Quality Improvement Goals for Acute Kidney Injury

Ferroptosis, necroptosis, and pyroptosis in calcium oxalate crystal-induced kidney injury

Kidney stones represent a highly prevalent urological disorder worldwide, with high incidence and recurrence rates. Calcium oxalate (CaOx) crystal-induced kidney injury serves as the foundational mechanism for the formation and progression of CaOx stones. Regulated cell death (RCD) such as ferroptosis, necroptosis, and pyroptosis are essential in the pathophysiological process of kidney injury. Ferroptosis, a newly discovered RCD, is characterized by its reliance on iron-mediated lipid peroxidation. Necroptosis, a widely studied programmed necrosis, initiates with a necrotic phenotype that resembles apoptosis in appearance. Pyroptosis, a type of RCD that involves the gasdermin protein, is accompanied by inflammation and immune response. In recent years, increasing amounts of evidence has demonstrated that ferroptosis, necroptosis, and pyroptosis are significant pathophysiological processes involved in CaOx crystal-induced kidney injury. Herein, we summed up the roles of ferroptosis, necroptosis, and pyroptosis in CaOx crystal-induced kidney injury. Furthermore, we delved into the curative potential of ferroptosis, necroptosis, and pyroptosis in CaOx crystal-induced kidney injury.

ASN Kidney Health Guidance on the Outpatient Management of Patients with Dialysis-Requiring Acute Kidney Injury

Podcast

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2025_03_11_KTS_March2025.mp3

Key performance indicators for acute intermittent kidney replacement therapy in critically ill patients: a protocol for a systematic review

INTRODUCTION

There have been previous initiatives to identify key performance indicators (KPIs) for continuous kidney replacement therapy. However, no formal reviews of the evidence for KPIs of intermittent kidney replacement therapy (IKRT) have been conducted. This systematic review will appraise the evidence for KPIs of IKRT in critically ill patients and is part of the DIALYZING WISELY (NCT05186636) programme which aims to improve the performance of acute renal replacement therapy in intensive care units by aligning local practices with evidence-based best practices.

METHODS AND ANALYSIS

Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library will be searched for studies involving KPIs for IKRT. Grey literature will also be searched and include technical reports, practice guidelines and conference proceedings as well as websites of relevant organisations. We will search the Agency of Healthcare Research and National Quality Measures Clearinghouse for IKRT-related KPIs. Studies will be included if they contain KPIs, occur in critically ill patients and are associated with IKRT. We will evaluate the risk of bias using the modified Cochrane tool and certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations methodology. The analysis will be primarily descriptive. Each KPI will be evaluated for importance, scientific acceptability, usability and feasibility using the four criteria proposed by the United States Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, KPIs will be appraised for potential operational characteristics, potential to be integrated into electronic medical records, adoptability by stakeholders and affordability, if applicable.

ETHICS AND DISSEMINATION

Ethics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication.

PROSPERO REGISTRATION NUMBER

CRD42022074444.

The Furosemide Stress Test: A Dynamic Tool for Predicting Acute Kidney Injury Progression in Critical Care Medicine

Acute kidney injury (AKI) remains a significant challenge in critical care medicine, affecting up to 50% of intensive care unit patients with substantial mortality rates. While traditional approaches to AKI assessment rely on static measurements like serum creatinine and urine output, the furosemide stress test (FST) has emerged as a dynamic functional tool for evaluating renal tubular function and predicting AKI progression. This comprehensive review examines the historical development, physiological basis, technical aspects, and clinical applications of FST in various patient populations. Originally developed and validated in 2013, FST has demonstrated superior predictive capabilities for AKI progression and the need for renal replacement therapy compared to conventional biomarkers. The test's mechanism relies on assessing the kidney's response to a standardized furosemide challenge, providing insights into both the structural integrity and functional reserve of the renal tubular system. Standardized protocols have been established for different clinical scenarios, though implementation challenges remain, including timing considerations, patient selection, and resource requirements. FST has shown utility in critical care, post-cardiac surgery, sepsis-associated AKI, and heart failure settings. Recent developments include integration with artificial intelligence, personalized medicine approaches, and combination with novel biomarkers. While limitations exist, including contraindications and technical challenges, ongoing research continues to refine protocols and expand applications. This review highlights FST's role as a valuable prognostic tool in modern AKI management and discusses future directions, including automated monitoring systems, protocol standardization efforts, and potential applications in different patient populations.

Quality Improvement Methodologies: An Application in Cardiac Anesthesiology

Quality improvement (QI) in medicine serves as the cornerstone of best practices. It enhances medical care by maximizing safety and efficiency while minimizing errors and waste. For a QI initiative to succeed it requires careful strategizing and effective change management plans, including the application of established QI methodologies to ensure sustainable success. Today, QI processes are integral to foundational learning for students and trainees, as well as for maintaining board certification for anesthesiologists. However, many anesthesiologists, including those actively pursuing QI efforts, are often unaware of these methodologies and their associated tools. A successful QI program that leads to sustainable improvement in outcomes relies on methodologies that assess the true current state, define value-added measures, evaluate defects and opportunities for enhancement, implement solutions through a robust change management plan, and ensure the sustainability of the process. This document provides a concise summary of methodologies that can be effectively led and executed by process improvement teams. We examine these methods within the context of cardiac anesthesiology, highlighting one institution's experience in reducing surgical site infections following coronary artery bypass graft surgery. However, these principles are applicable to various healthcare situations and beyond.

The role of sex and gender in acute kidney injury-consensus statements from the 33rd Acute Disease Quality Initiative

Sex differences exist in acute kidney injury (AKI), and the role that sex and gender play along the AKI care continuum remains unclear. The 33rd Acute Disease Quality Initiative meeting evaluated available data on the role of sex and gender in AKI and identified knowledge gaps. Data from experimental models, pathophysiology, epidemiology, clinical care, gender, social determinants of health, education, and advocacy were reviewed. Recommendations include incorporating sex and gender into research along the bench-to-bedside spectrum; analyzing sex-stratified results; evaluating the effects of sex chromosomes, hormones, and gender on outcomes; considering fluctuations of hormone levels; studying the impact gender may have on access to care; and developing educational tools to inform patients, providers, and stakeholders. This meeting report summarizes what is known about sex and gender along the AKI care continuum and proposes an agenda for translational discovery to elucidate the role of sex and gender in AKI across the lifespan.

Postdischarge Care of Acute Kidney Injury Survivors: An Opportunity for Targeted Nurse and Pharmacist Interventions

The incidence of acute kidney injury (AKI) is increasing, and with it, the population of individuals requiring post-AKI care. Postdischarge follow-up for AKI survivors is recommended within 90 days of an AKI episode to promote kidney recovery and potentially prevent progression of kidney disease. However, timely postdischarge care is often lacking or fragmented and poses a missed opportunity to prevent long-term complications of this condition. Suggested elements of follow-up care begin with a scheduled appointment with a physician and involve a bundled approach to care with health care providers' communicating across sites, remote patient monitoring devices, review of medications, education, access, kidney care evaluation, and interdisciplinary collaboration to achieve these patient care goals. This article provides an overview of guidance documents for post-AKI care and the roles of the nurse and pharmacist as part of an interdisciplinary team in postdischarge care after a patient incurs an episode of AKI.

Acute Kidney Injury Provider and Survivor Education: Current and Emerging Tools

Acute kidney injury (AKI) is associated with an increased risk of adverse health outcomes, but the proportion of patients receiving optimal care is low. Barriers to improving outcomes after AKI include limited recognition of AKI by providers, the required transitions of care from the inpatient and outpatient settings, and lack of patient awareness of the AKI event. Gaps in the care of AKI survivors may be improved with enhanced education for providers and patients. Some tools focused on early detection of AKI and improving AKI management have been developed with variable success in addressing adverse outcomes. Significant heterogeneity within the AKI population and complexities of care coordination continue to hinder programs focused on improving AKI survivorship. On the horizon, promising programs are emerging that may overcome these barriers by offering an individualized, patient-centered approach to AKI survivorship by integrating technological advances and multidisciplinary support. Greater emphasis is being placed on ensuring that tactics for AKI management can be implemented beyond the nephrology subspecialty. These programs can potentially prevent AKI, optimize recovery, and increase patient satisfaction. This review discusses the current and emerging educational resources for AKI survivors and their providers.

Pediatric Considerations in Post Acute Kidney Injury Care

Acute kidney injury in children is associated with adverse outcomes. These include longer hospital stays, increased mortality, and nonrecovery of kidney function in the short term and increased health care utilization, new onset hypertension, and chronic kidney disease in the long term. Systematic post acute kidney injury care may help mitigate some of the complications that follow acute kidney injury. Patient, family, and health care team education is a key aspect of post acute kidney injury care. This includes individualized education to the patient and family, ideally prior to hospital discharge, provision of a discharge summary with details of the acute kidney injury episode and follow-up plan, and communication with the primary care provider. Given that severe acute kidney injury may often be seen in patients with other underlying medical conditions, partnership between the primary care provider, non-nephrology specialist and the nephrologist, and the use of telehealth may facilitate follow-up without increasing caregiver burden. Ongoing surveillance includes monitoring kidney function, proteinuria, and hypertension. There are no guidelines on the frequency of this evaluation or the duration of follow-up. These decisions should be individualized based on the characteristics of the index acute kidney injury episode and underlying risk factors for chronic kidney disease.

Unraveling the Epidemiology of Acute Kidney Injury Recovery

Acute kidney injury (AKI) is a common complication among hospitalized patients and is associated with significant long-term morbidity, including the development of major adverse kidney events such as kidney failure. By definition, AKI holds the promise of potential kidney recovery, yet clearly not all patients will recover, and some will develop worsening kidney function even after initial recovery. Being able to identify which patients with AKI will recover vs have persistent or future kidney complications is a critically important question, both for counseling patients and for determining appropriate care of AKI survivors. In this article, we review and describe the key factors associated with kidney function nonrecovery after AKI, some of which are modifiable and may be future targets for intervention. We also describe recent studies developing clinical risk scores to predict post-AKI kidney outcomes and their potential role in the clinical setting. Despite progress, there remains significant opportunity to improve our understanding of the epidemiology of AKI recovery.

Acute Kidney Injury Care Following Hospitalization: Care Provision and Public Policy for Acute Kidney Injury Survivors

The global incidence of acute kidney injury (AKI) is increasing. AKI is associated with both short- and long-term risks, including increased risk of chronic kidney disease and kidney failure, cardiovascular events, and all-cause death. This review summarizes existing posthospitalization AKI care guidelines, interprets the current state of evidence for AKI survivor care models including nephrology-specific and multidisciplinary team interventions, and details the health policy landscape for AKI survivors receiving outpatient dialysis in the United States. The main finding of this review is that evidence supporting specific posthospitalization AKI care interventions is very limited, resulting in imprecise consensus-based practice recommendations by national and international kidney societies for AKI survivors. The main implication of this work is to highlight the urgent need for additional research evaluating the efficacy of different care models among AKI survivors at high risk of maintenance dialysis, progression of kidney disease, rehospitalization, and death to devise value-based care models and clinical interventions that improve patient outcomes.

Perspectives and Experiences of Patients with AKI: A Systematic Review

Key Points

Six themes have been identified reflecting the perspectives and experiences of adults with AKI. Patients are unaware of AKI diagnosis and prognosis, feel that care is fragmented, and are burdened by treatment. Providing education, reducing treatment burden, and ensuring excellence in care may help to address patients' needs and improve AKI management.

Background

AKI is associated with higher risk of mortality and progression to CKD. The challenges and uncertainty in the diagnosis, self-management, and prevention of AKI can be distressing for patients. We aimed to perform a systematic review of qualitative studies/surveys that reported the perspectives and experiences of adults with AKI.

Methods

We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception to January 17, 2024. Thematic textual analysis was used to synthesize the findings.

Results

We included 20 studies (ten qualitative studies, ten surveys) involving 867 participants. We identified six themes: navigating the unknown (an unexpected and unfamiliar diagnosis, tossed about in a fragmented system, and dismissed and vulnerable at discharge); impaired life participation, relationships, and well-being (limiting ability to do daily activities and straining relationships); unbearable and unsustainable treatment burden (adding strain on family members, financial pressure because of medical expenses, and cumulative stress of ongoing monitoring); uncertain whether recovery is attainable (possible permanence of kidney damage, fear about nephrotoxic medications, and terrified about the need for dialysis); less consequential than other health priorities (short term and reversible and prioritizing other comorbidities and conditions); and empowered in managing own health (focusing on optimizing kidney health, gaining confidence in self-management, and reassured with social and clinical support).

Conclusions

Patients may be unaware of their AKI diagnosis and prognosis, feel that care is fragmented, and be burdened by treatment. Providing education, alleviating treatment burden, and implementing a comprehensive model of care may help to address the needs of patients with AKI leading to better outcomes.

Hospital readmission for acute kidney injury is independently associated with de novo end-stage renal disease after liver transplantation

End-stage renal disease (ESRD) after liver transplantation (LT) is associated with high morbidity and mortality. The consequences of hospitalizations for post-LT acute kidney injury (AKI) are poorly understood. Using linked Medicare claims and transplant registry data, we analyzed adult liver alone recipients not receiving pretransplant dialysis between January 1, 2007, and December 31, 2016. Covariate-adjusted Cox proportional hazards models stratified by center evaluated factors associated with AKI readmission during the first post-LT year, and whether AKI readmission was associated with de novo early (<1 y) or late (≥1 y) ESRD post-LT. The cohort included 10,559 patients and was 64.5% male, 72.5% White, 8.1% Black, and 14.0% Hispanic with median age 62 years. Overall, 2875 (27.2%) patients had ≥1 AKI hospitalization during the first year. Estimated glomerular filtration rate at LT was associated with AKI readmission (adjusted HR: 1.16 per 10 mL/min/1.73m 2 decrease; p <0.001). The adjusted HR for early ESRD in patients with ≥1 AKI readmission <90 days post-LT was 1.90 ( p <0.001). The adjusted HRs for late ESRD with 1 and ≥2 prior AKI readmissions were 1.57 and 2.80, respectively ( p <0.001). AKI readmissions in the first post-LT year impact over one-quarter of recipients. These increase the risk of subsequent ESRD, but may represent an opportunity to intervene and mitigate further renal dysfunction.

Early, Individualized Recommendations for Hospitalized Patients With Acute Kidney Injury: A Randomized Clinical Trial

Importance

Acute kidney injury (AKI) is a common complication during hospitalization and is associated with adverse outcomes.

Objective

To evaluate whether diagnostic and therapeutic recommendations sent by a kidney action team through the electronic health record improve outcomes among patients hospitalized with AKI compared with usual care.

Design, Setting, and Participants

Randomized clinical trial conducted at 7 hospitals in 2 health systems: in New Haven, Bridgeport, New London, and Waterbury, Connecticut, and Westerly, Rhode Island; and in Baltimore, Maryland. Hospitalized patients with AKI were randomized between October 29, 2021, and February 8, 2024. Final follow-up occurred February 22, 2024.

Intervention

An alert about AKI was sent to the kidney action team, consisting of a study physician and study pharmacist, which sent personalized recommendations through the electronic health record in 5 major categories (diagnostic testing, volume, potassium, acid base, and medications) within 1 hour of AKI detection. The note was immediately visible to anyone with access to the electronic health record. Randomization to the intervention or usual care occurred after the recommendations were generated, but the note was only delivered to clinicians of patients randomized to the intervention group.

Main Outcomes and Measures

The primary outcome was a composite outcome consisting of AKI progression to a higher stage of AKI, dialysis, or mortality occurring while the patient remained hospitalized and within 14 days from randomization.

Results

Of the 4003 patients randomized (median age, 72 years [IQR, 61-81 years), 1874 (47%) were female and 931 (23%) were Black patients. The kidney action team made 14 539 recommendations, with a median of 3 (IQR, 2-5) per patient. The primary outcome occurred in 19.8% of the intervention group and in 18.4% in the usual care group (difference, 1.4%, 95% CI, -1.1% to 3.8,% P = .28). Of 6 secondary outcomes, only 1 secondary outcome, rates of recommendation implementation, significantly differed between the 2 groups: 2459 of 7270 recommendations (33.8%) were implemented in the intervention group and 1766 of 7269 undelivered recommendations (24.3%) were implemented in the usual care group within 24 hours (difference, 9.5%; 95% CI, 8.1% to 11.0%).

Conclusions and Relevance

Among patients hospitalized with AKI, recommendations from a kidney action team did not significantly reduce the composite outcome of worsening AKI stage, dialysis, or mortality, despite a higher rate of recommendation implementation in the intervention group than in the usual care group.

Trial Registration

ClinicalTrials.gov Identifier: NCT04040296.

Role of a Pharmacist in Postdischarge Care for Patients With Kidney Disease: A Scoping Review

OBJECTIVE

The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease.

DATA SOURCES

PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible.

STUDY SELECTION AND DATA EXTRACTION

Six unique interventions were described in 10 studies meeting inclusion criteria.

DATA SYNTHESIS

Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease.

CONCLUSIONS

The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.

Utilizing Raman spectroscopy for urinalysis to diagnose acute kidney injury stages in cardiac surgery patients

BACKGROUND

The successful treatment and improvement of acute kidney injury (AKI) depend on early-stage diagnosis. However, no study has differentiated between the three stages of AKI and non-AKI patients following heart surgery. This study will fill this gap in the literature and help to improve kidney disease management in the future.

METHODS

In this study, we applied Raman spectroscopy (RS) to uncover unique urine biomarkers distinguishing heart surgery patients with and without AKI. Given the amplified risk of renal complications post-cardiac surgery, this approach is of paramount importance. Further, we employed the partial least squares-support vector machine (PLS-SVM) model to distinguish between all three stages of AKI and non-AKI patients.

RESULTS

We noted significant metabolic disparities among the groups. Each AKI stage presented a distinct metabolic profile: stage 1 had elevated uric acid and reduced creatinine levels; stage 2 demonstrated increased tryptophan and nitrogenous compounds with diminished uric acid; stage 3 displayed the highest neopterin and the lowest creatinine levels. We utilized the PLS-SVM model for discriminant analysis, achieving over 90% identification rate in distinguishing AKI patients, encompassing all stages, from non-AKI subjects.

CONCLUSIONS

This study characterizes the incidence and risk factors for AKI after cardiac surgery. The unique spectral information garnered from this study can also pave the way for developing an in vivo RS method to detect and monitor AKI effectively.

10 tips on how to use dynamic risk assessment and alerts for AKI

Acute kidney injury (AKI) is a common syndrome in hospitalized patients and is associated with increased morbidity and mortality. The focus of AKI care requires a shift away from strictly supportive management of established injury to the early identification and timely prevention of worsening renal injury. Identifying patients at risk for developing or progression of severe AKI is crucial for improving patient outcomes, reducing the length of hospitalization and minimizing resource utilization. Implementation of dynamic risk scores and incorporation of novel biomarkers show promise for early detection and minimizing progression of AKI. Like any risk assessment tools, these require further external validation in a variety of clinical settings prior to widespread implementation. Additionally, alerts that may minimize exposure to a variety of nephrotoxic medications or prompt early nephrology consultation are shown to reduce the incidence and progression of AKI severity and enhance renal recovery. While dynamic risk scores and alerts are valuable, implementation requires thoughtfulness and should be used in conjunction with the overall clinical picture in certain situations, particularly when considering the initiation of fluid and diuretic administration or renal replacement therapy. Despite the contemporary challenges encountered with alert fatigue, implementing an alert-based bundle to improve AKI care is associated with improved outcomes, even when implementation is incomplete. Lastly, all alert-based interventions should be validated at an institutional level and assessed for their ability to improve institutionally relevant and clinically meaningful outcomes, reduce resource utilization and provide cost-effective interventions.

Acute Kidney Injury Survivor Remote Patient Monitoring: A Single Center's Experience and an Effectiveness Evaluation

Rationale & Objective

Remote patient monitoring (RPM) could improve the quality and efficiency of acute kidney injury (AKI) survivor care. This study described our experience with AKI RPM and characterized its effectiveness.

Study Design

A cohort study matched 1:3 to historical controls.

Setting & Participants

Patients hospitalized with an episode of AKI who were discharged home and were not treated with dialysis.

Exposure

Participation in an AKI RPM program, which included use of a home vital sign and symptom monitoring technology and weekly in-center laboratory assessments.

Outcomes

Risk of unplanned hospital readmission or emergency department (ED) visit within 6 months.

Analytic Approach

Endpoints were assessed using Cox proportional hazards models.

Results

Forty of the 49 patients enrolled in AKI RPM (82%) participated in the program after hospital discharge. Seventy three percent of patients experienced one AKI RPM alert, most commonly related to fluid status. Among those with stage 3 AKI, the risk of unplanned readmission or ED visit within 6 months of discharge was not different between AKI RPM patients (n = 34) and matched controls (n = 102) (HR 1.33 [95% CI, 0.81-2.18]; P = 0.27). The incidence of an ED visit without hospitalization was significantly higher in the AKI RPM group (HR 1.95, [95% CI, 1.05-3.62]; P = 0.035). The risk of an unplanned readmission or ED visit was higher in those with baseline eGFR < 45 mL/min/1.73 m2 exposed to AKI RPM (HR 2.24 [95% CI, 1.19-4.20]; P = 0.012) when compared with those with baseline eGFR ≥45 mL/min/1.73 m2 (HR 0.69 [95% CI, 0.29-1.67]; P = 0.41) (test of interaction P = 0.04).

Limitations

Small sample size that may have been underpowered for the effectiveness endpoints.

Conclusions

AKI RPM, when used after hospital discharge, led to alerts and interventions directed at optimizing kidney health and AKI complications but did not reduce the risk for rehospitalization.

Stepped-Wedge Trial of Decision Support for Acute Kidney Injury on Surgical Units

Introduction

Acute kidney injury (AKI) is common in the perioperative setting and associated with poor outcomes. Whether clinical decision support improves early management and outcomes of AKI on surgical units is uncertain.

Methods

In this cluster-randomized, stepped-wedge trial, 8 surgical units in Alberta, Canada were randomized to various start dates to receive an education and clinical decision support intervention for recognition and early management of AKI. Eligible patients were aged ≥18 years, receiving care on a surgical unit, not already receiving dialysis, and with AKI.

Results

There were 2135 admissions of 2038 patients who met the inclusion criteria; mean (SD) age was 64.3 (16.2) years, and 885 (41.4%) were females. The proportion of patients who experienced the composite primary outcome of progression of AKI to a higher stage, receipt of dialysis, or death was 16.0% (178 events/1113 admissions) in the intervention group; and 17.5% (179 events/1022 admissions) in the control group (time-adjusted odds ratio, 0.76; 95% confidence interval [CI], 0.53-1.08; P = 0.12). There were no significant differences between groups in process of care outcomes within 48 hours of AKI onset, including administration of i.v. fluids, or withdrawal of medications affecting kidney function. Both groups experienced similar lengths of stay in hospital after AKI and change in estimated glomerular filtration rate (eGFR) at 3 months.

Conclusion

An education and clinical decision support intervention did not significantly improve processes of care or reduce progression of AKI, length of hospital stays, or recovery of kidney function in patients with AKI on surgical units.

Outcomes after acute kidney injury and critical illness

PURPOSE OF REVIEW

Acute kidney injury (AKI) in critical illness is common, and survivors are faced with a host of adverse outcomes. In this article, we review the current landscape of outcomes and care in survivors of AKI and critical illness.

RECENT FINDINGS

Follow-up care of survivors of AKI and critical illness is prudent to monitor for and mitigate the risk of adverse outcomes. Observational data have suggested improvement in outcomes with nephrology-based follow-up care, and recent interventional studies demonstrate similar findings. However, current post-AKI care is suboptimal with various challenges, such as breakdowns in the transition of care during hospital episodes and into the community, barriers for patients in follow-up, and lack of identification of high-risk patients for nephrology-based follow-up. Tools predictive of renal nonrecovery and long-term outcomes may help to identify high-risk patients who may benefit the most from nephrology-based care post-AKI.

SUMMARY

Follow-up care of survivors of AKI and critical illness may improve outcomes and there is a need to prioritize transitions of care into the community. Further research is needed to elucidate the best ways to risk-stratify and manage post-AKI survivors to improve outcomes.

Transitions and Long-Term Clinical Outcomes in Patients Admitted in Intensive Care Units Receiving Continuous Renal Replacement Therapy

Introduction: Acute kidney injury (AKI) significantly disrupts vital renal functions and is a common and serious condition in intensive care units (ICUs). AKI leads to extended hospital stays, increases mortality rates, and often necessitates nephrology consultations. Continuous renal replacement therapy (CRRT) plays a central role in managing AKI, requiring a multidisciplinary approach involving nephrologists, intensivists, and anesthesiologists. This study examines the clinical profile and progression of AKI in ICU patients requiring CRRT, with a focus on CRRT indications and modalities. Materials and Methods: We conducted a single-center retrospective observational study on ICU patients with AKI requiring CRRT from January to December 2019. AKI diagnosis followed the RIFLE criteria, and patients who received CRRT for less than 36 h were excluded. Data collected included demographics, hemodynamic parameters, and renal function parameters, with follow-ups at 1 week, 1 month, 6 months, and 12 months. Statistical analyses evaluated outcomes and transitions between CRRT and other renal replacement therapies. Results: Among 123 evaluated patients, 95 met inclusion criteria. Fifteen patients received CRRT for less than 36 h, with an early mortality rate of 80%. The final cohort comprised 80 patients who underwent CRRT for over 36 h, with a mean age of 65.3 years (SD = 13.6) and a Charlson index of 6.4. Patients were categorized based on primary diagnosis into heart failure, cardiac surgery, sepsis, other surgeries, and miscellanea groups. Mortality rates were highest in the heart failure and miscellanea groups. Significant variability was observed in therapy transitions and long-term outcomes. Continuous venovenous hemodiafiltration (CVVHDF) was the most frequently used CRRT modality. Conclusions: This study highlights the variability in CRRT practices and the poor prognosis for critically ill patients with AKI requiring CRRT. Timely nephrology consultation and tailored treatment plans may improve patient outcomes and optimize CRRT utilization. Future research should focus on refining CRRT protocols and exploring preventive strategies for AKI.

Beyond the Valve: Incidence, Outcomes, and Modifiable Factors of Acute Kidney Injury in Patients with Infective Endocarditis Undergoing Valve Surgery-A Retrospective, Single-Center Study

Background/Objectives: Infective endocarditis (IE) often requires surgical intervention, with postoperative acute kidney injury (AKI), posing a significant concern. This retrospective study aimed to investigate AKI incidence, its impact on short-term mortality, and identify modifiable factors in patients with IE scheduled for valve surgery. Methods: This single-center study enrolled 130 consecutive IE patients from 2013 to 2021 undergoing valve surgery. The creatinine levels were monitored pre- and postoperatively, and AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patient demographics, comorbidities, procedural details, and complications were recorded. Primary outcomes included AKI incidence; the relevance of creatinine levels for AKI detection; and the association of AKI with 30-, 60-, and 180-day mortality. Modifiable factors contributing to AKI were explored as secondary outcomes. Results: Postoperatively, 35.4% developed AKI. The highest creatinine elevation occurred on the second postoperative day. Best predictive value for AKI was a creatinine level of 1.35 mg/dL on the second day (AUC: 0.901; sensitivity: 0.89, specificity: 0.79). Elevated creatinine levels on the second day were robust predictors for short-term mortality at 30, 60, and 180 days postoperatively (AUC ranging from 0.708 to 0.789). CK-MB levels at 24 h postoperatively and minimum hemoglobin during surgery were identified as independent predictors for AKI in logistic regression. Conclusions: This study highlights the crucial role of creatinine levels in predicting short-term mortality in surgical IE patients. A specific threshold (1.35 mg/dL) provides a practical marker for risk stratification, offering insights for refining perioperative strategies and optimizing outcomes in this challenging patient population.

Unveiling the enigma of acute kidney disease: predicting prognosis, exploring interventions, and embracing a multidisciplinary approach

Acute kidney disease (AKD) is a critical transitional period between acute kidney injury and chronic kidney disease. The incidence of AKD following acute kidney injury is approximately 33.6%, and it can occur without identifiable preceding acute kidney injury. The development of AKD is associated with increased risks of chronic kidney disease, dialysis, and mortality. Biomarkers and subphenotypes are promising tools to predict prognosis in AKD. The complex clinical situations in patients with AKD necessitate a comprehensive and structured approach, termed "KAMPS" (kidney function check, advocacy, medications, pressure, sick day protocols). We introduce "MAND-MASS," an acronym devised to summarize the reconciliation of medications during episodes of acute illness, as a critical component of the sick day protocols at AKD. A multidisciplinary team care, consisting of nephrologists, pharmacists, dietitians, health educators, and nurses, is an optimal model to achieve the care bundle in KAMPS. Although the evidence for patients with AKD is still lacking, several potential pharmacological agents may improve outcomes, including but not limited to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide 1 receptor agonists. In conclusion, accurate prognosis prediction and effective treatment for AKD are critical yet unmet clinical needs. Future studies are urgently needed to improve patient care in this complex and rapidly evolving field.

Intensive Care Unit Without Walls

Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.

Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting

Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.

The effect of pharmacist-led medication therapy management in the multidisciplinary care of acute kidney injury survivors

BACKGROUND

The Acute Disease Quality Initiative advocates multidisciplinary care for the survivors of acute kidney injury (AKI). The bundled care strategy recognizes the role of pharmacists. However, their specific contributions in this context remain underexplored.

METHODS

This retrospective study examined the efficacy of pharmacist-led post-AKI pharmaceutical care in outpatient settings at a single center. Adults with recent AKI during hospitalization, maintaining an estimated glomerular filtration rate <45 mL/min/1.73 m2 postdischarge, were enrolled in a multidisciplinary team care program from March 2022 to January 2023, with a 6-month follow-up period. Pharmacist-delivered care adhered to international multidisciplinary consensus guidelines. Efficacy was evaluated by analyzing medication-related recommendations, medication adherence, nephrotoxic drug utilization, and renoprotective medication usage before and after the intervention.

RESULTS

A total of 40 patients were referred to the pharmacist-managed clinic. Of these, 33 patients (mean age, 63 ± 15 years; 60.6% male) attended the clinic. Nineteen patients completed follow-up visits. The pharmacist provided 14 medication-related recommendations to relevant physicians, with 10 of these recommendations (71.4%) being accepted. There was a significant decrease in the use of modifiable nephrotoxic drugs (p = 0.03). However, no significant improvements were noted in medication adherence or the utilization of renoprotective medications.

CONCLUSION

Our study underscores the potential benefits of pharmacist-led post-AKI bundled care strategy in outpatient settings. We observed a significant reduction in the utilization of modifiable nephrotoxic drugs, indicating the effectiveness of pharmacist interventions in optimizing medication regimens to mitigate renal harm.

SGLT2i treatment during AKI and its association with major adverse kidney events

Background

The association between the administration of sodium-glucose cotransporter 2 inhibitors (SGLT2is) during acute kidney injury (AKI) and the incidence of major adverse kidney events (MAKEs) is not known.

Methods

This retrospective cohort study included patients with AKI and compared the outcomes for those who were treated with SGLT2is during hospitalization and those without SGLT2i treatment. The associations of SGLT2i use with MAKEs at 10 and 30-90 days, each individual MAKE component, and the pre-specified patient subgroups were analyzed.

Results

From 2021 to 2023, 374 patients were included in the study-316 without SGLT2i use and 58 with SGLT2i use. Patients who were treated with SGLT2is were older; had a greater prevalence of diabetes, hypertension, chronic heart failure, and chronic kidney disease; required hemodialysis less often; and presented stage 3 AKI less frequently than those who were not treated with SGLT2is. Logistic regression analysis with nearest-neighbor matching revealed that SGLT2i use was not associated with the risk of MAKE10 (OR 1.08 [0.45-2.56]) or with MAKE30-90 (OR 0.76 [0.42-1.36]). For death, the stepwise approach demonstrated that SGLT2i use was associated with a reduced risk (OR 0.08; 0.01-0.64), and no effect was found for kidney replacement therapy (KRT). The subgroups of patients who experienced a reduction in the risk of MAKEs in patients with AKI treated with SGLT2is were those older than 61 years, those with an eGFR >81, and those without a history of hypertension or DM (p ≤ 0.05 for all).

Conclusion

The use of SGLT2is during AKI had no effect on short- or medium-term MAKEs, but some subgroups of patients may have experienced benefits from SGLT2i treatment.

Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department: A Multisite Retrospective Cohort Study

RATIONALE & OBJECTIVE

The prevalence of community-acquired acute kidney injury (CA-AKI) in the United States and its clinical consequences are not well described. Our objective was to describe the epidemiology of CA-AKI and the associated clinical outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

178,927 encounters by 139,632 adults at 5 US emergency departments (EDs) between July 1, 2017, and December 31, 2022.

PREDICTORS

CA-AKI identified using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine (Scr)-based criteria.

OUTCOMES

For encounters resulting in hospitalization, the in-hospital trajectory of AKI severity, dialysis initiation, intensive care unit (ICU) admission, and death. For all encounters, occurrence over 180 days of hospitalization, ICU admission, new or progressive chronic kidney disease, dialysis initiation, and death.

ANALYTICAL APPROACH

Multivariable logistic regression analysis to test the association between CA-AKI and measured outcomes.

RESULTS

For all encounters, 10.4% of patients met the criteria for any stage of AKI on arrival to the ED. 16.6% of patients admitted to the hospital from the ED had CA-AKI on arrival to the ED. The likelihood of AKI recovery was inversely related to CA-AKI stage on arrival to the ED. Among encounters for hospitalized patients, CA-AKI was associated with in-hospital dialysis initiation (OR, 6.2; 95% CI, 5.1-7.5), ICU admission (OR, 1.9; 95% CI, 1.7-2.0), and death (OR, 2.2; 95% CI, 2.0-2.5) compared with patients without CA-AKI. Among all encounters, CA-AKI was associated with new or progressive chronic kidney disease (OR, 6.0; 95% CI, 5.6-6.4), dialysis initiation (OR, 5.1; 95% CI, 4.5-5.7), subsequent hospitalization (OR, 1.1; 95% CI, 1.1-1.2) including ICU admission (OR, 1.2; 95% CI, 1.1-1.4), and death (OR, 1.6; 95% CI, 1.5-1.7) during the subsequent 180 days.

LIMITATIONS

Residual confounding. Study implemented at a single university-based health system. Potential selection bias related to exclusion of patients without an available baseline Scr measurement. Potential ascertainment bias related to limited repeat Scr data during follow-up after an ED visit.

CONCLUSIONS

CA-AKI is a common and important entity that is associated with serious adverse clinical consequences during the 6-month period after diagnosis.

PLAIN-LANGUAGE SUMMARY

Acute kidney injury (AKI) is a condition characterized by a rapid decline in kidney function. There are many causes of AKI, but few studies have examined how often AKI is already present when patients first arrive to an emergency department seeking medical attention for any reason. We analyzed approximately 175,000 visits to Johns Hopkins emergency departments and found that AKI is common on presentation to the emergency department and that patients with AKI have increased risks of hospitalization, intensive care unit admission, development of chronic kidney disease, requirement of dialysis, and death in the first 6 months after diagnosis. AKI is an important condition for health care professionals to recognize and is associated with serious adverse outcomes.

The role of Testis-Specific Protein Y-encoded-Like 2 in kidney injury

Renal ischemia-reperfusion injury (IRI) is a major cause of acute kidney injury (AKI). Recent findings suggest that Testis-Specific Protein Y-encoded-Like 2 (TSPYL2) plays a fibrogenic role in diabetes-associated renal injury. However, the role of TSPYL2 in IRI-induced kidney damage is not entirely clear. In this study, we found that the expression of TSPYL2 was upregulated in a mouse model of AKI and in the hypoxia/reoxygenation (H/R) cell model. Knockdown of TSPYL2 attenuated kidney injury after IRI. More specifically, the knockdown of TSPYL2 or aminocarboxymuconate-semialdehyde decarboxylase (ACMSD) alleviated renal IRI-induced mitochondrial dysfunction and oxidative stress in vitro and in vivo. Further investigation showed that TSPYL2 regulated SREBP-2 acetylation by inhibiting SIRT1 and promoting p300 activity, thereby promoting the transcriptional activity of ACMSD. In conclusion, TSPYL2 was identified as a pivotal regulator of IRI-induced kidney damage by activating ACMSD, which may lead to NAD+ content and the damaging response in the kidney.

Efficacy and safety of Yiqi Peiyuan granules for improving the short-term prognosis of patients with acute kidney injury: A multicenter, double-blind, placebo-controlled, randomized trial

BACKGROUND

Yiqi Peiyuan (YQPY) prescription, a composite prescription of traditional Chinese medicine, has been used to prevent or delay the continued deterioration of renal function after acute kidney injury (AKI) in some institutions and has shown considerable efficacy.

OBJECTIVE

This is the first randomized controlled trial to assess efficacy and safety of YQPY for improving short-term prognosis in adult patients with AKI.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This is a prospective, double-blind, multicenter, randomized, and placebo-controlled clinical trial. A total of 144 enrolled participants were randomly allocated to two groups according to a randomization schedule. Participants, caregivers and investigators assessing the outcomes were blinded to group assignment. Patients in the YQPY group received 36 g YQPY granules twice a day for 28 days. Patients in the placebo group received a placebo in the same dose as the YQPY granules.

MAIN OUTCOME MEASURES

The primary outcome was the change in the estimated glomerular filtration rate (eGFR) between baseline and after 4 and 24 weeks of treatment. The secondary outcomes were the change of serum creatinine (Scr) level between baseline and after treatment, and the incidence of endpoint events, defined as eGFR increasing by more than 25% above baseline, eGFR >75 mL/min per 1.73 m2 or the composite endpoint, which was defined as the sum of patients meeting either of the above criteria.

RESULTS

Data from a total of 114 patients (59 in the YQPY group and 55 in the control group) were analyzed. The mean changes in eGFR and Scr in weeks 4 and 24 had no difference between the two groups. In further subgroup analysis (22 in the YQPY group and 31 in the control group), the mean change in eGFR after treatment for 4 weeks was 27.39 mL/min per 1.73 m2 in the YQPY group and 5.78 mL/min per 1.73 m2 in the placebo group, and the mean difference between groups was 21.61 mL/min per 1.73 m2 (P < 0.001). Thirteen (59.1%) patients in the YQPY group and 5 (16.1%) in the placebo group reached the composite endpoints (P = 0.002). During the intervention, 2 and 4 severe adverse events were reported in the YQPY and placebo groups, respectively.

CONCLUSION

The YQPY granules can effectively improve the renal function of patients 4 weeks after the onset of AKI, indicating that it has good efficacy for improving short-term renal outcomes in patients with AKI. The YQPY granules may be a promising therapy for adults with AKI.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100051723. Please cite this article as: Wu JJ, Zhang TY, Qi YH, Zhu MY, Fang Y, Qi CJ, Cao LO, Lu JF, Lu BH, Tang LM, Shen JX, Mou S. Efficacy and safety of Yiqi Peiyuan granules for improving the short-term prognosis of patients with acute kidney injury: a multicenter, double-blind, placebo-controlled, randomized trial. J Integr Med. 2024; 22(3): 279-285.

Development and validation of a medication-based risk prediction model for acute kidney injury in older outpatients

BACKGROUND

Older adults are at an increased risk of acute kidney injury (AKI), particularly in community settings, often due to medications. Effective prevention hinges on identifying high-risk patients, yet existing models for predicting AKI risk in older outpatients are scarce, particularly those incorporating medication variables. We aimed to develop an AKI risk prediction model that included medication-related variables for older outpatients.

METHODS

We constructed a cohort of 2,272,257 outpatients aged ≥65 years using a national claims database. This cohort was split into a development (70%) and validation (30%) groups. Our primary goal was to identify newly diagnosed AKI within one month of cohort entry in an outpatient context. We screened 170 variables and developed a risk prediction model using logistic regression.

RESULTS

The final model integrated 12 variables: 2 demographic, 4 comorbid, and 6 medication-related. It showed good performance with acceptable calibration. In the validation cohort, the area under the receiver operating characteristic curve value was 0.720 (95% confidence interval, 0.692-0.748). Sensitivity and specificity were 69.9% and 61.9%, respectively. Notably, the model identified high-risk patients as having a 27-fold increased AKI risk compared with low-risk individuals.

CONCLUSION

We have developed a new AKI risk prediction model for older outpatients, incorporating critical medication-related variables with good discrimination. This tool may be useful in identifying and targeting patients who may require interventions to prevent AKI in an outpatient setting.

Recovery Dynamics and Prognosis After Dialysis for Acute Kidney Injury

Importance

The interplay among baseline kidney function, severity of acute kidney disease (AKD), and post-AKD kidney function has significant associations with patient outcomes. However, a comprehensive understanding of how these factors are collectively associated with mortality, major adverse cardiac events (MACEs), and end-stage kidney disease (ESKD) in patients with dialysis-requiring acute kidney injury (AKI-D) is yet to be fully explored.

Objective

To investigate the associations of baseline kidney function, AKD severity, and post-AKD kidney function with mortality, MACEs, and ESKD in patients with AKI-D.

Design, Setting, and Participants

This nationwide, population-based cohort study of patients with AKI-D was conducted between January 1, 2015, and December 31, 2018, using data from various health care settings included in the Taiwan nationwide population-based cohort database. Data analysis was conducted from April 28, 2022, to June 30, 2023.

Exposure

Exposure to severe AKI and baseline and post-AKD kidney function.

Main Outcomes and Measures

The primary outcomes were all-cause mortality and incident MACEs, and secondary outcomes were risks of permanent dialysis and readmission.

Results

A total of 6703 of 22 232 patients (mean [SD] age, 68.0 [14.7] years; 3846 [57.4%] male) with AKI-D with post-AKD kidney function follow-up and AKD stage data were enrolled. During a mean (SD) 1.2 (0.9) years of follow-up, the all-cause mortality rate was 28.3% (n = 1899), while the incidence rates of MACEs and ESKD were 11.1% (n = 746) and 16.7% (n = 1119), respectively. After adjusting for known covariates, both post-AKD kidney function and baseline kidney function, but not AKD severity, were independently associated with all-cause mortality, MACEs, ESKD, and readmission. Moreover, worse post-AKD kidney function correlated with progressive and significant increases in the risk of adverse outcomes.

Conclusions and Relevance

In this cohort study of patients with AKI-D, more than one-quarter of patients died after 1.2 years of follow-up. Baseline and post-AKD kidney functions serve as important factors associated with the long-term prognosis of patients with AKI-D. Therefore, concerted efforts to understand the transition from post-AKD to chronic kidney disease are crucial.

Association of Dip in eGFR With Clinical Outcomes in Unilateral Primary Aldosteronism Patients After Adrenalectomy

CONTEXT

Primary aldosteronism (PA) leads to kidney function deterioration after treatment, but the effects of the estimated glomerular filtration rate (eGFR) dip following adrenalectomy and its long-term implications are unclear.

OBJECTIVE

This study aims to examine eGFR dip in patients with unilateral PA (uPA) after adrenalectomy and clarify their long-term prognosis.

METHODS

This multicenter prospective population-based cohort study, enrolled patients with uPA who underwent adrenalectomy. Patients were divided into 4 groups based on their eGFR dip ratio. Outcomes investigated included mortality, cardiovascular composite events, and major adverse kidney events (MAKEs).

RESULTS

Among 445 enrolled patients, those with an eGFR dip ratio worse than -30% (n = 74, 16.6%) were older, had higher blood pressure, higher aldosterone concentration, and lower serum potassium levels. During 5.0 ± 3.6 years of follow-up, 2.9% died, 14.6% had cardiovascular composite events, and 17.3% had MAKEs. The group with eGFR dip worse than -30% had a higher risk of MAKEs (P < .001), but no significant differences in mortality (P = .295) or new-onset cardiovascular composite outcomes (P = .373) were found. Multivariate analysis revealed that patients with an eGFR dip ratio worse than -30% were significantly associated with older age (odds ratio [OR], 1.04), preoperative eGFR (OR, 1.02), hypokalemia (OR, 0.45), preoperative systolic blood pressure (OR, 1.03), and plasma aldosterone concentration (OR, 0.99).

CONCLUSION

Within 5 years post adrenalectomy, 17.3% of patients had reduced kidney function. Notably, individuals with an eGFR dip ratio worse than -30% faced higher MAKE risks, underscoring the need to monitor kidney function in PA patients after surgery.

Incidence, Risk Factors, and Outcomes Associated With Recurrent Neonatal Acute Kidney Injury in the AWAKEN Study

Importance

The incidence and associated outcomes of recurrent acute kidney injury (rAKI) in neonates remain largely unknown.

Objective

To determine the incidence, risk factors, and clinical outcomes associated with rAKI in critically ill neonates.

Design, Setting, and Participants

This cohort study was a secondary analysis of the multicenter, international Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates retrospective study. Comparisons were made among neonates with no AKI, a single AKI episode (sAKI), and rAKI. All neonates younger than 14 days who were admitted between January 1 and March 31, 2014, to 24 participating level II to IV neonatal intensive care units and received intravenous fluids for at least 48 hours were considered for inclusion. Neonates with congenital heart disease requiring surgery within the first week of life, lethal chromosomal anomalies, death within 48 hours of admission, or severe congenital kidney abnormalities were excluded. Data were analyzed from May 23, 2022, to December 8, 2023.

Exposure

Recurrent AKI using the neonatal Kidney Disease: Improving Global Outcomes criteria. Determination of each rAKI required a complete return to the baseline serum creatinine level that defined the prior AKI episode.

Main Outcomes and Measures

Incidence and risk factors of rAKI and associations of rAKI with length of stay (LOS; ie, birth to hospital discharge) and mortality.

Results

The study cohort (n = 2162) included 1233 male neonates (57.0%). Gestational age distribution was less than 29 weeks for 276 neonates (12.8%), 29 to less than 36 weeks for 958 (44.3%), and 36 weeks or older for 928 (42.9%). Of 605 neonates with AKI, 133 (22.0%) developed rAKI with risk factors including younger gestational age, lower birthweight, and higher stage of initial AKI. Infants with rAKI experienced longer median LOS (no AKI, 17 [IQR, 8-34] days; sAKI, 18 [IQR, 9-45] days; rAKI, 60 [IQR, 25-109] days; P < .001). Time-varying Cox proportional hazards regression models suggest rAKI is independently associated with a lower hazard of discharge (adjusted hazard ratio, 0.7 [95% CI, 0.6-0.9]; P = .01) when compared with sAKI, but mortality did not differ between groups (adjusted hazard ratio, 1.4 [95% CI, 0.6-3.0]; P = .44).

Conclusions and Relevance

In this cohort study, neonatal rAKI was independently associated with longer LOS when compared with sAKI, suggesting that rAKI in neonates may be an important clinical distinction warranting further study and careful monitoring after an initial AKI episode.

Processes of Care After Hospital Discharge for Survivors of Acute Kidney Injury: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Survivors of acute kidney injury (AKI) are at high risk of adverse outcomes. Monitoring of kidney function, screening for proteinuria, use of statins and renin-angiotensin-aldosterone system (RAAS) inhibitors, and nephrology follow-up among survivors have not been fully characterized. We examined these processes of care after discharge in survivors of hospitalized AKI.

STUDY DESIGN

Population-based retrospective cohort study.

SETTING & PARTICIPANTS

Adults in Alberta, Canada, admitted to the hospital between 2009 and 2017, then followed from their discharge date until 2019 for a median follow-up of 2.7 years.

EXPOSURE

Hospital-acquired AKI diagnostically conforming to Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria for stage 2 or stage 3 disease, or the need for acute dialysis.

OUTCOME

Outcomes after hospital discharge included the proportion of participants who had evaluation of kidney function, were seen by a specialist or general practitioner, and received postdischarge prescriptions for recommended medications for chronic kidney disease (CKD).

ANALYTICAL APPROACH

Cumulative incidence curves to characterize the proportion of participants who received each process of care outcome within the first 90 days and subsequent 1-year follow-up period after hospital discharge. To avoid risks associated with multiple hypothesis testing, differences were not statistically compared across groups.

RESULTS

The cohort (n=23,921) included 50.2% men (n=12,015) with a median age of 68.1 [IQR, 56.9-78.8] years. Within 90 days after discharge, 21.2% and 8.6% of patients with and without pre-existing CKD, respectively, were seen by a nephrologist; 60.1% of AKI survivors had at least 1 serum creatinine measured, but only 25.5% had an assessment for albuminuria within 90 days after discharge; 52.7% of AKI survivors with pre-existing CKD, and 51.6% with de novo CKD were prescribed a RAAS inhibitor within 4-15 months after discharge.

LIMITATIONS

Retrospective data were collected as part of routine clinical care.

CONCLUSIONS

The proportion of patients receiving optimal care after an episode of AKI in Alberta was low and may represent a target for improving long-term outcomes for this population.

PLAIN-LANGUAGE SUMMARY

A study in Alberta, Canada, examined the care received by patients with acute kidney disease (AKI) during hospitalization and after discharge between 2007 and 2019. The results showed that a low proportion of patients with moderate to severe AKI were seen by a kidney specialist during hospitalization or within 90 days after discharge. Fewer than 25% of AKI patients had their kidney function monitored with both blood and urine tests within 90 days of discharge. Additionally, about half of AKI survivors with chronic kidney disease (CKD) were prescribed guideline recommended medications for CKD within 15 months after discharge. There is potential to improve health care delivery to these patients both in hospital and after hospital discharge.

Optimum Care of AKI Survivors Not Requiring Dialysis after Discharge: An AKINow Recovery Workgroup Report

AKI survivors experience gaps in care that contribute to worse outcomes, experience, and cost.Challenges to optimal care include issues with information transfer, education, collaborative care, and use of digital health tools.Research is needed to study these challenges and inform optimal use of diagnostic and therapeutic interventions to promote recovery AKI affects one in five hospitalized patients and is associated with poor short-term and long-term clinical and patient-centered outcomes. Among those who survive to discharge, significant gaps in documentation, education, communication, and follow-up have been observed. The American Society of Nephrology established the AKINow taskforce to address these gaps and improve AKI care. The AKINow Recovery workgroup convened two focus groups, one each focused on dialysis-independent and dialysis-requiring AKI, to summarize the key considerations, challenges, and opportunities in the care of AKI survivors. This article highlights the discussion surrounding care of AKI survivors discharged without the need for dialysis. On May 3, 2022, 48 patients and multidisciplinary clinicians from diverse settings were gathered virtually. The agenda included a patient testimonial, plenary sessions, facilitated small group discussions, and debriefing. Core challenges and opportunities for AKI care identified were in the domains of transitions of care, education, collaborative care delivery, diagnostic and therapeutic interventions, and digital health applications. Integrated multispecialty care delivery was identified as one of the greatest challenges to AKI survivor care. Adequate templates for communication and documentation; education of patients, care partners, and clinicians about AKI; and a well-coordinated multidisciplinary posthospital follow-up plan form the basis for a successful care transition at hospital discharge. The AKINow Recovery workgroup concluded that advancements in evidence-based, patient-centered care of AKI survivors are needed to improve health outcomes, care quality, and patient and provider experience. Tools are being developed by the AKINow Recovery workgroup for use at the hospital discharge to facilitate care continuity.

A Systematic Bibliometric Analysis of High-Impact Articles in Critical Care Nephrology

INTRODUCTION

Critical care nephrology is a subspecialty that merges critical care and nephrology in response to shared pathobiology, clinical care, and technological innovations. To date, there has been no description of the highest impact articles. Accordingly, we systematically identified high impact articles in critical care nephrology.

METHODS

This was a bibliometric analysis. The search was developed by a research librarian. Web of Science was searched for articles published between January 1, 2000 and December 31, 2020. Articles required a minimum of 30 citations, publication in English language, and reporting of primary (or secondary) original data. Articles were screened by two reviewers for eligibility and further adjudicated by three experts. The "Top 100" articles were hierarchically ranked by adjudication, citations in the 2 years following publication and journal impact factor (IF). For each article, we extracted detailed bibliometric data. Risk of bias was assessed for randomized trials by the Cochrane Risk of Bias tool. Analyses were descriptive.

RESULTS

The search yielded 2,805 articles. Following initial screening, 307 articles were selected for full review and adjudication. The Top 100 articles were published across 20 journals (median [IQR] IF 10.6 [8.9-56.3]), 38% were published in the 5 years ending in 2020 and 62% were open access. The agreement between adjudicators was excellent (intraclass correlation, 0.96; 95% CI, 0.84-0.99). Of the Top 100, 44% were randomized trials, 35% were observational, 14% were systematic reviews, 6% were nonrandomized interventional studies and one article was a consensus document. The risk of bias among randomized trials was low. Common subgroup themes were RRT (42%), AKI (30%), fluids/resuscitation (14%), pediatrics (10%), interventions (8%), and perioperative care (6%). The citations for the Top 100 articles were 175 (95-393) and 9 were cited >1,000 times.

CONCLUSION

Critical care nephrology has matured as an important subspecialty of critical care and nephrology. These high impact papers have focused largely on original studies, mostly clinical trials, within a few core themes. This list can be leveraged for curricula development, to stimulate research, and for quality assurance.

CaMKII may regulate renal tubular epithelial cell apoptosis through YAP/NFAT2 in acute kidney injury mice

AIM

Renal tubular epithelial cell (RTEC) apoptosis is important in acute kidney injury (AKI). Calcium/calmodulin-dependent protein kinase II (CaMKII) plays an important role in cell apoptosis, but its potential role in AKI remains unknown.

METHODS

Using co-immunoprecipitation, immunofluorescence, immunohistochemistry, western blotting, flow cytometry, and cell transfection, this study aimed to verify whether CaMKII is involved in RTEC apoptosis and to explore the underlying mechanism.

RESULTS

We found that CaMKII was involved in RTEC apoptosis. In adriamycin-induced AKI mice, serum creatinine levels, cell apoptosis, CaMKII activity, and nuclear factor of activated T cells 2 (NFAT2) levels increased, whereas nuclear Yes-associated protein (YAP) expression decreased; inhibition of CaMKII activity reversed these changes. Phosphorylated CaMKII could bind to phosphorylated YAP in the cytoplasm and block it from entering the nucleus, thereby failing to inhibit NFAT2-mediated cell apoptosis. Sequestrated phosphorylated YAP in the RTEC cytoplasm was finally degraded by ubiquitination.

CONCLUSION

CaMKII may regulate RTEC apoptosis through YAP/NFAT2 in AKI mice. CaMKII may be a potent molecular target for AKI treatment.

Posthospital Multidisciplinary Care for AKI Survivors: A Feasibility Pilot

Rationale & Objective

Innovative models are needed to address significant gaps in kidney care follow-up for acute kidney injury (AKI) survivors.

Study Design

This quasi-experimental pilot study reports the feasibility of the AKI in Care Transitions (ACT) program, a multidisciplinary approach to AKI survivor care based in the primary care setting.

Setting & Participants

The study included consenting adults with stage 3 AKI discharged home without dialysis.

Interventions

The ACT intervention included predischarge education from nurses and coordinated postdischarge follow-up with a primary care provider and pharmacist within 14 days. ACT was implemented in phases (Usual Care, Education, ACT).

Outcomes

The primary outcome was feasibility. Secondary outcomes included process and clinical outcomes.

Results

In total, 46 of 110 eligible adults were enrolled. Education occurred in 18/18 and 14/15 participants in the Education and ACT groups, respectively. 30-day urine protein evaluation occurred in 15%, 28%, and 87% of the Usual Care, Education, and ACT groups, respectively (P < 0.001). Cumulative incidence of provider (primary care or nephrologist) and laboratory follow-up at 14 and 30 days was different across groups (14 days: Usual care 0%, Education 11%, ACT 73% [P < 0.01]; 30 days: 0%, 22%, and 73% [P < 0.01]). 30-day readmission rates were 23%, 44%, and 13% in the Usual Care, Education, and ACT groups, respectively (P = 0.13).

Limitations

Patients were not randomly assigned to treatment groups. The sample size limited the ability to detect some differences or perform multivariable analysis.

Conclusions

This study demonstrated the feasibility of multidisciplinary AKI survivor follow-up beginning in primary care. We observed a higher cumulative incidence of laboratory and provider follow-up in ACT participants.

Trial Registration

ClinicalTrials.gov (NCT04505891).

Plain-Language Summary

Abrupt loss of kidney function in hospitalized patients, acute kidney injury (AKI), increases the chances of long-term kidney disease and a worse health care experience for patients. One out of 3 people who experience AKI do not get the follow-up kidney care they need. We performed a pilot study to test whether a program that facilitates structured AKI follow-up in primary care called the AKI in Care Transitions (ACT) program was possible. ACT brings together the unique expertise of nurses, doctors, and pharmacists to look at the patient's kidney health plan from all angles. The study found that the ACT program was possible and led to more complete kidney care follow-up after discharge than the normal approach to care.

Digital health and acute kidney injury: consensus report of the 27th Acute Disease Quality Initiative workgroup

Acute kidney injury (AKI), which is a common complication of acute illnesses, affects the health of individuals in community, acute care and post-acute care settings. Although the recognition, prevention and management of AKI has advanced over the past decades, its incidence and related morbidity, mortality and health care burden remain overwhelming. The rapid growth of digital technologies has provided a new platform to improve patient care, and reports show demonstrable benefits in care processes and, in some instances, in patient outcomes. However, despite great progress, the potential benefits of using digital technology to manage AKI has not yet been fully explored or implemented in clinical practice. Digital health studies in AKI have shown variable evidence of benefits, and the digital divide means that access to digital technologies is not equitable. Upstream research and development costs, limited stakeholder participation and acceptance, and poor scalability of digital health solutions have hindered their widespread implementation and use. Here, we provide recommendations from the Acute Disease Quality Initiative consensus meeting, which involved experts in adult and paediatric nephrology, critical care, pharmacy and data science, at which the use of digital health for risk prediction, prevention, identification and management of AKI and its consequences was discussed.

Digital health utilities in acute kidney injury management

PURPOSE OF REVIEW

Acute kidney injury (AKI) is a highly prevalent clinical syndrome that substantially impacts patient outcomes. It is accepted by the clinical communities that the management of AKI is time-sensitive. Unfortunately, despite growing proof of its preventability, AKI management remains suboptimal in community, acute care, and postacute care settings. Digital health solutions comprise various tools and models to improve care processes and patient outcomes in multiple medical fields. AKI development, progression, recovery, or lack thereof, offers tremendous opportunities for developing, validating, and implementing digital health solutions in multiple settings. This article will review the definitions and components of digital health, the characteristics of AKI that allow digital health solutions to be considered, and the opportunities and threats in implementing these solutions.

RECENT FINDINGS

Over the past two decades, the academic output related to the use of digital health solutions in AKI has exponentially grown. While this indicates the growing interest in the topic, most topics are primarily related to clinical decision support by detecting AKI within hospitals or using artificial intelligence or machine learning technologies to predict AKI within acute care settings. However, recently, projects to assess the impact of digital health solutions in more complex scenarios, for example, managing nephrotoxins among adults of pediatric patients who already have AKI, is increasing. Depending on the type of patients, chosen digital health solution intervention, comparator groups, and selected outcomes, some of these studies showed benefits, while some did not indicate additional gain in care processes or clinical outcomes.

SUMMARY

Careful needs assessment, selection of the correct digital health solution, and appropriate clinical validation of the benefits while avoiding additional health disparities are moral, professional, and ethical obligations for all individuals using these healthcare tools, including clinicians, data scientists, and administrators.

Utilising routine clinical laboratory data to support quality improvement in health care: Application of a national acute kidney injury alert system as a proof of concept

BACKGROUND

Acute kidney injury (AKI) is a global health issue known to cause avoidable harm and death. Improvement in its prevention and management is therefore considered an important goal for the health-care sector. The work here aimed to develop a tool which could be used to robustly and reliably measure, monitor, and compare the effectiveness of health-care interventions related to AKI across the Welsh NHS, a mechanism which did not exist previously.

METHODS

Using serum creatinine (SCr) as a biomarker for AKI and a validated national data-set collected from the all Wales Laboratory Information Management System, work involved applying Donabedian's framework to develop indicators with which to measure outcomes related to AKI, and exploring the potential of statistical process control (SPC) techniques for analysing data on these indicators.

RESULTS

Rate of AKI incidence and 30-day AKI-associated mortality are proposed as valid, feasible indicators with which to measure the effectiveness of health-care interventions related to AKI. The control chart, funnel plot, and Pareto chart are proposed as appropriate, robust SPC techniques to analyse and visualise variation in AKI-related outcomes.

CONCLUSIONS

This work demonstrates that routinely collected large SCr data offer a significant opportunity to monitor and therefore inform improvement in patient outcomes related to AKI. Moreover, while this work concerns utilisation of SCr data for improvement in AKI strategies, it is a proof of concept which could be replicated for other routinely collected clinical laboratory data, to improve the prevention and/or management of the conditions to which they relate.

Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions

In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.

Probiotics in septic acute kidney injury, a double blind, randomized control trial

INTRODUCTION

During acute kidney injury (AKI) due to sepsis, the intestinal microbiota changes to dysbiosis, which affects the kidney function recovery (KFR) and amplifies the injury. Therefore, the administration of probiotics could improve dysbiosis and thereby increase the probability of KFR.

METHODS

In this double-blind clinical trial, patients with AKI associated with sepsis were randomized (1:1) to receive probiotics or placebo for 7 consecutive days, with the objectives of evaluate the effect on KFR, mortality, kidney replacement therapy (KRT), urea, urine volume, serum electrolytes and adverse events at day 7.

RESULTS

From February 2019 to March 2022, a total of 92 patients were randomized, 48 to the Probiotic and 44 to Placebo group. When comparing with placebo, those in the Probiotics did not observe a higher KFR (HR 0.93, 0.52-1.68, p = 0.81), nor was there a benefit in mortality at 6 months (95% CI 0.32-1.04, p = 0.06). With probiotics, urea values decreased significantly, an event not observed with placebo (from 154 to 80 mg/dl, p = 0.04 and from 130 to 109 mg/dl, p = 0.09, respectively). Urinary volume, need for KRT, electrolyte abnormalities, and adverse events were similar between groups. (ClinicalTrial.gov NCT03877081) (registered 03/15/2019).

CONCLUSION

In AKI related to sepsis, probiotics for 7 consecutive days did not increase the probability of KFR, nor did other variables related to clinical improvement, although they were safe.

Early recognition and prevention of acute kidney injury in hospitalised children

Acute kidney injury is common in hospitalised children and is associated with poor patient outcomes. Once acute kidney injury occurs, effective therapies to improve patient outcomes or kidney recovery are scarce. Early identification of children at risk of acute kidney injury or at an early injury stage is essential to prevent progression and mitigate complications. Paediatric acute kidney injury is under-recognised by clinicians, which is a barrier to optimisation of inpatient care and follow-up. Acute kidney injury definitions rely on functional biomarkers (ie, serum creatinine and urine output) that are inadequate, since they do not account for biological variability, analytical issues, or physiological responses to volume depletion. Improved predictive tools and diagnostic biomarkers of kidney injury are needed for earlier detection. Novel strategies, including biomarker-guided care algorithms, machine-learning methods, and electronic alerts tied to clinical decision support tools, could improve paediatric acute kidney injury care. Clinical prediction models should be studied in different paediatric populations and acute kidney injury phenotypes. Research is needed to develop and test prevention strategies for acute kidney injury in hospitalised children, including care bundles and therapeutics.

Impact of Clinical Pharmacy Surveillance on Pharmacy Services: A Quality Improvement Project

GOAL

The purpose of this quality improvement project was to retrospectively evaluate pharmacist time to clinical surveillance alert intervention before and after implementing a pharmacy-directed alert priority category across a large for-profit United States health system with well-established clinical pharmacy surveillance software integrated into the clinical pharmacy workflow. The findings contributed to a financial evaluation of pharmacist productivity compared with drug spend for pharmacy-directed interventions that included intravenous (IV)-to-oral-conversion and renal dosing opportunities.

METHODS

A retrospective quality improvement pre-/postanalysis of deidentified, prepopulated clinical surveillance alert data for the preimplementation period of January 1, 2021, through September 30, 2021, was compared with that for the postimplementation period of November 1, 2021, to January 31, 2022, for 169 hospitals. Clinical pharmacist workflow was mapped pre- and postimplementation. The average time to alert intervention was calculated using the mean time in minutes between the alert firing within the software and when the pharmacist reviewed the alert, grouped by hospital, alert status, and priority category. Medications converted from IV to oral were assessed using the clinical surveillance software IV-to-oral calculator. Postimplementation renal dose cost savings were modeled using pharmacist-completed alerts by rule name that indicated a possible dose decrease based on the patient's renal function and current medication.

PRINCIPAL FINDINGS

Time to alert intervention for all completed pharmacist interventions was reduced for high-priority alerts by 32.6 min (p < .001) and routine-priority alerts by 65.1 min (p = .147). Alerts that moved to the pharmacy-directed alert priority category resulted in a reduced time to alert intervention of 38.7 min (p = .003). Normalized average wholesale price (AWP) cost savings from IV-to-oral conversion within 3 days of conversion eligibility were $1,693,600 in the preimplementation period and $1,867,400 in the postimplementation period, a $173,700 increase in cost savings. A total of 7,972 completed postimplementation renal dose adjustments resulted in a modeled AWP normalized cost savings of $1,076,700.

PRACTICAL APPLICATIONS

Results indicated that optimizing clinical surveillance software alerts was effective and increased pharmacist productivity. Specifically, creating a pharmacy-directed alert category that pharmacists were able to complete by hospital policy or protocol improved workflow efficiency and increased IV-to-oral medication conversion cost savings. Further study is needed to validate the renal dose-modeled cost savings and address the financial benefits of quality measures to prevent acute kidney injury.

Development and Implementation of an Acute Kidney Injury Remote Patient Monitoring Program: Research Letter

Acute kidney injury (AKI) survivors have a dynamic posthospital course which warrants close monitoring. Remote patient monitoring (RPM) could be used to improve quality and efficiency of AKI survivor care.

Objective

The objective of this report was to describe the development and preliminary feasibility of an AKI RPM program launched in October 2021.

Setting

Academic medical center.

Patients

Patients enrolled in the AKI RPM program were those who experienced AKI during a hospitalization and underwent nephrology consultation.

Measurements/Methods

At enrollment, patients were provided with home monitoring technology and underwent weekly laboratory assessments. Nurses evaluated the data daily and adhered to prespecified protocols for management and escalation of care if needed.

Results

Twenty patients were enrolled in AKI RPM in the first 5 months. Median duration of program participation was 36 (31, 40) days. Eight patients (40%) experienced an unplanned readmission, or an emergency department visit, half (N = 4) of which were attributed to AKI and related circumstances. Of the 9 postgraduation survey respondents, all were satisfied with the RPM program and 89% would recommend RPM to other patients with similar health conditions.

Limitations

Acute kidney injury RPM was made possible by the existing infrastructure in our integrated health system and the robust resources available in the Mayo Clinic Center for Digital Health. Such infrastructure may not be universally available which could limit scale and generalizability of such a program.

Conclusions

Remote patient monitoring can offer a unique opportunity to bridge the care transition from hospital to home and increase access to quality care for the AKI survivors.

Implementation Strategies for Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) to Prevent Neonatal Medication-Induced Kidney Injury

Acute kidney injury (AKI) is a common complication among patients admitted to the neonatal intensive care unit. Nephrotoxic medications (NTMs) are known to increase the incidence of AKI, but the use of these -medications is often unavoidable. Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) is a -quality improvement (QI) project that may be implemented at individual institutions and aims to systematically identify AKI in neonates and infants receiving NTMs. The purpose of this review is to describe nephrotoxic AKI in the neonatal population, introduce the Baby NINJA QI project and its potential to reduce neonatal AKI, and outline strategies for effective implementation of Baby NINJA.