Medical practice

Better kidney care could save thousands of lives

“Thousands die with treatable kidney problems,” reports The Daily Telegraph while Sky News informs us that thousands of hospital patients are “dying of thirst”.

The coverage is based on new guidance for the care of acute kidney injury (AKI, previously termed acute kidney failure), a condition that relates to the loss of kidney function over the course of hours or days. The guidance, developed by the National Institute for Health and Care Excellence (NICE), aims to standardise care and build on improvements in care for this condition.

A press release from NICE indicates that a 2009 report by the National Confidential Enquiry into Patient Outcome and Death found only half of patients with AKI received ‘good’ care.

According to the press release, the NHS could prevent at least 12,000 deaths from AKI each year by following recommendations set out in the guidelines. These included early identification of the condition and monitoring people’s urine output and creatinine levels (a waste product filtered by the kidneys).

They say there are low levels of awareness and education among health professionals and the general public about the condition. The chairperson of the guideline developing group, Dr Mark Thomas, has been widely quoted as referring to AKI as “Cinderella condition” – wrongly overlooked and neglected.

While these guidelines focus on the care of people with or at risk of AKI and sets out best practice for this care, the media’s coverage is far reaching. Many papers have included stories about poor patient care relating to hydration. While these are obvious causes for concern it is uncertain if any of these individual stories had anything to do with AKI.

Similarly there are many misleading headlines that thousands are dying from thirst which is not reported in the guidance. 

What is acute kidney injury?

Acute kidney injury (AKI), previously known as acute renal (kidney) failure, is a condition that relates to loss of kidney function over hours or days, not just kidney failure.

The definition of the condition has changed in recent years and there is no widely accepted ‘gold standard’ for the diagnosis of AKI.

Detection of the condition is mostly based on monitoring levels of creatinine, a chemical waste product produced by the muscles which is filtered out by the kidneys and excreted in the urine. This is usually done by means of a blood test.

AKI is a common problem among hospitalised patients, in particular the elderly population.

There may be no signs or symptoms for a person with AKI, however, low urine output is common.

Other symptoms can include nausea, vomiting, dehydration and mental confusion.

Risk factors for AKI include high blood pressure, pre-existing kidney disease and heart failure.

Low blood volume, which may be caused by loss of body fluids such as through bleeding, excessive vomiting or diarrhoea, or severe dehydration, is another risk factor for AKI.

This may be why the media has made the link that people are ‘dying of thirst’. But though severe dehydration is a risk factor for AKI, there is no suggestion in the NICE publication or press release that patients are routinely having fluid withheld from them. 

How much of a problem is acute kidney injury in the UK?

According to NICE, AKI affects one in five people admitted to hospital via emergency departments and it is estimated to be fatal in around 25-30% of cases; often due to a dangerous build-up of waste products in the blood. Also, many people who develop AKI are already ill due to another condition so this makes them more vulnerable to the effects of the condition.

They say that prevention or improvement of just 20% of emergency cases of AKI would save around 12,000 lives each year in England.

According to NHS Kidney Care, the cost of AKI to the NHS (not including AKI in the community) is estimated to be between £434 and £620 million per year, which is more than is spent on breast cancer or lung and skin cancer combined.

NICE advises that AKI is seen increasingly in primary care in the absence of acute illness and that there is a need to raise awareness of the condition among primary care health professionals so that AKI can be managed appropriately.

What are the main recommendations of the guidelines?

The guidance aims to standardise care for people with or at risk of AKI across the NHS and emphasises the importance of early detection of the condition.

The main recommendations from the guidelines are described below.

Identify acute kidney injury

Identify acute kidney injury (AKI) in patients with acute illness by measuring blood levels of creatinine in adults, young people and children with acute illness if certain risk factors are present.

These risk factors include:

Assess risk

Assess the risk of AKI in adults who have risk factors (such as diabetes and heart failure) and who are having surgery or certain diagnostic imaging procedures where a dye will need to be injected – for example during an angiography, which is used to look at the blood vessels, a dye has to be injected to make the blood vessels ‘show up’ on X-ray; however, this dye can sometimes cause damage when it is filtered through the kidneys.

Ongoing monitoring

Perform ongoing monitoring for people identified as being at risk of AKI such as monitoring creatinine levels and urine volumes and ensure systems are in place to respond to warning signs.

Identify causes

Identify the cause of AKI and document this in the patient notes (if no cause is identified, and/or there is suspicion of obstruction somewhere along the urinary tract, ultrasound should be offered and performed within 24 hours of assessment).

Discuss management and give information

Discuss management of AKI with kidney specialists (medically termed a nephrologist or paediatric nephrologist) as soon as possible.

Give information about long-term treatment options, monitoring and self-management to people who have had AKI that is appropriate to the person’s needs.

How accurate is the media’s reporting on the guidelines?

Reporting of the guidance in the UK media was mixed. The Daily Telegraph, BBC News and The Times all had headlines focusing on treating preventable kidney problems, with The Times reporting ‘kidney injury a preventable killer’. The Telegraph’s headline that ‘thousands die with treatable kidney problems’ did not accurately reflect the focus of the guidelines which provide recommendations for best practice on the care of people with AKI.

In other reporting, the Daily Mail and Sky News,appear to want to use what is useful advice on improving patient care as a stick to beat the NHS with. Both had bold headlines indicating that thousands of hospital patients are ‘dying of thirst’. These headlines also do not accurately reflect recommendations set out in the guidelines. This may have been interpreted from the fact that low blood volume/severe dehydration is a risk factor for AKI.

However, there is no evidence that patients are routinely being deprived of fluids (though some conditions do require a limited fluid intake). So the implication that NHS staff are letting people die of thirst is both inaccurate and insulting.

What the guidance does state is that health professionals should monitor patients for signs and symptoms of AKI, which include monitoring urine output and dehydration.  

Conclusion

You can’t always prevent all causes of AKI but you can take steps to improve the general health of your kidneys.

These include:

For more information and advice visit the NHS Choices Kidney health hub


NHS Attribution