•Kidney
By Yinka Shokunbi Assistant Life Editor
With the rising profile of people coming down with kidney diseases also known as renal failure, Clinicians in the United Kingdom have called for the review of management of patients with spectrum of diseases manifesting in kidney injury.
Authors of a newly published finding that looked at about 2, 215 patients with acute kidney injury and were under the use of antihypertensive treatment drugs as well as Non Steroidals (NSAIDs) gave indications in a publication in a recent edition of the British Medical Journal on why it is highly essential to have a global management review especially in their drug management.
The study design looked at concomitant use of ace inhibitors, angiotensin receptor blockers (ARB), Diuretics and NSAIDs and it was found that taking one type of antihypertensive alongside an NSAID was not associated with an increased risk of AKI.
However, patients who had been prescribed a triple regimen consisting of either an ace inhibitor or an ARB, a Diuretic and an NSAID had a greater likelihood of developing AKI.
Acute kidney injury (AKI) has technically now replaced the term Acute Renal Failure (ARF) a universal definition and staging system to allow earlier detection and management of AKI.
According to the BMJ publication, the new terminology enables healthcare professionals to consider the disease as a spectrum of injury.
This spectrum extends from less severe forms of injury to more advanced injury when acute kidney failure may require renal replacement therapy (RRT).
Clinically AKI is characterised by a rapid reduction in kidney function resulting in a failure to maintain fluid, electrolyte and acid-base homoeostasis.
There have previously been many different definitions of AKI used in the literature which has made it difficult to determine the epidemiology and outcomes of AKI. Over recent years there has been increasing recognition that relatively small rises in serum creatinine in a variety of clinical settings are associated with worse outcomes.
To address the lack of a universal definition for AKI a collaborative network of international experts representing nephrology and intensive care societies established the Acute Dialysis Quality Initiative (ADQI) and devised the RIFLE definition and staging system for AKI. Shortly after this many of the original members of the ADQI group collaborated to form the Acute Kidney Injury Network (AKIN).
The AKIN group modified the RIFLE staging system to reflect the clinical significance of relatively small rises in serum creatinine.
Most recently the international guideline group, Kidney Disease: Improving Global Outcomes (KDIGO) has brought together international experts from many different specialties to produce a definition and staging system that harmonises the previous definitions and staging systems proposed by both ADQI and AKIN5. It is anticipated that this definition and staging system will be adopted globally. This will enable future comparisons of the incidence, outcomes and efficacy of therapeutic interventions for AKI.
To date there is a paucity of data on the incidence of AKI whether community or hospital-acquired. The reported prevalence of AKI from US data ranges from 1% (community-acquired) up to 7.1 percent (hospital-acquired) of all hospital admissions.
The population incidence of AKI from UK data ranges from 172 per million population (pmp) per year from early data up to 486-630 pmp/year from more recent series, again depending on definition. The incidence of AKI requiring renal replacement therapy (RRT) ranges from 22 pmp/year7 to 203 pmp/year.
An estimated 5–20 percent of critically ill patients experience an episode of AKI during the course of their illness and AKI receiving RRT has been reported in 4·9 percent of all admissions to intensive-care units (ICU). Data from the Intensive Care National Audit Research Centre (ICNARC) suggests that AKI accounts for nearly 10 percent of all ICU bed days.
Acute kidney injury is common in hospitalised patients and also has a poor prognosis with the mortality ranging from 10 percent to 80 percent dependent upon the patient population studied. Patients, who present with uncomplicated AKI, have a mortality rate of up to 10 percent.
In contrast, patients presenting with AKI and multi organ failure have been reported to have mortality rates of over 50 percent. If renal replacement therapy is required the mortality rate rises further to as high as 80 percent.
Acute kidney injury is no longer considered to be an innocent bystander merely reflecting co-existent pathologies. It has been demonstrated to be an independent risk factor for mortality. The cause of this is unclear but is possibly associated with an increased risk of “non-renal” complications such as bleeding and sepsis. An alternative explanation may lie in experimental work that has demonstrated the “distant effects” of ischaemic AKI on the other organs. In these experimental models isolated ischaemic AKI upregulates inflammatory mediators in other organs including the brain, lungs and heart.
The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) adding insult to injury acute kidney injury report was published last year. This report examined the care of patients who died with a diagnosis of AKI. It identified many deficiencies in the care of patients who developed AKI and reported that only 50 percent of patients received good care. There was poor attention to detail, inadequate assessment of risk factors for AKI and an unacceptable delay in recognising post admission AKI. The report made a number of recommendations which included the following all emergency admissions should have a risk assessment for AKI all emergency admissions should have electrolytes checked on admission and appropriately thereafter predictable avoidable AKI should not occur all acute admission should receive adequate senior reviews (consultant review within 12 hours) there should be sufficient critical care and renal beds to allow rapid step up care undergraduate medical training should include the recognition of the acutely ill patient and the prevention, diagnosis and management of AKI postgraduate training in all specialties should include training in the detection, prevention and management of AKI.
The NCEPOD report was used to support a successful proposal made to the National Institute for Health and Clinical Excellence (NICE) for an AKI guideline. It is hoped that the guideline will be available in the near future.
Once a patient has developed AKI the therapeutic options are limited with the mainstay of treatment being renal replacement therapy (RRT).
However there are many important aspects surrounding the care of a patient with AKI that must be considered which include timely referral and transfer to renal services if appropriate. There is a paucity of evidence to guide the optimal time to initiate RRT and the decision remains the choice of the individual physician. If a patient commences RRT then there are number of practical issues to be considered including the modality, the choice of filter membrane, the optimal site of vascular access, anticoagulation and the intensity of the treatment.
The purpose of these clinical practice guidelines is to review the available evidence and provide a pragmatic approach to the patient with AKI. There is a pressing need for renal physicians to engage in undergraduate and postgraduate educational programmes to improve the current management of AKI.
Speaking on the BMJ publication, President, Nigerian Medical Association, (NMA), Dr. Osahon Enabulele, though noted he was yet to read about the finding but lamented the dearth of local research studies to enable practitioners discover the peculiarity of conditions among Nigerians and proffer indigenous solutions .
According to Enabulele, “Resources for scientific researches are scarce because there is no government dedicated fund or research grant for scientific researches in our various institutions to drive indigenous and local treatments for peculiar conditions; and individuals have had to source for funds to do their researches which is sometimes unhelpful”.
On the common causes of acute renal failure or acute kidney injury, Osahon noted it is a condition that could happen suddenly and for a short time, but redeemable if right things are done quickly; “not like chronic failure which could be terminal”.
Said he, “As simple as analgesics are, they can affect the kidneys just they can affect the liver. Even as basic as not taking enough fluids to perfuse the kidneys in terms of the normal daily requirements for water, it can make the kidneys not to be properly perfuse and not have enough hydration and that can invariably serve to injure the kidney.
“Again, infections as simple as urinary tract infections (UTI), can also trigger acute renal problems and even conditions of common malaria not well treated, can as part of its complications can cause acute renal short down; that is why it has always been known as a spectrum of injury.”
He however urged Nigerian scientists to take a look at the finding of the UK clinicians in the BMJ to understand the basis of the new finding for possible local review and consumption.
“The challenge for our own people is to also do our own study, but we know a few people are doing individual studies because of the challenge of resources to make a global case study for our local use.