Quality Improvement Goals for Acute Kidney Injury

Abstract

AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with significant clinical consequences and increased health care costs. Preventive measures, as well as rapid identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, are goals that have not been universally achieved. Therefore, understanding how the management of AKI may be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an international group of experts including physicians, a nurse practitioner, and pharmacists provided a framework for current and future quality improvement projects in the area of AKI. Where possible, best practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This article provides a summary of the key messages and recommendations of the group, with an aim to equip and encourage health care providers to establish quality care delivery for patients with AKI and to measure key quality indicators.

Preventing CKD in Developed Countries

“…83,84 Major risk factors for AKI include pre-existing CKD, extremes of age, exposure to nephrotoxic substances, renal hypoperfusion, and infection. 85 These risk factors in hospitalized patients are often superimposed on existing comorbidities that increase the risk of CKD, such as diabetes, hypertension, and obesity. Incomplete recovery of AKI, and thereby progression to acute kidney disease and CKD occurs in approximately 10% of those experiencing AKI in high-income countries.…”

“…Multiple strategies have been suggested for prevention of AKI, including campaigns to increase awareness of AKI, introduction of electronic alert systems, 86,87 development of prediction algorithms, 88 and clinical pathways across the spectrum of health care, although the long-term impact of such measures requires further study. 85 Documentation of AKI episodes in discharge summaries and follow-up after AKI is important for detecting CKD early. 86,89 Nephrotoxic agents such as nonsteroidal antiinflammatory drugs (NSAIDS), antibiotics, iodinated contrast media, and chemotherapeutic drugs are frequent causes of AKI, and the association is often fairly clear given the short lag-times between administration of the dose and the change in kidney function.…”

Prediction of Acute Kidney Injury in Hospitalized, Non-Critically III Patients

“…The growing emphasis on harm reduction through the identification of patients at increased risk of AKI, combined with careful monitoring of renal function and tailored management, is leading to improved renal outcomes 7 and is becoming a measure of quality of care. 1,8 The development, validation, and implementation of AKI risk prediction tools such as those proposed by Safadi et al, 3 Koyner and colleagues, 5,6 and others promises to yield more improvements in our efforts to prevent and treat AKI.…”

INCEPTION: is a larger trial to evaluate intraoperative renal replacement therapy in liver transplant patients more than just a dream?

“…A more general related challenge to any trial assessing the application of CRRT in critically ill patients is the heterogeneity in CRRT practice 21 and the lack of validated benchmarks for CRRT quality. 22,23 Variation in the application of IoCRRT across centres (e.g., use of regional citrate anticoagulation for LT has been reported by some centres despite most centres not recommending it because of the potential risk of citrate toxicity) 6 introduces another potential source of variation in outcomes across centres for any multicentre trial. This has implications for trial planning and ensuring adequate sample size to detect a difference in outcomes related to the intervention.…”

“…Un défi plus général lié à toute étude évaluant l'application d'un traitement substitutif de l'insuffisance rénale en continu chez des patients en état critique réside dans l'hétérogénéité de la pratique de ce type de traitement et l'absence d'étalons validés en ce qui touche à la qualité du traitement substitutif de l'insuffisance rénale en continu. 22,23 En raison des variations dans l'application du traitement substitutif peropératoire continu de l'insuffisance rénale entre les différents centres (par ex., l'utilisation d'une anticoagulation au citrate pour la greffe hépatique a été rapportée par certains centres, malgré le fait que la plupart des centres ne recommandent pas cette pratique en raison du risque potentiel de toxicité au citrate), 6 toute étude multicentrique comporte donc d'autres sources potentielles de variation dans les résultats obtenus d'un centre à l'autre. Cela a un impact sur la planification de l'étude et la garantie d'une taille d'échantillon adéquate afin de déceler une différence de résultat liée à l'intervention.…”