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Support for implementing

the NICE clinical guideline on acute


kidney injury (CG169)
What this presentation covers
• Background

• Scope and methodology

• Recommendations

• Discussion

• Find out more

Implementing NICE guidance www.nice.org.uk


Background
• Acute kidney injury (previously known as acute renal
failure) covers a wide spectrum of injury to the kidneys,
not just kidney failure

• Up to 18% of all hospital admissions have AKI

• Inpatient AKI-related mortality is between 25 and 30%

• Between 20 and 30% of cases of AKI are preventable.


Prevention could save up to 12,000 lives each year

• NHS costs related to AKI are between £434 and £620


million per year

Implementing NICE guidance www.nice.org.uk


NCEPOD: Key findings

• AKI avoidable in 14% of cases


• Only 50% of patients received “good care”
• Post admission AKI: poor recognition and
care
• 24% did not receive adequate senior review
• Quality of care in this group was judged to be
less good
• 85% did not have documented evidence of
critical care outreach involvement

June 2009
Implementing NICE guidance www.nice.org.uk
Background: prevention and early
identification
• AKI can be readily identified by close monitoring of routine
serum creatinine and urine output results

• AKI can be prevented by early recognition and treatment of


the underlying cause, for example:
– Early treatment of infections/sepsis
– Early treatment/prevention of dehydration
– Correcting hypovolaemia

• AKI can also be prevented by:


– Monitoring use of drugs such as NSAIDs and ACE inhibitors,
especially if a patient is acutely unwell
– Taking care with at-risk patients who need iodinated contrast agents
with scans

Implementing NICE guidance www.nice.org.uk


Observations and assessment

Use an
early warning score
that recognises
and responds to
deterioration
and acute illness

Staff should have competencies in:


•monitoring
•measurement
•interpretation
•recognition and prompt response to acute illness (CG50)

Implementing NICE guidance www.nice.org.uk


Guideline development

Implementing NICE guidance www.nice.org.uk


Guideline scope
• Multidisciplinary input from stakeholders, including
Royal Colleges and NHS trusts
• Practical guidance for NHS services
• Not a textbook of acute kidney injury
• Avoids duplication of aligned NICE guidance, such
as the clinical guideline on acutely ill patients in
hospital (CG50)

Covers:
 Adults (excluding pregnancy and renal transplant patients)
 Young people and children older than 1 month (excludes
neonates)

Implementing NICE guidance www.nice.org.uk


Outside of scope
• Renal replacement therapy, including dialysis
(existing NICE guidance covers this)
• The use of biomarkers
(evidence of cost effectiveness versus standard care not
yet available)
• Intravenous fluid management in adults and in children
and young people (separate NICE guidelines currently in
development)
• Management of less common causes of acute kidney
injury, such as vasculitis and haemolytic uraemic syndrome

Implementing NICE guidance www.nice.org.uk


• Identifying acute kidney injury in patients with acute illness
• Identifying acute kidney injury in patients with no obvious acute
illness*

• Assessing risk factors in adults having iodinated contrast agents


and in adults having surgery

• Ongoing assessment of patients in hospital


• Detecting acute kidney injury AKI:
• Identifying the cause(s) of acute kidney injury Key priorities
• Urinalysis*
• Ultrasound
for implementation
• Managing acute kidney injury
• Relieving urological obstruction*
• Pharmacological management*
• Referring for renal replacement therapy*
• Referring to nephrology
• Information and support for patients and carers

* not a KPI, but considered a key issue by the guideline development group
Implementing NICE guidance www.nice.org.uk
Risk factors: adults
• Chronic kidney disease (or history of)
• Diabetes
• Heart failure
• Sepsis
• Hypovolaemia
• Age 65 years or over
• Use of drugs with nephrotoxic potential (for example,
NSAIDs, ACE inhibitors)
• Use of iodinated contrast agents within past week
• Oliguria
• Liver disease
• Limited access to fluids, e.g. via neurological impairment
• Deteriorating early warning scores
• Symptoms or history of urological obstruction

Implementing NICE guidance www.nice.org.uk


Risk factors: children and young people

As for adults, with the following additional risks:


•Abnormal or deteriorating paediatric early warning
score
•Young age, disability or cognitive impairment with
dependency on carers for access to fluids
•Severe diarrhoea, especially bloody diarrhoea
•Signs or symptoms of nephritis (for example,
oedema or haematuria)
•Haematological malignancy
•Hypotension

Implementing NICE guidance www.nice.org.uk


Assessing risk of AKI
• Acute illness:
– in adults
– in children and young people

• Adults having iodinated contrast agents

• Adults having surgery

• In patients with no obvious acute illness, with risk factors

Implementing NICE guidance www.nice.org.uk


Acute kidney injury stages
AKI STAGE Serum creatinine criteria Urine output criteria

1 Increase in serum creatinine of 26 Less than 0.5 ml/kg/hour


micromol/litre or more within 48 hours for more than 6 hours*
OR
1.5 to 2-fold increase from baseline

2 Increase in serum creatinine to more Less than 0.5 ml/kg/hour


than 2 to 3-fold from baseline for more than 12 hours

3 Increase in serum creatinine to more Less than 0.3 ml/kg/hour


than 3-fold from baseline for 24 hours or anuria for
OR 12 hours
Serum creatinine more than 354
micromol/litre with an acute increase of
at least 44 micromol/ litre

* Urine output of less than 0.5 ml/kg/hour more than 8 hours in children and young people

Implementing NICE guidance www.nice.org.uk


Detecting AKI
• Investigate for AKI when risks factors are present
• Compare serum creatinine with the patient’s baseline
Detect AKI using (p)RIFLE, AKIN, KDIGO criteria:

Serum creatinine rise ≥ 26 micromol/litre from baseline within


48 hours
Serum creatinine rise by 50% or more in 7 days

Urine output < 0.5ml/kg body weight/hour for 6


consecutive hours in adults

• Urine output < 0.5ml/kg/hour for more than 8 hours in children


and young people
• In children and young people – a 25% or greater fall in eGFR

Implementing NICE guidance www.nice.org.uk


Risk factors in adults having
surgery or iodinated contrast agents
Risk factor Surgery Iodinated contrast agents
Age Age 65 years or over Age 75 years or over

CKD CKD with eGFR <60 CKD with eGFR <40


Diabetes Yes Yes, if also has CKD
Heart failure Yes Yes
Hypovolaemia Yes, especially if acutely unwell Yes
Other conditions Liver disease Renal transplant

Clinical treatments or a) Emergency surgery, Increased volumes of contrast


drugs especially if patient has sepsis agent
or hypovolaemia
b) Nephrotoxic drugs in the Intra-arterial route
perioperative period
c) Intraperitoneal surgery

Implementing NICE guidance www.nice.org.uk


Adults: ongoing hospital assessment
• Use early warning scores (track and trigger systems)
(CG50)
• Ensure there is a system in place to recognise and
respond to oliguria <0.5ml/kg/hour (if not part of early
warning score)
• Continue to monitor serum creatinine
regularly in all patients with, or at risk,
of acute kidney injury

Implementing NICE guidance www.nice.org.uk


Children and young people: ongoing
hospital assessment
• Consider a paediatric early warning score (PEWS) to identify
children and young people at risk of acute kidney injury
• Record physiological observations at admission and then
according to local protocols for given PEWS
• Increase the frequency of observations if abnormal physiology is
detected
• Use PEWS with multiple-parameter or aggregate weighted scoring
systems that allow a graded response and include:
• heart rate
• respiratory rate
• systolic blood pressure
• level of consciousness
• oxygen saturation
• temperature
• capillary refill time

Implementing NICE guidance www.nice.org.uk


Patients without obvious acute illness
Consider acute kidney injury when an adult, child or young person
with acute illness with no clear cause has any of the following:
Chronic kidney disease, especially stage 3B, 4 or 5,
or urological disease
Symptoms suggesting complications of acute kidney injury

New onset or significant worsening of urological symptoms

Symptoms or signs of a multi-system disease affecting the


kidneys and other organ systems. For example, signs of acute
kidney injury, plus a purpuric rash

A rise in serum creatinine could indicate acute kidney injury rather


than a worsening of any existing chronic kidney disease

Implementing NICE guidance www.nice.org.uk


Identifying the cause of acute kidney
injury and ultrasound
• Record cause(s) of AKI in the patient’s notes, for
example, “AKI secondary to sepsis”
• Urinalysis: via dipstick. If proteinuria or haematuria in
absence of infection/trauma consider nephritis diagnosis.

DO NOT routinely perform ultrasound scan of the


renal tract if the cause of AKI has been identified
DO offer urgent ultrasound scan of the renal tract
within 24 hours of detection of AKI:
• if there is no identified cause
• if there is risk or suspicion of renal tract
obstruction
Implementing NICE guidance www.nice.org.uk
Interventions: iodinated contrast agents
in adults
Offer intravenous volume expansion to adults having iodinated
contrast agents if at increased risk of contrast-induced AKI because:
They have any of the risk factors Or they have an acute illness
from slide 12

Discuss care with a nephrology team before offering iodinated contrast


agent to adults with contraindications to IV fluids if they:
Are at increased risk of contrast- Have an acute illness
induced acute kidney injury
Are on renal replacement therapy

Implementing NICE guidance www.nice.org.uk


Managing AKI

• Pharmacological management

• Relieving urological obstruction

• Referral

• Information and support for patients and carers

Implementing NICE guidance www.nice.org.uk


Relieving urological obstruction
• Refer all patients with upper tract urological obstruction to a
urologist.

• Immediate referral if one or more of following present:


• Pyonephrosis
• Obstructed single kidney
• Bilateral upper urinary tract obstruction
• Complications of AKI secondary to urological
obstruction

• When nephrostomy or stenting required – undertake as


soon as possible and within 12 hours of diagnosis

Implementing NICE guidance www.nice.org.uk


Referral
Nephrology:
Discuss AKI management with a nephrologist/paediatric nephrologist as
soon as possible (and within 24 hours) if one of the following is present:

Potential diagnosis requiring AKI with no clear Inadequate treatment


specialist treatment (for example, cause response
vasculitis or glomerulonephritis)
Complications associated with AKI Stage 3 AKI eGFR is less than < 30
ml/min/1.73 m2 after
AKI episode
Patients with renal transplant and CKD stage 4 or
AKI 5
Renal replacement therapy:
Refer adults, children and young people immediately for RRT if any of the
following are not responding to medical management:
Hyperkalaemia Metabolic Symptoms or complications Fluid overload
acidosis of uraemia such as +/- pulmonary
pericarditis or oedema
encephalopathy

Implementing NICE guidance www.nice.org.uk


Patient information and support
• Discuss immediate treatment options, monitoring, prognosis, and
support options as soon as possible.

• Give information about long-term options, monitoring and self-


management in collaboration with the multidisciplinary team.

• Discuss future risk of AKI, especially for patients with eGFR < 60 or
those with neurological or cognitive impairment. In particular, discuss
the risk associated with:

• conditions that may lead to dehydration


• use of drugs with nephrotoxic potential, including over the
counter NSAIDs.

Implementing NICE guidance www.nice.org.uk


Chronic kidney disease stages
Stage eGFR Description Qualifier
(ml/min/1.73m2)

1 ≥90 Kidney damage, normal or Kidney damage


increased GFR (presence of structural
abnormalities and/or
2 60–89 Kidney damage, mildly persistent haematuria,
reduced GFR proteinuria or
microalbuminuria) for
3A 45–59 Moderately reduced GFR ≥3 months
+/- other evidence of
kidney damage
3B 30–44
GFR < 60 ml/min/1.73
4 14–29 Severely reduced GFR +/- m2 for ≥ 3months +/-
other evidence of kidney kidney damage
damage

Implementing NICE guidance www.nice.org.uk


Discussion 1
• How can your trust’s admission or clerking proforma be
adjusted to include an AKI risk assessment?
• What system could be used in your trust for reporting AKI alerts
via laboratory services?
• What does your trust’s AKI management pathway look like?
• How can your trust ensure access to 24-hour nephrology/
urology services?
• What processes are in place within your radiology department
to identify high-risk patients requiring iodinated contrast?
• How can pharmacists in your trust support AKI-related
initiatives? For example, involvement in ward rounds or an
electronic system to review medication/nephrotoxic drugs.

Implementing NICE guidance www.nice.org.uk


Discussion 2
• How does your ward or team currently identify a decline
in urine output in an inpatient with acute illness?

• If you suspect AKI in an acutely ill patient, what


investigations or checks should you run?

• When should a clinical response be escalated for


suspected AKI?

• What information do you provide for patients and carers


about AKI?

Implementing NICE guidance www.nice.org.uk


Reflection: learning and actions
• What did you learn from today’s session? And how does
this relate to your clinical practice?

• What are the key messages from the NICE guideline?

• What will you do differently when you return to your


workplace or clinical practice?

• Did you identify any further learning needs during


today’s session?

Implementing NICE guidance www.nice.org.uk


NICE Pathways

An online tool
providing
quick and
easy access,
topic by topic,

to the full
range of
guidance
from NICE

Click here to go
the pathway

Implementing NICE guidance www.nice.org.uk


NICE Evidence Services

Click here to go t
o NICE Evidence Se
rvices AKI page

Implementing NICE guidance www.nice.org.uk


If background information on
methodology is not appropriate
for your audience, or if you
have less than an hour available
for your presentation, please
delete this and the following 4
slides.
If limited time is available, you
may benefit from using just one
of the ‘discussion’ slides.
Please delete this note before
using the presentation.

Implementing NICE guidance www.nice.org.uk


Developing the recommendations 1
• Each recommendation relates to an original clinical question.

• The clinical questions are based on the clinical areas in the scope and
are formulated into PICO method questions:
• Population
• Intervention
• Comparison
• Outcome(s)

• Each question is addressed with a systematic review of the evidence:


• comprehensive search and sift strategy used to find studies
• studies are reviewed and quality assessed using NICE quality
checklists
• data extracted into evidence tables
• outcome data synthesised into a meta-analysis (where
possible)
• Each outcome is assessed for risk of bias using GRADE
Implementing NICE guidance www.nice.org.uk
Developing the recommendations 2
• Recommendations are formulated based upon:
• available clinical evidence
• Cost-effectiveness evidence
• GDG expert opinion

• The strength of the evidence is reflected in the wording of the


recommendation , e.g.:

• ‘offer’, ‘refer’, ‘advise’ are used as a direct instruction


from strong evidence, therefore strong recommendations
• ‘consider’ is used for weaker evidence

• The rationale for making the recommendations is clearly


explained in the ‘Linking Evidence to Recommendations ‘
sections of the full guideline

Implementing NICE guidance www.nice.org.uk


Versions of NICE clinical guidelines
NICE produces 4 versions of its clinical guidelines:

•The FULL GUIDELINE, contains all the recommendations plus details


of the methods used and the underpinning evidence.

•The NICE GUIDELINE presents the recommendations from the full


version in a format suited to implementation by health professionals and
NHS bodies.

•The NICE PATHWAY is on an online tool for health and social care
professionals that brings together all related NICE guidance, quality
standards and implementation tools on a topic in a set of interactive
flowcharts.

•INFORMATION FOR THE PUBLIC is written using language for


people without specialist medical knowledge.

Implementing NICE guidance www.nice.org.uk


AKI Guideline Development Group, the National
Collaborating Centre and NICE team

Guideline Development Group National Clinical Guideline Centre


Andrew Lewington Caroline Blaine
Annette Davies Elisabetta Fenu
Anne Dawnay Joanna Ashe
Chris Laing Izaba Younis
Coral Hulse
David Milford Ralph Hughes
Fiona Loud Saoussen Ftouh
Mark Devonald Susan Latchem
Mark Thomas
Marlies Ostermann
Nicholas Palmer NICE project team
Sue Shaw Alison Foskett
Anne-Louise Clayton
Expert advisors Ben Doak
John Lemberger
Lyda Jadresic Elaine Clydesdale
Mark Downes Emma McFarlane
Mark Rigby Jasdeep Hayre
Rajib Pal Judith Thornton
Shelagh O’Riordan Sharon Summers-Ma
Implementing NICE guidance www.nice.org.uk
Find out more
• Visit http://guidance.nice.org.uk/CG169 for the:
– Guidance, including the full version with evidence tables
– NICE pathway
– Information for the public
– Baseline assessment tool
– Clinical audit tools
– Costing statement

– In February 2014, an AKI e-learning module for nursing


will also be published

Implementing NICE guidance www.nice.org.uk


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