More must be done to reduce risk of acute kidney injury, conference hears

Acute kidney injury is a “silent killer” that clinicians are unwittingly allowing patients to develop. Not until clinical staff get the basics right and more hospitals provide access to senior doctors seven days a week will the situation improve.

That was the message from speakers at a conference in London last week. Donal O’Donoghue, England’s national clinical director for kidney care, told delegates at the conference on improving outcomes and safety for the acutely ill patient that spotting risk factors, maintaining hydration, recognising deterioration, and seven day working across the health service were needed.

Dr O’Donoghue said that acute kidney injury was “the miner’s canary”—a marker of quality of acute care. “Acutely ill patients get AKI [acute kidney injury] because we don’t get the basics right. When we get [the basics] right for AKI, all acutely ill patients will benefit,” he told the conference.

Although statistics on incidence vary, depending on definition, US data indicate that numbers of cases are rising. Marion Kerr, a health economist for NHS Kidney Care, used recent academic studies to estimate that there are around 360 000 cases of acute kidney injury every year in England. Unpublished research shows that 60% of these are people with no history of kidney problems, she said.

A 2009 report from the National Confidential Enquiry into Patient Outcome and Death, Adding Insult to Injury (www.ncepod.org.uk/2009report1/Downloads/AKI_report.pdf), suggests one reason why: poor care. It found that less than half of patients (280 of 564) with acute kidney injury received good care. Reasons cited included inadequate assessment of risk factors, delay in recognising the condition, under-referral to nephrology services, and underuse of critical care outreach.

Because acute kidney injury affects patients across the specialties, a system-wide approach to tackling it is needed, said Paul Roderick, a professor of public health at the University of Southampton.

He reminded delegates that the risk factors for acute kidney injury included increasing age, being male, chronic kidney disease, and comorbidities. Triggers were sepsis, dehydration, shock, nephrotoxins, and obstruction.

“AKI is common, harmful, avoidable, treatable,” he said. If doctors could get the “three Rs” right (reducing risk, early recognition, and right response), they could go a long way towards reducing its incidence.

GPs were crucial for identifying people at risk or circumstances where people might be at risk and checking their kidney function, so reducing admissions to hospital, said Professor Roderick. GPs could also have a role in post-recovery management.

Ms Kerr said that the condition had severe effects on mortality and on long term quality of life and that its treatment meant high NHS costs. However, 20% to 30% of cases (75 000 to 110 000) were preventable.

Preventing 20% of cases would represent a cost saving of £87m to £124m a year to the NHS in England. This is equivalent to £500 000 to £700 000 per acute trust, she calculated.

“This could fund the salaries and overheads for 15 to 20 nurses or three to four consultants for every acute trust in England,” she said.

But Barbara Philips, a senior lecturer in intensive care medicine at St George’s, University of London, said, “This is not simple at all. Recognising a sick patient is very difficult. It takes confidence. It takes understanding of the physiology and pathophysiology of the patient.”

Speakers admitted that changes were needed to undergraduate and postgraduate education. “It is now in the curriculum for junior doctors. We do need to teach the physiology and give people the confidence,” said Dr O’Donoghue.

But he was not arguing for more teaching on acute kidney injury in the curriculum, as trainees would see the condition anyway in the context of a pneumonia or a myocardial infarction or where angiotensin converting enzyme inhibitors are continued inappropriately, he said.

What was needed was for doctors in training to hear patients’ experiences as they were going through the healthcare system. “We have fallen behind in the quality of our consultation skills: the ability to listen and to understand what is important to the patient,” said Dr O’Donoghue.

Ensuring that consultants saw the sickest patients promptly was also likely to improve prognosis. These doctors should be setting out what treatments were needed and reviewing patients when they had improved. At present it was often junior doctors who were left to struggle with sick people on admission.

Dr O’Donoghue urged people to go back to their health organisation and find out what it was doing to improve the detection of acute kidney injury.