by Charlie Tomson, Consultant Nephrologist and Co-Chair of the Intervention workstream<\/p>\n
What am I doing leading the Intervention workstream of the Think Kidneys Acute Kidney Injury programme? Good question. It\u2019s certainly not because I have special expertise or research experience in the finer points of AKI pathophysiology or management. \u00a0What little original research I\u2019ve done has been more focused on avoiding late referrals in CKD. However, I do have a long-standing interest in quality improvement \u2013 which can perhaps best be described as working out how to \u2018re-engineer\u2019 healthcare delivery systems so that evidence-based healthcare reaches the patient.<\/p>\n
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The pathway from basic research through to clinical research and then to clinical trials and then to guidelines is fairly well established \u2013 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) \u2013 so the opportunity to be involved in a national quality improvement programme focusing on AKI was too good to refuse!<\/p>\n
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\u2018Intervention\u2019 is just one of many work streams in the AKI programme, but obviously I think it\u2019s the most important (although I\u2019ll 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\u2019s 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.<\/p>\n
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Persuading clinicians (particularly doctors) to change how they do things requires careful attention to evidence. It\u2019s also really important to ensure that clinicians don\u2019t get conflicting messages (e.g. from different specialties). We soon discovered that the evidence base for \u2018interventions\u2019 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\u2019t work. We \u2018know\u2019 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 \u2013 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\u2019t much debate.<\/p>\n
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What have we done, then, to ensure that patients with AKI get appropriate \u2018interventions\u2019? We have developed evidence-based guidance on medicines management; dietetic management; medical management in secondary care (with a \u2018minimal care bundle\u2019 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.<\/p>\n
It\u2019s been fantastic working with the other people on the workstream. We\u2019ve scarcely ever met physically \u2013 all our work has been done on teleconferences and by email, to save time as much as carbon and money. I\u2019ve 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 \u2013 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.<\/p>\n
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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.<\/p>\n","protected":false},"excerpt":{"rendered":"
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\u2019s certainly not because I have special expertise or research experience in the finer points of AKI pathophysiology or management. \u00a0What little original research I\u2019ve done has been more focused on avoiding late referrals in CKD. However,…<\/p>\n","protected":false},"author":106,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"enabled":false},"version":2}},"categories":[1],"tags":[],"class_list":["post-3515","post","type-post","status-publish","format-standard","hentry","category-blog"],"acf":[],"yoast_head":"\n