Nephrologist Follow-Up versus Usual Care after an Acute Kidney Injury Hospitalization (FUSION): A Randomized Controlled Trial

Abstract

Background and Objectives: Survivors of acute kidney injury (AKI) are at higher risk of chronic kidney disease and death, but few patients see a nephrologist following hospital discharge. Our objectives during this 2-year vanguard phase were to determine the feasibility of randomizing survivors of AKI to early follow-up with a nephrologist or usual care, as well as to collect data on care processes and outcomes. Design, Setting, Participants, and Measurements: We performed a randomized controlled trial in patients hospitalized with Kidney Disease Improving Global Outcomes (KDIGO) stage 2-3 AKI at 4 hospitals in Toronto, Canada. We randomized patients to early nephrologist follow-up (standardized basket of care that emphasized blood pressure control, cardiovascular risk reduction, and medication safety) or usual care from July 2015 to June 2017. Feasibility outcomes included the proportion of eligible patients enrolled, seen by a nephrologist, and followed to 1-year. The primary clinical outcome was a major adverse kidney event at 1-year, defined as death, maintenance dialysis, or incident/progressive chronic kidney disease. Results: We screened 3687 participants from July 2015 to June 2017, of whom 269 were eligible. We randomized 71 (26%) patients (34 to nephrology follow-up and 37 to usual care). The primary reason stated for declining enrollment included hospitalization-related fatigue (n=65), reluctance to add more doctors to the healthcare team (n=59), and long travel times (n=40). Nephrologist visits occurred in 24/34 (71%) intervention participants compared to 3/37 (8%) randomized to usual care. The primary clinical outcome occurred in 15/34 (44%) patients in the nephrologist follow-up arm and 16/37 (43%) patients in the usual care arm (relative risk=1.02, 95% CI 0.60-1.73). Conclusions: Major adverse kidney events are common in AKI survivors, but we found that the in-person model of follow-up posed a variety of barriers that was not acceptable to many patients. (ClinicalTrials.gov, NCT02483039).

Development and Feasibility of a Multidisciplinary Approach to AKI Survivorship in Care Transitions: Research Letter

“…Moreover, the ACT approach shortens the time that patients could be exposed to modifiable determinants of kidney decline (ie, nephrotoxins) without intervention. Existing literature demonstrated a median time of 48 days to nephrologist follow-up, 5 whereas in this study, PCP/pharmacist visits were completed within 1 week of discharge. Future studies should aim to evaluate the perceptions of patients and caregivers about novel AKI survivor care workflows like ACT.…”

“…Historically, manual screening of inpatient service rosters has been used to identify individuals for enrollment in post-AKI clinics, with as little as 7% of targeted individuals appropriate for AKI survivor follow-up. 5 We identified many stage 3 AKI survivors who are not followed by nephrology specialists who would be missed by this method. Use of an informatics-enabled solution based on serum creatinine and urine output facilitates identification of eligible patients with AKI, particularly when not already receiving nephrology care.…”

“…Third, engagement of a nurse, PCP, and pharmacist to deliver components of post-AKI care with escalation to specialty nephrology consultation as needed maximizes the skills of the multidisciplinary team, to support the limited available resources within nephrology. 5 , 10 PCPs are well-positioned to deliver patient-centered care, address AKI alongside other health needs, and minimize care fragmentation, a barrier raised by patients regarding AKI follow-up. 5 Clinical and laboratory evaluation by a PCP may streamline a future nephrologist encounter if referred.…”

“… 5 , 10 PCPs are well-positioned to deliver patient-centered care, address AKI alongside other health needs, and minimize care fragmentation, a barrier raised by patients regarding AKI follow-up. 5 Clinical and laboratory evaluation by a PCP may streamline a future nephrologist encounter if referred. Moreover, the ACT approach shortens the time that patients could be exposed to modifiable determinants of kidney decline (ie, nephrotoxins) without intervention.…”

Prediction and Clinically Important Factors of Acute Kidney Injury Non-recovery

“…Another major contribution of this study includes its capability to derive reliable important features and validate an accurate AKI non-recovery predictive model based on a large AKI cohort with broad characteristic diversity. Given the poor outcomes among AKI survivors even in less severe AKI cases (3,7), these study results of AKI non-recovery predictors can facilitate risk assessment for identifying at-risk patients for poor kidney recovery before hospital discharge and promote nephrology referrals for post-discharge care for patients who may benefit most from such interventions (27,28).…”