Use of an electronic alert to identify patients with acute kidney injury.

Early intervention in the management of acute kidney injury (AKI) has been shown to improve outcomes. To facilitate early review we have introduced real time reporting for AKI. An algorithm using the laboratory computer system was implemented to report AKI for inpatients. Over 6 months there were 1,906 AKI reports in 1,518 patients: 56.3% AKI1, 26.9% AKI2 and 16.8% AKI3. 51.0% were male. Median age was 78 (interquartile range [IQR] 17) years. 62.6% were from general medical wards, 16.9% from surgical wards, 6.9% from orthopaedic wards and 5.3% from specialty wards. 8.3% were from peripheral hospitals. 31% of patients with AKI reports were clinically coded for AKI. 9% (n = 139) showed progression of AKI (mortality 42%). Patients with AKI had a significantly higher length of stay and mortality than those that did not. 4% of patients with AKI received acute renal replacement therapy (RRT). An e-alert system is feasible, allowing early identification of inpatients with AKI.

Hepatitis E seroprevalence in recipients of renal transplants or haemodialysis in southwest England: a case-control study.

Locally acquired HEV infection is increasingly recognized in developed countries. Anti-HEV IgG seroprevalence has been shown to be high in haemodialysis patients in a number of previous studies, employing assays of uncertain sensitivity. The aim of this study was to investigate anti-HEV IgG seroprevalence in recipients of haemodialysis and renal transplants compared to a control group using a validated, highly sensitive assay. Eighty-eight patients with functioning renal transplants and 76 receiving chronic haemodialysis were tested for HEV RNA and anti-HEV IgG and IgM. Six hundred seventy controls were tested for anti-HEV IgG. Anti-HEV IgG was positive in 28/76 (36.8%) of haemodialysis and 16/88 (18.2%) of transplant patients. HEV RNA was not found in any patient. 126/670 (18.8%) of control subjects were anti-HEV IgG positive. After adjusting for age and sex, there was a significantly higher anti-HEV IgG seroprevalence amongst haemodialysis patients compared to controls (OR = 1.97, 95% CI = 1.16-3.31, P = 0.01) or transplant recipients (OR = 2.63, 95% CI = 1.18-6.07, P = 0.02). Patients with a functioning transplant showed no difference in anti-HEV IgG seroprevalence compared to controls. The duration of haemodialysis or receipt of blood products were not significant risk factors for HEV IgG positivity. Patients receiving haemodialysis have a higher seroprevalence of anti-HEV IgG than both age- and sex-matched controls and a cohort of renal transplant patients. None of the haemodialysis patients had evidence of chronic infection. The reason haemodialysis patients have a high seroprevalence remains uncertain and merits further study.

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.

Severe hypercalcaemia mimicking acute myocardial infarction.

Significant hypercalcaemia can cause electrocardiogram (ECG) changes mimicking an acute myocardial infarction. It is important to recognise that some ECG changes are due to conditions other than cardiac disease so that appropriate treatment is given, and importantly, inappropriate treatments are avoided.

The Effects of Supplementary Food on the Breeding Performance of Eurasian Reed Warblers Acrocephalus scirpaceus; Implications for Climate Change Impacts.

Understanding the mechanisms by which climate variation can drive population changes requires information linking climate, local conditions, trophic resources, behaviour and demography. Climate change alters the seasonal pattern of emergence and abundance of invertebrate populations, which may have important consequences for the breeding performance and population change of insectivorous birds. In this study, we examine the role of food availability in driving behavioural changes in an insectivorous migratory songbird; the Eurasian reed warbler Acrocephalus scirpaceus. We use a feeding experiment to examine the effect of increased food supply on different components of breeding behaviour and first-brood productivity, over three breeding seasons (2012-2014). Reed warblers respond to food-supplementation by advancing their laying date by up to 5.6 days. Incubation periods are shorter in supplemented groups during the warmest mean spring temperatures. Nestling growth rates are increased in nests provisioned by supplemented parents. In addition, nest predation is reduced, possibly because supplemented adults spend more time at the nest and faster nestling growth reduces the period of vulnerability of eggs and nestlings to predators (and brood parasites). The net effect of these changes is to advance the fledging completion date and to increase the overall productivity of the first brood for supplemented birds. European populations of reed warblers are currently increasing; our results suggest that advancing spring phenology, leading to increased food availability early in the breeding season, could account for this change by facilitating higher productivity. Furthermore, the earlier brood completion potentially allows multiple breeding attempts. This study identifies the likely trophic and behavioural mechanisms by which climate-driven changes in invertebrate phenology and abundance may lead to changes in breeding phenology, nest survival and net reproductive performance of insectivorous birds.

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.

Habitat Use and Body Mass Regulation among Warblers in the Sahel Region during the Non-Breeding Season.

Migratory birds face significant challenges across their annual cycle, including occupying an appropriate non-breeding home range with sufficient foraging resources. This can affect demographic processes such as over-winter survival, migration mortality and subsequent breeding success. In the Sahel region of Africa, where millions of migratory songbirds attempt to survive the winter, some species of insectivorous warblers occupy both wetland and dry-scrubland habitats, whereas other species are wetland or dry-scrubland specialists. In this study we examine evidence for strategic regulation of body reserves and competition-driven habitat selection, by comparing invertebrate prey activity-density, warbler body size and extent of fat and pectoral muscle deposits, in each habitat type during the non-breeding season. Invertebrate activity-density was substantially higher in wetland habitats than in dry-scrubland. Eurasian reed warblers Acrocephalus scirpaceus occupying wetland habitats maintained lower body reserves than conspecifics occupying dry-scrub habitats, consistent with buffering of reserves against starvation in food-poor habitat. A similar, but smaller, difference in body reserves between wet and dry habitat was found among subalpine warblers Sylvia cantillans but not in chiffchaffs Phylloscopus collybita inhabiting dry-scrub and scrub fringing wetlands. Body reserves were relatively low among habitat specialist species; resident African reed warbler A. baeticatus and migratory sedge warbler A. schoenobaenus exclusively occupying wetland habitats, and Western olivaceous warblers Iduna opaca exclusively occupying dry habitats. These results suggest that specialists in preferred habitats and generalists occupying prey-rich habitats can reduce body reserves, whereas generalists occupying prey-poor habitats carry an increased level of body reserves as a strategic buffer against starvation.