How good are we at managing acute kidney injury in hospital?

Abstract

IntroductionAcute kidney injury (AKI) is a common clinical problem associated with adverse outcomes. This study identifies the incidence of AKI in two UK district general hospitals' without on-site renal services and assesses AKI management and level of nephrologist input.MethodsThe AKIN classification was used to identify 1020 AKI patients over 6 months. Data were collated on patient demographics, AKI management and referral to nephrology and intensive care services. Short/long-term renal outcomes were investigated. Patients were followed up for 14 months post-discharge.ResultsIncidence of hospital-based AKI was 6.4%. Mean patient age was 73 years. There was 28.1% acute in-hospital mortality with a further 21.6% 14-month mortality. Only 8.3% of patients were referred to nephrology services for in-hospital review, and only 8.1% had outpatient nephrology follow-up. Compliance with the AKI National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) recommendations was poor with 32.8% of patients having renal imaging and 15% of patients having acid–base status assessed. NCEPOD compliance improved with nephrology input. Patients referred to nephrology were likely to be younger with pre-existing CKD and severe AKI. 10.5% of AKI episodes were unrecognized. Forty percent of those with unrecognized AKI, (compared with 15% of recognized AKI) developed de novo or progression of pre-existing CKD.ConclusionAKI in DGHs is mostly managed without nephrology input. There are significant shortcomings in AKI recognition and management in this setting. This is associated with poor mortality and long-term CKD. This study supports a need to improve the teaching and training of front-line medical staff in identifying AKI. Additionally, implementation of AKI e-alert systems may encourage early recognition and provide a prompt for renal referral.

Acute Kidney Injury in Asia

“…In developed counties, it is reported that about 10% of AKI cases have not been recognized by the attending doctors [58], whereas the recently published national survey of AKI in China reveals a dramatic nonrecognition rate of AKI across the country [4]. About 3/4 of the AKI patients had not been recognized by the physicians in charge, and patients coming from less economically developed regions were at a higher risk for underrecognition of AKI.…”

Cardiovascular-Specific Mortality and Kidney Disease in Patients Undergoing Vascular Surgery

“…47,48 Standardized follow-up is important after an episode of AKI and can help to prevent the development of CKD. 49 This area can be addressed quickly and relatively easily because less than50%ofpatientswith the most severe AKI will have a follow-up creatinine level measured within the first 3 months of hospitalization, and followup is even less likely to be obtained after less severe AKI. 50 We acknowledge the limitations of all retrospective studies.…”

Evaluation of Acute Kidney Injury in the Hospital Setting

“…77 Evaluating acute changes in urine output has important prognostic implications for the severity of AKI as seen by classification of RIFLE criteria. [4][5][6]10 Oliguria is defined as reduction in urine output of less than 500 mL/d, and anuria as less than 50 mL. Furthermore, oliguric ATN has been associated with increased risk of mortality and requirement for renal replacement therapy in comparison to nonoliguric AKI conditions.…”

“…[4][5][6][7][8][9] More importantly, the development of AKI is independently associated with high mortality rates, increased length of stay, and risk of developing permanent chronic kidney disease (CKD). [4][5][6][7][9][10][11] …”