This is my first blog from a critical care perspective for ThinkKidneys.
This winter has seen the NHS face some of its toughest operational challenges to date, with many patients attending hospital being far sicker and in greater numbers. In the district general hospital where I work, there has been a noticeable rise in AKI associated inpatient mortality, rising from an average of 16.7% in non-elective admissions with AKI to 27.1% in December 2017. Interestingly, in non-elective admissions where AKI never occurred, inpatient mortality has remained consistent throughout the year at 1-2% despite increased acuity of admissions in December.
So why a spike in AKI mortality?
The cause of this 10.4% rise in mortality is not easy to explain and is likely to be multifactorial spanning community and hospital care and probably not isolated to just my hospital. Overall, the number of AKI 1-3 cases per month was similar, with a slight increase in AKI-3 numbers by the end of the year. When trying to assess this data trend, one must be careful in saying that this spike in the number of AKI patients dying could have been prevented, where the reality, unfortunately, is that many cases would not have been. From our ongoing audit, we know that sepsis and dehydration are the commonest causes of AKI, and that a higher proportion of cases are elderly (over 65yrs), medical patients. The UK this winter has seen a rise in norovirus, pneumonia and influenza cases. It also has been cold. Data from NHS England shows that for every one-degree centigrade drop below five degrees in outdoor average temperature, there is more than a 10 per cent increase in older people consulting their GP for breathing problems, a 0.8 per cent increase in emergency hospital admissions and a 3.4 per increase in deaths. With an increase in sicker, older more complex medical patients and when NHS resources are stretched, when patients are not able to see their GP promptly, or have to wait longer for an ambulance or treatment in the Emergency Department, there will undoubtedly be a rise in AKI cases and unfortunately deaths, some of which would have been preventable.
So what does the presence of AKI actually mean and what can we do to impact this mortality?
The presence of AKI to me, as a Critical Care Consultant is more than just a kidney problem. AKI has evolved into a marker of disease severity and imminent multi-organ failure. The problem is, that unlike a raised troponin indicative of a likely heart attack with a specific treatment, the presence of AKI, because of the vast number of potential causes and how development and progress can be influenced by many patient and service factors, makes management of such a problem so extremely difficult. AKI recognition and management could be perfect, but the patient still may go onto deteriorate and even die! The NCEPOD report in 2009, suggested that up to 30% of AKI cases in hospital could have been prevented, but this still leaves up to 70% that could not!
Before we all become too despondent, it is worth thinking that even a 5-10% reduction in AKI cases would save many lives and reduce the financial burden on the NHS considerably. This is what we are fighting to achieve!
AKI is a medical emergency and this fact needs to be communicated effectively up and down the country. AKI-1 in the past termed ‘mild’ AKI is anything but, with such a high associated inpatient mortality compared with similar patients who did not develop AKI. Ok, we are not going to achieve a 100% reduction in AKI mortality, as this is impossible due to the heterogeneity of AKI causes and influences, but we can keep continuing this quest to bring it down!
Initiatives like ThinkKidneys are paramount in trying to prevent AKI from developing in the first place, and if it does, that it is recognised early with timely intervention. Such interventions need a much more focused national approach, as currently there is little evidence for anything that we do, including AKI bundles! We need to drill down further and ask: what specific elements of AKI bundles would have the greatest effect on AKI outcomes / mortality? How can community and hospitals work better together, considering up to 60% of all AKI cases start in the community? Are there any other specific biomarkers / results that could stratify AKI patients into those that their AKI is reversible or preventable to patients whose condition is not for example? Should the aim be about doing basic things well e.g. ensuring someone is drinking appropriately, that certain medications are held (‘sick-day rules’ if appropriate), that fluid balance monitoring is actually done and sepsis treatment started in a timely manner, before spending lots of resources on other interventions?
This is the challenge we face in 2018, to find effective ways of bringing down AKI mortality and to improve community and hospital understanding of this massive problem. Keep vigilant in your hospitals for a potential AKI mortality spike this Winter!