National recommendations to standardise acute kidney injury detection and alerting.

BACKGROUND: National Health Service England issued a Patient Safety Alert in 2014 mandating all acute Trusts in England to implement Acute Kidney Injury (AKI) warning stage results and to do so using a standardised algorithm. In 2021, the Renal and Pathology Getting It Right First Time (GIRFT) teams found significant variation in AKI reporting across the UK. A survey was designed to capture information on the entire AKI detection and alerting process to investigate the potential sources of this unwarranted variation. METHODS: In August 2021, an online survey consisting of 54 questions was made available to all UK laboratories. The questions covered creatinine assays, laboratory information management systems (LIMS), the AKI algorithm and AKI reporting. RESULTS: We received 101 responses from laboratories. Data were reviewed for England only - 91 laboratories. Findings included that 72% used enzymatic creatinine. In addition, 7 manufacturer-analytical platforms, 15 different LIMS and a wide range of creatinine reference ranges were in use. In 68% of laboratories, the AKI algorithm was installed by the LIMS provider. Marked variation was found in the minimum age of AKI reporting with only 18% starting at the recommended 1 month/28-days. Some 89% phoned all new AKI2s and AKI3s, as per AKI guidance while 76% provided comments/hyperlinks in reports. CONCLUSIONS: The national survey has identified laboratory practices that potentially contribute to unwarranted variation in the reporting of AKI in the England. This has formed the basis for improvement work to remedy the situation, including national recommendations, included within this article.

Acute Kidney Injury in Primary Care: A Review of Patient Follow-Up, Mortality, and Hospital Admissions following the Introduction of an AKI Alert System.

BACKGROUND/AIMS: In February 2017, our laboratory implemented an electronic AKI flagging system for primary care using the NHS England AKI detection algorithm. Our study investigated the impact on patient follow-up, hospital admission, length of stay, and mortality. METHODS: Primary care results March 2017-February 2018 with an AKI test code were downloaded from the pathology computer. RESULTS: Over 12 months, 1,784 AKI episodes were identified; 81.3% AKI1, 11.3%, AKI2, and 7.5% AKI3. A repeat creatinine was requested within 14 days on 55% AKI1s, 84% AKI2s, and 86% AKI3s. Primary care took the repeat sample in 73.2% AKI1s and 56.7% AKI2s and acute hospital locations for 47.4% AKI3s. Median time to hospital admission was 34 days for AKI1, 6 for AKI2, and 1 for AKI3 (p < 0.05). Length of stay was found to be 1, 2, and 4 days for AKI 1/2/3, respectively (p < 0.05). The 90-day mortality for admitted patients was 15, 18, and 21% for AKI 1/2/3, respectively (p = 0.180). The 90-day mortality for the non-admitted patients was 4, 9, and 50% for AKI 1/2/3, respectively (p < 0.05). AKI patient outcome data pre versus post the start of the AKI flag system were compared. A statistically significant reduction was found in the median length of stay for AKI1 and AKI3 and in mortality for AKI1 and AKI3 patients and for all AKIs as a whole. A further analysis was performed to take into account the difference in pre- and post-alert populations. Mortality overall was significantly improved (p < 0.001), and length of stay was reduced in AKI3 patients (p = 0.048). DISCUSSION/CONCLUSION: Our study demonstrates that an electronic AKI warning alert system for primary care appears to be associated with a beneficial impact on patient management and outcome.

The Cornish experience of the ASSIST-CKD project.

Introduction The ASSIST-CKD project is a national quality improvement programme, aiming to decrease the number of patients presenting late to renal services by enabling laboratories to review up to five years of estimated glomerular filtration rate results graphically and report deteriorating patients to their general practitioner. Aim To assess the impact of the project on the laboratory, and of patient reporting on general practitioner management and the local renal service. Method Each week two searches were performed (Search A: maximum age 65 years, maximum eGFR 50 ml/min/1.73 m2 and Search B: Age 66-120 years, maximum eGFR 40 ml/min/1.73 m2) on patients with an estimated glomerular filtration rate requested by their general practitioner within the previous seven days. Patients showing deterioration in estimated glomerular filtration rate had a printed graph sent to their general practitioner. Feedback on the graphs and their impact on patient management were obtained from the general practitioners via a questionnaire. Results A median of 37 patients/week were listed for review for Search A, with 32% reported; and Search B a median of 227 patients/week listed, 32% reported. General practitioner surgery questionnaires (29) showed the reports were well received. Of general practitioners responding to the questionnaire, 67% had reviewed a patient earlier than intended, 54% had reviewed local guidance, 48% had emailed the renal team and 48% had referred a patient on receipt of a graph; 34% had shown a graph to their patients, of whom 70% found that useful. Conclusion There is some evidence that ASSIST-CKD reporting has enhanced patient care; however, further long-term assessment is still required.

One Year's Observational Study of Acute Kidney Injury Incidence in Primary Care; Frequency of Follow-Up Serum Creatinine and Mortality Risk.

BACKGROUND/AIMS: Publications on acute kidney injury (AKI) have concentrated on the inpatient population. We wanted to determine the extent of AKI in the community, its follow-up and patient impact. METHOD: Primary Care creatinine results for May 2012-April 2013 from Cornwall, United Kingdom, were screened for AKI. RESULTS: Over 12 months, 991 AKI episodes were identified (0.4% of all Primary Care creatinine requests); 51% were AKI1, 29% AKI2 and 10% AKI3. Of these, 51% AKI1s, 72% AKI2s and 77% AKI3s had a repeat creatinine requested within 14 days as per National Institute for Health and Care Excellence (NICE) guidelines. Admissions (May 2012-July 2013) were identified on 46% AKI1s, 58% AKI2s and 65% AKI3s (p < 0.05). The median time from AKI identification to hospital admission was 33 days for AKI1, 12 days for AKI2 and 1 day for AKI3 (p < 0.05); with a median length of stay of 2, 4 and 7 days, respectively (p < 0.05). The 90-day mortality from AKI identification for the admitted patients was 12% AKI1s, 20% AKI2s and 27% AKI3s (p < 0.05) vs. 11, 21 and 65% (p < 0.05) for those that were not admitted. There was no significant difference in mortality for admitted patients vs. non-admitted patients, except for the AKI3s. CONCLUSION: AKI is associated with increased admission and mortality rates; although a large proportion of patients had repeat creatinine testing within 14 days, there was still a significant number with delayed follow-up. Education within Primary Care is required on how to prevent, identify, follow-up and manage AKI.

Targeting c-Myb expression in human disease.

c-Myb is a transcription factor employed in the haematopoietic system and gastrointestinal tract to regulate the exquisite balance between cell division, differentiation and survival. In its absence, these tissues either fail to form, or show aberrant biology. Mice lacking a functional c-myb gene die in utero by day 15 of development. When inappropriately expressed, as is common in leukaemia and epithelial cancers of the breast, colon and gastro-oesophagus, c-Myb appears to activate gene targets of key importance to cancer progression and metastasis. These genes include cyclooxygenase-2 (COX-2), Bcl-2, BclX(L) and c-Myc, which influence diverse processes such as angiogenesis, proliferation and apoptosis. The clinical potential for blocking c-Myb expression in malignancies is based upon strong preclinical data and some trial-based evidence. The modest clinical experience to date has been with haematopoietic malignancies, but other disease classes may be amenable to similar interventions. The frontline agents to achieve this are nuclease-resistant oligodeoxynucleotides (ODNs), which are proving to be acceptable therapeutic reagents in terms of tolerable toxicities and delivery. Nevertheless, further effort must be focused on improving their efficacy, eliminating non-specific toxicity and optimising delivery. Optimisation issues aside, it would appear that anti-c-Myb therapies will be used with most success when combined with other agents, some of which will be established cytotoxic and differentiation-inducing drugs. This review will explore the future strategic use of ODNs in vivo, focusing on a wide spectrum of diseases, including several beyond the haematopoietic malignancies, in which c-Myb appears to play a role.