Prevention, detection and management of acute kidney injury: concise guideline
Abstract
Acute kidney injury (AKI) is considered a silent disease that commonly occurs in patients with acute illness; however, given that it has few specific symptoms and signs in its early stages, detection can be delayed. AKI can also occur in patients with no obvious acute illness or secondary to more rare causes. In both these scenarios, patients are often under the care of specialists outside of nephrology, who might fail to detect that AKI is developing and might not be familiar with its optimum management. Therefore, there is a need to increase the awareness of AKI among many different healthcare specialists. In this article, we summarise the key recommendations from the National Institute for Health and Care Excellence (NICE) AKI guideline. The guideline provides recommendations for adult and paediatric patients on the prevention, early detection and management of AKI, as well as information on AKI and sources of support. Implementation of this guideline will contribute to improving patient safety and saving lives.
Introduction
Acute kidney injury (AKI) is a syndrome with many different causes that represents an independent risk factor associated with worse patient outcomes.1 It is a common condition that occurs in up to 18% of patients admitted to acute medical units,2 but has few specific symptoms and signs, which can delay detection.3 In most cases, AKI occurs in an at-risk population of patients secondary to reduced perfusion of the kidneys resulting from hypovolaemia and/or sepsis exacerbated by exposure to nephrotoxins.4 AKI can also occur in patients with risk factors following major surgery5 or might have a more rare cause (eg vasculitis) that requires urgent referral to nephrology for specific therapy.
The definition of AKI is based upon increases in serum creatinine or reductions in urine output, both of which are relatively poor biomarkers; therefore, there is a need to develop more sensitive and specific biomarkers.6 The treatment of AKI is largely supportive, with no specific therapy available other than renal replacement therapy (RRT). Patients who develop AKI are now recognised as being at risk of subsequent chronic kidney disease (CKD). In 2009, the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report Acute kidney injury; adding insult to injury found that less than 50% of patients who died from a diagnosis of AKI received good care.7 It has also been estimated that up to 30% of cases of AKI are preventable8 and, therefore, 12,000 lives could potentially be saved annually. Since then, there has been a coordinated effort across the UK to raise awareness about AKI. The NCEPOD report informed a referral from the Department of Health for the National Institute for Health and Care Excellence (NICE) to develop its first national guideline on AKI.
Scope and purpose
NICE published a guideline on AKI in August 2013.9 The guideline is based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. It is primarily aimed at non-specialist clinicians, who will care for most patients with AKI. The guideline addresses known and unacceptable variations in the prevention, detection and management of AKI in both adult and paediatric patients. Given the predetermined scope of the guideline, it does not cover every aspect of the management of AKI but does provide recommendations on particularly crucial elements, such as:
risk factors for developing AKI
the principles of preventing AKI
the management of AKI (restricted to the relief of urological obstruction, pharmacological > management and referral -criteria to nephrology)
essential information and support required for patients and carers.
The aim of this concise guideline is to emphasise and highlight the core content of the guidance that is relevant to non-specialist physicians in both adult medicine and child health (Box 1), thus supporting a wider improvement in the care of patients with AKI, which in turn could save lives. The full set of recommendations can be found on the NICE website (http://guidance.nice.org.uk/CG169).
Box 1. Core content of the clinical guideline for acute kidney injury.
Limitations of the guideline
It must be recognised that the NICE AKI guideline is not a comprehensive textbook of every aspect of AKI and does not include recommendations regarding aspects of RRT beyond the decision on its initiation. The guideline covers those topics that were included in the scope and which were prioritised by stakeholders as being the key areas where guidance was needed. The guideline is based on systematic reviews of the best available evidence and explicit consideration of the cost effectiveness. When there is insufficient evidence available, the recommendations are based upon the experience and opinion of what the guideline development group considered as good practice. The topic of the prevention and management of AKI with intravenous fluid therapy was not within the scope and is covered in the NICE intravenous fluid therapy in adults in hospital clinical practice guideline.10 A separate NICE guideline on intravenous fluid therapy in children is also being developed.
Implications for implementation
Over the past few years, and particularly since the publication of the NCEPOD report,7 there has been a concerted effort across the UK to raise awareness and improve health care professionals’ understanding of AKI. It is anticipated that implementation of the NICE AKI guideline will further support this and improve patient safety and outcomes. Implementation will require a coordinated national approach and dedicated AKI clinical leads at the local level. There needs to be increased emphasis on multiprofessional AKI education at both an undergraduate and postgraduate level covering primary and secondary care. The Academy of Royal Medical Colleges has developed an AKI core competency framework that describes the training required for different healthcare professionals in identifying patients at risk of AKI and those who are developing it with a recommended response.11 NICE have developed a set of implementation and audit tools (Box 2) and will be publishing further educational online learning modules, which are aimed at nurses, healthcare assistants and non-renal practitioners. NICE is also committed to increasing awareness in primary care and is working collaboratively with the Royal College of General Practitioners on a joint AKI communications and awareness raising plan. Electronic learning also includes e-learning packages available at the BMJ12 and an AKI app, free to download from the website of the Royal College of Physicians of Edinburgh (RCPE).13 The Royal College of Physicians is also developing an AKI toolkit.
Box 2. Additional tools from the National Institute for Health and Care Excellence.
Patients with risk factors for AKI should be identified in primary and secondary care, and drug holidays should be considered if they become acutely ill. The detection of AKI will be facilitated by the national development of electronic AKI alerts, as advised by the RCPE AKI Consensus Conference14 and the validation of AKI risk factor calculators. There will be implications for the provision of radiology services to National Health Service (NHS) hospitals and patient pathways should be developed and overseen by AKI networks.15 The NICE guideline also recommends key areas where research should be focused that include long-term outcomes following AKI and the effect of rapid referral to renal services should be focused.
Acknowledgements
The members of the guideline development group were Mark Thomas (chair), Annette Davies, Anne Dawnay, Mark Devonald, Coral Hulse, Chris Laing, Andrew Lewington, Fiona Loud, David Milford, Marlies Ostermann, Nicholas Palmer and Sue Shaw. The technical team at the National Clinical Guideline Centre included Joanna Ashe, Caroline Blaine, Elisabetta Fenu, Saoussen Ftouh, Ralph Hughes, Susan Latchem and Izaba Younis. The co-opted expert advisors were Mark Downes, Lyda Jadresic, John Lemberger, Shelagh O’Riordan, Rajib Pal and Mark Rigby.
- © 2014 Royal College of Physicians
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