Early nephrology consultation can have an impact on outcome of acute kidney injury patients

Ponce, Daniela; Zorzenon, Caroline de Pietro Franco; Santos, Nara Yamane dos; Balbi, André Luís

doi:10.1093/ndt/gfr359

Cited by 97 publications

(93 citation statements)

References 17 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Our study promotes a culture of recording and reporting changes in hourly urine output for critically ill patients. If hourly urine output is documented, electronic alert mechanisms could be developed to actively survey for oliguria and facilitate patient assessment, fluid or vasopressor administration, nephrology specialist consultation, or early RRT before additional biochemical evidence of AKI is observed (32,33). Evaluating pretest probability using a 3-hour oliguria cutoff may aid in the decision to deploy other diagnostic tests (e.g., AKI biomarkers), potentially increasing their accuracy and cost-effectiveness (34).…”

Section: Discussionmentioning

confidence: 99%

Derivation of Urine Output Thresholds That Identify a Very High Risk of AKI in Patients with Septic Shock

Leedahl

Frazee²,

Schramm³

et al. 2014

Clinical Journal of the American Society of Nephrology

View full text Add to dashboard Cite

Background and objectives To promote early detection of AKI, recently proposed pretest probability models combine sub-Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria with baseline AKI risk. The primary objective of this study was to determine sub-KDIGO thresholds that identify patients with septic shock at highest risk for AKI.Design, setting, participants, & measurements This was a retrospective analysis of 390 adult patients admitted to the medical intensive care unit (ICU) of a tertiary, academic medical center with septic shock between January 2008 and December 2010. Hourly urine output was collected from the time of septic shock recognition (hour 0) to hour 96, urine catheter removal, or ICU discharge (whichever occurred first). All available serum creatinine (SCr) measurements were collected until hour 96. The AKI pretest probability model was assessed during the first 12 hours of resuscitation and included the initial episode of oliguria, increase from baseline to peak SCr level, and Acute Physiology and Chronic Health Evaluation (APACHE) III score in a multivariable receiver-operator characteristic (ROC) analysis. The primary outcome was the incidence of stage II or III (stage II+) AKI defined by KDIGO criteria. Secondary outcomes included the need for RRT and 28-day mortality.Results Ninety-eight (25%) patients developed stage II+ AKI after septic shock recognition. APACHE III score and increase in SCr level in the first 12 hours were not statistically associated with stage II+ AKI in multivariable ROC analysis. Consecutive oliguria for 3 hours had fair predictive ability for achieving stage II+ AKI criteria (area under ROC curve, 0.73; 95% confidence interval [95% CI], 0.68 to 0.78), and oliguria for 5 hours demonstrated optimal accuracy (82%; 95% CI, 79% to 86%).Conclusions Three to 5 hours of consecutive oliguria in patients with septic shock may provide a valuable measure of AKI risk. Further validation to support this finding is needed.

show abstract

Section: Discussionmentioning

confidence: 99%

Derivation of Urine Output Thresholds That Identify a Very High Risk of AKI in Patients with Septic Shock

Leedahl

Frazee²,

Schramm³

et al. 2014

Clinical Journal of the American Society of Nephrology

View full text Add to dashboard Cite

show abstract

“…It has been suggested that the development of effective therapeutic maneuvers for the prevention or early treatment of AKI have been impeded by late diagnosis of this disorder. 5 We undertook a multicentre cohort study to characterize the incidence and outcomes of AKI in an unselected cohort of patients admitted to Canadian intensive care units (ICUs). Among the patients with AKI, we sought to identify clinical predictors of mortality at the time of AKI diagnosis.…”

Section: Résumémentioning

confidence: 99%

Epidemiology of acute kidney injury in Canadian critical care units: a prospective cohort study

Odutayo

Adhikari

Barton

et al. 2012

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

show abstract

“…Similarly, Perez-Valdivieso et al (4) reported that an increase of Ͼ100% in serum creatinine level at the time of nephrology consultation was associated with higher mortality and impaired renal recovery on discharge. Most recently, Ponce et al (5) have confirmed these findings in 148 ICU patients with AKI at a Brazilian teaching hospital. Nephrology consultation was delayed (Ն48 hours) in 62.3%, which was associated with increased ICU mortality (65.4% versus 88.2%, P Ͻ 0.001).…”

mentioning

confidence: 73%

Management of Acute Kidney Injury

Mehta¹

2011

Clinical Journal of the American Society of Nephrology

View full text Add to dashboard Cite

Acute kidney injury (AKI) has attracted considerable attention with the recognition that even small changes in renal function may have profound effects on major outcomes, regardless of the setting. Despite advances in diagnosis and staging of AKI (1) with emerging biomarkers informing our knowledge of mechanisms and pathways, we do not as yet know how AKI contributes to the increased mortality and morbidity in hospitalized patients. We have blamed the lack of progress in this area on the heterogeneity of the population and disease mechanisms coupled with difficulties in ascertaining the attributable risk, particularly when AKI is a component of multiorgan failure. However, several pieces of evidence now suggest that we should consider additional process of care factors that may influence a patient's course and outcomes. Data from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) audit of 564 patients who died with a diagnosis of AKI in United Kingdom hospitals revealed significant gaps in performance for management of AKI, with over 50% of cases failing to meet criteria for good care, and only 30% of those who developed AKI in the hospital meeting these criteria (2). In 12% of cases, there was delayed recognition, 29% had inadequate assessment of risk factors, and both diagnostic and therapeutic interventions were subject to poor performance in a significant number of patients. The level of prior training of the physician influenced the quality of care, and senior physicians were deemed to provide better care. Only 31% of patients were referred to a nephrologist for advice or management support, whereas an additional 20% were considered as having needed nephrology support. 21% of the referrals to nephrology were considered by the advisors to be delayed. We have previously shown in a prospective observational study that delayed nephrology consultation (Ͼ48 hours from AKI diagnosis) in patients admitted to the intensive care unit (ICU) was associated with increased mortality and morbidity (3). Similarly, reported that an increase of Ͼ100% in serum creatinine level at the time of nephrology consultation was associated with higher mortality and impaired renal recovery on discharge. Most recently, Ponce et al. (5) have confirmed these findings in 148 ICU patients with AKI at a Brazilian teaching hospital. Nephrology consultation was delayed (Ն48 hours) in 62.3%, which was associated with increased ICU mortality (65.4% versus 88.2%, P Ͻ 0.001). These studies support the notion that early nephrology involvement in managing AKI may improve outcomes but raises several questions: what determines when a nephrologist is involved, what is the optimal time for nephrology involvement, and what is the nephrologist's role?The study from Meier et al. (6) in this issue of CJASN provides additional information on some of these issues detailing the management of AKI in a large tertiary care academic hospital in Switzerland. The authors characterized the care of 4296 noncritically ill patients who experienc...

show abstract

Early nephrology consultation can have an impact on outcome of acute kidney injury patients

Abstract: In AKI, patients evaluated by nephrologists seem to be more seriously ill than those not evaluated and present similar mortality rate. The delayed nephrology consultation can be associated with increased ICU mortality.

Cited by 97 publications

References 17 publications

Derivation of Urine Output Thresholds That Identify a Very High Risk of AKI in Patients with Septic Shock

Derivation of Urine Output Thresholds That Identify a Very High Risk of AKI in Patients with Septic Shock

Epidemiology of acute kidney injury in Canadian critical care units: a prospective cohort study

Management of Acute Kidney Injury

Contact Info

Product

Resources

About