Quality and Safety Measures in Acute Kidney Disease (AKD) –ADQI XXII

Jay L. Koyner MD

@jaykoyner

Section of Nephrology

Department of Medicine

University of Chicago

Disclosures

Research funding from NIH, Astute,

Bioporto, NxStage, Satellite

Healthcare

Consulting Fees from Astute

Medical, Sphingotec, Pfizer, Baxter

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Outline

Defining AKD

Defining the Denominator

Intensity and timing of follow up care

Evidenced based follow up care for • AKI

• AKI-D

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141 Pages Long

132 Page Appendix

64 Pages of Tables

271 Pages Long

126 ReferencesSlide from Lui Forni

2.3.4: Evaluate patients 3 months after AKI for resolution, new onset, or worsening of pre-existing CKD. (Not Graded)

If patients have CKD, manage these patients as detailed in the KDOQI CKD Guideline (Guidelines 7–15). (Not Graded)

If patients do not have CKD, consider them to be at increased risk for CKD and care for them as detailed in the KDOQI CKD Guideline 3 for patients at increased risk for CKD. (Not Graded)

KDIGO 2012 Clinical Practice Recommendations for

Post-AKI Care

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Defining Acute Kidney Disease

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Defining Acute Kidney Disease

AKD: Where Tertiary Prevention meets Primary Prevention

Kashani et al., CJASN 2019 – ADQI XXII 9

Statement #1 - In order to optimize the care of patients with AKI/AKD health care systems need to quantitate the number of patients who need and do receive follow-up care subsequent to their index AKI hospitalization.

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Kidney Surveillance after AKI

Serum

Creatinine

Albuminuria/

Proteinuria

USRDS 2015 ADR: Medicare AKI patients age 66 & older, 2012.

Siew et al. JASN 2012 12

Outpatient Nephrology Referral Among Patients with eGFR <60 ml/min/1.73 m2 After AKI

44% Recovered/

Improved

8.5% Referred

0.2% on RRT

11.5% Died

36% None

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Disparity between Nephrologists' Opinions and Contemporary Practices for

Follow-up after AKI Hospitalization.

Divya J. Karsanji et al. CJASN 2017;12:1753-1761

Statement #2 - Intensity and appropriateness of follow-up depends on patient characteristics as well as severity, duration and course of AKI.

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1 in 5 Patients with AKI Are Re-Hospitalized Within 30 Days

(N=111,778 Matched Pairs)

Silver, SA et al. Am J Med 2016; Oct (epub)

Slide Courtesy of E. Siew

HR 1.53 [95% CI: 1.50-1.57]

18% Rehospitalized

10% ER Visit

Est. cost of readmission = $40 million/yr

Relapsing AKI –Associated with Adverse outcomes

Kellum JA et al, Am J Resp Crit Care Med, 2017

Sawhney et al NDT

2018

• 7,491 patients

referred to

Nephrology in BC,

Canada

• Looking at predictors

of Kidney failure and

Death

• Prior history of AKI

increased the risk

failure and death in

those with eGFR >

30 ml/min

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Can we utilize other physicians to care for those with AKD?

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KAMPS Components

Kidney Function

• Kidney function measurement by serum creatinine or cystatin C; measured or

estimated GFR

• Proteinuria / albuminuria

• When available consider biomarkers, imaging and other tests as feasible and

indicated

Advocacy

• Patient and Caregiver education about AKI and CKD

• Communication with other care providers (i.e., general practitioners, dieticians,

nurses, pharmacists and social workers)

Medications

• Medication reconciliation, review and management

• Specifically discuss risk benefits of ACEI/ARB

• Review RENDS-Renal Excreted and Nephrotoxic Drugs and OTC medications

Pressure

• Ensure patient understands blood pressure goals and targets

• Discuss fluid status, ideal weight and the role of diuretics

Sick Day Protocols

• Educate patients on medications that need monitoring during

acute illnesses

Statement #3 - Post AKI - AKD Care should be evidenced based and evolve with emerging data.

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Alan S. Go et al. CJASN doi:10.2215/CJN.12591117©2018 by American Society of Nephrology

Siew: AKI increased risk of CHF in Veterans • Observational study of 300,868

hospitalized veterans (2004-11)

• Matching Pairs

• Incident HF defined as 1 hospitalization

or >2 outpatient visits with CHF

• 1 year incidence of CHF in those with

AKI was 30.8 per 1,000 person years

vs. 24.9 (p<0.001)

• Relative Risk of CHF post AKI was 1.28

(1.23 to 1.34)

• AKI associated with increased mortality

too

Strategies to Improve OutcomesWho?

9,973 patients in Alberta, Canada, who survived for > 3 months after AKI with baseline eGFR > 45 mL/min/1.73 m2

Externally validated in 2,761 AKI survivors in Ontario

Primary outcome: sustained eGFR < 30 mL/min/1.73m2

James MT et al, JAMA, 2017

James MT et al,

JAMA, 2017

Pannu et al – Mortality and ACE/ARB Post AKI • 46,253 Hospitalized Canadian

adults with AKI – 50% increase in

SCr from preadmit values

• ACE/ARB exposure within 6 month

(n=22,193)

• Propensity score matched-pairs

• ACE/ARB exposure associated

with decreased mortality after 2

years (aHR 0.85(0.81-0.89)

• However increased risk of Renal

Hospitalization 1.28(1.12-1.46)

• No increased risk of ESRD

Strategies to Improve OutcomesHow?

Does follow-up with a nephrologist in an AKI Follow-up Clinic within 30-days after hospital discharge reduce the number of major adverse kidney events at one year?

Nephrologist Follow-up versus USual care after an acute kidney Injury hospitalizatiON (FUSION): A randomized controlled trial

Clinicaltrials.gov NCT02483039

4-site RCT, envisioned as a vanguard phase for a definitive clinical trial

Sam Silver and Ron Wald PI

Predicting CKD: With AKI Biomarkers- ASSESS-AKI…

CV Surgery

Go et al. BMC Nephrology 2010 Follow-up supported by NIH-NIDDK

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Statement 4: Quality metrics for AKI-D and post-discharge AKD-D should be similar to quality metrics during hospitalization, and distinct from ESRD measures. In addition, there need to be specific quality metrics for the outpatient setting.

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WATCH-ME Components

Weight Assessment

Discuss Dry Weight monitoring and permissive hypervolemia

Discuss the role for diuretics in maintaining urine output and ideal volume status

Access

Educate patients about the care of central venous catheters

Vein preservation protocols / awareness

When appropriate begin to plan and educate about the role of arteriovenous access

and other RRT modalities

Teaching

Patient and Caregiver education about dialysis requiring AKD and short- and long-term

risks and consequence

Communication with other care providers (e.g., general practitioners, dieticians, nurses,

pharmacists and social workers) about patient needs (e.g., alterations in medication

regimens in the setting of new RRT).

Clearance

Frequent assessments of underlying renal function (via pre-dialysis labs or timed

clearances)

Frequent assessments of the quality of the RRT being provided to ensure adequate

clearance

Hypotension

Patient Education and optimization of care to avoid intradialytic about hypotension

Education around blood pressure medications administration in the peri-RRT period

MEdications

Medication reconciliation, review and management

Specifically discuss risk benefits of ACEI/ARB

Review RENDS (Renal Excreted and Nephrotoxic Drugs) and over the counter

medications

Conclusions

As Nephrologists we can do a better job of following up patients after AKI / AKD

This follow up should be standardized and evidence based and should include more than just those with AKI-RRT

Future studies should inform the timing, intensity and method of AKI/ AKD follow-up.

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Thanks Kathleen Liu

Michael Heung

Vin-Cent Wu

Lui Forni (not pictured)

ADQI Leadership Kashani, Haase, Rosner

Sam Silver and Ed Siew

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Thanksjkoyner@uchicago.edu@jaykoyner