Hi Phil,
We've had a real time AKI system in place for the past year or so, with similar systems being used by several other hospitals in London.
We use Winpath and add a comment with a link to London AKI network guidelines if there is > 50% increase on the previous result within the previous 90 days. If the creatinine is > 100 umol/L, the result gets phoned by a BMS at result validation. They all also get reviewed by the duty biochemist. Since Christmas we have had a fully automated e-mail going out to ITU outreach with details of all alerts, patients details and a list of previous creatinine results so they can follow up as they see appropriate. We don't attempt to stage the AKI.
We¡¯ve audited these alerts, and found that about 2/3rds are true AKI (about 5 cases of AKI a day), but the rest are false alarms (about 2-3 per day). Most of the time, this is just due to the previous result being slightly low, and the creatinine that has triggered the delta check is not actually >50% above baseline, as per KDIGO definitions. Occasionally you also get the odd sample mix up!
As for the 26 umol/L increase ¨C we don¡¯t apply this. As far as we know, Winpath only allows us to use one delta check (although if anyone else using Winpath has figured out how to use > 1, please let me know!). Also, we see quite a few false positives even with a 50% increase ¨C I¡¯d imagine that if we used a 26 umol/L increase, the number of samples flagged as ?AKI would go through the roof. This is especially true in patients with CKD, as above about 200 umol/L a 26 umol/L increase is probably not even statistically significant (the RCV for creatinine is often quoted at about 15%).
As for recognising the lowest creatinine... The lowest result tends to underestimate baseline, sometimes quite severely, so you again risk producing a lot of false alarms. There was a nice paper looking at automated methods to estimate baseline creatinine (Siew et al, CJASN, 2012; 7:712-9) and the lowest creatinine method came out pretty badly (I summarised this paper for the ¡°Journal Club¡± in the latest Annals, so you can have a look at that if you can¡¯t access CJASN.)
I¡¯ve attached a poster on our alerts, and am happy to discuss further if you have any questions.
Nick
Nick Flynn
Trainee Clinical Scientist
UCLH Clinical Biochemistry
60 Whitfield Street, London, W1T 4EU
E: [log in to unmask]
T: 020 344 72966
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From: Clinical biochemistry discussion list [[log in to unmask]] On Behalf Of Phillip Monaghan [[log in to unmask]]
Sent: 21 March 2013 16:12
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Subject: AKI detection
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Dear colleagues,
We are currently liaising with our LIMS supplier (Technidata, TDLIMS) for real-time AKI detection. Has anyone had any good experience or advice on implementation of the rules based on the KDIGO guidelines that they would be willing to share?
Additionally, with regard to AKI stage 1, I seek clarification on 1) the absolute increase stipulated in the guidance is 26.5umol/L, are labs therefore using 26 or 27? 2) When exactly is the 90 day reference interval for a baseline creatinine applicable? Is this just for AKI stages 2 and 3, or can we look at previous 90 days for AKI stage 1 (¡İ1.5 to 1.9x baseline) if there isn¡¯t a creatinine result from within the previous 7 days.
Furthermore, are LIS systems able to recognise the lowest (baseline) creatinine from within the previous 3 months, assuming that the previous creatinine result was not the baseline result?
All help and guidance gratefully appreciated.
Best wishes
Phil
___________________________________
Dr Phillip J Monaghan BSc MSc PhD
Principal Clinical Scientist
Department of Clinical Biochemistry
The Christie Hospital NHS Foundation Trust
Wilmslow Road
Withington
Manchester
M20 4BX
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