Gary Mascall raises some important issues in his email of 28th July

These require a full response so please excuse the length of this email:



Will the national algorithm be reviewed?



The answer to that is yes. There are two principle drivers to adjustment of the algorithm. The first is if new evidence becomes available suggesting that the underpinning KDIGO guidelines need to be modified.

The second case is where the performance of the algorithm can be improved. We have been aware from the beginning of this project that a relatively crude algorithm based only on serum creatinine changes will not identify AKI correctly  in all cases. The algorithm takes no account of recent clinical history and relies (in most cases) on the median serum creatinine over the last year providing an appropriate baseline. There will clearly be scenarios in which the assumptions behind these two factors do not hold. You will be aware of two publications assessing the performance of the algorithm which broadly suggest that it performs well and cannot at this current time be practically improved (1,2)

Importantly, this is why we emphasise that the AKI warning stage test result should not be regarded as a diagnosis. The result should be a stimulus to review the clinical situation and reassess a patient's serum creatinine results to support diagnosis and intervention.



Primary Care Case scenarios



The Think Kidneys programme is very aware that both the clinical context in primary care and implications may be different than in secondary care. Therefore, we strongly recommended that deploying AKI test results into primary care should be delayed. Our decision to place the use of the algorithm in primary care in the second phase of the project was taken after identifying that primary care needed some advance warning and preparation before switching on automated AKI detection. We recognise however that, those Trusts providing some form of AKI alerting to primary care before the NHS England project started, might find it difficult to delay switching over to the algorithm once it was operating in secondary care as required by the safety notice. It those cases, Trusts should be ensuring that they have provided appropriate support to primary care to support interpretation of AKI test results.

In summary: We would not rule out modifying the algorithm if a small change would lead to a large improvement in the appropriateness of AKI detection. However, there are sound logistical reasons for making stepwise alterations to the algorithm rather than multiple small changes and such adjustments should be based on appropriate population level analysis. We would also reiterate that the AKI Test result should not be viewed in isolation from the other elements required to improve AKI management – education of professionals, effective intervention and enhanced recovery that early diagnosis, of which this test result is part, supports and complements.

The “Think Kidneys” Programme Board continues to recognise the contribution that clinical chemistry departments make to the viability of the programme. The decision whether or not to review all AKI warning stage test results before release to primary care must remain local and dependent on available resources. Commissioners have been engaged at all stages of the programme but local health priorities may occasionally supersede national priorities. The Board encourages further discussion on the effectiveness of its programme and thanks the participants who contribute to this discussion forum.



Robert Hill Chair Detection workstream,  Charles Tomson Chair Intervention workstream,  Tom Blakeman Chair Primary Care group,  Richard Fluck Chair Programme Board and NHS England National Clinical Director (Renal)

 

References

1: Sawhney S, Marks A, Ali T, Clark L, Fluck N, Prescott GJ, Simpson WG, Black C. Maximising Acute Kidney Injury Alerts - A Cross-Sectional Comparison with the Clinical Diagnosis. PLoS One. 2015 Jun 30;10(6):e0131909. doi: 10.1371/journal.pone.0131909. eCollection 2015. PubMed PMID: 26125553; PubMed Central PMCID: PMC4488369.

2: Sawhney S, Fluck N, Marks A, Prescott G, Simpson W, Tomlinson L, Black C. Acute kidney injury-how does automated detection perform? Nephrol Dial Transplant. 2015 Apr 28. pii: gfv094. [Epub ahead of print] PubMed PMID: 25925702.





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