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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 Implementing NICE guidance June 2009 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 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 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 • 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 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 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 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 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 Implementing NICE guidance Intra-arterial route 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 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 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 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 Implementing NICE guidance Metabolic acidosis Symptoms or complications of uraemia such as pericarditis or encephalopathy Fluid overload +/- pulmonary oedema 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 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. Implementing NICE guidance www.nice.org.uk 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 Implementing NICE guidance Severely reduced GFR +/other evidence of kidney damage GFR < 60 ml/min/1.73 m2 for ≥ 3months +/kidney damage 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 to NICE Evidence Services 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 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 Implementing NICE guidance 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 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 What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form If you are experiencing problems accessing or using this tool, please email [email protected] To open the links in this slide set right click over the link and choose ‘Open Hyperlink’ Implementing NICE guidance www.nice.org.uk