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Horne K, Noble R, Karelia S, Selby NM. Electronic alerts in acute kidney injury: why does evidence of benefit remain elusive? Curr Opin Nephrol Hypertens 2023; 32:522-527. [PMID: 37615506 DOI: 10.1097/mnh.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is a common syndrome characterized by a sudden reduction in kidney function. It is strongly associated with high mortality and longer, more expensive hospital stays. As AKI often presents silently, a lack of recognition can prevent recommended standards of care. Over the last decade or more, electronic alerts (eAlerts) for AKI have been studied and implemented to address this. This review will summarize the major randomized trials in this area. RECENT FINDINGS A number of randomized trials now exist that study the effectiveness of AKI eAlerts in isolation or as part of more complex interventions. Varying results arise from differences in study design, healthcare system in which the eAlert is introduced, nature of alert, supporting interventions, implementation plan, stated aim (prevention or treatment of established AKI) and choice of outcome measures. SUMMARY Current randomized trial evidence does not show any benefit of eAlerts on mortality. However, variously reported reductions in AKI incidence, AKI progression and AKI duration support a conclusion that strategies incorporating eAlerts can meaningfully benefit delivery of AKI care. Future work should consider how best eAlerts can be utilised, targeted and implemented.
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Affiliation(s)
- Kerry Horne
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rebecca Noble
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Shivaali Karelia
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Impact of an Electronic Alert in Combination with a Care Bundle on the Outcomes of Acute Kidney Injury. Diagnostics (Basel) 2022; 12:diagnostics12123121. [PMID: 36553128 PMCID: PMC9777607 DOI: 10.3390/diagnostics12123121] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Early diagnosis is essential for the appropriate management of acute kidney injury (AKI). We evaluated the impact of an electronic AKI alert together with a care bundle on the progression and mortality of AKI. This was a single-center prospective study that included AKI patients aged ≥ 18 years, whereas those in palliative care, nephrology, and transplantation departments were excluded. An AKI alert was issued in electronic medical records and a care bundle was suggested. A series of classes were administered to the multidisciplinary teams by nephrologists, and a clinical pharmacist audited prescriptions. Patients were categorized into pre-alert and post-alert groups. The baseline characteristics were comparable between the pre-alert (n = 1613) and post-alert (n = 1561) groups. The 30-day mortality rate was 33.6% in the entire cohort and was lower in the post-alert group (30.5% vs. 36.7%; p < 0.001). Age, pulmonary disease, malignancy, and ICU admission were associated with an increase in 30-day mortality. The electronic AKI alert together with a care bundle and a multidisciplinary education program was associated with a reduction in 30-day mortality in patients with AKI.
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Algaze CA, Margetson TD, Sutherland SM, Kwiatkowski DM, Maeda K, Navaratnam M, Samreth SP, Price EP, Zook NB, Yang JK, Hollander SA. Impact of a clinical pathway on acute kidney injury in patients undergoing heart transplant. Pediatr Transplant 2022; 26:e14166. [PMID: 34727417 DOI: 10.1111/petr.14166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To evaluate the impact of a clinical pathway on the incidence and severity of acute kidney injury in patients undergoing heart transplant. METHODS This was a 2.5-year retrospective evaluation using 3 years of historical controls within a cardiac intensive care unit in an academic children's hospital. Patients undergoing heart transplant between May 27, 2014, and April 5, 2017 (pre-pathway) and May 1, 2017, and November 30, 2019 (pathway) were included. The clinical pathway focused on supporting renal perfusion through hemodynamic management, avoiding or delaying nephrotoxic medications, and providing pharmacoprophylaxis against AKI. RESULTS There were 57 consecutive patients included. There was an unadjusted 20% reduction in incidence of any acute kidney injury (p = .05) and a 17% reduction in Stage 2/3 acute kidney injury (p = .09). In multivariable adjusted analysis, avoidance of Stage 2/3 acute kidney injury was independently associated with the clinical pathway era (AOR -1.3 [95% CI -2.5 to -0.2]; p = .03), achieving a central venous pressure of or less than 12 mmHg (AOR -1.3 [95% CI -2.4 to -0.2]; p = .03) and mean arterial pressure above 60 mmHg (AOR -1.6 [95% CI -3.1 to -0.01]; p = .05) in the first 48 h post-transplant, and older age at transplant (AOR - 0.2 [95% CI -0.2 to -0.06]; p = .002). CONCLUSIONS This report describes a renal protection clinical pathway associated with a reduction in perioperative acute kidney injury in patients undergoing heart transplant and highlights the importance of normalizing perioperative central venous pressure and mean arterial blood pressure to support optimal renal perfusion.
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Affiliation(s)
- Claudia A Algaze
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.,Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tristan D Margetson
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - David M Kwiatkowski
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Manchula Navaratnam
- Department of Anesthesia, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sarah P Samreth
- Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth P Price
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nina B Zook
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey K Yang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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Chua HR, Zheng K, Vathsala A, Ngiam KY, Yap HK, Lu L, Tiong HY, Mukhopadhyay A, MacLaren G, Lim SL, Akalya K, Ooi BC. Health Care Analytics With Time-Invariant and Time-Variant Feature Importance to Predict Hospital-Acquired Acute Kidney Injury: Observational Longitudinal Study. J Med Internet Res 2021; 23:e30805. [PMID: 34951595 PMCID: PMC8742216 DOI: 10.2196/30805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/26/2021] [Accepted: 10/29/2021] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) develops in 4% of hospitalized patients and is a marker of clinical deterioration and nephrotoxicity. AKI onset is highly variable in hospitals, which makes it difficult to time biomarker assessment in all patients for preemptive care. Objective The study sought to apply machine learning techniques to electronic health records and predict hospital-acquired AKI by a 48-hour lead time, with the aim to create an AKI surveillance algorithm that is deployable in real time. Methods The data were sourced from 20,732 case admissions in 16,288 patients over 1 year in our institution. We enhanced the bidirectional recurrent neural network model with a novel time-invariant and time-variant aggregated module to capture important clinical features temporal to AKI in every patient. Time-series features included laboratory parameters that preceded a 48-hour prediction window before AKI onset; the latter’s corresponding reference was the final in-hospital serum creatinine performed in case admissions without AKI episodes. Results The cohort was of mean age 53 (SD 25) years, of whom 29%, 12%, 12%, and 53% had diabetes, ischemic heart disease, cancers, and baseline eGFR <90 mL/min/1.73 m2, respectively. There were 911 AKI episodes in 869 patients. We derived and validated an algorithm in the testing dataset with an AUROC of 0.81 (0.78-0.85) for predicting AKI. At a 15% prediction threshold, our model generated 699 AKI alerts with 2 false positives for every true AKI and predicted 26% of AKIs. A lowered 5% prediction threshold improved the recall to 60% but generated 3746 AKI alerts with 6 false positives for every true AKI. Representative interpretation results produced by our model alluded to the top-ranked features that predicted AKI that could be categorized in association with sepsis, acute coronary syndrome, nephrotoxicity, or multiorgan injury, specific to every case at risk. Conclusions We generated an accurate algorithm from electronic health records through machine learning that predicted AKI by a lead time of at least 48 hours. The prediction threshold could be adjusted during deployment to optimize recall and minimize alert fatigue, while its precision could potentially be augmented by targeted AKI biomarker assessment in the high-risk cohort identified.
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Affiliation(s)
- Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kaiping Zheng
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
| | - Anantharaman Vathsala
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kee-Yuan Ngiam
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui-Kim Yap
- Division of Paediatric Nephrology, Department of Paediatrics, National University Children's Medical Institute, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Liangjian Lu
- Division of Paediatric Nephrology, Department of Paediatrics, National University Children's Medical Institute, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ho-Yee Tiong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Urology, National University Hospital, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Graeme MacLaren
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore, Singapore
| | - Shir-Lynn Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - K Akalya
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Beng-Chin Ooi
- Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore
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Schaubroeck HAI, Vargas D, Vandenberghe W, Hoste EAJ. Impact of AKI care bundles on kidney and patient outcomes in hospitalized patients: a systematic review and meta-analysis. BMC Nephrol 2021; 22:335. [PMID: 34625046 PMCID: PMC8501614 DOI: 10.1186/s12882-021-02534-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/15/2021] [Indexed: 12/29/2022] Open
Abstract
Background A bundle of preventive measures can be taken to avoid acute kidney injury (AKI) or progression of AKI. We performed a systematic review and meta-analysis to evaluate the compliance to AKI care bundles in hospitalized patients and its impact on kidney and patient outcomes. Methods Randomized controlled trials, observational and interventional studies were included. Studied outcomes were care bundle compliance, occurrence of AKI and moderate-severe AKI, use of kidney replacement therapy (KRT), kidney recovery, mortality (ICU, in-hospital and 30-day) and length-of-stay (ICU, hospital). The search engines PubMed, Embase and Google Scholar were used (January 1, 2012 - June 30, 2021). Meta-analysis was performed with the Mantel Haenszel test (risk ratio) and inverse variance (mean difference). Bias was assessed by the Cochrane risk of bias tool (RCT) and the NIH study quality tool (non-RCT). Results We included 23 papers of which 13 were used for quantitative analysis (4 RCT and 9 non-randomized studies with 25,776 patients and 30,276 AKI episodes). Six were performed in ICU setting. The number of trials pooled per outcome was low. There was a high variability in care bundle compliance (8 to 100%). Moderate-severe AKI was less frequent after bundle implementation [RR 0.78, 95%CI 0.62–0.97]. AKI occurrence and KRT use did not differ between the groups [resp RR 0.90, 95%CI 0.76–1.05; RR 0.67, 95%CI 0.38–1.19]. In-hospital and 30-day mortality was lower in AKI patients exposed to a care bundle [resp RR 0.81, 95%CI 0.73–0.90, RR 0.95 95%CI 0.90–0.99]; this could not be confirmed by randomized trials. Hospital length-of-stay was similar in both groups [MD -0.65, 95%CI -1.40,0.09]. Conclusion This systematic review and meta-analysis shows that implementation of AKI care bundles in hospitalized patients reduces moderate-severe AKI. This result is mainly driven by studies performed in ICU setting. Lack of data and heterogeneity in study design impede drawing firm conclusions about patient outcomes. Moreover, compliance to AKI care bundles in hospitalized patients is highly variable. Additional research in targeted patient groups at risk for moderate-severe AKI with correct and complete implementation of a feasible, well-tailored AKI care bundle is warranted. (CRD42020207523). Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02534-4.
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Affiliation(s)
- Hannah A I Schaubroeck
- Intensive Care Unit, Ghent University Hospital, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Diana Vargas
- Department of Nephrology, Saint Ignacio University Hospital, Bogota, Colombia
| | - Wim Vandenberghe
- Intensive Care Unit, Ghent University Hospital, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Eric A J Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
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Huddles and their effectiveness at the frontlines of clinical care: a scoping review. J Gen Intern Med 2021; 36:2772-2783. [PMID: 33559062 PMCID: PMC8390736 DOI: 10.1007/s11606-021-06632-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research. METHODS A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts. RESULTS Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%). DISCUSSION Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes. STUDY REGISTRATION This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).
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7
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Bell JS, James BD, Al-Chalabi S, Sykes L, Kalra PA, Green D. Community- versus hospital-acquired acute kidney injury in hospitalised COVID-19 patients. BMC Nephrol 2021; 22:269. [PMID: 34301204 PMCID: PMC8299737 DOI: 10.1186/s12882-021-02471-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/09/2021] [Indexed: 01/08/2023] Open
Abstract
Background Acute kidney injury (AKI) is a recognised complication of coronavirus disease 2019 (COVID-19), yet the reported incidence varies widely and the associated risk factors are poorly understood. Methods Data was collected on all adult patients who returned a positive COVID-19 swab while hospitalised at a large UK teaching hospital between 1st March 2020 and 3rd June 2020. Patients were stratified into community- and hospital-acquired AKI based on the timing of AKI onset. Results Out of the 448 eligible patients with COVID-19, 118 (26.3 %) recorded an AKI during their admission. Significant independent risk factors for community-acquired AKI were chronic kidney disease (CKD), diabetes, clinical frailty score and admission C-reactive protein (CRP), systolic blood pressure and respiratory rate. Similar risk factors were significant for hospital-acquired AKI including CKD and trough systolic blood pressure, peak heart rate, peak CRP and trough lymphocytes during admission. In addition, invasive mechanical ventilation was the most significant risk factor for hospital-acquired AKI (adjusted odds ratio 9.1, p < 0.0001) while atrial fibrillation conferred a protective effect (adjusted odds ratio 0.29, p < 0.0209). Mortality was significantly higher for patients who had an AKI compared to those who didn’t have an AKI (54.3 % vs. 29.4 % respectively, p < 0.0001). On Cox regression, hospital-acquired AKI was significantly associated with mortality (adjusted hazard ratio 4.64, p < 0.0001) while community-acquired AKI was not. Conclusions AKI occurred in over a quarter of our hospitalised COVID-19 patients. Community- and hospital-acquired AKI have many shared risk factors which appear to converge on a pre-renal mechanism of injury. Hospital- but not community acquired AKI was a significant risk factor for death.
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Affiliation(s)
- Jack S Bell
- Salford Royal NHS Foundation Trust, Salford, UK.
| | | | - Saif Al-Chalabi
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Lynne Sykes
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Darren Green
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Emergency Assessment Unit, Salford Royal NHS Foundation Trust, Salford, UK
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8
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Goswami EAS, Sexton E, Fadrowski JJ. Pediatric Nurse and Pharmacist Knowledge of Acute Kidney Injury. Hosp Pediatr 2021; 11:871-877. [PMID: 34301718 DOI: 10.1542/hpeds.2020-005773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In this study, we assessed the knowledge and experience of pediatric pharmacists and nurses at a US tertiary-care pediatric center regarding the risk factors for, recognition of, and best practices for managing an acute kidney injury (AKI) in children. METHODS The authors developed a survey to assess the attitudes and knowledge of nurses and pharmacists regarding AKI in hospitalized children, which was reviewed by a small multidisciplinary group for content and length. The final 16-item survey consisted of demographic, self-assessment and attitude, and knowledge questions. All pediatric pharmacists and nurses at the study site received a voluntary online survey via e-mail. Data were analyzed by using descriptive statistics. RESULTS A survey was sent to 620 nurses and 50 pharmacists; 148 (25%) and 22 (44%), respectively, completed it. Most respondents were <35 years old and had ≤10 years of experience in both their professions and pediatrics. A total of 72% of pediatric nurses felt identification of AKI was within their scope of practice, and ∼60% felt confident in their ability to do so. More than 80% of pediatric pharmacists felt confident in their abilities to adjust medication doses in pediatric patients with AKI, but <60% felt confident in their ability to estimate the glomerular filtration rate in these patients. Nurses and pharmacists were able to correctly identify specific AKI criteria 60% to 70% and 70% to 90% of the time, respectively. CONCLUSIONS Although pediatric nurses and pharmacists have knowledge of AKI prevention and mitigation, gaps exist, and there is a desire for education in recognition of their key roles in the clinical team.
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Affiliation(s)
| | | | - Jeffrey J Fadrowski
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Chew CKT, Hogan H, Jani Y. Scoping review exploring the impact of digital systems on processes and outcomes in the care management of acute kidney injury and progress towards establishing learning healthcare systems. BMJ Health Care Inform 2021; 28:e100345. [PMID: 34233898 PMCID: PMC8264899 DOI: 10.1136/bmjhci-2021-100345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/08/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Digital systems have long been used to improve the quality and safety of care when managing acute kidney injury (AKI). The availability of digitised clinical data can also turn organisations and their networks into learning healthcare systems (LHSs) if used across all levels of health and care. This review explores the impact of digital systems i.e. on patients with AKI care, to gauge progress towards establishing LHSs and to identify existing gaps in the research. METHODS Embase, PubMed, MEDLINE, Cochrane, Scopus and Web of Science databases were searched. Studies of real-time or near real-time digital AKI management systems which reported process and outcome measures were included. RESULTS Thematic analysis of 43 studies showed that most interventions used real-time serum creatinine levels to trigger responses to enable risk prediction, early recognition of AKI or harm prevention by individual clinicians (micro level) or specialist teams (meso level). Interventions at system (macro level) were rare. There was limited evidence of change in outcomes. DISCUSSION While the benefits of real-time digital clinical data at micro level for AKI management have been evident for some time, their application at meso and macro levels is emergent therefore limiting progress towards establishing LHSs. Lack of progress is due to digital maturity, system design, human factors and policy levers. CONCLUSION Future approaches need to harness the potential of interoperability, data analytical advances and include multiple stakeholder perspectives to develop effective digital LHSs in order to gain benefits across the system.
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Affiliation(s)
- Clair Ka Tze Chew
- Transformation and Innovation Team, University College London Hospitals NHS Foundation Trust, London, UK
| | - Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Yogini Jani
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- UCL School of Pharmacy, University College London, London, UK
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Zhang Y, Wang Y, Xu J, Zhu B, Chen X, Ding X, Li Y. Comparison of Prediction Models for Acute Kidney Injury Among Patients with Hepatobiliary Malignancies Based on XGBoost and LASSO-Logistic Algorithms. Int J Gen Med 2021; 14:1325-1335. [PMID: 33889012 PMCID: PMC8057825 DOI: 10.2147/ijgm.s302795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/17/2021] [Indexed: 01/07/2023] Open
Abstract
Background Based on the admission data, we applied the XGBoost algorithm to create a prediction model to estimate the AKI risk in patients with hepatobiliary malignancies and then compare its prediction capacity with the logistic model. Methods We reviewed clinical data of 7968 and 589 liver/gallbladder cancer patients admitted to Zhongshan Hospital during 2014 and 2015. They were randomly divided into the training set and test set. Data were collected from the electronic medical record system. XGBoost and LASSO-logistic were used to develop prediction models, respectively. The performance measures included the classification matrix, the area under the receiver operating characteristic curve (AUC), lift chart and learning curve. Results Of 6846 participants in the training set, 792 (11.6%) cases developed AKI. In XGBoost model, the top 3 most important variables for AKI were serum creatinine (SCr), glomerular filtration rate (eGFR) and antitumor treatment in liver cancer patients. Similarly, SCr and eGFR also ranked second and third most important variables in the gallbladder cancer-related AKI model just after phosphorus. In the classification matrix, XGBoost model possessed a comparably better agreement between the actual observations and the predictions than LASSO-logistic model. The Youden’s index of XGBoost model was 47.5% and 59.3%, respectively, which was significantly higher than that of LASSO-logistic model (41.6% and 32.7%). The AUCs of XGBoost model were 0.822 in liver cancer and 0.850 in gallbladder cancer. By comparison, the AUC values of Logistic models were significantly lower as 0.793 and 0.740 (p=0.024 and 0.018). With the accumulation of training samples, XGBoost model maintained greater robustness in the learning curve. Conclusion XGBoost model based on admission data has higher accuracy and stronger robustness in predicting AKI. It will benefit AKI risk classification management in clinical practice and take an advanced intervention among patients with hepatobiliary malignancies.
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Affiliation(s)
- Yunlu Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
| | - Yimei Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
| | - Jiarui Xu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
| | - Bowen Zhu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
| | - Xiaohong Chen
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
| | - Yang Li
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Medical Center of Kidney, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, People's Republic of China
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Bendall AC, Tan SJ, See EJ, Toussaint ND. Electronic alerts for early detection of acute kidney injury: considering their implementation in Australian hospitals. Med J Aust 2021; 214:347-349.e1. [PMID: 33847000 DOI: 10.5694/mja2.51024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 01/07/2023]
Affiliation(s)
| | - Sven-Jean Tan
- Royal Melbourne Hospital, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Emily J See
- Royal Melbourne Hospital, Melbourne, VIC.,Austin Health, Melbourne, VIC
| | - Nigel D Toussaint
- Royal Melbourne Hospital, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
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12
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Selby NM, Korrodi-Gregório L, Casula A, Kolhe NV, Arbonés DR, Bukieda KD, Sahu D, Rao C, Basadonna G. Randomized Controlled Trial Evidence of Cost-Effectiveness of a Multifaceted AKI Intervention Approach. Kidney Int Rep 2020; 6:636-644. [PMID: 33732978 PMCID: PMC7938080 DOI: 10.1016/j.ekir.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction Acute kidney injury (AKI) is associated with increased health care utilization and higher costs. The Tackling AKI study was a multicenter, pragmatic, stepped-wedge cluster randomized trial that demonstrated a reduced hospital length of stay after implementation of a multifaceted AKI intervention (e-alerts, care bundle, and an education program). We tested whether this would result in cost savings. Methods A decision-analytic tree model from the payer perspective (National Health Service in the United Kingdom) was generated on which cost-effectiveness analyses were performed using a probabilistic sensitivity analysis, accounting only for direct medical costs. Clinical data from the Tackling AKI study were used as inputs and economic and utility data derived from relevant published literature. Results A total of 24,059 AKI episodes occurred during the study period, and in 18,887 admissions the patient was discharged alive. When all AKI stages were considered together, the cost per AKI admission was £5065 in the control arm and £4333 in the intervention arm, representing an incremental cost saving of £732 per admission with the intervention. Similar results were obtained when AKI stages were included as separate variables. Costs per quality-adjusted life year were £61,194 in the control group and £51,161 in the intervention group. At a willingness to pay threshold of £20,000 per quality-adjusted life year, the probability of the intervention being cost-effective compared with standard care was 90%. Conclusion An organizational level approach to improve standards of AKI care reduces the cost of hospital admissions and is cost effective within the National Health Service in the United Kingdom.
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Affiliation(s)
- Nicholas M Selby
- Centre for Kidney Research and Innovation, School of Medicine, University of Nottingham, UK.,Department of Renal Medicine, University Hospitals of Derby and Burton National Health Service Foundation Trust, Derby, UK
| | | | - Anna Casula
- UK Renal Registry and Translational Health Sciences, University of Bristol, UK
| | - Nitin V Kolhe
- Department of Renal Medicine, University Hospitals of Derby and Burton National Health Service Foundation Trust, Derby, UK
| | | | | | - Deepak Sahu
- Alira Health, Framingham, Massachusetts, USA
| | - Chris Rao
- Alira Health, Framingham, Massachusetts, USA
| | - Giacomo Basadonna
- Alira Health, Framingham, Massachusetts, USA.,Department of Surgery, School of Medicine, University of Massachusetts, Amherst, Massachusetts, USA
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13
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Howard SJ, Elvey R, Ohrnberger J, Turner AJ, Anselmi L, Martindale AM, Blakeman T. Post-discharge care following acute kidney injury: quality improvement in primary care. BMJ Open Qual 2020; 9:e000891. [PMID: 33328317 PMCID: PMC7745694 DOI: 10.1136/bmjoq-2019-000891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI. DESIGN We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI. RESULTS AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality. CONCLUSION The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.
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Affiliation(s)
- Susan J Howard
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
| | - Rebecca Elvey
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Julius Ohrnberger
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Alex J Turner
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Laura Anselmi
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Anne-Marie Martindale
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
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14
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Macedo E, Bihorac A, Siew ED, Palevsky PM, Kellum JA, Ronco C, Mehta RL, Rosner MH, Haase M, Kashani KB, Barreto EF. Quality of care after AKI development in the hospital: Consensus from the 22nd Acute Disease Quality Initiative (ADQI) conference. Eur J Intern Med 2020; 80:45-53. [PMID: 32616340 PMCID: PMC7553709 DOI: 10.1016/j.ejim.2020.04.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is independently associated with increased morbidity and mortality. Quality improvement has been identified as an important goal in the care of patients with AKI. Different settings can be targeted to improve AKI care, broadly classified these include the inpatient and outpatient environments. In this paper, we will emphasize quality indicators associated with the management and secondary prevention of AKI in hospitalized patients to limit the severity, duration, and complications. METHODS During the 22nd Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for AKI-related quality indicators (QIs) and care processes to improve patient outcomes. The management and secondary prevention of AKI in hospitalized patients were discussed, and recommendations were summarized. RESULTS The first step in optimizing the quality of AKI management is the determination of baseline performance. Data regarding each institution's/center's performance can provide a reference point from which to benchmark quality efforts. Quality program initiatives should prioritize achievable goals likely to have the highest impact according to the setting and context. Key AKI quality metrics should include improvement in timely recognition, appropriate diagnostic workup, and implementation of known interventions that limit progression and severity, facilitating recovery, and mitigating AKI-associated complications. We propose the Recognition-Action-Results framework to plan, measure, and report the progress toward improving AKI management quality. CONCLUSIONS These recommendations identified and outlined an approach to define and evaluate the quality of AKI management in hospitalized patients.
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Affiliation(s)
- Etienne Macedo
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, United States.
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Edward D Siew
- Tennessee Valley Healthcare System (TVHS), Veterans Administration (VA) Medical Center, Veteran's Health Administration; Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center; Vanderbilt Center for Kidney Disease (VCKD), Nashville, TN, United States
| | - Paul M Palevsky
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA, United States
| | - Claudio Ronco
- University of Padova. Director Department of Nephrology Dialysis & Transplantation; AULSS8 Regione Veneto, Vicenza, Italy; Director International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - Ravindra L Mehta
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, United States
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Michael Haase
- Medical Faculty, Otto-von Guericke University Magdeburg, Magdeburg, Germany; MVZ Diaverum, Potsdam, Germany
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Erin F Barreto
- Department of Pharmacy; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
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15
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Heslop P, Baker-Glenn E, Fleming P, Knight M, Mason M, Turnbull P, Wade C. The impact of the national clinical outcome review programmes in England: a review of the evidence. Clin Med (Lond) 2020; 20:e52-e58. [DOI: 10.7861/clinmed.2019-0359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Aglae C, Muller L, Reboul P, Cariou S, Saber Davide B, Trusson R, Messikh Z, De Brauwere DP, Lefrant JY, Moranne O. Heterogeneity of Cause, Care, and Prognosis in Severe Acute Kidney Injury in Hospitalized Patients: A Prospective Observational Study. Can J Kidney Health Dis 2019; 6:2054358119892174. [PMID: 31839974 PMCID: PMC6896136 DOI: 10.1177/2054358119892174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background: KDIGO (Kidney Disease: Improving Global Outcomes) defines acute kidney injury (AKI) solely by serum creatinine (SCr) and urine output variation. Severe AKI is a syndrome covering various clinical situations. Objective: To describe severe AKI heterogeneity by department of hospitalization. Design: This is a prospective observational single-center study. Setting: Adult patients hospitalized in a French tertiary hospital from August 2016 to December 2017. Patients: All adults with severe AKI, defined by dialysis for AKI or an increase in SCr above 354 μmol/L. Measurements: Patient characteristics, clinical and laboratory presentation, AKI cause, medical indication for renal replacement therapy (RRT), planned palliative care, and vital status 30 days after severe AKI. Methods: A global description of patient characteristics, care, and prognosis and comparison by department of hospitalization: intensive care unit (ICU), nephrology, and others. Results: The study included 480 patients (73% men, median age: 72 years, range: 64-83), with medical histories including cardiovascular disease, diabetes, cancer, and chronic kidney disease. Principal causes were sepsis (104; 22%), hypovolemia (98; 20%), obstructive AKI (84; 18%), acute tubular necrosis (ATN; 74; 15%), and cardiorenal syndrome (51; 11%). Severe AKI was diagnosed in the ICU for 188 (39%) patients, the nephrology department for 130 (27%), and in other wards for 162 (34%). Patient characteristics differed by department for age, comorbidity, cause, and RRT use and indications. Palliative care was planned for 72 (15%) patients, most frequently in other wards. Limitations: We studied a subgroup of stage 3 KDIGO AKI patients in a single center without cardiac surgery. Conclusion: Patients hospitalized for severe AKI have frequent and various comorbidities, different clinical presentations, care, hospitalization in various departments, and different prognosis. The heterogeneity of this severe AKI implies the need for personalized care, which requires prognostic tools that include information besides SCr and diuresis.
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Affiliation(s)
- Cedric Aglae
- Service Nephrologie-Dialyse-Aphérèse, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Laurent Muller
- Service des Réanimation, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Pascal Reboul
- Service Nephrologie-Dialyse-Aphérèse, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Sylvain Cariou
- Service Nephrologie-Dialyse-Aphérèse, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Barbar Saber Davide
- Service des Réanimation, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Remi Trusson
- Service des Réanimation, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Ziyad Messikh
- Service Nephrologie-Dialyse-Aphérèse, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - David-Paul De Brauwere
- Service de Biochimie et Biologie Moléculaire, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Jean-Yves Lefrant
- Service des Réanimation, CHU Carémeau, Université de Montpellier-Nîmes, France
| | - Olivier Moranne
- Service Nephrologie-Dialyse-Aphérèse, CHU Carémeau, Université de Montpellier-Nîmes, France
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17
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Tollitt J, Bennett N, Darby D, Flanagan E, Chadwick P, Sinha S, Kalra PA, Ritchie J, Poulikakos D. The importance of acute kidney injury in suspected community acquired infection. PLoS One 2019; 14:e0216412. [PMID: 31063508 PMCID: PMC6504101 DOI: 10.1371/journal.pone.0216412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 04/21/2019] [Indexed: 01/18/2023] Open
Abstract
Background Most sepsis and acute kidney injury (AKI) cases are community acquired (CA). The aim of this study was to evaluate the characteristics of suspected community acquired infection (sCA-I) and CA-AKI and their impact upon patient outcomes. Methods All adult creatinine blood tests from non-elective, non-dialysis attendances to a single centre over a 29-month period were analysed retrospectively. We defined sCA-I and CA-AKI cases as antibiotic prescription and AKI alert within 48 hours of attendance respectively. Binary logistic regression models were created to determine associations with 30-day mortality, intensive care unit (ICU) admission and length of stay (LOS) dichotomised at median. Results Of 61,471 attendances 28.1% and 5.7% suffered sCA-I or CA-AKI in isolation respectively, 3.4% suffered both. sCA-I was present in 58.8% of CA-AKI cases and CA-AKI was present in 11.9% of CA-I cases. The combination of sCA-I and CA-AKI was associated with a higher risk for all outcomes compared to sCA-I or CA-AKI in isolation. The 30-day mortality was 8.1%, 11.8% and 26.2% in patients with sCA-I, CA-AKI and when sCA-I and CA-AKI occurred in combination respectively. The adjusted odds ratios (OR) and 95% confidence intervals (CI) for 30-day mortality, ICU admission and LOS for sCA-I combined with CA-AKI stage 1 were OR 6.09:CI: 5.21–7.12, OR 12.52 CI: 10.54–14.88 and OR 8.97 CI: 7.62–10.56, respectively, and for combined sCA-I and CA-AKI stage 3 were OR 9.23 CI: 6.91–12.33, OR 29.26 CI: 22.46–38.18 and OR 9.48 CI: 6.82–13.18 respectively. Conclusion The combination of sCA-I and CA-AKI is associated with worse outcomes.
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Affiliation(s)
- James Tollitt
- Renal Department, Salford Royal NHS Trust, Salford, United Kingdom
- University of Manchester, Oxford Road, Manchester, United Kingdom
- * E-mail:
| | - Nicola Bennett
- University of Manchester, Oxford Road, Manchester, United Kingdom
| | - Denise Darby
- Pathology Department, Salford Royal NHS Trust, Salford, United Kingdom
| | - Emma Flanagan
- Informatics Department, Salford Royal NHS Trust, Salford, United Kingdom
| | - Paul Chadwick
- Pathology Department, Salford Royal NHS Trust, Salford, United Kingdom
| | - Smeeta Sinha
- Renal Department, Salford Royal NHS Trust, Salford, United Kingdom
- University of Manchester, Oxford Road, Manchester, United Kingdom
| | - Philip A. Kalra
- Renal Department, Salford Royal NHS Trust, Salford, United Kingdom
- University of Manchester, Oxford Road, Manchester, United Kingdom
| | - James Ritchie
- Renal Department, Salford Royal NHS Trust, Salford, United Kingdom
- University of Manchester, Oxford Road, Manchester, United Kingdom
| | - Dimitrios Poulikakos
- Renal Department, Salford Royal NHS Trust, Salford, United Kingdom
- University of Manchester, Oxford Road, Manchester, United Kingdom
- AKI Lead for Greater Manchester and Eastern Cheshire Strategic Clinical Networks, Manchester, United Kingdom
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18
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Sykes L, Kalra PA, Green D. Comparison of impact on death and critical care admission of acute kidney injury between common medical and surgical diagnoses. PLoS One 2019; 14:e0215105. [PMID: 30973921 PMCID: PMC6459489 DOI: 10.1371/journal.pone.0215105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/26/2019] [Indexed: 11/18/2022] Open
Abstract
Background Acute Kidney Injury (AKI) is common and associated with increased morbidity and mortality. This retrospective analysis quantified and compared the association between AKI and the risk of death and admission to critical care in acute admissions of different aetiology. Methods Data were extracted anonymously from the Trust ‘data warehouse’ for admissions between 2011and 2017. We applied KDIGO AKI criteria to establish AKI stage. Odds ratios (OR) for death and critical care admission were calculated for patients with AKI stage 3 (compared to all other patients), and patients with any stage AKI (compared to non-AKI admissions). Analyses were performed using logistic regression, adjusted for age, pre-existing CKD, co-morbid index, and gender. Results There were 26,052 medical and 12,560 surgical patient episodes within sixteen common diagnoses with 3823 medical and 1520 surgical patients with AKI events. The likelihood of AKI was highest in sepsis (31.8%), and the likelihood of death in AKI 3 highest in femoral neck fracture (54.5%). AKI 3 has a OR for death for acute coronary syndrome of 12.8 and a OR of 24.6 in femoral neck fracture. Admission to critical care for any AKI in medical patients has a OR of 9.6, but increases to OR 37.2 for heart failure. Conclusion The clinical impact of AKI differs across medical and surgical diagnoses, but is a significant contributor to the risk for death and critical care admission. This body of work may indicate a benefit to a more diagnosis-specific stratified approach to AKI care.
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Affiliation(s)
- Lynne Sykes
- Emergency Assessment Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, United Kingdom
- * E-mail:
| | - Philip A. Kalra
- Renal department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, United Kingdom
| | - Darren Green
- Emergency Assessment Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, United Kingdom
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