1. Measurement for Improvement
Management of Acute Kidney Injury in
primary care
Measurement for improvement event
16.03.2016
Charlie Tomson
Consultant Nephrologist, Freeman Hospital Newcastle upon Tyne
Chair, Intervention Workstream, NHS England/UKRR Think Kidneys Programme
@CharlieTomson
charles.tomson@nhs.net

2. What would excellent care of AKI in primary care deliver?
Community-acquired AKI:
Early recognition
Appropriate treatment referral and follow-up
Reduced morbidity and mortality
Hospital-managed AKI:
Appropriate post-discharge management
Appropriate follow-up
Reduced morbidity, ESRD, late referral, and mortality

3. Frequency of AKI in primary care
Based on reports from 6 centres, using the AKI algorithm for generation of AKI warning
stage test results:
Likely incidence 0.5-1.0 cases/WTE GP/month
• Assumes 1500 patients/WTE GP
~70% AKI stage 1
~20% AKI stage 2
~10% AKI stage 3

4. Prognosis of AKI in adults managed in 1o care (not admitted)
Hobbs H et al. BMC Nephrol 2014;15: 206

5. NICE standards (AKI: CG 169):
Measure serum creatinine and compare with baseline in adults with acute illness and
• CKD G3-5 (eGFR<60); Heart failure; Liver disease; Diabetes; Previous history of AKI;
age>65
• Oliguria (less than 0.5 ml/lg/h)
• Limited access to fluids caused by neurological/cognitive dysfunction
• Hypovolaemia
• “Drugs with nephrotoxic potential” (NSAIDs, aminoglycosides, ACEI, ARB, diuretics)
• Use of iodinated contrast within the last week
• Symptoms or history of urological conditions or disease that might cause obstruction
• Sepsis; falling early warning scores
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 5

6. NICE standards (CKD: CG182)
1.1.28 Offer testing for CKD using eGFRcreatinine and ACR to people with any of the
following risk factors:
…..acute kidney injury
Acute kidney injury and CKD
1.3.9 Monitor people for the development and progression of CKD for at least 2-3 years
after acute kidney injury, even if serum creatinine has returned to baseline
1.3.10 Advise people who have had acute kidney injury that they are at increased risk of
CKD developing or progressing
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7. Think Kidneys: Best Practice Guidance
Publication 04.04.2016

8. Aims:
•Put the test result in a clinical context
•Treat the patient not the test result
•Maximise clinical utility
•Minimise information overload and burden
•Ensure primary care engagement

9. 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

10. 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]

11. Proposed audit measures: structures
• 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

12. Proposed audit measures: prevention
• Use of NSAIDs amongst patients with CKD (NICE CKD CG182 2014)
• ??high risk subset e.g. those also on diuretics, ACEI/ARB 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 CKD CG182 2014)
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13. Proposed audit measures: post-AKI care
• Denominator: patients with a discharge diagnosis of AKI
• Numerators: proportion coded with
• AKI diagnosis
• AKI stage
• Cause
• Given information about AKI and risk of CKD and coded ‘at risk’ of AKI
• Proportion who have had a medication review within ??4/52 of discharge
• Proportion of patients previously coded as hypertensive who have had BP rechecked within
?? 4/52 of discharge
• Proportion who have had repeat serum creatinine/eGFR within 3/12 of discharge
• Proportion who have had a urine albumin:creatinine within 3/12 of discharge
• Proportion who have had repeat eGFR/UACR at 1,2 and 3 years post discharge
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14. Proposed audit measures: outcomes
• Further episodes of AKI
• New cases of CKD at 12 months
• CKD progression at 12 months
• Community-acquired AKI admission
• Readmission within 90 days
• Heart failure admission
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15. For each patient with AKI
• Where were they managed?
– Acute trust
– Community
• Which CCG were they in?
• Which acute hospital (if admitted)?
• Mortality
• Did their creatinine return to baseline?
– If so, when?
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What can the Measurement Workstream deliver?

16. For each CCG
• Proportion of patients with AKI who are admitted
• Mortality
– Age, AKI stage, measures of clinical complexity
• Return of creatinine to baseline level
– Time to return
| 16
What can the Measurement Workstream deliver?

17. 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
28.11.2014Acute Kidney Injury National Programme | Introducing the Think Kidneys campaign | Karen Thomas | 17
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
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www.thinkkidneys.nhs.uk