Acute kidney injury in primary care: where are we now and where are we going?

Abstract

INTRODUCTIONAcute kidney injury (AKI) is defined as 'a clinical and biochemical diagnosis reflecting abrupt kidney dysfunction'. 1 AKI is graded on a scale of 1-3 based on the size of the creatinine increase from baseline. Higher AKI scores are associated with higher mortality, longer length of stay, and less renal recovery. 2 AKI complicates almost one in five hospital admissions and is associated with a 20-33% mortality rate, increased length of hospital stay, and an estimated annual cost to the NHS in England of £1.02 billion. 3 Two-thirds of AKI cases identified in hospital start in the community. 2 NHS England and the UK Renal Association Renal Registry's Think Kidneys programme have supported changes and improvement in AKI identification, measurement, risk assessment, and education across UK health care including the implementation of a national electronic system that alerts clinicians to potential cases of AKI. 1 AKI IN THE COMMUNITYAround 60% of all patients with AKI identified in hospital have it when they reach hospital. 2 The mortality of these patients with community-acquired AKI detected in hospital (CAH-AKI) is 19.6% during hospitalisation, which increases to an alarming 45% 14 months post-discharge. 4 Although CAH-AKI has a lower mortality rate than hospital-acquired AKI, CAH-AKI represents a noteworthy risk factor for death.The incidence of community-acquired AKI detected in primary care (CAP-AKI) varies according to the use of different AKI definitions and different methodologies for acquiring a baseline creatinine. Sawhney et al 5 used the official NHS AKI algorithm and reported that 1.4% of 50 835 patients in a Scottish registry who also had a known creatinine within 12 months suffered CAP-AKI. They defined CAP-AKI as AKI detected in primary care but not admitted to hospital within the next 7 days. This study showed that patients with CAP-AKI were of similar age but suffered fewer comorbidities than patients with CAH-AKI. Reported mortality rates were 2.6% for CAP-AKI vs. 20.2% for CAH-AKI at 30 days that increased to 17% and 42.3% respectively at 1 year. Interestingly, in 30-day survivors adjusted 5-year mortality for CAP-AKI was not significantly different from CAH-AKI or hospital-acquired AKI.

The importance of acute kidney injury in suspected community acquired infection

“…A UK study has shown that the majority of patients who attend the ED have also consulted their primary care provider first [22]. However, in primary care there is often a lag time between decision to take blood tests (if such decision is made) and phlebotomy and between phlebotomy and the result being reviewed, usually by another clinician and this lag may have an effect on outcomes in infections associated AKI and sepsis [23]. Improvement in time to response to AKI alerts has been associated with decreased mortality in AKI 2&3 alerting in primary care [24] and prompt delivery of the sepsis bundle has been shown to improve outcomes.…”

Risk Factors for Community-Acquired Acute Kidney Injury in Medical Patients: A Nested Case-Control Study

“…Therefore, timely intervention with "sick day guidance" could be possible for patients using nephrotoxic drugs as it is a leading risk factor for CA-AKI. Thus, further work should be encouraged to generate evidence in this issue in which the patients are advised to avoid diuretics, non-steroidal antiinflammatory drugs, angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors during acute illness [22].…”

Monitoring of the Renal Function in the Nursing Practice

“…Due to overloaded primary care services, efforts are desirable for the development of risk stratification models and monitoring of the health users aiming at effective actions and better Quality of Life (QoL) [3].…”