Blog entry by Meguid El Nahas

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by Meguid El Nahas - Wednesday, 2 March 2016, 12:04 PM
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Kidney Int. 2015 Nov;88(5):1161-9. doi: 10.1038/ki.2015.234. Epub 2015 Jul 29.

National trends in acute kidney injury requiring dialysis in England between 1998 and 2013.

Acute kidney injury (AKI) severe enough to require dialysis is increasing and associated with high mortality, yet robust information about temporal epidemiology of AKI requiring dialysis in England is lacking. In this retrospective observational study of the Hospital Episode Statistics (HES) data set covering the entire English National Health Service, we identified all patients with a diagnosis of AKI requiring dialysis between 1998 and 2013. This incidence increased from 774 cases (15.9 per million people) in 1998-1999 to 11,164 cases (208.7 per million people) in 2012-2013. The unadjusted in-hospital case-fatality was 30.3% in 1998-2003 and 30.2% in 2003-2008, but significantly increased to 41.1% in 2008-2013. Compared with 2003-2008, the multivariable adjusted odds ratio for death was higher in 1998-2003 at 1.20 (95% CI: 1.10-1.30) and in 2008-2013 at 1.13 (1.07-1.18). Charlson comorbidity scores of more than five (odds ratio 2.35; 95% CI: 2.20-2.51) and emergency admissions (2.46 (2.32-2.61) had higher odds for death. The odds for death decreased in patients over 85 years from 4.83 (3.04-7.67) in 1998-2003 to 2.19 (1.99-2.41) in 2008-2013. AKI in secondary diagnosis and in other diagnoses codes had higher odds for death compared with AKI in primary diagnosis code in all three periods. Thus, the incidence of AKI requiring dialysis has increased progressively over 15 years in England. Improvement in case-fatality in 2003-2008 has not been sustained in the last 5 years.

COMMENT:

An increased trend of AKI has been observed in the UK over the last 15 years. The ageing of the population and increasing co-morbidities have to be contributing factors. 

Of note the sharp in increase in AKI between 2004-2008. So we have to ask ourselves what happened in the UK during that time that may explain the sudden, and it is a sudden surge in 2006-2008 in the number of cases of AKI.

2003: KDOQI: CKD Classification

2004-5: eGFR reporting in the UK NHS and associated increase in RAAS prescribing. THis was observed in other countries worldwide. http://www.ncbi.nlm.nih.gov/pubmed/22437415

2004: Introduction of Quality and Outcomes Framework (QOF) to General Practitioners in the UK, encouraging to detect "CKD" and prescribe ACE inhibitors and other Renin Angiotensin Aldosterone System (RAAS) blockers. In fact, they get renumerated and increase their income if they prescribe ACE inhibitors...

2006: Onward surge in numbers of cases of AKI in the UK...

Is that a coincidence?!

Or is the rise in AKI in the UK the direct consequence of the inappropriate and increased prescribing of these potentially nephrotoxic agents?

In one study, up to 15% of the increase in AKI admissions in England over a 4-year time period (2007-2010) could be traced and attribued to increased prescribing of ACE-I and ARBs. http://www.ncbi.nlm.nih.gov/pubmed/24223154

The authors of the above report on AKI national trends in the UK are questioning what needs to be done to prevent further rise in AKI,

The answer is simple:

1. Educate GP to stop the indiscriminate prescribing of RAAS blockers to older people with co-morbidities including those with T2DM

2. Stop rewarding GPs in the UK for prescribing potentially nephrotoxic agents such as ACE inhibitors to the older population with comorbidities and vascular pathologies including CKD due to ischemic nephropathy

3. Educate Non-Nephrologists to the potential nephrotoxicity of RAAS blockers more specifically amongst the older population

4. Improve the understanding of CKD in the elderly; a mere reduction in eGFR that is age-related in most and inconsequential...that doesnt warrant RAAS blockade! In fact recent evidence suggest that aggressive BP control in this age group increases the incidence of both AKI and CKD: http://www.ncbi.nlm.nih.gov/pubmed/26551272

5. In fact, stopping RAAS blockers in this age group may be protective!:
http://www.ncbi.nlm.nih.gov/pubmed/19820248

6. Declassify many older patients from the label of "CKD" by a more age-sensitive CKD classification: http://www.ncbi.nlm.nih.gov/pubmed/26023760

7. Stop treating microalbuminuria in the older population with RAAS blockers; it is merely a reflection of age-related vascular disease. 

8. Debunk the myth that early treatment of CKD prevents late complications...in fact, the number needed to treat (NNT) with a RAAS blocker in those with early CKD (3a), in the absence of proteinuria, is 2,500 to prevent 1 case of ESRD...and NNT in those with CKD3a and microalbuminuria (or proteinuria = 1+) exceeds 1,000 patients treated with RAAS blockers to prevent 1 ESRD...

http://www.ncbi.nlm.nih.gov/pubmed/?term=O%27+Hare+A%2C+tamura%2C+larson%2C+batten

ALL IN ALL,

IT IS HIGH TIME TO RETHINK THE USE OF RAAS BLOCKERS IN THE OLDER GENERAL POPULATION AND IN CKD.

IT IS HIGH TIME THAT PRESCRIBING OF RAAS BLOCKERS IS CURBED AND CONTROLLED IN THE UK TO PREVENT MORE AKI AND CKD...!!!

 

  

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