Workstreams

The Intervention Workstream recognised that improving detection rates and identification of AKI meant that both primary and secondary care clinicians needed easy access to comprehensive advice on how to care for patients with AKI. The Intervention Workstream developed the tools to enable clinicians to Think Kidneys. The aim was to provide advice which describes actions that clinicians should take to reduce harm to patients with AKI, both in the community, primary care, secondary care, and critical care, together with those patients receiving renal support.

Guidance was produced for the follow-up management of patients who had experienced an episode of AKI.

These included

• when to re-start drug treatment e.g. ACEI, ARB, diuretics
• adjustment of medications such as insulin, oral hypoglycemic agents, to prevent further complications
• long-term follow-up of patients, given risk of CKD and further AKI

Information was developed to empower patients, care givers and pharmacists to stop ACEIs, ARBs and diuretics during a period of acute illness. Tools were developed for primary care clinicians, including GPs, practice nurses, pharmacists, and for secondary care clinicians, including junior and senior doctors in all specialties, specialist nurses and pharmacists. The online resources were all developed for the Think Kidneys website.

Dr Blakeman led on the development of a consensus on responding to AKI warning stage test results in primary care, which started to be received in many areas in April 2016. This work has now been published: Blakeman et al: Development of guidance on the timeliness in response to acute kidney injury warning stage test results for adults in primary care: an appropriateness ratings evaluation. BMJ Open 2016; 6:e012865.

Drs Tomson and Blakeman contributed to a systematic review, now in press in BMJ Open, entitled “What are the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury” – work co-ordinated by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (Bristol CLAHRC).

The most successful element of the Intervention Workstream’s work is the package of advice for primary care clinicians. To date, much of the advice on management of AKI has focused on secondary care; indeed, much of the research evidence comes from intensive care settings. Developing guidance for primary care entailed engagement with primary clinicians using the UCLA RAND Consensus Process and then subsequent meetings with clinicians in the North East and South West (Bristol). The primary care advice has been accessed by many primary care clinicians and the resource web pages are the second most popular on the website, with over 25,000 downloads and page views. The Medicines Optimisation Guide has been the most accessed resource on the website with over 7,550 views and downloads (February 2017).

The greatest challenge for the Intervention Workstream has been the calibration of the advice – ensuring that an appropriate response to an AKI warning stage test result would occur with high reliability, while ensuring that we do not set expectations unrealistically high. This was particularly important when advising on the appropriate response to AKI warning stage test results in primary care – a setting in which immediate clinical assessment of patients whose test results trigger an AKI warning stage test result can be very difficult and disruptive.