• A simple care bundle for use in acute kidney injury: a propensity score matched cohort study.

      Kolhe, Nitin; Taal, Maarten; Selby, Nicholas; Fluck, Richard; Leung, Janson; Reilly, Timothy; Swinscoe, Kirsty (2016-05)
      BACKGROUND: Consensus guidelines for acute kidney injury (AKI) have recommended prompt treatment including attention to fluid balance, drug dosing and avoidance of nephrotoxins. These simple measures can be incorporated in a care bundle to facilitate early implementation. The objective of this study was to assess the effect of compliance with the AKI care bundle (AKI-CB) on in-hospital case-fatality and AKI progression. METHODS: In this larger, propensity score-matched cohort of multifactorial AKI, we examined the impact of compliance with an AKI-CB in 3717 consecutive episodes of AKI in 3518 patients between 1 August 2013 and 31 January 2015. Propensity score matching was performed to match 939 AKI events where the AKI-CB was completed with 1823 AKI events where AKI-CB was not completed. RESULTS: The AKI-CB was completed in 25.6% of patients within 24 h. The unadjusted case-fatality was higher when the AKI-CB was not completed versus when the AKI-CB was completed (24.4 versus 20.4%, P = 0.017). In multivariable analysis, AKI-CB completion within 24 h was associated with lower odds for in-hospital death [odds ratio (OR): 0.76; 95% confidence interval (95% CI): 0.62-0.92]. Increasing age (OR: 1.04; 95% CI: 1.03-1.05), hospital-acquired AKI (OR: 1.28; 95% CI: 1.04-1.58), AKI stage 2 (OR: 1.91; 95% CI: 1.53-2.39) and increasing Charlson's comorbidity index (CCI) [OR: 3.31 (95% CI: 2.37-4.64) for CCI of more than 5 compared with zero] had higher odds for death, whereas AKI during elective admission was associated with lower odds for death (OR: 0.29; 95% CI: 0.16-0.52). Progression to higher AKI stages was lower when the AKI-CB was completed (4.2 versus 6.7%, P = 0.02). CONCLUSIONS: Compliance with an AKI-CB was associated with lower mortality and reduced progression of AKI to higher stages. The AKI-CB is simple and inexpensive, and could therefore be applied in all healthcare settings to improve outcomes.
    • Acute kidney injury in urology patients: incidence, causes and outcomes.

      Caddeo, Giacomo; Williams, Simon; McIntyre, Christopher; Selby, Nicholas (2013-11)
      BACKGROUND: Acute kidney injury (AKI) is common in hospitalised patients and is associated with high mortality rates. However, the epidemiology of AKI in urology patients may differ due to a higher proportion of post-renal causes and surgical procedures that result in the intentional removal of renal parenchyma. OBJECTIVES: We performed a study to examine the incidence, aetiology and outcomes of AKI in a urological population. PATIENTS AND METHODS: We performed a single-centre observational study including all hospitalised patients who sustained AKI within the Urology Department over an 18 month period. Patients with AKI were prospectively identified by a hospital-wide, electronic AKI reporting system that also allows demographic, hospital admission and co-morbidity data collection. Data regarding aetiology of AKI and details of surgical procedures were added retrospectively by manual case-note search. RESULTS: 587 episodes of AKI occurred in 410 urology patients, giving an overall incidence of 6.7%. 137 (33.4%) were elective cases of whom 58 had undergone nephrectomy (radical and partial). Urinary obstruction and sepsis were the predominant causes of AKI in the 273 patients (66.6%) admitted as an emergency. Overall 30-day mortality was 7.8%; increasing severity of AKI was associated with mortality (4.8% in stage 1, 9.1% in stage 2, 14.9% in stage 3, P = 0.007). At time of discharge, only 57.7% of patients had recovered pre-morbid renal function. The observational nature of this study is a limitation, preventing determination of causality of associations. CONCLUSIONS: AKI is common in urology patients. The underlying aetiologies of AKI in this group may explain a lower overall mortality, although increasing AKI severity remains a marker of patients at higher risk of poor outcomes. The low rate of renal recovery suggests that urology patients who sustain AKI are exposed to a significant risk of CKD and its attendant consequences for long term health.
    • Acute kidney injury is independently associated with death in patients with cirrhosis

      Scott, Robert; Austin, Andrew; Kolhe, Nitin; McIntyre, Christopher; Selby, Nicholas (2013-07)
      BACKGROUND AND AIMS: Current creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes. METHODS: We prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI. RESULTS: 162 cirrhotic patients were studied with a mean age of 56.8±14 years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child-Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0 days (IQR 4.0-8.75) versus 16.0 days (IQR 6.0-27.5), p<0.001. Multivariate analysis identified AKI and Child-Pugh classes B and C as independent factors associated with mortality. CONCLUSIONS: The utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.
    • Barriers and enablers to the implementation of a complex quality improvement intervention for acute kidney injury: A qualitative evaluation of stakeholder perceptions of the Tackling AKI study.

      Fluck, Richard; Selby, Nicholas (2019-09)
      BACKGROUND: Acute kidney injury in hospital patients is common and associated with reduced survival and higher healthcare costs. The Tackling Acute Kidney Injury (TAKI) quality improvement project aimed to reduce mortality rates in patients with acute kidney injury by implementing a multicomponent intervention comprising of an electronic alert, care bundle and education in five UK hospitals across a variety of wards. A parallel developmental evaluation using a case study approach was conducted to provide the implementation teams with insights into factors that might impact intervention implementation and fidelity. The qualitative element of the evaluation will be reported. METHODS: 29 semi-structured interviews with implementation teams across the five hospitals were carried out to identify perceived barriers and enablers to implementation. Interviews were taped and transcribed verbatim and Framework analysis was conducted. RESULTS: Interviews generated four 'barriers and enablers' to implementation themes: i) practical/contextual factors, ii) skills and make-up of the TAKI implementation team, iii) design, development and implementation approach, iv) staff knowledge, attitudes, behaviours and support. Enablers included availability of specialist teams (e.g. educational teams), multi-disciplinary implementation teams with strong leadership, team-based package completion and proactive staff. Barriers were frequently the converse of facilitators. CONCLUSIONS: Despite diversity of sites, a range of common local factors-contextual, intervention-based and individual-were identified as potential barriers and enablers to fidelity, including intervention structure/design and process of/approach to implementation. Future efforts should focus on early identification and management of barriers and tailored optimisation of known enablers such as leadership and multidisciplinary teams to encourage buy-in. Improved measures of real-time intervention and implementation fidelity would further assist local teams to target their support during such quality improvement initiatives.
    • Be on alert for pediatric AKI

      Selby, Nicholas (2017-08)
      Acute kidney injury in children is associated with adverse outcomes, although much of our current understanding originates from studies in intensive care units. Holmes et al. used an automated acute kidney injury detection method to obtain epidemiologic data on pediatric acute kidney injury at a national level in outpatient, inpatient, and intensive care unit settings. We discuss the impact of these important results and the considerations needed with this approach.
    • Care Bundles for Acute Kidney Injury: Do They Work?

      Selby, Nicholas; Kolhe, Nitin (2016-07)
      Acute kidney injury (AKI) is common and is associated with poor patient outcomes, which in some cases appear associated with deficiencies in the provision of care. Care bundles (CBs) are a structured set of practices designed to improve the processes of care delivery and ultimately patient outcomes, and there have been some demonstrations of their utility in areas such as ventilator-associated pneumonia and in sepsis management. While there is a strong rationale for their use, the evidence base around AKI CBs is small but growing. Here, we review the existing data on the effectiveness of AKI CB and discuss optimal approaches to their future study.
    • A Comment on the Diagnosis and Definition of Acute Kidney Injury.

      Selby, Nicholas (2019-01)
      CONTEXT: International criteria for describing the presence and severity of acute kidney injury (AKI) based on changes in serum creatinine concentration and/or degree of oliguria are now widely accepted. Subject of Review: Three recent articles have debated the definition and diagnosis of AKI, offering conflicting opinions. On one side [Lancet 2017; 389: 779-781 and Nephrology Times 2018] an argument is made that a focus on creatinine-based staging has de-emphasised the traditional clinical approach of determining cause of AKI (pre-renal, renal or post-renal), and that any classification system based on serum creatinine is inherently flawed. The opposing argument, is that serum creatinine-based staging brings value via the consistent, robust and gradated associations between AKI stage and outcomes, and that many cases of AKI have multiple co-existing intra- and extra-renal processes that do not fit neatly into the traditional aetiological groupings [Lancet 2018; 391: 202-203]. Second Opinion: Determining the cause of AKI is a key element of clinical management, so it is important that AKI is not regarded as a single disease, rather a syndrome with multiple potential causes. This article critiques current, clinical approaches to determining AKI aetiology alongside future areas in which significant developments in patient phenotyping based on pathophysiological principles may occur. In the absence of current alternatives to serum creatinine, current AKI criteria (e.g., those from Kidney Disease Improving Global Outcomes) bring significant advantages in clinical and research environments, including facilitation of efforts to address current variations in the delivery of AKI care. However, their application needs to be accompanied by 2 aspects: an appreciation of the limitations of serum creatinine as a diagnostic test; and an absolute requirement for clinical assessment and diagnostic workup to establish the cause of AKI.
    • Defining the cause of death in hospitalised patients with acute kidney injury.

      Selby, Nicholas; Kolhe, Nitin; McIntyre, Christopher; Packington, Rebecca; Fluck, Richard (2012-11)
      BACKGROUND: The high mortality rates that follow the onset of acute kidney injury (AKI) are well recognised. However, the mode of death in patients with AKI remains relatively under-studied, particularly in general hospitalised populations who represent the majority of those affected. We sought to describe the primary cause of death in a large group of prospectively identified patients with AKI. METHODS: All patients sustaining AKI at our centre between 1(st) October 2010 and 31(st) October 2011 were identified by real-time, hospital-wide, electronic AKI reporting based on the Acute Kidney Injury Network (AKIN) diagnostic criteria. Using this system we are able to generate a prospective database of all AKI cases that includes demographic, outcome and hospital coding data. For those patients that died during hospital admission, cause of death was derived from the Medical Certificate of Cause of Death. RESULTS: During the study period there were 3,930 patients who sustained AKI; 62.0% had AKI stage 1, 20.6% had stage 2 and 17.4% stage 3. In-hospital mortality rate was 21.9% (859 patients). Cause of death could be identified in 93.4% of cases. There were three main disease categories accounting for three quarters of all mortality; sepsis (41.1%), cardiovascular disease (19.2%) and malignancy (12.9%). The major diagnosis leading to sepsis was pneumonia, whilst cardiovascular death was largely a result of heart failure and ischaemic heart disease. AKI was the primary cause of death in only 3% of cases. CONCLUSIONS: Mortality associated with AKI remains high, although cause of death is usually concurrent illness. Specific strategies to improve outcomes may therefore need to target not just the management of AKI but also the most relevant co-existing conditions.
    • Design and Rationale of 'Tackling Acute Kidney Injury', a Multicentre Quality Improvement Study

      Selby, Nicholas (2016-11)
      Acute kidney injury (AKI) is common and associated with extremely poor outcomes. While strategies to tackle deficiencies in basic care delivery are advocated, robust testing of their effectiveness is also needed. The Tackling AKI study was designed to test whether a complex intervention (consisting of an e-alert, care bundle and education programme) can be successfully implemented across a range of UK hospitals, and whether this will deliver improved patient outcomes. This multicentre, pragmatic clinical trial will employ a cluster randomised stepped wedge design to study this in all adult patients who sustain AKI in the 5 participating hospitals over a 2-year period. The intervention will be supported by a comprehensive change management framework. Data collection will include patient outcomes, process measures and a qualitative assessment of barriers and enablers to implementation. This article describes the rationale and design behind the Tackling AKI study.
    • Developing an interactive booklet for patients with acute kidney injury

      Moreland, Jane; Phiri, Elita (2015-05)
      Providing renal patients with written information about their condition can encourage active care participation and promote recovery. Jane Moreland and Elita Phiri discuss the production of an interactive booklet for adults with acute kidney injury at Royal Derby Hospital.
    • Effect of weekend admission on mortality associated with severe acute kidney injury in England: A propensity score matched, population-based study

      Kolhe, Nitin; Fluck, Richard; Taal, Maarten (2017-10)
      Background Increased in-hospital mortality associated with weekend admission has been reported for many acute conditions, but no study has investigated “weekend effect” for acute kidney injury requiring dialysis (AKI-D). Methods In this large, propensity score matched cohort of AKI-D, we examined the impact of weekend admission and in-centre nephrology services in 53,170 AKI-D admissions between 1st April 2003 and 31st March 2015 using a hospital episode statistic dataset. Propensity score matching (PSM) was performed to match 4284 weekend admissions with AKI-D with 14,788 admissions on weekdays. Results Of the 53,170 admissions with AKI-D in the whole dataset, 12,357 (23%) were at weekends. The unadjusted mortality for weekend admissions was significantly higher compared to admissions on weekdays (40·6% versus 39·6%, p 0·046). However, in multivariable analysis of the PSM cohort, the odds of death for weekend admissions with AKI-D was 1·01 (95%CI 0·93,1·09). Mortality was higher for weekend admissions in West Midlands (odds ratio (OR) 1·32, 95% confidence interval (CI) 1·05, 1·66) and lower in East of England (OR 0·77, 95%CI 0·59, 1·00) but was not different to weekday admissions in all other regions. In 2003–04, weekend admissions had lower odds of death (OR 0·45, 95%CI 0·21, 0·96) and in 2010–11 higher odds of death (OR 1·28, 95%CI 1·00, 1·63) but in the other ten years observed, there was no significant difference in mortality between weekday and weekend admissions. Provision of in-centre nephrology services was associated with lower odds of death at 0·57 (95%CI 0·54, 0·62). Conclusions Weekend admissions in patients with AKI-D had no effect on mortality. Further research is warranted to elucidate the reasons for the lower mortality in hospitals with in-centre nephrology services.
    • Electronic alerts for acute kidney injury.

      Selby, Nicholas (2013-11)
      PURPOSE OF REVIEW: Acute kidney injury (AKI) is extremely common in hospitalized patients and its presence infers a poorer chance of survival, longer hospital stays and an increased risk of subsequent chronic kidney disease. Recent reports have suggested that standards of care for patients with AKI are often suboptimal and that this contributes to poor outcomes. In an attempt to address delays in diagnosing AKI, there has been increasing interest in e-alert systems for AKI. This review aims to discuss recent developments in e-alert methodologies, as well as examining the evidence to support their effectiveness. RECENT FINDINGS: Several e-alert systems for AKI have been reported, including more recent descriptions of hospital-wide systems that apply current diagnostic criteria and run sustainably in routine clinical practice. Evidence is accumulating to show their impact in altering physician behaviour and triggering earlier intervention. Emerging data suggest that in combination with other service improvement strategies, this may translate into improved patient outcomes. SUMMARY: The current ad-hoc development of e-alert systems needs to be addressed by arriving at consensus around the way in which these systems should apply diagnostic criteria, particularly with respect to selection of baseline creatinine value. Enhancements in IT provision may provide the only durable solution to this, while at the same time facilitating wider uptake. Wider use will allow for further study of the value of e-alerts, including their use in other settings such as primary care.
    • Evaluating a process of academic detailing in primary care: an educational programme for acute kidney injury.

      Noble, Rebecca; McKinnell, Joanna; Shaw, Susan; Bassett, Sally; Kolhe, Nitin; Selby, Nicholas (2019-07)
      BACKGROUND: Primary care has a significant role in AKI management: two-thirds of AKI originates in the community. Through academic detailing (an evidence-based educational approach) we aimed to implement and measure the effect of a primary care-based education programme based around academic detailing and peer-reviewed audit. METHODS: The education programme took place across a large clinical commissioning group (CCG) consisting of 55 primary care practices. All 55 practices participated in large group teaching sessions, 25 practices participated in academic detailing and 28 of the remaining 30 practices performed internal AKI audit. Over a 12 month period, an educational programme was delivered consisting of large group teaching sessions followed by either academic detailing sessions or self-directed AKI audit activity. Academic detailing sessions consisted of a short presentation by a consultant nephrologist followed by discussion of cases. Qualitative feedback was collected from all participants at peer review sessions. Web-based, CCG-wide questionnaires assessed baseline and post-intervention knowledge levels. RESULTS: Nine hundred ninety-six individuals completed the questionnaires (556 at baseline, 440 at 1 yr., 288 participated in both). Exposure to AKI teaching, self-reported awareness and confidence levels were higher in the second questionnaire. There was a significant increase in the percentage of correct answers before and after the intervention (55.6 ± 21% versus 87.5 ± 20%, p < 0.001). Improvements were also seen in practices that did not participate in academic detailing. 92.9% of participants in the academic detailing sessions ranked their usefulness as high, but half of participants expressed some anxiety about discussion of cases in front of peers. CONCLUSION: Primary care education can improve knowledge and awareness of AKI. Small group teaching with involvement of a nephrologist was popular, although there were mixed responses to group discussion of real cases. Academic detailing did not appear more effective than other educational formats.
    • Impact of Compliance with a Care Bundle on Acute Kidney Injury Outcomes: A Prospective Observational Study.

      Kolhe, Nitin; Staples, David; Reilly, Timothy; Merrison, Daniel; McIntyre, Christopher; Fluck, Richard; Selby, Nicholas; Taal, Maarten (2015-07)
      BACKGROUND: A recent report has highlighted suboptimal standards of care for acute kidney injury (AKI) patients in England. The objective of this study was to ascertain if improvement in basic standard of care by implementing a care bundle (CB) with interruptive alert improved outcomes in patients with AKI. METHODS: An AKI CB linked to electronic recognition of AKI, coupled with an interruptive alert, was introduced to improve basic care delivered to patients with AKI. Outcomes were compared in patients who had the CB completed within 24 hours (early CB group) versus those who didn't have the CB completed or had it completed after 24 hours. RESULTS: In the 11-month period, 2297 patients had 2500 AKI episodes, with 1209 and 1291 episodes occurring before and after implementation of the AKI CB with interruptive alert, respectively. The CB was completed within 24 hours in 306 (12.2%) of AKI episodes. In-hospital case-fatality was significantly lower in the early CB group (18% versus 23.1%, p 0.046). Progression to higher AKI stages was lower in the early CB group (3.9% vs. 8.1%, p 0.01). In multivariate analysis, patients in the early CB group had lower odds of death at discharge (0.641; 95% CI 0.46, 0.891), 30 days (0.707; 95% CI 0.527, 0.950), 60 days (0.704; 95% CI 0.526, 0.941) and after a median of 134 days (0.771; 95% CI 0.62, 0.958). CONCLUSIONS: Compliance with AKI CB was associated with a decrease in case-fatality and reduced progression to higher AKI stage. Further interventions are required to improve utilization of the CB.
    • Improving Clinical Prediction Rules In Acute Kidney Injury With The Use of Biomarkers of Cell Cycle Arrest: A Pilot Study.

      Selby, Nicholas (2018-06)
      INTRODUCTION: Early recognition of patients developing acute kidney injury is of considerable interest, we report the first use of a combination of a clinical prediction rule with a biomarker in emergent adult medical patients to improve AKI recognition. METHODS: Single-centre prospective pilot study of medical admissions without AKI identified as high risk by a clinical prediction rule. Urine samples were obtained and tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) - biomarkers associated with cell cycle arrest, were measured. OUTCOME: Creatinine based KDIGO hospital-acquired AKI (HA-AKI). RESULTS: Of 69 patients recruited, HA-AKI developed in 13% (n = 9), in whom biomarker values were higher (median 0.43 [interquartile range 0.21-1.25] vs. 0.07 [0.03-0.16] in cases without (P = 0.008). Peak rise in creatinine was higher in biomarker positive cases (median 30 μmol/l (7-72) vs 1 μmol/l (0-16), P = 0.002). AUROC was 0.78 (95% CI 0.57-0.98). At the suggested cut-off (0.3) sensitivity for predicting AKI was 78% (95% CI 40-97%), specificity 89% (78-95%), positive predictive value 50% (31-69%) and negative predictive value 96% (89-99%). DISCUSSION: Addition of a urinary biomarker allows exclusion of a significant number of patients identified to be at higher risk of AKI by a clinical prediction rule.
    • International Criteria for Acute Kidney Injury: Advantages and Remaining Challenges.

      Selby, Nicholas; Fluck, Richard; Kolhe, Nitin; Taal, Maarten (2016-09)
      Nicholas Selby and colleagues describe how the definition of acute kidney injury brings opportunities and challenges in identifying patients at higher risk of adverse outcomes.
    • Long Term Outcomes after Acute Kidney Injury: Lessons from the ARID Study.

      Horne, Kerry; Shardlow, Adam; Selby, Nicholas (2015-09)
      The high incidence and poor short-term outcomes of acute kidney injury (AKI) have focused attention on this global healthcare issue. Concurrently, the long-term effects of AKI are increasingly appreciated, namely, increased risk of subsequent chronic kidney disease, end stage kidney disease requiring renal replacement therapies and a higher rate of cardiovascular events. Whilst there is little doubt about the strength of these associations, knowledge gaps remain. To address some of these, the AKI Risk In Derby study commenced in 2013. This is a prospective case-control study investigating the long-term effects of AKI in a general hospitalized population (including those with less severe AKI). This review will summarize the background and rationale of this study, its design and methodology, as well as the 1-year outcome results from a preceding pilot study.
    • Long-term outcomes after AKI-a major unmet clinical need.

      Selby, Nicholas; Taal, Maarten (2019-01)
      In this issue of Kidney International, a comprehensive systematic review and meta-analysis provides an up-to-date picture of the long-term risks of death, chronic kidney disease (CKD), and end-stage kidney disease (ESKD) that follow an episode of acute kidney injury (AKI). Results confirm the significant event rate of these adverse outcomes following AKI and demonstrate that AKI severity and the clinical setting in which AKI occurs are important determinants of risk. In this commentary we discuss the implications of this study and how the results signal some key priorities for future research in an area of substantial clinical need.