1. Objectives Understand why AKI matters Natural history Associated risk Be able to recognise AKI Do small changes in creatinine/eGFR really matter? Be confident about what to do Be confident about when to refer

2. KIDNEYS

3. Understand why AKI matters

4. NICE Guidance 28 th August 2013 The National Confidential Enquiry into Patient Outcome and Death found that only half of patients with AKI had received 'good' care Up to 30 per cent of cases of AKI can be prevented - that equates to at least 12,000 unnecessary deaths per year Inadequate assessment of risk factors in 24% of patients admitted with AKI Commonest risk factors not assessed were medication, co-morbidity and hypovolaemia

5. Understand why AKI matters: Natural history Acute kidney injury results most often from ‘external’ insults threatening glomerular perfusion Exacerbated by ‘toxic’ insults Often in setting of ‘damaged’ kidneys Significant biochemical changes have no ‘immediate’ clinical correlate but are ‘red flags’ for potentially significant ongoing insult/s to kidneys If the insult is not corrected kidney injury will progress and reversible injury may become irreversible

6. Understand why AKI matters: Associated risk AKI is associated with increased mortality Degree of change directly proportional to increased risk CKD≥3 is associated with increased mortality AKI may be irreversible or only partially reversible resulting in CKD ‘Angina of the kidneys’ Need to stop becoming MI

7. (N=1,120,295) 1.0 1.4 2.0 2.8 3.4 Hazard ratio for CV event 0 1 2 3 4 Reduced kidney function is associated with a higher risk of CV events ≥6045-5930-4415-29<15 eGFR (mL/min/1.73 m 2 ) Go et al. N Engl J Med 2004 351: 1296–1305 Tonelli et al. J Am Soc Nephrol 2006 17: 2034–2047 Eeg-Olofsson et al. J Internal Medicine 2010 268: 471–482 Khaw Nature Reviews Endocrinology 2009 5: 130-131 8.0-8.9 9.0-9.9 CKD3

8. Be able to recognise AKI: Classification A rise in serum creatinine of ≥26.5 μmol/L in 48 hours A rise in serum creatinine of ≥50% in 7 days AKI stage 1: a rise in creatinine of ≥26.5 μmol/L or 1.5- 1.9 × baseline AKI stage 2: a rise in creatinine of 2.0-2.9 × baseline AKI stage 3: a rise in creatinine of ≥3 × baseline or increase in creatinine to ≥353 μmol/L

9. Be able to recognise AKI: Small changes A rise in serum creatinine of ≥26.5 μmol/L in 48 hours A rise in serum creatinine of ≥50% in 7 days AKI stage 1: a rise in creatinine of ≥26.5 μmol/L or 1.5- 1.9 × baseline AKI stage 2: a rise in creatinine of 2.0-2.9 × baseline AKI stage 3: a rise in creatinine of ≥3 × baseline or increase in creatinine to ≥353 μmol/L

10. Be able to recognise AKI: Change from baseline 140 120 100 140 120 100

11. Hemmelgarn BR. Kidney International 2006: 29: 2155 10,184 community-dwelling subjects aged 66 or over Decline in eGFR greatest in diabetics (2.1 and 2.7 ml/min/1.73m 2 /year in F and M respectively) Decline in eGFR in non-diabetics: 0.8 and 1.4 ml/min/1.73m 2 /year in F and M respectively Decline more likely if baseline eGFR <30 Decline of GFR in elderly people

12. RRT 60 50 40 30 20 10 eGFR CKD3 CKD4 X Be able to recognise AKI: Is it really CKD? Do not ignore eGFR 30- 59ml/min until know direction of travel and significant causes ruled out

13. Direction of travel is everything Haematuria and proteinuria are flags for further investigation Risk factors for AKI include age >65, diabetes, CVD and ACEI/ARB Infection is a trigger for AKI in at risk patients even if not involving urinary tract Summary

14. What to do Recognise at risk patient Identify and treat reversible insults irrespective of kidney function Document kidney function

15. What to do: Medications ACEI/ARBStop Loop DiureticsStop MetforminStop SUsReview MetiglinidesNo change GliptinsNo change StatinsNo change AspirinNo change NSAIDsStop/Avoid TrimethoprimAvoid

16. When to refer AKI 1: Can be managed in primary care if cause treatable and kidney function stabilises AKI 2: Refer general medicine AKI 3: Refer nephrology NB Obstruction and rapidly progressive glomerulonephritis should be referred to specialist unit directly whatever level of kidney function

17. Challenges: A lot of work for no return? Need baseline defined in all at risk patients and technology to allow interpretation Rapid turn round of creatinine in at risk patient with acute illness Urinalysis Patient education: sick day rules for kidneys

18. Recognition and Prevention of AKI Is this an at risk patient? Age >65 years Vascular disease DM ACEI/ARB CKD Is glomerular perfusion threatened ? Hypotension or sepsis NSAID/COXi/COX-2i Kidney medicine in primary care: 7 minutes

19. Recognising the at risk patient: ACEI ACEI/ARB essential part of managing IHD and preventing progression of CKD ACEI/ARB, IHD and CKD are important risk factors for AKI

20. 48 yr old man. Routine health check. Found to have eGFR of 35ml/min Referred for investigation of his “CKD 3” No previous eGFR Protein ++++ No haematuria BP 122/74 Case 1 Renal biopsy demonstrated FSGS

21. Mrs MA 74 year old eGFR 46ml/min/1.73m 2 USS demonstrated ‘normal’ size kidneys Serum electrophoresis revealed a paraprotein with urinary BJP Case 2 Dipstick of urine revealed + protein

22. Mr PS 80 year old ‘Stable’ IHD Not diabetic No ACEI Acutely SOB with possible rigor Few crackles L base Clarithromycin prescribed Case 3

23. 24 hours later confused and hypotensive Emergency admission Treated as CAP according to hospital protocol Rx Vancomycin 1g x 2 Gentamicin 160mg x 2 Case 3 continued

24. 48 hours later AKI diagnosed Baseline eGFR 42ml/min/1.73m 2 4 week hospital admission Probably avoidable with recognition that patient likely to have CKD and risk conferred by this CKD Admission eGFR 22ml/min/1.73m 2 ‘48h’ eGFR 12ml/min/1.73m 2 Case 3 continued

25. 74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease Most recent HbA1c 7.4% First thoughts? Case 4 Rx Ramipril 5mg daily and Metformin 500mg bd

26. 74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease Rx Ramipril 5mg daily and Metformin 500mg bd Pyrexial. BP 130/74. Euvolaemic WCC 10.6x10 9 /l CRP 48ng/ml eGFR 42ml/min with a potassium of 4.2mmol/l Case 5

27. 92 year old is seen in clinic having been found by GP to have ‘CKD4’ She is well with an eGFR of 26ml/min Rest of biochemistry is safe, urine reveals neither blood nor protein What do I do? Case 6 USS shows echobright kidneys of 8.2cm and 8.4cm with no evidence of obstruction eGFR was 28ml/min in 2008

28. Case 7 A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable. What do I do?

29. Case 7 A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non- blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable. What do I do Dipstick of urine revealed blood ++ and protein ++

30. 78 year old with stable CKD3. Rx Ramipril 5mg daily eGFR June 2011 47ml/min April 2014 41ml/min Cares for terminally ill husband therefore deferred R hip replacement What pain killers would you recommend? Case 8 Pharmacist recommended Ibuprofen 400mg daily 4 th July 2014 16ml/min Stopped ibuprofen 14 th July 2014 39ml/min

31. Slides and more info available at www.clinimeded.co.ukwww.clinimeded.co.uk https://www.thinkkidneys.nhs.uk Wales Deanery CPD for GP http://gpcpd.walesdeanery.org/http://gpcpd.walesdeanery.org/ Clinical Acute Kidney Injury Quiz: http://www.doctors.net.ukhttp://www.doctors.net.uk More information available at

32. Objectives Understand why AKI matters Natural history Associated risk Be able to recognise AKI Do small changes in creatinine/eGFR really matter? Be confident about what to do Be confident about when to refer