How Do We Raise the Awareness of AKI?
The multiple and very diverse stakeholders on the management of AKI can be likened to the story of The Elephant in the Village of the Blind of the Indian subcontinent tradition, which illustrates the need for communication and respect for different perspectives when overall knowledge is difficult to achieve all at once. Thus, it is necessary to design a common framework that is anchored on evidence, and that builds on a rapidly expanding wealth of knowledge. The current conceptual framework for AKI recognizes that the disease is a process that evolves from early injury through severe damage, resulting in kidney failure and the need for RRT. The natural course can vary from complete renal recovery to dialysis dependency or death. Individuals transition from one state to another during the course of the disease (Figure 3). This conceptual framework also recognizes that AKI can occur in individuals who have normal kidney function or have preexisting kidney damage, thus allowing risk assessment. Based on this conceptual framework, we propose a strategy for raising awareness that emphasizes five areas of focus: risk assessment, recognition, response, renal support, and rehabilitation ( Table 3 ). Each of these areas has specific components that can be adapted to develop an educational strategy and to target specific stakeholders, with an appropriate emphasis in each particular domain. Although physicians and nursing personnel would need to be aware of the overall concept, risk assessment and early recognition could be emphasized for allied health professionals.
Based on the principles described above, we recommend a multipronged strategy ( Table 4 ).
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Figure 3.
Conceptual framework and targeted approach for raising awareness of acute kidney injury (AKI). GFR, glomerular filtration rate. Modified from Mehta.
First, it is essential to improve education on AKI at both undergraduate and postgraduate levels for all health-care professionals, and to emphasize the importance of identifying patients at risk of AKI. The Academy of Royal Medical Colleges has published a core competency for AKI. This document provides a pragmatic approach relevant to each specific health-care professional. It defines the knowledge, skills, and behaviors required for safe and effective patient care along the Chain of Response as described by National Institute of Health and Clinical Excellence (NICE). The Chain of Response reflects escalating levels of intervention in the care of an acute patient with input from staff with a variety of different backgrounds and skills. The health-care team must have the competencies to record patient information and vital signs, recognize abnormal values, and institute intervention at a level appropriate to the patient's clinical condition. Five levels of competency are recognized that are: recorder, recognizer, and primary, secondary, and tertiary responders. It is hoped that the implementation of the AKI Core Competencies framework will assist in improving the care that patients with AKI receive.
Second, physicians should be provided specific guidance for evaluating and managing patients with AKI based on the 5R approach. The recently published AKI Clinical Practice Guidelines in 2012 from KDIGO has provided a strong platform for this purpose. This international guideline has harmonized the definitions previously proposed by the Acute Dialysis Quality Initiative (RIFLE) and the Acute Kidney Injury Network and provides guidelines for prevention, assessment, and management of AKI that are designed to be applicable globally. These guidelines provide an opportunity to raise the awareness of AKI around a clearly characterized disease condition that has previously been poorly defined. We propose utilizing these guidelines as a common component to educate stakeholders in raising awareness of AKI.
Third, hospital administrators and quality control personnel should be made aware of the evidence for including AKI as a core measure of general medical care and as a key factor determining outcomes. Hospitals should be encouraged to adopt audit measures around the care of patients who develop AKI as proposed by NCEPOD and other guideline bodies. Episodes of avoidable AKI should be used as a benchmark for the care of acutely ill patients. This will provide an incentive to improve patient safety and reduce the number of episodes of AKI that are potentially avoidable. Specific AKI guidelines should be developed for community-based health-care professionals and systems put in place to help detect patients developing AKI at an earlier stage in the disease process. The utilization of e-alerts in electronic medical records should be encouraged to provide real-time feedback to caregivers for recognizing high-risk patients, early diagnosis, and timely intervention including referral and follow-up.
Fourth, an AKI toolkit should be developed to be used globally including a checklist of simple measures that can be instituted to reduce the risk of AKI and how to manage it if it occurs. These checklists may be specific to individual groups of patients in a variety of different settings to take into account contrasting causes of AKI that occur in the developed and the developing world. For certain groups of health-care professionals, it will be essential to provide clear referral criteria. Patient education needs to be improved with the provision of information on websites. Patients who have suffered an episode of AKI should be provided with information regarding the causes of the episode and the need for long-term follow-up.
Finally, there are opportunities to raise the awareness of AKI as a complication of other disease processes in the developing world and mobilize local resources to manage it at an early phase. The World Health Organization (WHO)/United Nations UNDP Millennium Project and the Campaign to Eradicate Malaria deal with the main root causes of community disease in developing countries. The Millennium Project attempts to eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, improve maternal health and reduce child mortality, combat HIV/AIDS, malaria and other diseases, ensure environmental sustainability, and promote a global partnership for development. All these issues are intimately related to AKI in developing countries. Malaria is a main cause of AKI in Sub-Saharan Africa and South-East Asia, obstetrical complications constitute a large cause of fatal AKI, and hemolytic uremic syndrome causes AKI frequently resulting in ESRD in children. Furthermore, it is important to recognize that in many cases, gender and social/economical discrimination is at the cause root of the problem. International and regional initiatives must make all efforts to address that important aspect of the problem. The recognition and management of AKI in developing countries should be leveraged on such international initiatives, with the development of databases to demonstrate the scale of the problem.