Ambulatory Care after Acute Kidney Injury: An Opportunity to Improve Patient Outcomes

Abstract

Purpose of reviewAcute kidney injury (AKI) is an increasingly common problem among hospitalized patients. Patients who survive an AKI-associated hospitalization are at higher risk of de novo and worsening chronic kidney disease, end-stage kidney disease, cardiovascular disease, and death. For hospitalized patients with dialysis-requiring AKI, outpatient follow-up with a nephrologist within 90 days of hospital discharge has been associated with enhanced survival. However, most patients who survive an AKI episode do not receive any follow-up nephrology care. This narrative review describes the experience of two new clinical programs to care for AKI patients after hospital discharge: the Acute Kidney Injury Follow-up Clinic for adults (St. Michael’s Hospital and University Health Network, Toronto, Canada) and the AKI Survivor Clinic for children (Cincinnati Children’s Hospital, USA).Sources of informationMEDLINE, PubMed, ISI Web of ScienceFindingsThese two ambulatory clinics have been in existence for close to two (adult) and four (pediatric) years, and were developed separately and independently in different populations and health systems. The components of both clinics are described, including the target population, referral process, medical interventions, patient education activities, and follow-up schedule. Common elements include targeting patients with KDIGO stage 2 or 3 AKI, regular audits of the inpatient nephrology census to track eligible patients, medication reconciliation, and education on the long-term consequences of AKI.LimitationsDespite the theoretical benefits of post-AKI follow-up and the clinic components described, there is no high quality evidence to prove that the interventions implemented in these clinics will reduce morbidity or mortality. Therefore, we also present a plan to evaluate the adult AKI Follow-up Clinic in order to determine if it can improve clinical outcomes compared to patients with AKI who do not receive follow-up care.ImplicationsFollow-up of AKI survivors is low, and this review describes two different clinics that care for patients who survive an AKI episode. We believe that sharing the experiences of the AKI Follow-up Clinic and AKI Survivor Clinic provide physicians with a feasible framework to implement their own clinics, which may help AKI patients receive outpatient care commensurate with their high risk status.Electronic supplementary materialThe online version of this article (doi:10.1186/s40697-015-0071-8) contains supplementary material, which is available to authorized users.

Leveraging Big Data and Electronic Health Records to Enhance Novel Approaches to Acute Kidney Injury Research and Care

“…One approach would be to use the AKI tag at discharge to automatically notify primary care physicians and generate a nephrology follow-up appointment [58]. The discharge order itself could trigger the follow-up encounter and populate the patient's discharge instructions.…”

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.…”

Points of Concern in Post Acute Kidney Injury Management

“…Figure 1 summarizes a suggestion of an algorithm on post AKI renal follow-up, based on the scarce available literature [53, 54]. …”

“…Silver et al [53, 54] established a post-AKI clinic in 2 tertiary hospitals in Toronto where all patients are seen 30–90 days after hospital discharge following an AKI episode. Such clinics might not only expose previously unrecognized CKD but also deliver appropriate prevention and treatment of CKD and its complications, avoiding early readmissions [48].…”