Acute Kidney Injury The Role of Primary Care - NECN Kidney Injury The Role of Primary Care ... This...

Acute Kidney Injury

The Role of Primary Care

Prof Ahmet Fuat PhD FRCGP FRCP

PG Dip (Cardiology) GP & GPSI Cardiology Darlington

Professor of Primary Care Cardiology Durham

University

President CVGP Society

Primary Care Industry Lead CRN NENC

Talk Outline

GP role

- CKD and its management

- AKI

GPSI role

- Heart Failure management

Some case studies

Summary

RAAS therapeutic intervention sites

Aldosterone release

Blood vessel

constriction

Blood pressure

Angiotensinogen

secreted by the liver Renin

secreted by kidney

Angiotensin

converting enzyme

(ACE)

from lung tissue

Angiotensin I

Angiotensin II

- potent

vasoconstrictor

Adrenal cortex

Adapted from Stier CT et al. Heart Disease 2003; 5 (2): 102-118 and

McMahon EG. Current Opinion in Pharmacology 2001; 1: 190-196.

ACE inhibitors X

X

Angiotensin II

receptor

antagonists

X

X

Target organ effects

Aldosterone receptor

antagonists

RAAS drug use in Primary Care

• Hypertension

• Heart Failure

• Post MI

• Diabetes

• CKD and AKI

• Remember all anti-hypertensives and renal perfusion

Cardiovascular intelligence pack

March 2015 Version 1.2

CCG: NHS DARLINGTON CCG

Contents 1. Introduction 3

2. CVD risk

– The narrative 9

– The data 10

3. Stroke

– The narrative 33

– The data 34

4. Diabetes


– The data 48

5. Kidney


– The data 55

6. Heart


– The data 66

7. Outcomes 84

8. Appendix 90

6 CVD Intelligence packs

If this PowerPoint presentation is printed into hard copy, you must first check that the version number on your copy matches that of the

Cardiovascular intelligence PDF pack online. Printed copies are uncontrolled copies.

• Dr Matt Kearney Dr Chris Arden

• Prof Ahmet Fuat Dr Matt Fay

• Dr Yassir Javaid Prof Kamlesh Khunti

• Ms Jan Proctor –King Prof Ruth Chambers

• Dr Clare Hawley Dr Kathryn Griffith


This CVD Intelligence Pack has been compiled by the National Cardiovascular Intelligence Network in collaboration with GPs and nurses in primary care

Chronic Kidney Disease can

progress to kidney failure and it

substantially increases the risk of

heart attack and stroke.

Chronic Kidney Disease (CKD) is common.

It is one of the commonest co-morbidities and

affects a third of people over 65. In 2010 it was

estimated to cost the NHS around £1.5bn.

Average length of stay in hospital tends to be

longer and outcomes are considerably worse:

approximately 7,000 excess strokes and 12,000

excess heart attacks occur each year in people

with CKD compared to those without.

Individuals with CKD are also at much higher

risk of developing acute kidney injury when they

have an intercurrent illness such as pneumonia.

What might help

• Promote participation by all practices in the National

CKD Audit

• Obtain and benchmark practice level data from the

National CKD Audit

• Promote uptake of and follow up from the NHS

Health Check to aid detection and management of

CKD

• Local training and education in the detection and

management of CKD

What questions should we ask in our CCG?

1. For each indicator how wide is the variation in achievement and

exception reporting?

2. How many people would benefit if all practices performed as well

as the best?

3. How can we support practices who are average and below

average to perform as well as the best in:

• Detection of CKD

• More systematic delivery of evidence based care

Late diagnosis of CKD is common.

Around a third of people with CKD are

undiagnosed. More opportunistic testing

and improved uptake of the NHS Health

Check will increase detection rates.

Evidence based guidance from NICE

identifies CVD risk reduction, good blood

pressure control and management of

proteinuria as essential steps to reduce the risk

of cardiovascular events and progression to

kidney failure. Despite this there is often

significant variation between practices in

achievement and exception reporting.

Management of Chronic Kidney Disease

QOF 2014/2015 CKD QOF Indicators

1. Register of patients 18+ with CKD

2. % last BP < 140/85

3. % with HTN and proteinuria on ACE/ARB

4. % with Urine Albumin:creatinine ratio test

Results

• National prevalence 4.1% NE 4.5%

• National achieved points 94.8% NE 95.9%

• National exceptions 7.5% NE 7.2%


Chronic kidney disease (CKD) observed prevalence (2012/13) compared to expected prevalence (2011) by CCG

Graph 0.72 ratio of observed to expected

CKD prevalence in NHS Darlington

CCG compared to 0.7 in England

This suggests that 72% of people

with chronic kidney disease have

been diagnosed

Comparison with CCGs in the SCN

Note: This slide compares the prevalence of

CKD recorded in QOF in 2012/13 to the

expected prevalence of CKD produced by the

University of Southampton in 2011. A small

number of CCGs have a ratio greater than

1. It is unlikely that all people with CKD will be

diagnosed in any CCG and therefore a ratio

greater than 1 suggests that the figures are

underestimating the true CKD prevalence in

the area. These ratios should be taken as an

indication of the comparative scale of

undiagnosed CKD rather than absolute

figures.

The QOF 2013/14 data for CKD has a coding

issue around episodes which has led to an

underreporting of CKD. Therefore, 2012/13

QOF has been used to ensure accuracy.

0.70

0.35

0.51

0.64

0.68

0.71

0.72

0.72

0.74

0.78

0.92

0.92

0.92

1.12

1.17

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40

England

NHS South Tyneside CCG

NHS Hambleton, Richmondshire and Whitby CCG

NHS Sunderland CCG

NHS South Tees CCG

NHS Cumbria CCG

NHS Hartlepool and Stockton-On-Tees CCG

NHS Darlington CCG

NHS Durham Dales, Easington and SedgefieldCCG

NHS North Durham CCG

NHS Gateshead CCG

NHS North Tyneside CCG

NHS Northumberland CCG

NHS Newcastle North and East CCG

NHS Newcastle West CCG

ratio of observed to expected


CKD prevalence by GP practice, 2012/13

Graph

It is estimated that there are 1,496

people with undiagnosed chronic

kidney disease in NHS Darlington

CCG

GP practice range of observed CKD:

0.3% to 6.8%

Note: CCG estimates for the estimated

number of people with CKD are based on

applying a proportion from a resident

based population estimate to a GP

registered population. The characteristics

of registered and resident populations

may vary in some CCGs, and local

interpretation is required. 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

Darlington Health Centre Y02607

Blacketts Medical Practice A83034

Rockliffe Court Surgery A83048

Neasham Road Surgery A83013

Parkgate Surgery A83641

Charlton And Partners A83006

Moorlands Surgery A83010

Clifton Court Practice A83040

Whinfield Medical Practice A83005

Metcalfe And Partners A83031

Marshall And Partners A83070

Denmark Street Surgery A83047

prevalence %

GP practice CCG


Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2012/13

Graph

3,882 people with CKD (diagnosed)*

in NHS Darlington CCG

2,773 (71.4%) people whose blood

pressure is <= 140 / 85

288 (7.4%) people who are

exceptions

821 (21.1%) additional people whose

blood pressure is not <= 140 / 85


*Using the QOF clinical indicator

CKD03 denominator plus exceptions

71.6%

70.0%

70.7%

70.9%

71.4%

71.4%

71.6%

72.2%

72.3%

72.5%

72.7%

72.8%

73.6%

76.0%

76.8%

0% 20% 40% 60% 80% 100%

England

NHS Gateshead CCG

NHS Cumbria CCG



NHS Darlington CCG

NHS South Tees CCG

NHS Durham Dales, Easington and Sedgefield CCG


NHS Sunderland CCG






Below 140/85 Not below 140/85 Exceptions reported


Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less by CCG, 2012/13

Graph

Comparison with demographically similar CCGs

67.9%

70.4%

71.4%

71.8%

72.2%

73.2%

73.8%

73.9%

74.9%

76.0%

78.2%

0% 20% 40% 60% 80% 100%

NHS Hardwick CCG

NHS Newark & Sherwood CCG

NHS Darlington CCG

NHS Warwickshire North CCG


NHS Barnsley CCG

NHS Chorley and South Ribble CCG

NHS North Lincolnshire CCG

NHS Bassetlaw CCG

NHS North East Lincolnshire CCG

NHS St Helens CCG

Below 140/85 Not below 140/85 Exceptions reported


Percentage of patients on the CKD register whose last blood pressure reading (measured in the preceding 12 months) is not 140/85 mmHg or less by GP practice, 2012/13

Graph

In total, including exceptions, there

are 1,109 people whose blood

pressure is not <= 140 / 85

GP practice range: 20.0% to 100.0

%

If all practices were to achieve as

well as the average of the best

achieving practices, then an

additional 159 people would have

their blood pressure controlled

0% 20% 40% 60% 80% 100% 120%













Not below 140/85 Exceptions reported


Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2012/13

Graph

3,882 people with CKD (diagnosed)*

in NHS Darlington CCG

3,163 (81.5%) people who have a

record of a urine albumin: creatinine

ratio test

159 (4.1%) people who are

exceptions

560 (14.4%) additional people who

have no record of a urine albumin:

creatinine ratio test


*Using the QOF clinical indicator

CKD06 denominator plus exceptions

78.8%

77.0%

78.6%

78.6%

79.4%

79.6%

79.8%

80.0%

80.4%

81.5%

81.7%

82.5%

82.8%

83.1%

83.8%

0% 20% 40% 60% 80% 100%

England

NHS Gateshead CCG

NHS Sunderland CCG

NHS Cumbria CCG



NHS South Tees CCG



NHS Darlington CCG






Recorded Not recorded Exceptions reported


Percentage of patients on the CKD register whose notes have a record of a urine albumin: creatinine ratio test in the preceding 12 months by CCG, 2012/13

Graph

Comparison with demographically similar CCGs

75.2%

77.3%

78.1%

80.0%

81.5%

82.0%

82.1%

82.4%

82.8%

83.0%

83.4%

0% 20% 40% 60% 80% 100%

NHS Barnsley CCG

NHS Hardwick CCG

NHS Warwickshire North CCG

NHS Bassetlaw CCG

NHS Darlington CCG

NHS North Lincolnshire CCG

NHS Chorley and South Ribble CCG

NHS Newark & Sherwood CCG


NHS St Helens CCG

NHS North East Lincolnshire CCG

Recorded Not recorded Exceptions reported


Percentage of patients on the CKD register whose notes do not have a record of a urine albumin: creatinine ratio test in the preceding 12 months by GP practice,

2012/13

Graph

In total, including exceptions, there

are 719 people who have no record

of a urine albumin: creatinine ratio

test

GP practice range: 8.1% to 100.0 %

If all practices were to achieve as

well as the average of the best

achieving practices, then an

additional 197 people who have a

record of a urine albumin: creatinine

ratio test

0% 20% 40% 60% 80% 100% 120%













Not recorded Exceptions reported

Acute Kidney Injury – What GPs say…

• “What does AKI mean?”

• “I haven't really thought about it”

• “Is that dehydration?”

• “Isn’t that what we called acute renal failure?

• “If they’ve had an injury isn’t that A+E’s job?”

• “If it’s not QOF we won’t be coding it…”

AKI= Acute Kidney Injury Detection in Primary Care

AKI Stage Serum creatinine Urine output

Stage 1 Increase of more than or

equal to 26.5 umol/l or

increase of 150-200% from

baseline

Less than 0.5ml/kg/h

for more than 6

hours

Stage 2 Increase of 200-300% from

baseline i.e. 2-3 fold


for more than 12

hours

Stage 3 Increase to more than 300%

i.e.3 fold increase from

baseline or more than 354

umol/l


for more than 24

hours. Or anuria for

12 hours

Misconception Number 1 AKI is a secondary care problem

• 2/3 of all AKI starts in primary care •1/5 of all emergency hospital admissions will have AKI

Misconception Number 2 AKI needs special tests for diagnosis

AKI: Make it simple please!

• This is a loss of kidney function over hours or days

• Diagnosis starts with the identification of hypotension and falling urine output during acute illness, and arranging kidney function testing

• Urine should be dipstick tested for blood, leucocytes, protein, nitrites and glucose.

• Acute nephritis should be suspected with blood and protein and no infection or trauma

• Hydration and safe prescribing are priorities

Misconception 3:- An eGFR <60 doesn’t matter when you are over 80

Causes of AKI Exposures Susceptibilities

Sepsis Dehydration or volume depletion

Critical illness Advanced age

Circulatory shock Female gender

Burns Black race

Trauma CKD

Cardiac surgery especially

bypass

Chronic heart, lung or liver

disease

Major surgery Diabetes mellitus

Nephrotoxic drugs Cancer

Radiocontrast agents Anaemia

Poisonous plants and animals

• Targets of the National Think Kidneys programme •Improve prevention of AKI •Improve early detection of AKI •Improve the management of AKI •Improve recovery and care after discharge

Improve early detection with eAlerts

• Laboratories identify those with a significant change in creatinine and report to practices after April 2016

• Contact practices to review patients in a timely way ( within 12 hours)? Phone ? email

• Need plan for out of hours with results after 6pm

• NOT ALL AKI PATIENTS NEED ADMITTING

Strategies

• Sick day Guidance

• “ CKD” what to tell/warn patients

• NSAIDs

• Acute Illness and what to do – patients

• Acute Illness and what to do- GPs

GP skills needed..

• Clinical assessment of volume status

Wet or dry?

• Assessment of sepsis load

CRP

• Knowledge of medication inc OTC

Joined up Medical Record

• Management Plan – the “2% Vulnerable ”

Shared with Patient

Sick Day Guidance not Rules for Selected Patients not ALL

Flags

Warnings on

• Computer records

• Pharmacy records

• Hospital records

• Out-of-hours records

• 111 access to records

SAD MAN: Drugs to be aware of if patient is hypotensive and unwell

• Sulphonylureas

• ACE/ARB

• Diuretics

• Metformin

• Aldosterone antagonists

• NSAIDs

NHS Highland card for selected patients

NHS Highland card to be given by professionals

CKD and NSAID: Nephrotoxic • Prostaglandins are important to maintain perfusion

within the kidney

• Block of prostaglandins reduces renal blood flow with fluid retention, increased creatinine and potassium

• Acute use reversible fall in GFR

• Chronic use linked with hypertension and CKD progression

• RECOMMEND annual U and E and BP with NSAID

• RECOMMEND avoid NSAID with ACE/ARB and diuretic combination

AKI eAlert • Recommendation for laboratory to report results

when there is a change in creatinine in line with AKI

• Started in hospital but roll out to primary care soon

• Phone through to the practice if patient NOT an inpatient

• This is NOT the diagnosis of AKI which requires clinical symptoms and signs as well

• Pseudo AKI with trimethoprim

• Increasing creatinine in well person having CVD drugs up titrated

Avoiding pitfalls

• Telephone access for labs or urgent email box

• Clinician Education

• AKI is not just blood result need context

• Assess patient

• Action plan for home management

• Avoid unplanned admissions

• Follow up blood tests

Improve management

• Strong links with secondary care

• Telephone support from specialist

• Admission avoidance

• Pathways with CCG

• Action plan in nursing homes

• Changes to medication

Improved recovery

• Clear discharge summaries in timely way

• Electronic summaries to facilitate this

• AKI and stage top line

• Cause of AKI if known

• Creatinine at worst and before discharge

• Changes in medication and plan for restarting if required

• Follow up blood tests, BP weight etc

• CQUIN

Summary of Treatment of AKI

• Recognise the diagnosis

• Treat the patient not the figures

• Identify the cause

• Replace fluid

• Correct BP

• Review all medications

• May require hospital admission

Beta blocker

Mineralocorticoid receptor

antagonist

Drugs That Reduce Mortality in Heart Failure With Reduced Ejection Fraction

ACE inhibitor

Angiotensin receptor blocker

Based on results of SOLVD-Treatment, CHARM-Alternative,

COPERNICUS, MERIT-HF, CIBIS II, RALES and EMPHASIS-HF

10%

20%

30%

40%

0%

% D

ec

rea

se

in

Mo

rta

lity

10%

Angiotensin Neprilysin Inhibition With LCZ696 Doubles Effect on Cardiovascular Death of Current

Inhibitors of the Renin-Angiotensin System

20%

30%

40%

ACE inhibitor

Angiotensin receptor blocker

0%

% D

ec

rea

se

in

Mo

rta

lity

18%

20%

Effect of ARB vs placebo derived from CHARM-Alternative trial

Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial

Effect of LCZ696 vs ACE inhibitor derived from PARADIGM-HF trial

Angiotensin neprilysin inhibition

15%

Practical use of ACE (or ARB) in LVSD

Worsening renal function and hyperkalaemia

•Some rise in urea, creatinine, and potassium is to be expected after an ACE inhibitor; if an increase is small and asymptomatic, no action is necessary

•An increase in creatinine of up to 50% above baseline, or 266 μmol/L (3 mg/dL)/eGFR <25 mL/min/1.73 m, whichever is the smaller, is acceptable

•An increase in potassium to ≤5.5 mmol/L (locally 5.8) is acceptable

•If urea, creatinine, or potassium does rise excessively, consider stopping concomitant nephrotoxic drugs (e.g. NSAIDs) and other K supplements or retaining agents (triamterene, amiloride) and, if no signs of congestion, reducing the dose of diuretic

•If greater rises in creatinine or potassium than those outlined above persist despite adjustment of concomitant medications, the dose of the ACE inhibitor (or ARB) should be halved and blood chemistry re-checked with 1-2 weeks; if there is still an unsatisfactory response, specialist advise should be sought

Practical use of ACE (or ARB) in LVSD

• If potassium rises to >6.0 mmol/L or creatinine increases by >100% or to >310 μmol/L (3.5 mg/dL)/eGFR <20 mL/min/1.73 m, the ACE inhibitor (or ARB) should be stopped and specialist advice sought

• Blood chemistry should be monitored frequently and serially until potassium and creatinine have plateaued

Practical guidance on use of key disease

modifying drugs and diuretics in HF

www.escardio.org

Case Study – non HF Mrs AG dob 11.11.18 (age 96)

P/H – HTN, CVA/TIA, Mild depression

Meds: Aspirin 75mgs, Lisinopril 10mgs daily, sertaline 50mgs

Fall at home – no dizziness, LOC, says tripped and bruised hip – 111 advised A&E – xrays normal but admitted MAU 3.10.15

BP 140/80 on admission U 9.8 creat 91 eGFR 50

AKI 1 diagnosed

Lisinopril stopped with advice to GP to check urine and U&Es in 1w, no mention of restarting ACE

Seen in surgery BP 188/96 pulse regular 88/min

Case Study - HF Mrs MM – dob 8.4.32 (age 83)

P/H: LVSD/LVDD, HTN, Hypothyroidism, PVD

Meds: Aspirin 75mgs, Atorvastatin 40mgs, BFZ 2.5mgs, Bisoprolol 2.5mgs, Levothyroxine 75mcgs, Ramipril 10mgs, Spironolactone 25mgs

Admitted 26.12.15 UTI, URTI, AKI 1 diagnosed – see results, BP not low!

Discharged 30.12.15 BFZ, Ramipril and Sopironolactone all stopped

Advice GP to check U&Es at 1w and re-start ramipril 1.25mgs and to send ACR sample and check U&Es 14 days post discharge

Case Study – end stage HF

Mr TC dob 30.9.43 (aged 72)

P/H: Advanced CCF with RVF, COPD, PHT

Meds: Inhalers, Zomorph 10mgs bd, Oxygen, Spironolactone 50mgs, Furosemide 80mgs bd, BFZ 2.5mgs, Pregabalin 150mgs bd

Admitted 10.9.15 by OOH service bilateral cellulitis and aspiration pneumonia

3.9.15 U 15.1 Creat 119 eGFR 62

30.9.15 U 20.2 Creat 151 eGFR 48

3.10.15 Discharged U 14.8 Creat 124 eGFR 58

Case Study – end stage HF

Discharged with AKI 1 and usual GP advice

Stopped Spironolactone, Zomorph and BFZ

Furosemide 40mgs bd

Seen 5.10.15 by SHFN at wife’s request with severe pain in legs, toe to knee marked pitting oedema, increasing sob

Restarted pre-admission drugs within 72 hours comfortable!

Summary

• CKD Common ; AKI uncommon in Primary Care

• Use Drug day guidance

• Remain vigilant in older patients with acute illness

• Sepsis screening may be improved with CRP at Point of Care

• Treat Patient not figures

• HF drugs save lives, try not to stop

Management of ADHF

Wet and Warm

• Majority of patients

• Diurese, diurese, diurese

• Keep on beta-blockers and ACEi and

other home meds if you can

• Temporarily stopping BB, ACEi &

Spiro to avoid deteriorating renal

function

• Do not try to do too much too quickly !

Wet and Warm

Failure to respond to diuretics

Increase diuretic dose

Sodium and fluid restriction (1.5- 2L/day)

Continuous diuretic infusion

Addition of second type of diuretic for synergy (e.g. metolazone, Thiazide)

Ultrafiltration

Wet and Warm

IV Vasodilators

May be added to diuretic therapy in

absence of symptomatic hypotension

and still with severe HF

Causes rapid improvement in

congestion

Useful in pulmonary edema and severe

hypertension

Wet and Cold

• IV Inotropes

–Low EF and low output syndrome with:

–Marginal BP ≤ 90 mm Hg

–Unresponsive to vasodilators

–Poor response to diuretics

–Worsening renal function

Dry and Cold

• Usually need fluids

• Consider cutting back diuretics

• Check renal function

• Low BP – temporarily stop BB/ACEi

• Inotropes if low BP

• Assess functional status/consider

palliative approach if appropriate

Dry and Warm

• Stable chronic HF

• Carefully assess fluid status

• Symptoms are from something else –

chest infection, PE

• Check glucose, renal function and Hb

• O2 sats

Monitoring

• At least daily

– Weight

– Fluid intake and output

– Symptoms

– Signs – JVP, oedema, lung creps

– Renal function and electrolytes

Treatment Goals

• Improve symptoms

• Optimize volume status

• Optimize oral therapy

• Identify etiology (if not known previously)

• Review need for device or revascularization

• Consider Palliative Care if appropriate

Discharge

• Near optimal volume status achieved

• Near optimal oral therapy achieved

• Adequate transition from IV to oral

medications

• No IV diuretics/vasodilators or

inotropes for 48 h

• Oral medication regimen stable for

48h

Date post:	14-Apr-2018
Category:	Documents
Upload:	vuphuc
View:	217 times
Download:	2 times

Acute Kidney Injury The Role of Primary Care - NECN Kidney Injury The Role of Primary Care ... This...

Documents