Strategies to Enhance Rehabilitation After Acute Kidney Injury in the Developing World

Acute kidney disease: an overview of the epidemiology, pathophysiology, and management

Acute kidney injury (AKI) increases the risk of chronic kidney disease (CKD), and AKI and CKD are seen as interconnected syndromes. Acute kidney disease (AKD) is defined as subacute damage and/or loss of kidney function occurring 7 to 90 days after AKI, during which period key interventions may be initiated to hinder the development of CKD. While AKD is usually under-recognized, it is associated with high morbidity and mortality globally. This review article aims to summarize the current knowledge concerning the epidemiology, pathophysiology, and management of AKD with the aim to develop monitoring strategies and therapeutic agents of AKD. Generally, AKD tends to occur more frequently in the elderly and those with chronic diseases, such as hypertension, diabetes mellitus, and metabolic syndrome. In addition, the severity, duration, and frequency of AKI are independent risk factors for AKD. Investigations of several mechanisms of AKD, such as renal tubular epithelium cell-cycle arrest, epigenetic change, chronic inflammation, mitochondria dysfunction, failed regeneration of tubular cells, metabolic reprogramming, and renin-angiotensin system (RAS) activation, have identified additional potential pharmacotherapy targets. Management of AKD includes prevention of repeated AKI, early and regular follow-up by a nephrologist, resumption and adjustment of essential medication, optimization of blood pressure control and nutrition management, and development of new pharmaceutical agents including RAS inhibitors. Finally, we outline a care bundle for AKD patients based on important lessons learned from studies and registries and identify the need for clinical trials of RAS inhibitors or other novel agents to impede ensuing CKD development.

Glittre activities of daily living test is reliable and valid in hemodialysis patients

PURPOSE

To examine the validity, and the relative and absolute within-day reliability of the TGlittre in chronic kidney disease patients undergoing hemodialysis (HD).

MATERIALS AND METHODS

Thirty HD patients (52 ± 12 years) undertook the TGlittre twice on a single day, in a cross-sectional design. For validation purposes, participants TGlittre performance and accelerometry-based physical activity were correlated. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimal detectable change (MDC) were determined to assess within-day reliability.

RESULTS

There was a moderate correlation between TGlittre performance and moderate to vigorous physical activity (r= -0.587; p= 0.001). The relative reliability of the test showed an ICC of 0.96. For the absolute reliability, the SEM was 13.05 s (0.22 min), and the MDC was 36.17 s (0.60 min).

CONCLUSIONS

TGlittre performance is associated with moderate to vigorous physical activity in HD patients, highlighting that those with higher levels of physical activity are likely to perform better on the TGlittre. Additionally, TGlittre shows a good to excellent intra-rater reliability and a low SEM. An MDC value was established.Implications for rehabilitationPatients on hemodialysis have a low physical capacity and often struggle to simply complete their physical activities of daily living.The TGlittre is a tool for assessing functional capacity through completion of multiple physical activities of daily living and can be easily applied in a clinical setting.TGlittre is a valid test that elicit reliable physiological, hemodynamic, and physical performance responses in HD patients.

Update on prognosis driven classification of pediatric AKI

Acute kidney injury (AKI) affects a large proportion of hospitalized children and increases morbidity and mortality in this population. Initially thought to be a self-limiting condition with uniformly good prognosis, we now know that AKI can persist and progress to acute kidney disease (AKD) and chronic kidney disease (CKD). AKI is presently categorized by stage of injury defined by increase in creatinine, decrease in eGFR, or decrease in urine output. These commonly used biomarkers of acute kidney injury do not change until the injury is well established and are unable to detect early stage of the disease when intervention is likely to reverse injury. The kidneys have the ability to compensate and return serum creatinine to a normal or baseline level despite nephron loss in the setting of AKI possibly masking persistent dysfunction. Though these definitions are important, classifying children by their propensity for progression to AKD and CKD and defining these risk strata by other factors besides creatinine may allow for better prognosis driven discussion, expectation setting, and care for our patients. In order to develop a classification strategy, we must first be able to recognize children who are at risk for AKD and CKD based on modifiable and non-modifiable factors as well as early biomarkers that identify their risk of persistent injury. Prevention of initial injury, prompt evaluation and treatment if injury occurs, and mitigating further injury during the recovery period may be important factors in decreasing risk of AKD and CKD after AKI. This review will cover presently used definitions of AKI, AKD, and CKD, recent findings in epidemiology and risk factors for AKI to AKD to CKD progression, novel biomarkers for early identification of AKI and AKI that may progress to CKD and future directions for improving outcome in children with AKI.

Post-COVID-19 rehabilitation: a special look at chronic kidney disease patients

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can infect the kidney and the presence of chronic kidney disease (CKD) constitutes a higher risk of negative prognosis. SARS-CoV-2 main sequelae in CKD patients are an incomplete recovery of kidney function, muscle weakness and atrophy, breathiness, tiredness, pulmonary fibrosis, and initiation of kidney replacement therapy. The overall aim of this review is to provide a theoretical basis for early improvements of physical function health to all CKD stages by rehabilitation therapies.

CONCLUSION

Chronic kidney disease patients infected with SARS-CoV-2 should be monitored by rehabilitation professionals as the cardiopulmonary, musculoskeletal, and cognitive systems might be deteriorated. Long-term consequences of SARS-CoV-2 are unknown and preventive rehabilitation may attenuate them.

Acute kidney injury in a tertiary care center of South India

Background and Objective:

Data regarding the epidemiology and outcomes of acute kidney injury (AKI) from our part of the world are limited. The irking consequences of AKI, both on the patient and the health care system, are being increasingly recognized. We aimed to study the epidemiology and short-term outcomes of AKI and to analyze the factors associated with adverse renal outcomes.

Materials and Methods:

We retrospectively studied AKI patients stratified according to the Kidney Disease: Improving Global Outcomes (KDIGO) stage, regarding clinicodemographic data, renal replacement therapy (RRT), and 90-day outcomes. Those with preexisting CKD Stage 4 (defined by estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m²) and above, prior renal transplant (s), or acute glomerulonephritis were excluded. The primary outcome was a composite of de novo CKD (eGFR <60 mL/min/1.73 m²) or CKD progression (decline in eGFR category to any higher stage) in patients with baseline CKD at 90 days. The secondary outcome was a composite of de novo CKD, CKD progression, or death at 90 days.

Results:

Of the 358 patients, 52.5% had Stage 3 AKI. Eighty-eight patients (24.6%) had baseline CKD. Sepsis (51.4%) was the predominant etiology followed by nephrotoxins (42.5%). Renal replacement therapy (RRT) was required in 94 (26.3%) patients with hemodialysis being the most common modality. After excluding lost to follow-up, 66 patients (20.3%) had the primary outcome, and 195 patients (60%) had the secondary outcome. The 90-day mortality was observed in 39.7% of patients. AKI stage (P = 0.002), baseline CKD (P = 0.000) and RRT need (P = 0.005) were significantly associated with the primary outcome, while age >60 (P = 0.018), SOFA (Sequential Organ Failure Assessment) ≥9 (P = 0.000), hypoalbuminemia (P = 0.024), baseline CKD (P = 0.000) and RRT need (P = 0.001) were associated with the secondary outcome.

Conclusion:

Sepsis was the dominant precipitant of AKI and a major proportion had preventable etiology. AKI severity, baseline CKD status, and RRT need were found to predict the development or progression of CKD.

Prevention and Therapy of AKI in Asia: A Big Challenge

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

Predicting kidney failure risk after acute kidney injury among people receiving nephrology clinic care

Background

Outcomes after acute kidney injury (AKI) are well described, but not for those already under nephrology clinic care. This is where discussions about kidney failure risk are commonplace. We evaluated whether the established kidney failure risk equation (KFRE) should account for previous AKI episodes when used in this setting.

Methods

This observational cohort study included 7491 people referred for nephrology clinic care in British Columbia in 2003–09 followed to 2016. Predictors were previous Kidney Disease: Improving Global Outcomes–based AKI, age, sex, proteinuria, estimated glomerular filtration rate (eGFR) and renal diagnosis. Outcomes were 5-year kidney failure and death. We developed cause-specific Cox models (AKI versus no AKI) for kidney failure and death, stratified by eGFR (</≥30 mL/min/1.73 m²). We also compared prediction models comparing the 5-year KFRE with two refitted models, one with and one without AKI as a predictor.

Results

AKI was associated with increased kidney failure (33.1% versus 26.3%) and death (23.8% versus 16.8%) (P  < 0.001). In Cox models, AKI was independently associated with increased kidney failure in those with an eGFR ≥30 mL/min/1.73 m² {hazard ratio [HR] 1.35 [95% confidence interval (CI) 1.07–1.70]}, no increase in those with eGFR <30 mL/min/1.73 m² ([HR 1.05 95% CI 0.91–1.21)] and increased mortality in both subgroups [respective HRs 1.89 (95% CI 1.56–2.30) and 1.43 (1.16–1.75)]. Incorporating AKI into a refitted kidney failure prediction model did not improve predictions on comparison of receiver operating characteristics (P = 0.16) or decision curve analysis. The original KFRE calibrated poorly in this setting, underpredicting risk.

Conclusions

AKI carries a poorer long-term prognosis among those already under nephrology care. AKI may not alter kidney failure risk predictions, but the use of prediction models without appreciating the full impact of AKI, including increased mortality, would be simplistic. People with kidney diseases have risks beyond simply kidney failure. This complexity and variability of outcomes of individuals is important.

Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation

OBJECTIVES

We sought to understand the factors influencing the implementation of a primary care intervention to improve post-discharge care following acute kidney injury (AKI).

DESIGN

Qualitative study using semi-structured interviews and thematic analysis.

SETTING

General practices in one Clinical Commissioning Group area in England.

PARTICIPANTS

A total of 18 healthcare staff took part in interviews. Participants were practice pharmacists, general practitioners, practice managers and administrators involved in implementing the intervention.

RESULTS

We identified three main factors influencing implementation: differentiation of the new intervention from other practice work; development of skill mix and communication across organisations. Overall, post-AKI processes of care were deemed straightforward to embed into existing practice. However, it was also important to separate the intervention from other work in general practice. Dedicating staff time to proactively identify AKI on discharge summaries and to coordinate the provision of care enabled implementation of the intervention. The post-AKI intervention provided an opportunity for practice pharmacists to expand their primary care role. Working in a new setting also brought challenges; time to develop trusting relationships including an understanding of boundaries of clinical expertise influenced pharmacists' roles. Unclear and inconsistent information on discharge summaries contributed to concerns about additional work in primary care.

CONCLUSIONS

The research highlights challenges around post-discharge management in the primary care context. Coordination and communication were key factors for improving follow-up care following AKI. Further consideration is required to understand patient experiences of the interface between secondary and primary care. The issues pertaining to discharge care following AKI are relevant to practitioners and commissioners as they work to improve transitions of care for vulnerable patient populations.

Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation

BACKGROUND

Acute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care.

AIM

To establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI.

DESIGN & SETTING

An appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK.

METHOD

A 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria.

RESULTS

Taking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1-2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI.

CONCLUSION

Systems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.

Effect of nephrology follow-up on long-term outcomes in patients with acute kidney injury: A systematic review and meta-analysis

AIM

Acute kidney injury (AKI) is associated with poor short-term and long-term clinical outcomes. The role of nephrology follow-up in post-AKI management remains uncertain.

METHODS

A systematic review and meta-analysis were performed examining all randomized controlled trials and observational studies assessing the effect of nephrology follow-up on patients' clinical outcomes. The primary outcome was all-cause mortality. The secondary outcomes were renal outcomes, which were defined as a composite of requirement of permanent dialysis and recurrent AKI. Pooled analysis was performed using a random-effect model.

RESULTS

We identified six studies (8972 patients, mean follow-up of 49 months). Five were retrospective cohort studies and one was a prospective cohort study. Risk of bias was a concern with all studied. Only four studies reported primary and/or secondary outcomes and were included. Compared with patients without nephrology follow-up, patients with nephrology follow-up had significantly reduced mortality by 22% (three studies, 3240 patients, relative risk [RR] = 0.78, 95% confidence interval [CI] = 0.70-0.88, I² = 0.0%). Nephrology follow-up did not improve composite renal outcomes with high heterogeneity due to significant differences in reported renal outcomes and follow-up period (two studies, 2537 patients, RR = 1.72, 95% CI = 0.49-6.05, I² = 90.1%).

CONCLUSION

Current evidence from observational studies is biased. It suggests long-term survival benefits with post-discharge nephrology follow-up in AKI patients. However, due to its low quality, such evidence is only hypothesis-generating. Nonetheless, it provides a rationale for future randomized controlled trials of nephrology follow-up in AKI patients. SUMMARY AT A GLANCE The present meta-analysis assessed the effect of nephrology follow-up on patients' clinical outcomes, and suggested long-term survival benefits in acute kidney injury (AKI) survivors. Although the study inherently comprises potential risks of bias due to paucity of available data, the results provide a rationale for future randomized controlled trials.