The Impact of Integrating Nephrologists into the Postoperative Cardiac Intensive Care Unit: A Cohort Study

Abstract

Background/Aims: We evaluated the potential preventive effect of Nephrology On-Site (i.e. nephrologists integrated into the postoperative cardiac intensive care unit, ICU, team) versus Nephrology On-Demand (i.e. nephrology consultation depending on intensivist criteria) in the ICU on in-hospital outcomes. Methods: This was a retrospective cohort study comparing outcomes during 2 consecutive time periods: from March 1, 2009 to February 28, 2010 with Nephrology On-Demand, and from March 1, 2010 to February 28, 2011 with Nephrology On-Site. Adult patients admitted to the postoperative cardiac ICU in an academic hospital in Mexico City were eligible. Patients with chronic kidney disease stage 5 or minimally invasive procedures were excluded. Results: We analyzed 1,096 patients, 558 and 538 in the respective periods. The patients were 52.4 ± 16.2 years old, 56.1% were males, 17.2% had diabetes and 37.6% had hypertension. Further, the patients' median Euroscore was 5 (3-5) and their median Thakar score was 3 (2-4). With Nephrology On-Site, we observed a lower incidence of acute kidney injury [AKI; 25.7 vs. 31.9%, p = 0.02; adjusted OR 0.71 (0.53-0.95), p = 0.02], lower in-hospital mortality among patients with severe AKI [34.1 vs. 55.9%, p = 0.06; adjusted OR 0.33 (0.12-0.95), p = 0.04] and higher renal recovery [61.0 vs. 35.3%, p = 0.03; adjusted OR 3.57 (1.27-10.11), p = 0.02]. No differences were found in the length of stay at the ICU and mechanical ventilation. Conclusion: Integrating nephrologists into the postoperative cardiac ICU team was associated with a lower incidence of AKI. Patients who developed severe AKI had lower in-hospital mortality and higher renal recovery.

Delayed Nephrology Consultation and High Mortality on Acute Kidney Injury: A Meta-Analysis

“…Flores-Gama et al [15], in a retrospective cohort study, revealed the potential preventive effects of a nephrologist integrated into the postoperative cardiac ICU vs. nephrology consultation depending on intensivist's criteria in the ICU based on in-hospital outcomes. The results were favorable to a nephrologist 'part of the team', with a lower incidence of AKI, lower in-hospital mortality among patients with severe AKI and higher renal recovery rates.…”

“…The results were favorable to a nephrologist 'part of the team', with a lower incidence of AKI, lower in-hospital mortality among patients with severe AKI and higher renal recovery rates. Integrating nephrologists into the postoperative cardiac ICU team was associated with a lower incidence of AKI, and even patients who developed severe AKI had lower in-hospital mortality and higher renal recovery [15] . Table 1 presents the main statistics from the 6 papers described above.…”

Recovery from AKI in the critically ill: potential confounders in the evaluation

“…The majority of the available studies reported recovery at hospital discharge [17,[19][20][21][22][23][24][25]. With the exception of studies focusing on long-term follow-up [4,5,10], recovery is mostly reported for all AKI patients (survivors and non-survivors) [15,16,18,19,[21][22][23]26]. Although inclusion of non-survivors is important from a pathophysiological point of view and essential for intervention trials, recovery of kidney function among survivors is probably more relevant from a patient's perspective and crucial for determining the burden of postdischarge nephrological follow-up.…”

“…The available clinical trials either excluded patients with an unknown baseline Screat [9,19], used an imputed baseline Screat based on the Modification of Diet in Renal Disease (MDRD) equation (as suggested by ADQI and KDIGO) [4,16,17,23,25], used the minimum Screat measured during hospitalization [5,21], or did not mention how baseline Screat was determined [18,24]. The impact of using an imputed instead of the observed baseline on the incidence of AKI has been reported [30][31][32].…”

Acute Kidney Injury and Renal Replacement Therapy: ADOPPS Wanted!

“…For example, how important is the cooperation of nephrologists and intensivists in the management of renal replacement therapy in the acute patient? [4]. How much weight on outcome can a cooperative approach like the one described in the Vicenza Model have?…”