A Multinational Observational Study Exploring Adherence With the Kidney Disease: Improving Global Outcomes Recommendations for Prevention of Acute Kidney Injury After Cardiac Surgery

Abstract

BACKGROUND: The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend a bundle of different measures for patients at increased risk of acute kidney injury (AKI). Prospective, single-center, randomized controlled trials (RCTs) have shown that management in accordance with the KDIGO recommendations was associated with a significant reduction in the incidence of postoperative AKI in high-risk patients. However, compliance with the KDIGO bundle in routine clinical practice is unknown. METHODS: This observational prevalence study was performed in conjunction with a prospective RCT investigating the role of the KDIGO bundle in high-risk patients undergoing cardiac surgery. A 2-day observational prevalence study was performed in all participating centers before the RCT to explore routine clinical practice. The participating hospitals provided the following data: demographics and surgical characteristics, AKI rates, and compliance rates with the individual components of the bundle. RESULTS: Ninety-five patients were enrolled in 12 participating hospitals. The incidence of AKI within 72 hours after cardiac surgery was 24.2%. In 5.3% of all patients, clinical management was fully compliant with all 6 components of the bundle. Nephrotoxic drugs were discontinued in 52.6% of patients, volume optimization was performed in 70.5%, 52.6% of the patients underwent functional hemodynamic monitoring, close monitoring of serum creatinine and urine output was undertaken in 24.2% of patients, hyperglycemia was avoided in 41.1% of patients, and no patient received radiocontrast agents. The patients received on average 3.4 (standard deviation [SD] ±1.1) of 6 supportive measures as recommended by the KDIGO guidelines. There was no significant difference in the number of applied measures between AKI and non-AKI patients (3.2 [SD ±1.1] vs 3.5 [SD ±1.1]; P = .347). CONCLUSIONS: In patients after cardiac surgery, compliance with the KDIGO recommendations was low in routine clinical practice.

Performance of a Standardized Clinical Assay for Urinary C–C Motif Chemokine Ligand 14 (CCL14) for Persistent Severe Acute Kidney Injury

“…There is an increasing body of literature demonstrating that patients with established AKI do not often receive guideline-based care (22)(23)(24). In multiple large-scale retrospective single-center cohorts and one multicenter international cohort, patients with known KDIGO AKI continued to receive nephrotoxins (including nonsteroidal anti-inflammatory drugs and aminoglycosides) and experienced persistent hypotension (e.g., mean arterial pressures ,55 mmHg), even in the setting of established stage 2 AKI (22,23). One of the most significant barriers to delivering these recommended clinical actions is that most AKI resolves spontaneously or with initial clinical management, and it is quite difficult to know which patients will require discontinuation of nephrotoxic drugs or a more intensive assessment of hemodynamics/ volume status.…”

Interventions, Barriers, and Proposed Solutions Associated With the Implementation of a Protocol That Uses Clinical Decision Support and a Stress Biomarker Test to Identify ICU Patients at High-Risk for Drug Associated Acute Kidney Injury

“…Using biomarkers to identify patients who were at high risk for AKI influenced nephrotoxin discontinuation as a treatment strategy in our real-world evaluation which is consistent with a randomized clinical trial using TIMP-2•IGFBP7 to find cardiac surgery patients at high-risk for AKI progression. 20 Still, interventions were conducted at low risk per biomarker because the alert was effective at identifying high-risk scenarios for AKI development and the need for re-evaluation with the administration of 3 or more nephrotoxins. 16 This quality improvement project demonstrates the clinical utility of obtaining stress biomarker tests when prompted by use of a CDSS alert to identify additional risk for AKI development for further interventions, in particular with nephrotoxin discontinuation, avoiding nephrotoxins, and therapeutic drug monitoring.…”

“…The biomarker test was not ordered when the 3 or more nephrotoxins identified by the CDSS tool were not actually administered, if the patient already had AKI, the patient was already receiving renal replacement therapy, if an alert had previously fired for which a TIMP-2•IGFBP7 had already been ordered, if more than 12 hours had passed since the CDSS alert fired, if the patient was no longer being cared for by the critical care medicine team, or if additional testing was not within patient goals. 20 If TIMP-2•IGFBP7 testing was completed, subsequent results were interpreted by the pharmacist in conjunction with the patient care team. If the TIMP-2•IGFBP7 result was elevated (value >0.3), the pharmacist delivered recommendations relating to nephrotoxin stewardship to the team.…”

Prävention des akuten Nierenversagens

“…Eine multizentrische Observationsstudie hat kürzlich aufgedeckt, dass die Adhärenz der Maßnahmen verbesserungswürdig ist und die Komponenten des KDIGO-Maßnahmenbündels im Klinikalltag nur unzureichend umgesetzt werden 3 . Die Identifizierung von Risikopatienten und die Sensibilisierung der Behandelnden hinsichtlich der Leitlinienumsetzung sind daher ausschlaggebend.…”