AKI Transition of Care

Abstract

SummaryThe incidence rate of AKI is increasing across the spectrum of hospitalized children and adults. Given the increased morbidity and mortality associated with AKI, significant research effort has been appropriately focused on standardizing AKI definitions, identifying risk factors, and discovering and validating novel, earlier structural biomarkers of kidney injury. In addition, a growing body of evidence demonstrates that AKI is a risk factor for the future development or accelerated progression of CKD. Unfortunately, prospective observational studies have not consistently followed survivors of episodes of AKI for longitudinal outcomes after hospital discharge, which could lead to ascertainment bias in terms of over-or underestimation of CKD development. Furthermore, data show that clinical follow-up of AKI survivors is low. This lack of systematic study and clinical follow-up represents a potential missed opportunity to prevent chronic disease after an acute illness and improve outcomes. Therefore, prospective study of transitions of care after episodes of AKI is needed to identify which patients are at risk for CKD development and to optimally target therapeutic interventions.

Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup

“…The American Society of Nephrology AKI Advisory Group has highlighted the transition of care as a potential opportunity to reduce the long-term impact of AKI 88 , and hence, AKD. However, a paucity of data exists to indicate which interventions can reduce morbidity and mortality in AKI/AKD survivors.…”

“…Improving patient awareness of AKD and conditions or symptoms that might require evaluation of kidney function (such as oedema and volume-depleting illness), documenting that AKI and/or AKD has occurred particularly if moderate to severe or persistent, and processes of care including medication reconciliation to facilitate appropriate dosing and nephrotoxin avoidance, might help to alert future care providers to the risk of AKD, reduce the risk of adverse events including recurrent AKI, and potentially improve the probability of recovery 88,[105][106][107] …”

“…Combining nephrotoxins can result in pharmacodynamic drug interactions, such as the 'triple whammy' of NSAIDs, diuretics and ACE inhibitors or ARBs 125 . In the non-ICU setting, escalating the burden of nephrotoxic medications from two to three medications more than doubles the risk of developing AKI, and 25% of non-critically ill patients who receive three or more nephrotoxins develop AKI 88,144 . Pharmacokinetic drug interactions arising from the administration of some macrolide antibiotics (such as clarithromycin or erythromycin) together with a 3-hydroxy-3-methylglutaryl-coenzyme-A (HMG-CoA) reductase inhibitor (statin) result in a greater number of hospitalizations for AKI from rhabdomyolysis, than those arising from administration of azithromycin (a macrolide that does not powerfully inhibit cytochrome p450 enzyme CYP 3A4 and therefore impair statin clearance) 145 .…”

Epidemiology of acute kidney injury in critically ill children and young adults

“…Because children who survive acute kidney injury are at risk for chronic kidney disease, long-term follow-up of these survivors is warranted. 24,25 Although the daily prevalence of acute kidney injury increased from 14.5% on day 1 to 20.4% on day 7, approximately 75% of the increase occurred within 4 days after admission. This increase probably results from the earlier discharge of less severely ill patients who would be at lower risk for multiorgan failure and acute kidney injury.…”

Defining renal recovery: pitfalls to be avoided

“…This definition should facilitate the estimate of the exact burden of post-AKI non-recovery and the assessment of preventive measures of long-term renal sequelae. In clinical practice, such a definition should help to detect patients with persistent renal dysfunction who could benefit from referral to nephrologists [17,18]. …”