It is with some trepidation that I am embarking on my first ever blog. My name is James and I am a doctor training as a kidney specialist. When I qualified in 2008, I had the same perceptions as most non-kidney doctors: kidneys are the sacrificial lamb of many illnesses. Be it surgery, major infection or a drug side effect – acute renal failure, as it was called back in 2008, was considered almost “par for the course” if someone was poorly. It is difficult to establish why there was such apathy towards acute ‘renal’ failure. Perhaps it was because the kidney fails silently. Unlike the lungs, brain or the heart there are no immediate symptoms. Since commencing nephrology training in 2012, I have come to realise how vital kidneys are to the health and wellbeing of the human body, and any apathy I may have displayed has been wiped out. For me, it is clear that a sustained change and improvement is required in relation to professional and public knowledge and awareness of acute kidney problems.
Fortunately, the last few years have seen a massive change in how doctors view acute kidney failure. Just like anyone else, doctors take note of a change in the name of a condition. Just like Marathon bars became Snickers, Federal Express became FedEx, acute kidney failure changed its name to acute kidney injury (AKI). This name change galvanised the minds of doctors. Injuries are often partially or fully reversible, whereas failure has the sound of permanency.
It was not just the name that changed; research papers and government reports identified the importance of identifying patients who had suffered AKI. We now know that AKI increases the chance of a longer stay in hospital, suffering long-term health problems and in some cases leads to death. One particular review of nearly 1000 patients who had AKI identified that clinicians could have improved their care in somewhere between a quarter and a third of cases.
Here at Salford Royal, we are making a wealth of changes to how we identify and manage AKI. Our IT system now highlights all patients with AKI so when doctors review patient’s blood tests, AKI is easily identified and its severity assessed. We have also developed an educational programme to teach the junior doctors the importance and optimal management of AKI.
Salford is also pioneering an exciting venture into the community to collaborate with GPs, community nurses and pharmacists thanks to a hook up with CLAHRC Greater Manchester, the CCG and Salford Royal. We know that approximately two thirdsof AKI begins in the community and therefore need to try and stop the problem at the source.
How do we reduce the risk of AKI – what can you do to protect yourself or your loved ones?
We know that if you have long-term abnormal kidney function – also called chronic kidney disease (CKD) – you are at particular risk of AKI if unwell for another reason, e.g. diarrhoea. We also know that many patients with CKD are on medications that are brilliant at slowing or stopping CKD from getting worse. These medications are called ACE inhibitors, for example, ramipril and lisinopril, or ‘ARBs’ such as losartan or irbersartan. Whilst these medications are really valuable when you are well, if you become unwell, dehydrated or requiring special dye for certain types of scans then they can actually increase your chance of getting AKI!
Similarly, many patients take water tablets, e.g. furosemide/bumetanide, to help their kidneys remove more water. Some patients also take regular anti-inflammatory medications for pain, e.g. ibuprofen. What we now know is that we should be educating our patients with a background of CKD or transplant that if you are unwell with a dehydrating illness – you can safely stop these sorts of tablets until you can at least drink normally again; and if you are unwell for more than 48 hours – you need to see your doctor. It is also, of course, vital that you restart them when better because, in the long term, most of these medications either improve the health of the kidneys or relieve some of the symptoms of kidney disease. It is worth emphasising that if you have a kidney transplant – you must never stop your anti-rejection medications, and if you are too unwell to keep them down – you must see a doctor urgently.
Our hope is that with work in both the community and in the hospital – we can really change the outlook for AKI locally. We won’t rest until we have reduced the frequency of people with AKI turning up at the hospital and we have correctly assessed and managed all patients that get AKI.
As a kidney specialist, I hope to play my part in us all getting to this goal and would like to let you know via GMKIN how we are doing later in 2015. If you would like more info – try these websites.
Dr James Tollitt
Specialist Registrar in Nephrology
Salford Royal Foundation Trust
