by Charlie Tomson, Consultant Nephrologist and Co-Chair of the Intervention workstream
What am I doing leading the Intervention workstream of the Think Kidneys Acute Kidney Injury programme? Good question. It’s certainly not because I have special expertise or research experience in the finer points of AKI pathophysiology or management. What little original research I’ve done has been more focused on avoiding late referrals in CKD. However, I do have a long-standing interest in quality improvement – which can perhaps best be described as working out how to ‘re-engineer’ healthcare delivery systems so that evidence-based healthcare reaches the patient.
The pathway from basic research through to clinical research and then to clinical trials and then to guidelines is fairly well established – the real challenge is how to get the guidelines into reliable everyday use. We have NICE guidelines for AKI, and we know how strongly AKI is associated with apparently avoidable harm (prolonged hospital stay, higher mortality, increased risk of subsequent AKI, increased risk of CKD/ESRD) – so the opportunity to be involved in a national quality improvement programme focusing on AKI was too good to refuse!
‘Intervention’ is just one of many work streams in the AKI programme, but obviously I think it’s the most important (although I’ll accept that identification of people at risk of AKI would be important if we actually knew how to reduce their chances of developing it!). There’s no point improving the detection of AKI (using the algorithm) or being able to measure how many people get AKI, or educating the public or professionals, unless we know what needs to happen to reduce the harm associated with AKI.
Persuading clinicians (particularly doctors) to change how they do things requires careful attention to evidence. It’s also really important to ensure that clinicians don’t get conflicting messages (e.g. from different specialties). We soon discovered that the evidence base for ‘interventions’ to reduce the incidence, severity, or adverse outcomes of AKI was extraordinarily weak. We have no proven drug-based interventions that ameliorate AKI, although we do now have a long list of drug treatments that we know don’t work. We ‘know’ that early recognition of hypovolaemia, sepsis, and hypotension will help, although the evidence base here is weak, and we also know that oedematous and fluid overloaded patients are more likely to get AKI. We all pride ourselves on the clinical assessment of fluid status, but struggle to write down exactly how we assess it – and we know that the inter-observer agreement on clinical signs such as JVP, skin turgor, capillary refill, etc is poor. We do know that early recognition of parenchymal renal disease and of obstructive nephropathy is important, and here at least there isn’t much debate.
What have we done, then, to ensure that patients with AKI get appropriate ‘interventions’? We have developed evidence-based guidance on medicines management; dietetic management; medical management in secondary care (with a ‘minimal care bundle’ and an associated audit package); and medical management in primary care. The latter has been the most challenging, and novel. As well as providing detailed advice on how GPs should respond to AKI warning stage test results, with an associated audit package, we have also developed advice on when to re-start drugs stopped during an episode of AKI, how to monitor patients long-term after AKI, and how to respond to changes in kidney function during treatment with ACEIs, ARBs, and diuretics.
It’s been fantastic working with the other people on the workstream. We’ve scarcely ever met physically – all our work has been done on teleconferences and by email, to save time as much as carbon and money. I’ve learnt lots, particularly from the GPs on the group (and the GPs on the other workstreams). A special mention for Tom Blakeman and Caroline Ashley, my co-chairs – Tom has been a thoughtful and energetic architect of all the advice to GPs, and Caroline has used her contacts and expertise in pharmacy to provide what I think is very sensible balanced advice on drug treatment for patients with AKI. The project managers have managed to cajole us to meet deadlines and have been a great source of support.
The real challenge now will be to ensure that clinicians across England (and beyond) know about, trust, and adopt the guidance that we have developed. This will be a long game, and will require a multi-pronged approach, with journal articles, news articles, comparative audits, and social media. In many ways, the real work is only just beginning.
Charlie Tomson
Charlie is a consultant kidney specialist at Freeman Hospital, Newcastle on Tyne and was Chair of the Intervention workstream for the acute kidney injury national programme.
Charlie trained at Cambridge, Oxford, Bath, Nottingham, Newcastle on Tyne, and Leicester, and held Consultant posts in London and Bristol before moving to Newcastle in 2014. His areas of special interest are the management of chronic kidney disease, evaluation of quality improvement initiatives, and environmental sustainability in health.
Charlie claims he’s a Luddite and not very IT literate, but posts about kidney disease on Twitter. He keeps fairly fit cycling in Northumberland at weekends, and his favourite place to walk is the Lake District.