proposal for public education campaign (unfunded)
Patient educational resources (with BKPA)
Care homes guidance
Centre for Postgraduate Pharmacy Education campaign
Development of an app
DETECTION: the AKI algorithm
| 9
| 10
Answer: at least as well as any other algorithm; any ‘improvements’ would increase false
+ rate
UK Renal
Registry
Patient
Renal Units LABS
LABS
LABS
The UKRR: AKI direct from labs
From renal IT systems
CKD4/5, D-AKI and ESRD
HES, ONS
etc
Direct from labs
AKI in 1y and 2y care
AKI data specification
https://www.thinkkidneys.nhs.uk/resources/
1. The Warning Grade Test Result
• Patient Identifiers
• The index creatinine and eGFR
2. Retrospective & Prospective Lab Data
• All creatinine & eGFR data from
preceding 15 months
• All creatinine & eGFR data from
next 15 months
Data submissions from lab to UKRR
https://www.thinkkidneys.nhs.uk/aki/aki-data/
INTERVENTION
Medicines management toolkit
• Audit measures
Dietetic management
Minimum content for secondary care bundle
• Audit measures
Minimum AKI-related content for discharge summaries
Advice on re-starting drugs stopped during AKI admissions
Agreeement with RCPath on communication of warning stage test results
Primary care: guide to responding to AKI warning stage test results
• Audit measures
SECONDARY CARE ‘BUNDLE’ components
| 15
SECONDARY CARE audit measures (TBC…)
Denominator: inpatients with an AKI 1,2,or 3 warning stage test result
• Exclude ‘false positives’ e.g. progression of CKD, completion of pregnancy, Trimethoprim
Numerators: % of patients with
• Evidence of an ABCDE assessment
• Evidence of a decision on whether patient has sepsis
• Evidence in the medical notes of a decision on whether the patient is
hypovolaemic/normovolaemic/hypervolaemic (within x of test result)
• Evidence in the medical notes of the results of dipstick urinalysis (within x h of test result)
• Evidence of a review of drug treatment in the light of AKI
• Evidence of request for renal ultrasound (when indicated –operational definition required)
• Completion of minimum AKI-related dataset in discharge summary
Minimum AKI-related content for discharge summary
Community-acquired or hospital-acquired?
Highest AKI stage
Serum creatinine at discharge
• Increasing, stable, or falling?
ITU admission yes/no
RRT given yes/no
Cause of AKI (?? hypovolaemia/hypotension/sepsis/intrinsic renal/post-renal)
Drugs stopped during admission
• Restarted prior to discharge?
• Considered contraindicated in future?
Requirement and arrangements (1o or 2o care) for follow-up of renal function
MANAGEMENT OF AKI IN PRIMARY CARE
60-70% of all AKI is community-acquired
AKI warning stage test results to be released to primary care April 2016
• Likely frequency = 1 per FTE GP every 1-2 months
• 70% AKI stage 1
Many GP tests on sick patients taken on lunchtime visits: results dealt with OOH
Expected response requires careful calibration
RAND Consensus process: 2 clinical pathologists, 2 acute physicians, 2 nephrologists, 4
GPS (including rural, urban, out of hours, anti-over-medicalisation) – 2-stage voting on
appropriate lab and GP response to ~700 scenarios
Acute Kidney Injury
Best practice guidance: Responding to
AKI Warning Stage Test Results for
Adults in Primary Care
Publication date April 2016
Draft Version Table 1 09.03.2016
Provide hyperlink to main guidance document here
¥ UK Renal Association Clinical Practice Guidelines (2014) recommends emergency assessment and treatment of severe hyperkalaemia (K
+
≥6.5mmol/l) – needs hyperlink
The table is a guide to support an initial response to an AKI Warning Stage Test Result but clinical judgement must prevail.
The table does not apply to children and young people (<18 years) or patients receiving end of life care.
Table1: Recommended response times to AKI Warning Stage Test Results for Adults in Primary Care
AKI Warning Stage Test Result
Confirm or refute automated AKI Test Result by
comparing patient’s current creatinine within
clinical context against baseline creatinine
Clinical Context Within Which Blood Test Taken
#
If clinical context is unknown, then assume high pre-test probability until proven otherwise
LOW Pre-test Probability of AKI
Stable Clinical Context
HIGH Pre-test Probability of AKI
Context of Acute Illness
AKI Warning Stage 1
Current creatinine >1.5 x baseline level
(or creatinine rise >26 mmol/L £48 hrs)
Consider clinical review £ 72 hours of e-alert*
If AKI confirmed® manage as per table 2
Consider clinical review £ 24 hours of e-alert*
Likely Stage 1 AKI® manage as per table 2
AKI Warning Stage 2
Current creatinine >2 x baseline level
Consider clinical review £ 24 hours of e-alert*
If AKI confirmed® manage as per table 2
Consider clinical review £ 6 hours of e-alert*
Likely Stage 2 AKI® manage as per table 2
AKI Warning Stage 3
Current creatinine >3 x baseline level
(or creatinine >1.5 x baseline and >354 mmol/L)
Consider clinical review £ 6 hours of e-alert*
If AKI confirmed® consider admission
Consider Immediate Admission*
Likely Stage 3 AKI
#
Clinical Context
Why was the blood test taken?
· Routine chronic disease monitoring
· Drug monitoring
· Assessment of acute illness
Creatinine rise within stable clinical context
may reflect unstable CKD instead of AKI,
especially if longer time period between
current and baseline creatinine.
*AKI Risk Factors/Clinical Features Prompting Earlier Review
· Poor oral intake/urine output
· Evidence of hyperkalaemia, especially if moderate(K+
6.0-6.4) or severe (K+
≥ 6.5)¥
· Known history of CKD stages 4 & 5 or history of kidney transplant
· Deficient Immunity
· Frail with co-morbidities (CKD, diabetes, heart failure, liver disease, neurological or
cognitive impairment)
· Past history of AKI
· Suspected intrinsic kidney disease
· Suspected urinary tract obstruction
21
Table 2 09.03.2016
The table is a guide to support recognition and response to AKI in primary care
The table does not apply to children and young people (<18 years) or patients receiving end of life care
Table 2: Recognising and Responding to Acute Kidney Injury in Primary Care*
"Think"
Cause
"Think"
Medication#
"Think"
Fluids
"Think"
Review¥
History of acute Illness?
· Think Sepsis
· Think Hypotension
Intrinsic kidney disease?
(E.g. vasculitis)
Urinary tract obstruction?
Any medication which could
exacerbate AKI?
Consider withholding:
· NSAIDs
· Diuretics
· Antihypertensive
medication
Any medication which may
accumulate and cause harm
during AKI?
Any new medication that may
cause AKI?(E.g. drug induced
tubulo-interstitial nephritis)
What is the patient’s volume
status?
If hypovolemia present:
· When did patient last pass
urine?
· Can the patient increase
fluid intake?
· Is admission for IV fluid
replacement and
monitoring required?
Does the patient have and/or
need carer support?
Does the patient need acute
admission?
If not, when will you review?
Have you ensured handover?
¥
* Refer to main guidance document [INSERT HYPERLINK]
#
Refer to medicines optimisation toolkit for primary care www.thinkkidneys.nhs.uk/medicines-optimisation-toolkit-for-aki/[CHECK CORRECT
HYPERLINK]
¥
Refer to overarching principles in communication of diagnostic test results[INSERT HYPERLINK]
Proposed primary care audit measures: structure
Practice systems to ensure that AKI warning stage test results are seen and responded
to by the appropriate clinician, including response to critical test results
Establish an AKI register and ‘alerts’ to identify and support management of patients
who have had a history of AKI
Proposed primary care audit measures: prevention
Use of NSAIDs amongst patients with CKD (NICE CG182)
• ? Restrict to high-risk subset e.g. those on , or both
Communicate and code risk of AKI (NICE QS76) in patients with
• Previous history of AKI
• CKD3 (eGFR<60 over >=3/12)
• Neurological or cognitive impairment
Carer status clarified and coded
Up to date with immunisation
Avoid combination of ACEI and ARB in patients with CKD (NICE CG182)
Proposed primary care audit measures: post-AKI care
Denominator: patients with a discharge diagnosis of AKI
Numerators: proportions with
• Coded AKI diagnosis
• Coded AKI stage
• Coded Cause
• Given information about AKI and risk of CKD and coded ‘at risk’ of AKI
• Medication review within ??4/52 of discharge
• Previously coded as hypertensive who have had BP rechecked within ?? 4/52 of
discharge
• Repeat serum creatinine/eGFR within 3/12 of discharge
• Urine albumin:creatinine within 3/12 of discharge
• Repeat eGFR/UACR at 1,2 and 3 years post discharge
Position statement on ‘sick day guidance’
https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2015/07/Think-
Kidneys-Sick-Day-Guidance-v8-131115.pdf
Summary
Ambitious national programme to reduce harm associated with AKI
(once labs get their LIMS sorted) ‘Free’ measurement system for incidence and
outcomes
AHSN Patient Safety Collaborative to drive implementation
Evidence base for proposed interventions: largely expert opinion
Direction of causality unclear
• IF AKI is just a very good marker of severity of underlying illness, mortality will be driven
largely by the underlying illness rather than specific management of AKI
• If AKI is just a very good marker of ‘susceptible kidneys’, then better management of AKI
will not necessarily prevent future CKD/ESKD
No (current) plan for formal evaluation of the impact of the programme
How to find out more
Karen Thomas
Think Kidneys Programme Manager
UK Renal Registry
Karen.Thomas@renalregistry.nhs.uk
Teresa Wallace
Think Kidneys Programme Coordinator
UK Renal Registry
Teresajane.Wallace@renalregistry.nhs.uk
| 28
Contact Think Kidneys
Richard Fluck
National Clinical Director for Renal
NHS England
Richard.fluck@nhs.net
Joan Russell
Head of Patient Safety
NHS England
Joan.russell@nhs.net
Ron Cullen
Director
UK Renal Registry
Ron.cullen@renalregistry.nhs.uk
www.linkedin.com/company/think-kidneys
www.twitter.com/ThinkKidneys
www.facebook.com/thinkkidneys
www.youtube.com/user/thinkkidneys
www.slideshare.net/ThinkKidneys
www.thinkkidneys.nhs.uk

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Improving the prevention, recognition and management of AKI: the ‘Think Kidneys’ initiative

  • 1. Improving the prevention, recognition and management of AKI: the ‘Think Kidneys’ initiative Charlie Tomson - @CharlieTomson; charles.tomson@nhs.net Chair, Intervention Workstream, NHS England ‘Think Kidneys’ RCPSG meeting 18.03.2016; 1335-1410 No conflicts of interest to declare
  • 2. 2
  • 3. Think Kidneys: programme objectives The primary aim of the National Programme is to ensure avoidable harm related to AKI is prevented in all care settings. It will aim to do this by ensuring that: A variety of tools and interventions are developed and implemented to support the prevention, early detection, treatment and enhanced recovery of patients with AKI Patients who develop AKI are appropriately managed to reduce further deterioration, long term disability and death Appropriate education and training programmes are developed for all health professionals based on best available evidence. | 3
  • 4. | 4 Hydration Theme Expert ReferenceGroup Algorithm Sub-Group NHS England Patient Safety Steering Group UK Renal Registry Risk workstream Education workstream Detection workstream Intervention workstream Implementation workstream Measurement workstream Acute Kidney Injury National Programme Board
  • 5. Workstreams Risk: identify patients at risk Education: develop educational resources for public, patients, professionals Detection: automated laboratory generation of AKI warning stage test results Measurement: national AKI registry linked to UKRR/HES/ONS, supporting local regional and national QI Intervention: appropriate clinical management of AKI (1o and 2o care) Implementation: using commissioning and other quality levers Hydration
  • 6. RISK: Communities at risk of AKI Secondary care: Any acute illness; frail, elderly; CKD; heart failure; liver disease; diabetes mellitus (esp if albuminuric); neurological or cognitive impairment Primary care: Diabetes mellitus; CKD; dementia; heart failure; frail, elderly; psychiatric disease; children with CKD; patients with cancer https://www.thinkkidneys.nhs.uk/wp-content/uploads/2015/07/Communities-at-risk-of-developing-AKI-Think- Kidneys-010715.pdf
  • 7. RISK: Example: adults having surgery Non-modifiable risk factors: Age>=65y; eGFR<60; kidney transplant; Diabetes mellitus; Heart failure; Liver disease Previous episode of AKI Emergency surgery Intraperitoneal surgery Modifiable risk factors: Use of drugs that could be harmful to kidney function eg NSAIDs
  • 8. EDUCATION Infographic GP educational resources (with RCGP) Undergraduate curriculum Proposal for public education campaign (unfunded) Patient educational resources (with BKPA) Care homes guidance Centre for Postgraduate Pharmacy Education campaign Development of an app
  • 9. DETECTION: the AKI algorithm | 9
  • 10. | 10 Answer: at least as well as any other algorithm; any ‘improvements’ would increase false + rate
  • 11. UK Renal Registry Patient Renal Units LABS LABS LABS The UKRR: AKI direct from labs From renal IT systems CKD4/5, D-AKI and ESRD HES, ONS etc Direct from labs AKI in 1y and 2y care
  • 12. AKI data specification https://www.thinkkidneys.nhs.uk/resources/ 1. The Warning Grade Test Result • Patient Identifiers • The index creatinine and eGFR 2. Retrospective & Prospective Lab Data • All creatinine & eGFR data from preceding 15 months • All creatinine & eGFR data from next 15 months
  • 13. Data submissions from lab to UKRR https://www.thinkkidneys.nhs.uk/aki/aki-data/
  • 14. INTERVENTION Medicines management toolkit • Audit measures Dietetic management Minimum content for secondary care bundle • Audit measures Minimum AKI-related content for discharge summaries Advice on re-starting drugs stopped during AKI admissions Agreeement with RCPath on communication of warning stage test results Primary care: guide to responding to AKI warning stage test results • Audit measures
  • 15. SECONDARY CARE ‘BUNDLE’ components | 15
  • 16. SECONDARY CARE audit measures (TBC…) Denominator: inpatients with an AKI 1,2,or 3 warning stage test result • Exclude ‘false positives’ e.g. progression of CKD, completion of pregnancy, Trimethoprim Numerators: % of patients with • Evidence of an ABCDE assessment • Evidence of a decision on whether patient has sepsis • Evidence in the medical notes of a decision on whether the patient is hypovolaemic/normovolaemic/hypervolaemic (within x of test result) • Evidence in the medical notes of the results of dipstick urinalysis (within x h of test result) • Evidence of a review of drug treatment in the light of AKI • Evidence of request for renal ultrasound (when indicated –operational definition required) • Completion of minimum AKI-related dataset in discharge summary
  • 17. Minimum AKI-related content for discharge summary Community-acquired or hospital-acquired? Highest AKI stage Serum creatinine at discharge • Increasing, stable, or falling? ITU admission yes/no RRT given yes/no Cause of AKI (?? hypovolaemia/hypotension/sepsis/intrinsic renal/post-renal) Drugs stopped during admission • Restarted prior to discharge? • Considered contraindicated in future? Requirement and arrangements (1o or 2o care) for follow-up of renal function
  • 18. MANAGEMENT OF AKI IN PRIMARY CARE 60-70% of all AKI is community-acquired AKI warning stage test results to be released to primary care April 2016 • Likely frequency = 1 per FTE GP every 1-2 months • 70% AKI stage 1 Many GP tests on sick patients taken on lunchtime visits: results dealt with OOH Expected response requires careful calibration RAND Consensus process: 2 clinical pathologists, 2 acute physicians, 2 nephrologists, 4 GPS (including rural, urban, out of hours, anti-over-medicalisation) – 2-stage voting on appropriate lab and GP response to ~700 scenarios
  • 19. Acute Kidney Injury Best practice guidance: Responding to AKI Warning Stage Test Results for Adults in Primary Care Publication date April 2016
  • 20. Draft Version Table 1 09.03.2016 Provide hyperlink to main guidance document here ¥ UK Renal Association Clinical Practice Guidelines (2014) recommends emergency assessment and treatment of severe hyperkalaemia (K + ≥6.5mmol/l) – needs hyperlink The table is a guide to support an initial response to an AKI Warning Stage Test Result but clinical judgement must prevail. The table does not apply to children and young people (<18 years) or patients receiving end of life care. Table1: Recommended response times to AKI Warning Stage Test Results for Adults in Primary Care AKI Warning Stage Test Result Confirm or refute automated AKI Test Result by comparing patient’s current creatinine within clinical context against baseline creatinine Clinical Context Within Which Blood Test Taken # If clinical context is unknown, then assume high pre-test probability until proven otherwise LOW Pre-test Probability of AKI Stable Clinical Context HIGH Pre-test Probability of AKI Context of Acute Illness AKI Warning Stage 1 Current creatinine >1.5 x baseline level (or creatinine rise >26 mmol/L £48 hrs) Consider clinical review £ 72 hours of e-alert* If AKI confirmed® manage as per table 2 Consider clinical review £ 24 hours of e-alert* Likely Stage 1 AKI® manage as per table 2 AKI Warning Stage 2 Current creatinine >2 x baseline level Consider clinical review £ 24 hours of e-alert* If AKI confirmed® manage as per table 2 Consider clinical review £ 6 hours of e-alert* Likely Stage 2 AKI® manage as per table 2 AKI Warning Stage 3 Current creatinine >3 x baseline level (or creatinine >1.5 x baseline and >354 mmol/L) Consider clinical review £ 6 hours of e-alert* If AKI confirmed® consider admission Consider Immediate Admission* Likely Stage 3 AKI # Clinical Context Why was the blood test taken? · Routine chronic disease monitoring · Drug monitoring · Assessment of acute illness Creatinine rise within stable clinical context may reflect unstable CKD instead of AKI, especially if longer time period between current and baseline creatinine. *AKI Risk Factors/Clinical Features Prompting Earlier Review · Poor oral intake/urine output · Evidence of hyperkalaemia, especially if moderate(K+ 6.0-6.4) or severe (K+ ≥ 6.5)¥ · Known history of CKD stages 4 & 5 or history of kidney transplant · Deficient Immunity · Frail with co-morbidities (CKD, diabetes, heart failure, liver disease, neurological or cognitive impairment) · Past history of AKI · Suspected intrinsic kidney disease · Suspected urinary tract obstruction
  • 21. 21
  • 22. Table 2 09.03.2016 The table is a guide to support recognition and response to AKI in primary care The table does not apply to children and young people (<18 years) or patients receiving end of life care Table 2: Recognising and Responding to Acute Kidney Injury in Primary Care* "Think" Cause "Think" Medication# "Think" Fluids "Think" Review¥ History of acute Illness? · Think Sepsis · Think Hypotension Intrinsic kidney disease? (E.g. vasculitis) Urinary tract obstruction? Any medication which could exacerbate AKI? Consider withholding: · NSAIDs · Diuretics · Antihypertensive medication Any medication which may accumulate and cause harm during AKI? Any new medication that may cause AKI?(E.g. drug induced tubulo-interstitial nephritis) What is the patient’s volume status? If hypovolemia present: · When did patient last pass urine? · Can the patient increase fluid intake? · Is admission for IV fluid replacement and monitoring required? Does the patient have and/or need carer support? Does the patient need acute admission? If not, when will you review? Have you ensured handover? ¥ * Refer to main guidance document [INSERT HYPERLINK] # Refer to medicines optimisation toolkit for primary care www.thinkkidneys.nhs.uk/medicines-optimisation-toolkit-for-aki/[CHECK CORRECT HYPERLINK] ¥ Refer to overarching principles in communication of diagnostic test results[INSERT HYPERLINK]
  • 23. Proposed primary care audit measures: structure Practice systems to ensure that AKI warning stage test results are seen and responded to by the appropriate clinician, including response to critical test results Establish an AKI register and ‘alerts’ to identify and support management of patients who have had a history of AKI
  • 24. Proposed primary care audit measures: prevention Use of NSAIDs amongst patients with CKD (NICE CG182) • ? Restrict to high-risk subset e.g. those on , or both Communicate and code risk of AKI (NICE QS76) in patients with • Previous history of AKI • CKD3 (eGFR<60 over >=3/12) • Neurological or cognitive impairment Carer status clarified and coded Up to date with immunisation Avoid combination of ACEI and ARB in patients with CKD (NICE CG182)
  • 25. Proposed primary care audit measures: post-AKI care Denominator: patients with a discharge diagnosis of AKI Numerators: proportions with • Coded AKI diagnosis • Coded AKI stage • Coded Cause • Given information about AKI and risk of CKD and coded ‘at risk’ of AKI • Medication review within ??4/52 of discharge • Previously coded as hypertensive who have had BP rechecked within ?? 4/52 of discharge • Repeat serum creatinine/eGFR within 3/12 of discharge • Urine albumin:creatinine within 3/12 of discharge • Repeat eGFR/UACR at 1,2 and 3 years post discharge
  • 26. Position statement on ‘sick day guidance’ https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2015/07/Think- Kidneys-Sick-Day-Guidance-v8-131115.pdf
  • 27. Summary Ambitious national programme to reduce harm associated with AKI (once labs get their LIMS sorted) ‘Free’ measurement system for incidence and outcomes AHSN Patient Safety Collaborative to drive implementation Evidence base for proposed interventions: largely expert opinion Direction of causality unclear • IF AKI is just a very good marker of severity of underlying illness, mortality will be driven largely by the underlying illness rather than specific management of AKI • If AKI is just a very good marker of ‘susceptible kidneys’, then better management of AKI will not necessarily prevent future CKD/ESKD No (current) plan for formal evaluation of the impact of the programme
  • 28. How to find out more Karen Thomas Think Kidneys Programme Manager UK Renal Registry Karen.Thomas@renalregistry.nhs.uk Teresa Wallace Think Kidneys Programme Coordinator UK Renal Registry Teresajane.Wallace@renalregistry.nhs.uk | 28 Contact Think Kidneys Richard Fluck National Clinical Director for Renal NHS England Richard.fluck@nhs.net Joan Russell Head of Patient Safety NHS England Joan.russell@nhs.net Ron Cullen Director UK Renal Registry Ron.cullen@renalregistry.nhs.uk www.linkedin.com/company/think-kidneys www.twitter.com/ThinkKidneys www.facebook.com/thinkkidneys www.youtube.com/user/thinkkidneys www.slideshare.net/ThinkKidneys www.thinkkidneys.nhs.uk