The Optimization of Outpatient Hemodialysis Management for Acute Kidney Injury Requiring Dialysis Patients: A Quality Improvement Study

Abstract

Introduction: In 2017, the Centers for Medicare and Medicaid Services allowed survivors of hospitalized acute kidney injury requiring dialysis (AKI-D) who were ambulatory and still dependent on hemodialysis (HD) to receive treatment in outpatient dialysis facilities. This policy change generated the ongoing need to improve AKI-D care in the outpatient setting. Methods: Quality improvement study in adult patients admitted to an outpatient HD unit with the diagnosis of AKI-D. We developed a protocol to manage these patients that included: a) multidisciplinary evaluations; b) personalized 3-tier HD prescription for dose/ultrafiltration rate and frequency; c) weekly assessment of kidney recovery; and d) patient empowerment. Patient- and protocol-specific characteristics were described. We analyzed hourly HD data and protocol adherence, and relevant hemodynamic data were compared according to HD-free survival at 90 days. Results: A total of 457.3 hours of HD from nine patients under the AKI-D protocol were interrogated. Three out of nine patients were alive and liberated from HD within the first 90 days of outpatient HD. Overall protocol adherence was 53.8% and did not differ by HD-free survival (54.5% vs. 53.7% in those that recovered vs. not). Protocol adherence was associated with fewer intradialytic hypotension events (peak to nadir BP, p<0.01), while intradialytic hypotension (pre to post BP) occurred more frequently in patients who did not recover kidney function (p=0.009). Conclusion: We demonstrated the feasibility of implementing a management protocol for AKI-D patients in an outpatient dialysis facility. We found that fewer episodes of intradialytic hypotension occurred when the outpatient HD management was adherent to the protocol. The feasibility of this protocol should be confirmed in other facilities, and importantly, efficacy testing to evaluate its impact on AKI-D outpatient care is necessary.

Challenges in the Care of Patients with AKI Receiving Outpatient Dialysis: AKINow Recovery Workgroup Report

“…The feasibility of implementing personalized hemodialysis prescriptions for AKI-D patients in outpatient dialysis units was recently highlighted in a pilot study. 38 Furthermore, the challenges of preclinical AKI models, beyond the scope of this manuscript but discussed elsewhere, 39 have stymied the translation of promising inventions into successful clinical trials. Data supporting the clinical management of AKI-D to promote kidney recovery are also lacking.…”

Initial Management and Potential Opportunities to Deprescribe Dialysis among Patients with AKI-D Patients after Hospital Discharge

“…5,6 Relying on the patient report of increasing urine output to trigger a timed urine collection is likely suboptimal because self-estimated urine volumes are often inaccurate. 7 Implementation science efforts will likely be needed to increase timed urine collections in AKI-D. 3,4 Third, we could deprescribe dialysis more often and earlier. Most patients with AKI-D who recovered (82%) never had their dialysis frequency decreased before stopping dialysis entirely.…”

“…5,6 Relying on the patient report of increasing urine output to trigger a timed urine collection is likely suboptimal because self-estimated urine volumes are often inaccurate. 7 Implementation science efforts will likely be needed to increase timed urine collections in AKI-D. 3,4…”

“…Numerous groups have independently concluded that patients with AKI-D being treated in outpatient dialysis units should have protocolized timed urine collections, as frequently as weekly. 3,4 Seminal studies of hospitalized patients with AKI-D have relied on timed urine collections to trigger trials of dialysis cessation. 5,6 Relying on the patient report of increasing urine output to trigger a timed urine collection is likely suboptimal because self-estimated urine volumes are often inaccurate.…”