Acute kidney injury (AKI) is associated with higher hospital mortality. However, the relationship between geriatric AKI and in-hospital complications is unclear. We prospectively enrolled elderly patients (≥65 years) from general medical wards of National Taiwan University Hospital, part of whom presented AKI at admission. We recorded subsequent in-hospital complications, including catastrophic events, incident gastrointestinal bleeding, hospital-associated infections, and new-onset electrolyte imbalances. Regression analyses were utilized to assess the associations between in-hospital complications and the initial AKI severity. A total of 163 elderly were recruited, with 39% presenting AKI (stage 1: 52%, stage 2: 23%, stage 3: 25%). The incidence of any in-hospital complication was significantly higher in the AKI group than in the non-AKI group (91% vs. 68%, p < 0.01). Multiple regression analyses indicated that elderly patients presenting with AKI had significantly higher risk of developing any complication (Odds ratio [OR] = 3.51, p = 0.01) and new-onset electrolyte imbalance (OR = 7.1, p < 0.01), and a trend toward more hospital-associated infections (OR = 1.99, p = 0.08). The risk of developing complications increased with higher AKI stage. In summary, our results indicate that initial AKI at admission in geriatric patients significantly increased the risk of in-hospital complications.

The hospitalist system has higher efficiency than the internist-run general wards under the NHI system in terms of costs and length of hospitalization. It may serve as an alternative model to address rising admissions and staff shortages.

Polypharmacy is common in the elderly due to multimorbidity and interventions. However, the temporal association between polypharmacy and renal outcomes is rarely addressed and recognized. We investigated the association between cardiovascular (CV) polypharmacy and the risk of acute kidney injury (AKI) in elderly patients.We used the Taiwan National Health Insurance PharmaCloud system to investigate the relationship between cumulative CV medications in the 3 months before admission and risk of AKI in the elderly at their admission to general medical wards in a single center. Community-dwelling elderly patients (>60 years) were prospectively enrolled and classified according to the number of preadmission CV medications. CV polypharmacy was defined as use of 2 or more CV medications.We enrolled 152 patients, 48% with AKI (based upon Kidney Disease Improving Global Outcomes [KDIGO] classification) and 64% with CV polypharmacy. The incidence of AKI was higher in patients taking more CV medications (0 drugs: 33%; 1 drug: 50%; 2 drugs: 57%; 3 or more drugs: 60%; P = 0.05) before admission. Patients with higher KDIGO grades also took more preadmission CV medications (P = 0.04). Multiple regression analysis showed that patients who used 1 or more CV medications before admission had increased risk of AKI at admission (1 drug: odds ratio [OR] = 1.63, P = 0.2; 2 drugs: OR = 4.74, P = 0.03; 3 or more drugs: OR = 5.92, P = 0.02), and that CV polypharmacy is associated with higher risk of AKI (OR 2.58; P = 0.02). Each additional CV medication increased the risk for AKI by 30%.We found that elderly patients taking more CV medications are associated with risk of adverse renal events. Further study to evaluate whether interventions that reduce polypharmacy could reduce the incidence of geriatric AKI is urgently needed.

BackgroundThe postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because postdischarge care continuity is often interrupted after hospitalist care, close follow-up may decrease patient readmission. In this study, we aimed to investigate the impact of a quality improvement program, integrated postdischarge transitional care (PDTC), in Taiwan's hospitalist system.MethodsFrom December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan and later discharged alive to home care were included. Efforts to improve the quality of interventions in the PDTC program, including a disease-specific care plan, telephone monitoring, hotline counseling and referral to a hospitalist-run clinic, were implemented in the latter four months in the intervention group, while the control group was recruited during the first two months of the study period. The primary end point was unplanned readmission or death within 30 days after discharge.ResultsThere were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics at the time of admission and at discharge. In the intervention group, 18 patients with worsening disease-specific indicators recorded during telephone monitoring and 21 patients with new or worsening symptoms recorded during hotline counseling had higher rates of unplanned readmission than those without worsening disease-specific indicators (P = 0.031) and worsening symptoms (P = 0.019), respectively. Patients who received PDTC had lower rates of readmission and death than the control group within 30 days after discharge (15% vs. 25%; P = 0.021). Nonuse of a hospitalist-run clinic and presence of underlying malignancy were other independent risk factors for readmission and death within 30 days after discharge.ConclusionIntegrated PDTC using disease-specific care, telephone monitoring, hotline counseling and a hospitalist-run clinic can reduce rates of postdischarge readmission and death.