Download Acute kidney injury: slide set

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
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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
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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
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NICE guidance
June 2009
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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
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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)
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Guideline development
TOPIC
• Topic referred by DH – AKI – in response to 2009 report from NCEPOD ‘Adding Insult to Injury’
• NICE AKI guideline commissioned (for England and Wales, and to be available for Northern Ireland)
SCOPE
• April 2011 – NICE scoping exercise to define the scope of the guideline.
• Stakeholder workshop including Royal Colleges, ICS, BACCN, Renal Association , NHS trusts
GDG
Timeline
DRAFT
FINAL
VERSION
• Guideline Development Group and technical team established
• Research questions set against the scope
• GDG meetings to analyse reviews of published evidence (September 2011 to May 2013)
• LETR, Linking evidence to recommendations; and recommendations then drafted
• Chapter write up.
• GDG member’s direct involvement in the production of the guideline ran from September 2011 to
August 2013
• 1st draft ready for May to June 2013 consultation with registered stakeholders
• GDG responses to stakeholder comments – amendments made where required
• Guideline published 28 August 2013 – implementation process begins
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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)
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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
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• 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
• Identifying the cause(s) of acute kidney injury
• Urinalysis*
• Ultrasound
AKI:
Key priorities
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
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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
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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
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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
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Acute kidney injury stages
AKI STAGE
Serum creatinine criteria
Urine output criteria
1
Increase in serum creatinine of 26
micromol/litre or more within 48 hours
OR
1.5 to 2-fold increase from baseline
Less than 0.5 ml/kg/hour
for more than 6 hours*
2
Increase in serum creatinine to more
than 2 to 3-fold from baseline
Less than 0.5 ml/kg/hour
for more than 12 hours
3
Increase in serum creatinine to more
than 3-fold from baseline
OR
Serum creatinine more than 354
micromol/litre with an acute increase of
at least 44 micromol/ litre
Less than 0.3 ml/kg/hour
for 24 hours or anuria for
12 hours
* Urine output of less than 0.5 ml/kg/hour more than 8 hours in children and young people
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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
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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
drugs
a) Emergency surgery,
especially if patient has sepsis
or hypovolaemia
b) Nephrotoxic drugs in the
perioperative period
c) Intraperitoneal surgery
Increased volumes of contrast
agent
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Intra-arterial route
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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
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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
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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
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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
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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
from slide 12
Or they have an acute illness
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 contrastinduced acute kidney injury
Have an acute illness
Are on renal replacement therapy
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Managing AKI
• Pharmacological management
• Relieving urological obstruction
• Referral
• Information and support for patients and carers
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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
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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
specialist treatment (for example,
vasculitis or glomerulonephritis)
AKI with no clear
cause
Inadequate treatment
response
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
AKI
CKD stage 4 or 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
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Metabolic
acidosis
Symptoms or complications
of uraemia such as
pericarditis or
encephalopathy
Fluid overload
+/- pulmonary
oedema
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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 selfmanagement 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.
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Chronic kidney disease stages
Stage
eGFR
(ml/min/1.73m2)
Description
Qualifier
1
≥90
Kidney damage, normal or
increased GFR
2
60–89
Kidney damage, mildly
reduced GFR
3A
45–59
3B
30–44
Moderately reduced GFR
+/- other evidence of
kidney damage
Kidney damage
(presence of structural
abnormalities and/or
persistent haematuria,
proteinuria or
microalbuminuria) for
≥3 months
4
14–29
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Severely reduced GFR +/other evidence of kidney
damage
GFR < 60 ml/min/1.73
m2 for ≥ 3months +/kidney damage
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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.
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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?
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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?
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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
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NICE Evidence Services
Click here to go to
NICE Evidence
Services AKI page
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If background information on
methodology is not appropriate
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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
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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
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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.
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AKI Guideline Development Group, the National
Collaborating Centre and NICE team
Guideline Development Group
Andrew Lewington
Annette Davies
Anne Dawnay
Chris Laing
Coral Hulse
David Milford
Fiona Loud
Mark Devonald
Mark Thomas
Marlies Ostermann
Nicholas Palmer
Sue Shaw
Expert advisors
John Lemberger
Lyda Jadresic
Mark Downes
Mark Rigby
Rajib Pal
Shelagh O’Riordan
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National Clinical Guideline Centre
Caroline Blaine
Elisabetta Fenu
Joanna Ashe
Izaba Younis
Ralph Hughes
Saoussen Ftouh
Susan Latchem
NICE project team
Alison Foskett
Anne-Louise Clayton
Ben Doak
Elaine Clydesdale
Emma McFarlane
Jasdeep Hayre
Judith Thornton
Sharon Summers-Ma
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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
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