1. The acutely unwell patient with diabetes;
thinking kidneys in primary care
Daniel Lasserson MA MD FRCP Edin MRCGP
Associate Professor and Senior Interface Physician
Co-chair, Measurement Workstream, Think Kidneys
Programme

2. 86 years old, retired book keeper, lives alone after the death of her husband.
She has hypertension, type 2 diabetes, atrial fibrillation, previous falls with hip
fracture, osteo-arthritis and needs carers twice a week to help her with
shopping and some housework.
Feeling ‘not right’ for several days. ‘Muddled’ at times. Seen by her GP who
visits her at home on a Monday. Seen by Out of Hours GP on Saturday night.
Found fallen at home by carers the following Tuesday. Ambulance takes her to
a community based ambulatory care centre.
A patient journey – Mrs C

3. Early presentations of disease on a background of
normality
Lack of access to diagnostics
‘Reverse triage’ in acute illness
‘In hours’ and ‘Out of hours’
Acute illness in primary care

4. Rapid decline in renal function
Usual functions of the kidney are impaired
electrolyte balance
fluid balance
acid base balance
Usually due to another illness and pre-existing risk
factor
What is acute kidney injury (AKI)?

5. At the ambulatory care unit, she describes deteriorating mobility and is now
unable to mobilise without assistance. She wants to go home.
Her usual creatinine is around 112 micromol/L . Her point of care creatinine
test shows a creatinine of 382 (> 3 times her usual creatinine) - this is stage 3
acute kidney injury.
After discussion with the on call renal team, she is admitted to an elderly care
ward for multidisciplinary assessment and treatment with renal input.
A patient journey – Mrs C

6. Measuring the scale of AKI in primary care

7. Barton et al Nephron 2015;130:175-181
Who gets AKI in primary care?

8. Oke et al BMJ Open 2015;5:e009459
Are we doing enough blood tests?

9. Is AKI increasing in primary care?

10. Home or hospital?
Barton et al Nephron 2015;130:175-181

11. Hobbs et al BMC Nephrology 2014;15:206
Home or hospital? The next 2 years

12. Treated for infection, medications altered, renal function improved. She had an
episode of confusion on the ward. Desperate to go home.
She was discharged from hospital early with daily review coordinated by the
ambulatory care unit with an increase in her care package. As her strength and
confidence returned she needed less care in the following months.
Primary care team aware of her AKI risk and the non-specific presentation ‘just
not right’
A patient journey – Mrs C

13. Acute ambulatory care unit embedded in a local community,
outside of an acute care setting
Nurses, physiotherapy, OT, social work, medics
Point of care diagnostics
Referrals from GPs, Out of Hours primary care, paramedics
AKI at the interface of primary and secondary care

14. Detecting AKI in Out of Hospital Settings
0
200
400
600
800
1000
1200
1400
1600
0 200 400 600 800 1000 1200 1400 1600
i-Stat
Laboratory
Creatinine i-Stat V Lab (micromol/l)
Line X=Y

15. Referrals with frailty syndromes….
Median age of 81 years, with 5 co-morbid conditions
18% have diabetes (majority type 2)
85% are living in their own home
AKI at the interface of primary and secondary care

16. What are the clinical features of AKI in the older patient?
General decline, reduced mobility
Falls
Confusion
20% of patients we see with diabetes have AKI
AKI at the interface of primary and secondary care

17. What does Mrs C’s journey tell us?
Non specific presentation of AKI
Importance of developing out of hospital diagnostics
vulnerable populations
appropriate reduction in threshold for testing
Identification of ‘at risk’ populations

18. ‘Think Kidneys’ – Primary Care guidance
When to suspect AKI
Timely response
What to do next
Future Strategies for AKI

19. Future Strategies for AKI

20. The Think Kidneys Measurement Workstream
CCG area
rates of AKI
outcomes (recovery, mortality)
Learn from variation
Help commissioners
What have we changed?

21. The acutely unwell patient with diabetes;
thinking kidneys in primary care
Daniel Lasserson MA MD FRCP Edin MRCGP
Associate Professor and Senior Interface Physician
Co-chair, Measurement Workstream, Think Kidneys
Programme