Review of the Literature on the Costs Associated With Acute Kidney Injury

Effect of acute kidney injury care bundle on kidney outcomes in cardiac patients receiving critical care: a systematic review and meta-analysis

BACKGROUND

Cardiac surgery is a major contributor to acute kidney injury (AKI); approximately 22% of patients who undergo cardiac surgery develop AKI, and among them, 2% will require renal replacement therapy (RRT). AKI is also associated with heightened risks of mortality and morbidity, longer intensive care stays, and increased treatment costs. Due to the challenges of treating AKI, prevention through the use of care bundles is suggested as an effective approach. This review aimed to assess the impact of care bundles on kidney outcomes, mortality, and hospital stay for cardiac patients in critical care.

METHODS

PubMed, Scopus, Web of Science, and EMBASE were searched up to November 2024. Inclusion criteria were studies on individuals with cardiac diseases receiving critical care, that used AKI care bundle as the intervention, and reported outcomes related to AKI, mortality, and other kidney-related events. We used the Cochrane Collaboration's risk of bias tool 2 and the Newcastle-Ottawa scale for quality assessment. Pooled odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Seven studies on total 5045 subjects, including five observational and two randomized controlled trials (RCTs) were included. The implementation of care bundles significantly reduced the incidence of all-stage AKI (OR: 0.78; 95%CI: 0.61-0.99) and moderate-severe AKI (OR: 0.56; 95%CI: 0.43-0.72). Also, the implementation of care bundle increased the incidence of persistent renal dysfunction after 30 days by 2.39 times. However, there were no significant changes in RRT, major adverse kidney events, or mortality between the groups. The mean quality assessment score for observational studies was 7.2 out of ten, while there were noted concerns in the risk of bias assessment of the RCTs.

CONCLUSIONS

The application of care bundles in patients, including those undergoing cardiac surgeries as well as non-cardiac critical illness, appears to be effective in reducing AKI, particularly in moderate and severe stages. However, given the inclusion of non-cardiac patients in some studies, the observed effect may not be solely attributable to cardiac surgery cases. Future large-scale RCTs focusing specifically on cardiac surgery patients are recommended to clarify the impact of care bundles within this subgroup.

REGISTRATION ID IN PROSPERO

CRD42024498972.

Economic burden of acute kidney injury in children and adults: a protocol for a systematic review and meta-analysis

INTRODUCTION

Acute kidney injury (AKI) is common in hospitalised adults and children and is associated with significantly increased mortality and worse short-term and long-term outcomes. This systematic review and meta-analysis will evaluate the cost associated with AKI.

METHODS AND ANALYSIS

This health economic analysis will be performed using systematic search of databases, including MEDLINE, EMBASE, CINAHL, Scopus and Cochrane Library from 2009 to the present (search completed on 27 May 2024). Two reviewers will independently complete study selection, data extraction and bias assessment. Inclusion criteria will be randomised controlled trials (RCTs) and observational studies (cohort or case-control) from all countries of hospitalised adults and children. The exposure will be AKI based on definitions using serum creatinine and/or urine output criteria, relative to patients without AKI. The primary outcome studied will be the cost of index hospitalisation associated with AKI episode. Other secondary outcomes will include the cost of intensive care unit admission during index hospitalisation, direct costs related to inpatient and outpatient care) and indirect (time) costs related to loss of productivity. Pooled random-effect meta-analysis ORs with 95% CIs will be reported.

ETHICS AND DISSEMINATION

Ethics approval was not required due to study methodology. The authors have no competing interests to report. The results will be disseminated in peer-reviewed publications according to guidelines by the Cochrane and Centre for Reviews and Dissemination.

PROSPERO REGISTRATION NUMBER

CRD42024512658.

A cost effectiveness analysis of a quality improvement intervention to increase preferential balanced fluid prescribing

BACKGROUND

The higher cost of balanced fluids has historically contributed to preferential normal saline (NS) use. Recent clinical trials demonstrated that balanced fluids reduced the incidence of major adverse kidney events among hospitalized patients and also reduced mortality among critically ill patients. This study sought to conduct an economic evaluation of a recently published quality improvement (QI) intervention to increase preferential balanced fluid prescribing, which significantly increased the relative proportion of balanced fluid orders.

METHODS

Using clinical trial data and real-world data from our prior QI intervention in conjunction with local and regional cost data, we constructed a decision tree to examine the economic cost and clinical consequences of using NS, lactated ringers (LR), and plasma-lyte for 30,000 hypothetical adult patients and 1,290 hypothetical critically ill adult patients with sepsis admitted to our institution over one year. Clinical outcomes (hospitalization to day 30) included development of acute kidney injury (AKI), new requirement for renal replacement therapy (RRT), and in-hospital mortality. The primary economic outcome was the difference in cost between the pre- and post-QI intervention periods. Sensitivity analyses and breakeven analyses were performed. Evaluation was conducted from South Carolina hospitals' perspective.

RESULTS

For the overall cohort, simulation predicted that 53 AKIs, 2 instances of RRT, and 62 deaths were avoided in the post-intervention year with a net cost savings of $704,507. For the critically ill patients with sepsis, simulation predicted that 32 AKIs, 4 instances of RRT, and 12 deaths were avoided with a net cost savings of $474,676. Sensitivity analyses using outcome data from additional clinical trials also estimated annual cost savings ($77,677-$414,872).

CONCLUSIONS

The QI intervention was predicted to improve patient outcomes while yielding significant cost-savings. The marginally increased cost of balanced fluids should not discourage implementation of interventions aimed at increasing evidence-supported balanced fluid prescribing.

A Systematic Review of the Costs of Drug-Associated Acute Kidney Injury and Potential Cost Savings with Nephrotoxin Stewardship Prevention Strategies

There is a scarcity of information related to the financial impact of acute kidney injury (AKI), and even more so the economics of drug-associated AKI (D-AKI). Our goal was to provide a comprehensive summary of the economic burden of D-AKI by evaluating the costs of D-AKI compared to not developing AKI and cost savings associated with nephrotoxin stewardship approaches. Following the PRISMA guidelines, a literature search was conducted using PubMed to identify articles from database inception through November 2023. The main outcomes included AKI incidence, resource use, and cost of nephrotoxin stewardship programs/D-AKI event or no event. Key findings were summarized based on whether the study compared the cost of D-AKI vs. no AKI or identified potential cost savings associated with a nephrotoxin stewardship method to prevent D-AKI or worsening D-AKI. All costs were adjusted to USD2023. Twenty-five studies met the inclusion criteria. Eight studies compared the cost of D-AKI to no AKI. Total admission costs of patients who developed D-AKI ranged from $47,696 to $173,569. Nineteen studies implemented nephrotoxin stewardship with 12 substituting a less nephrotoxic drug; five using therapeutic drug monitoring and two altering drug dosing to limit exposure. Overall, these prevention strategies ranged from $5,171 to $364,973 in total medical cost savings and $17 to $942 in total cost savings per patient-day. The in-hospital economic impact of D-AKI is substantial. Implementing nephrotoxin stewardship strategies to reduce D-AKI is associated with cost savings. Institutions should adopt strategic and efficient nephrotoxin stewardship programs to optimize patient care and reduce costs.

Nanotherapeutic kidney cell-specific targeting to ameliorate acute kidney injury

Acute kidney injury (AKI) increases the risk of in-hospital death, adds to expense of care, and risk of early chronic kidney disease. AKI often follows an acute event such that timely treatment could ameliorate AKI and potentially reduce the risk of additional disease. Despite therapeutic success of dexamethasone in animal models, clinical trials have not demonstrated broad success. To improve the safety and efficacy of dexamethasone for AKI, we developed and characterized a novel, kidney-specific nanoparticle enabling specific within-kidney targeting to proximal tubular epithelial cells provided by the megalin ligand cilastatin. Cilastatin and dexamethasone were complexed to H-Dot nanoparticles, which were constructed from generally recognized as safe components. Cilastatin/Dexamethasone/H-Dot nanotherapeutics were found to be stable at plasma pH and demonstrated salutary release kinetics at urine pH. In vivo, they were specifically biodistributed to the kidney and bladder, with 75% recovery in the urine and with reduced systemic toxicity compared to native dexamethasone. Cilastatin complexation conferred proximal tubular epithelial cell specificity within the kidney in vivo and enabled dexamethasone delivery to the proximal tubular epithelial cell nucleus in vitro. The Cilastatin/Dexamethasone/H-Dot nanotherapeutic improved kidney function and reduced kidney cellular injury when administered to male C57BL/6 mice in two translational models of AKI (rhabdomyolysis and bilateral ischemia reperfusion). Thus, our design-based targeting and therapeutic loading of a kidney-specific nanoparticle resulted in preservation of the efficacy of dexamethasone, combined with reduced off-target disposition and toxic effects. Hence, our study illustrates a potential strategy to target AKI and other diseases of the kidney.

Renal Protective Effect of Umbelliferone on Acute Kidney Injury in Rats via Alteration of HO-1/Nrf2 and NF-κB Signaling Pathway

Acute kidney injury (AKI), formerly known as acute renal failure, refers to a sudden and often reversible decline in kidney function. Inflammatory reaction and oxidative stress play a crucial role in the expansion of renal disease. In this experimental study, we scrutinized the renal protective effect of umbelliferone against gentamicin induced renal injury in the rats and explore the mechanism. Wistar rats were used in this study and Gentamicin was used for the induction the AKI in the rats and rats were received the oral administration of umbelliferone. The body weight, organ weight, renal, oxidative stress, cytokines, inflammatory parameters were estimated. The mRNA expression caspase-3, Bax, Bcl-2, TNF-α, IL-1β, IL-6, IL-10, HO-1, and Nrf2 were estimated. Umbelliferone remarkably improved the body weight and altered the absolute and relative weight of hepatic and renal tissue. Umbelliferone significantly suppressed the level of BUN, Scr, magnesium, calcium, phosphorus, sodium, and potassium along with altered the level of oxidative stress parameters like CAT, SOD, GSH, LPO, and GPx. Umbelliferone altered the level of cytokines viz., TNF-α, Il-1β, IL-6, IL-10; inflammatory parameters like PGE2, COX-2, TGF-β, NF-κB, respectively. Umbelliferone significantly altered the mRNA expression of caspase-3, Bax, Bcl-2, TNF-α, IL-1β, IL-6, IL-10, HO-1, and Nrf2. The result showed the renal protective effect of umbelliferone against gentamycin induced renal disease via alteration of HO-1/Nrf2 and NF-κB Signaling Pathway.

The evolution of public attention in acute kidney injury and continuous renal replacement therapy: trends analysis from 2004 to 2024

Background

Acute kidney injury (AKI) and the need for Continuous Renal Replacement Therapy (CRRT) are critically important health concerns. This study analyzes global and regional Internet search queries to understand public attention in AKI and CRRT over time.

Methods

We used Google Trends™ to analyze search queries for AKI and CRRT from January 2004 to March 2024. The study examined global trends and detailed insights from the United States, including state-by-state breakdowns. We identified patterns, peaks of attention, and temporal trends in public attention, comparing regional variations across the US and top-ranking countries worldwide.

Results

Global attention in AKI peaked in October 2022, with Portugal, Zambia, and Spain showing the highest regional attention. Within the United States, peak attention was in February 2008. Tennessee, Pennsylvania, and West Virginia were the top states that paid attention to AKI. Attention in CRRT peaked globally in March 2024. South Korea, Saudi Arabia, and Bahrain have led the global attention to CRRT. In the United States, peak attention was in April 2020. West Virginia, Tennessee, and Kentucky showed the highest state-specific attention in CRRT.

Conclusions

This study reveals significant temporal and geographical variations in online search patterns for AKI and CRRT, suggesting evolving public attention to these critical health issues. This knowledge can guide the development of targeted public health initiatives, enhance medical education efforts, and help healthcare systems tailor their approach to improving awareness and outcomes in kidney health across diverse populations.

Optimum Care of AKI Survivors Not Requiring Dialysis after Discharge: An AKINow Recovery Workgroup Report

AKI survivors experience gaps in care that contribute to worse outcomes, experience, and cost.Challenges to optimal care include issues with information transfer, education, collaborative care, and use of digital health tools.Research is needed to study these challenges and inform optimal use of diagnostic and therapeutic interventions to promote recovery AKI affects one in five hospitalized patients and is associated with poor short-term and long-term clinical and patient-centered outcomes. Among those who survive to discharge, significant gaps in documentation, education, communication, and follow-up have been observed. The American Society of Nephrology established the AKINow taskforce to address these gaps and improve AKI care. The AKINow Recovery workgroup convened two focus groups, one each focused on dialysis-independent and dialysis-requiring AKI, to summarize the key considerations, challenges, and opportunities in the care of AKI survivors. This article highlights the discussion surrounding care of AKI survivors discharged without the need for dialysis. On May 3, 2022, 48 patients and multidisciplinary clinicians from diverse settings were gathered virtually. The agenda included a patient testimonial, plenary sessions, facilitated small group discussions, and debriefing. Core challenges and opportunities for AKI care identified were in the domains of transitions of care, education, collaborative care delivery, diagnostic and therapeutic interventions, and digital health applications. Integrated multispecialty care delivery was identified as one of the greatest challenges to AKI survivor care. Adequate templates for communication and documentation; education of patients, care partners, and clinicians about AKI; and a well-coordinated multidisciplinary posthospital follow-up plan form the basis for a successful care transition at hospital discharge. The AKINow Recovery workgroup concluded that advancements in evidence-based, patient-centered care of AKI survivors are needed to improve health outcomes, care quality, and patient and provider experience. Tools are being developed by the AKINow Recovery workgroup for use at the hospital discharge to facilitate care continuity.

Risk of chronic kidney disease in patients with acute kidney injury following a major surgery: a US claims database analysis

Background

Acute kidney injury (AKI) is a common complication after major surgery. This study assessed the risk of developing or worsening of chronic kidney disease (CKD) and other clinical outcomes in patients experiencing AKI after major surgery.

Methods

This retrospective observational study used Optum's de-identified Clinformatics Data Mart Database to investigate cardiorenal outcomes in adult patients at the first AKI event following major surgery. The primary outcome was CKD stage ≥3; secondary outcomes included myocardial infarction (MI), stroke, heart failure, all-cause hospitalization, end-stage kidney disease, need for dialysis or kidney transplant and composite measures. Follow-up was up to 3 years. Additionally, the effect of intercurrent events on the risk of clinical outcomes was assessed.

Results

Of the included patients (N = 31 252), most were male (61.9%) and White (68.9%), with a median age of 72 years (interquartile range 64-79). The event rates were 25.5 events/100 patient-years (PY) for CKD stage ≥3, 3.1 events/100 PY for end-stage kidney disease, 3.0 events/100 PY for dialysis and 0.1 events/100 PY for kidney transplants. Additionally, there were 6.9 events/100 PY for MI, 8.7 events/100 PY for stroke and 49.8 events/100 PY for all-cause hospitalization during follow-up. Patients with AKI relapses as intercurrent events were more likely to develop CKD stage ≥3 than those with just one AKI event after major surgery.

Conclusion

This analysis demonstrated that patients experiencing AKI following major surgery are at high risk of developing severe CKD or worsening of pre-existing CKD and other cardiorenal clinical outcomes such as MI and stroke.

Prevention and management of antibiotic associated acute kidney injury in critically ill patients: new insights

PURPOSE OF REVIEW

Drug associated kidney injury (D-AKI) occurs in 19-26% of hospitalized patients and ranks as the third to fifth leading cause of acute kidney injury (AKI) in the intensive care unit (ICU). Given the high use of antimicrobials in the ICU and the emergence of new resistant organisms, the implementation of preventive measures to reduce the incidence of D-AKI has become increasingly important.

RECENT FINDINGS

Artificial intelligence is showcasing its capabilities in early recognition of at-risk patients for acquiring AKI. Furthermore, novel synthetic medications and formulations have demonstrated reduced nephrotoxicity compared to their traditional counterparts in animal models and/or limited clinical evaluations, offering promise in the prevention of D-AKI. Nephroprotective antioxidant agents have had limited translation from animal studies to clinical practice. The control of modifiable risk factors remains pivotal in avoiding D-AKI.

SUMMARY

The use of both old and new antimicrobials is increasingly important in combating the rise of resistant organisms. Advances in technology, such as artificial intelligence, and alternative formulations of traditional antimicrobials offer promise in reducing the incidence of D-AKI, while antioxidant medications may aid in minimizing nephrotoxicity. However, maintaining haemodynamic stability using isotonic fluids, drug monitoring, and reducing nephrotoxic burden combined with vigilant antimicrobial stewardship remain the core preventive measures for mitigating D-AKI while optimizing effective antimicrobial therapy.

Accurate and interpretable prediction of ICU-acquired AKI

PURPOSE

We developed and validated two parsimonious algorithms to predict the time of diagnosis of any stage of acute kidney injury (any-AKI) or moderate-to-severe AKI in clinically actionable prediction windows.

MATERIALS AND METHODS

In this retrospective single-center cohort of adult ICU admissions, we trained two gradient-boosting models: 1) any-AKI model, predicting the risk of any-AKI at least 6 h before diagnosis (50,342 admissions), and 2) moderate-to-severe AKI model, predicting the risk of moderate-to-severe AKI at least 12 h before diagnosis (39,087 admissions). Performance was assessed before disease diagnosis and validated prospectively.

RESULTS

The models achieved an area under the receiver operating characteristic curve (AUROC) of 0.756 at six hours (any-AKI) and 0.721 at 12 h (moderate-to-severe AKI) prior. Prospectively, both models had high positive predictive values (0.796 and 0.546 for any-AKI and moderate-to-severe AKI models, respectively) and triggered more in patients who developed AKI vs. those who did not (median of 1.82 [IQR 0-4.71] vs. 0 [IQR 0-0.73] and 2.35 [IQR 0.14-4.96] vs. 0 [IQR 0-0.8] triggers per 8 h for any-AKI and moderate-to-severe AKI models, respectively).

CONCLUSIONS

The two AKI prediction models have good discriminative performance using common features, which can aid in accurately and informatively monitoring AKI risk in ICU patients.

Incidence, predictors, clinical outcomes, and economic burden of recurrent acute kidney injury: a retrospective cohort study

OBJECTIVE

This study aimed to assess the incidence, predictors, mortality, and economic outcomes of recurrent Acute kidney injury (AKI) in Jordan.

METHODS

This was a retrospective cohort study that included adult patients who were admitted with AKI to university hospitals in the country from 2010-2019. Recurrent episodes of AKI, laboratory data, baseline medication list, and death dates were retrieved from patient's medical records. The incidence rate of recurrent AKI was estimated. Predictors of recurrent AKI and mortality during the five years post-discharge was evaluated. Total admission charges were described and evaluated in total and by service provided.

RESULTS

Among 1162 AKI patients, 57 patients (4.9%) died during the index admission (first admission during the study period), and among the survivors, 220 patients were re-hospitalized with a recurrent AKI during five years of follow-up. Patients with higher discharge serum creatinine level (SCr) at index admission had higher odds of AKI recurrence (OR = 1.001). Patients who were on respiratory, antineoplastic, or anticoagulant medications were also more susceptible to recurrence; ORs were 1.69, 2.77, and 4.16, respectively. Patients who were elderly, with recurrent AKI episodes, or with a more extended hospital stay at index admission were more likely to die during the five years post discharge. The median charge of recurrent admissions was higher than the median charge of the index admissions; 1519.17 JOD ($2142.7) versus 1362.85 JOD ($1922.2), respectively.

CONCLUSIONS

Recurrent AKI is associated with increased mortality and health expenditures. Higher discharge SCr levels at index admission, and chronic comorbidities are associated with a higher likelihood of AKI recurrence.

Health Care Resource Utilization and Costs of Persistent Severe Acute Kidney Injury (PS-AKI) Among Hospitalized Stage 2/3 AKI Patients

Key Points

Among hospitalized patients with stage 2/3 AKI, persistent severe acute kidney injury (PS-AKI) is associated with significantly longer length of stay (LOS) and higher costs during index hospitalization and 30 days postdischarge. Relative differences in LOS and costs for PS-AKI versus NPS-AKI were similar for intensive care (ICU) and non-ICU patients. Preventing PS-AKI among patients with stage 2/3 AKI may reduce hospital LOS and costs.

Background

Persistent severe acute kidney injury (PS-AKI) is associated with worse clinical outcomes, but there are no data on costs of PS-AKI. We compared costs and health care resource utilization for inpatients with PS-AKI versus not persistent severe AKI (NPS-AKI) overall and by ICU use.

Methods

This retrospective observational study included 126,528 adult US inpatients in the PINC AI Healthcare Database (PHD), discharged from January 1, 2017, to December 31, 2019, with KDIGO stage 2 or 3 AKI (by serum creatinine [SCr] criteria) during hospitalization, length of stay (LOS) ≥3 days, and ≥3 SCr measurements. Patients were categorized as PS-AKI (defined as stage 3 AKI lasting ≥3 days or with death within 3 days or stage 2/3 AKI (by SCr criteria) with dialysis within 3 days) or NPS-AKI. Generalized linear model regression compared LOS and costs during index hospitalization (total cohort) and 30 days postdischarge (survivors of index hospitalization), adjusted for patient, hospital, and clinical characteristics.

Results

Among 126,528 patients with stage 2/3 AKI, 30,916 developed PS-AKI. In adjusted models, compared with NPS-AKI, patients with PS-AKI had 32% longer total LOS (+3.3 days), 45% longer ICU LOS (+2.6 days), 46% higher total costs (+$13,143), 58% higher ICU costs (+$15,908), and during 30 days postdischarge 13% longer readmission LOS (+1.0 day), 22% higher readmission costs (+$4049), and 12% higher outpatient costs (+$206) (P <0.005 for all). Relative LOS and cost differences for PS-AKI versus NPS-AKI were similar for ICU (n=57,947) and non-ICU (n =68,581) patients.

Conclusions:

Among hospitalized patients with stage 2/3 AKI, PS-AKI was associated with significantly longer LOS and higher costs during index hospitalization and 30 days postdischarge, overall, and in ICU and non-ICU patients. Preventing PS-AKI among patients with stage 2/3 AKI may reduce hospital LOS and costs.

Outcomes, Healthcare Resource Utilization, and Costs of Overall, Community-Acquired, and Hospital-Acquired Acute Kidney Injury in COVID-19 Patients

Background: In hospitalized patients with COVID-19, acute kidney injury (AKI) is associated with higher mortality, but data are lacking on healthcare resource utilization (HRU) and costs related to AKI, community-acquired AKI (CA-AKI), and hospital-acquired AKI (HA-AKI). Objectives: To quantify the burden of AKI, CA-AKI, and HA-AKI among inpatients with COVID-19. Methods: This retrospective cohort study included inpatients with COVID-19 discharged from US hospitals in the Premier PINC AI™ Healthcare Database April 1-October 31, 2020, categorized as AKI, CA-AKI, HA-AKI, or no AKI by ICD-10-CM diagnosis codes. Outcomes were assessed during index (initial) hospitalization and 30 days postdischarge. Results: Among 208 583 COVID-19 inpatients, 30%, 25%, and 5% had AKI, CA-AKI, and HA-AKI, of whom 10%, 7%, and 23% received dialysis, respectively. Excess mortality, HRU, and costs were greater for HA-AKI than CA-AKI. In adjusted models, for patients with AKI vs no AKI and HA-AKI vs CA-AKI, odds ratios (ORs) (95% CI) were 3.70 (3.61-3.79) and 4.11 (3.92-4.31) for intensive care unit use and 3.52 (3.41-3.63) and 2.64 (2.52-2.78) for in-hospital mortality; mean length of stay (LOS) differences and LOS ratios (95% CI) were 1.8 days and 1.24 (1.23-1.25) and 5.1 days and 1.57 (1.54-1.59); and mean cost differences and cost ratios were $7163 and 1.35 (1.34-1.36) and $19 127 and 1.78 (1.75-1.81) (all P < .001). During the 30 days postdischarge, readmission LOS was ≥6% longer for AKI vs no AKI and HA-AKI vs CA-AKI; outpatient costs were ≥41% higher for HA-AKI vs CA-AKI or no AKI. Only 30-day new dialysis (among patients without index hospitalization dialysis) had similar odds for HA-AKI vs CA-AKI (2.37-2.8 times higher for AKI, HA-AKI, or CA-AKI vs no AKI). Discussion: Among inpatients with COVID-19, HA-AKI had higher excess mortality, HRU, and costs than CA-AKI. Other studies suggest that interventions to prevent HA-AKI could decrease excess morbidity, HRU, and costs among inpatients with COVID-19. Conclusions: In adjusted models among COVID-19 inpatients, AKI, especially HA-AKI, was associated with significantly higher mortality, HRU, and costs during index admission, and higher dialysis and longer readmission LOS during the 30 days postdischarge. These findings support implementation of interventions to prevent HA-AKI in COVID-19 patients.

A refined protocol for the isolation and monoculture of primary mouse renal peritubular endothelial cells

During an episode of acute kidney injury (AKI), a sudden and rapid decline in renal function is often accompanied by a persistent reduction in mitochondrial function, microvasculature dysfunction/rarefaction, and tubular epithelial injury/necrosis. Additionally, patients who have experienced an AKI are at an elevated risk of developing other progressive renal, cardiovascular, and cardiorenal related diseases. While restoration of the microvasculature is imperative for oxygen and nutrient delivery/transport during proper renal repair processes, the mechanism(s) by which neovascularization and/or inhibition of microvascular dysfunction improves renal recovery remain understudied. Interestingly, pharmacological stimulation of mitochondrial biogenesis (MB) post-AKI has been shown to restore mitochondrial and renal function in mice. Thus, targeting MB pathways in microvasculature endothelial cell (MV-EC) may provide a novel strategy to improve renal vascular function and repair processes post-AKI. However, limitations to studying such mechanisms include a lack of commercially available primary renal peritubular MV-ECs, the variability in both purity and outgrowth of primary renal MV-EC in monoculture, the tendency of primary renal MV-ECs to undergo phenotypic loss in primary monoculture, and a limited quantity of published protocols to obtain primary renal peritubular MV-ECs. Thus, we focused on refining the isolation and phenotypic retention of mouse renal peritubular endothelial cells (MRPEC) for future physiological and pharmacological based studies. Here, we present a refined isolation method that augments the purity, outgrowth, and phenotypic retention of primary MRPEC monocultures by utilizing a collagenase type I enzymatic digestion, CD326+ (EPCAM) magnetic microbead epithelial cell depletion, and two CD146+ (MCAM) magnetic microbead purification cycles to achieve a monoculture MRPEC purity of ≅ 91-99% by all markers evaluated.

Development and validation of clinical prediction models for acute kidney injury recovery at hospital discharge in critically ill adults

PURPOSE

Acute kidney injury (AKI) recovery prediction remains challenging. The purpose of the present study is to develop and validate prediction models for AKI recovery at hospital discharge in critically ill patients with ICU-acquired AKI stage 3 (AKI-3).

METHODS

Models were developed and validated in a development cohort (n = 229) and a matched validation cohort (n = 244) from the multicenter EPaNIC database to create prediction models with the least absolute shrinkage and selection operator (Lasso) machine-learning algorithm. We evaluated the discrimination and calibration of the models and compared their performance with plasma neutrophil gelatinase-associated lipocalin (NGAL) measured on first AKI-3 day (NGAL_AKI3) and reference model that only based on age.

RESULTS

Complete recovery and complete or partial recovery occurred in 33.20% and 51.23% of the validation cohort patients respectively. The prediction model for complete recovery based on age, need for renal replacement therapy (RRT), diagnostic group (cardiac/surgical/trauma/others), and sepsis on admission had an area under the receiver operating characteristics curve (AUROC) of 0.53. The prediction model for complete or partial recovery based on age, need for RRT, platelet count, urea, and white blood cell count had an AUROC of 0.61. NGAL_AKI3 showed AUROCs of 0.55 and 0.53 respectively. In cardiac patients, the models had higher AUROCs of 0.60 and 0.71 than NGAL_AKI3's AUROCs of 0.52 and 0.54. The developed models demonstrated a better performance over the reference models (only based on age) for cardiac surgery patients, but not for patients with sepsis and for a general ICU population.

CONCLUSION

Models to predict AKI recovery upon hospital discharge in critically ill patients with AKI-3 showed poor performance in the general ICU population, similar to the biomarker NGAL. In cardiac surgery patients, discrimination was acceptable, and better than NGAL. These findings demonstrate the difficulty of predicting non-reversible AKI early.

Frequency of Acute Kidney Injury and Association With Mortality Among Extremely Preterm Infants

IMPORTANCE

Neonatal acute kidney injury (AKI) is common and associated with morbidity and mortality. The temporal relationship between AKI and critical illness, as well as the frequency of AKI definition components (urine output and serum creatinine [sCr] concentration change), are unknown in extremely low-birth-weight (ELBW) (<1000 g), extremely preterm (<29 weeks' completed gestational age [GA]) infants.

OBJECTIVE

To measure the frequency of AKI from birth to death or discharge with attention to the definition components as well as the temporal relationship of AKI to critical illness and death.

DESIGN, SETTING, AND PARTICIPANTS

A single-center, multiyear, retrospective cohort study was conducted at an academic level IV neonatal intensive care unit between January 1, 2012, and January 1, 2020. Participants included inborn ELBW and infants at 22 to 28 weeks' completed GA with confirmed congenital anomalies who survived 12 hours or more.

EXPOSURES

Extremely preterm birth and ELBW.

MAIN OUTCOMES AND MEASURES

The primary outcome was AKI frequency. The timing, severity, and criteria for AKI were measured. The temporal relationship between AKI, organ dysfunction, and outcomes were quantified using odds ratios (ORs), logistic regression, and Shapley Additive Explanations. Acute kidney injury recognition, imaging, pediatric nephrology consultation, and follow-up were determined.

RESULTS

A total of 436 infants (52% male; 44% Black) met the inclusion criteria (median BW, 725 g; median GA, 25.7 wk). Acute kidney injury was common in the first week of life (44%), primarily based on the change in the sCr concentration criterion (88%), and negatively associated with GA (OR, 0.69; 95% CI, 0.60-0.78), but positively associated with antecedent critical illness (OR, 1.17; 95% CI, 1.12-1.23), severe intraventricular hemorrhage (OR, 1.86; 95% CI, 1.12-3.08), late-onset sepsis (OR, 1.03; 95% CI, 1.02-1.03), and mortality (OR, 2.77; 95% CI, 1.63-4.72). Acute kidney injury had negligible clinical contribution to death within the model (Shapley Additive Explanation, <0.5% change to outcome) relative to antecedent patient-concentration organ dysfunction (6%-15% change). Among infants with severe AKI, recognition (32%), nephrology inpatient consultation (16%), and outpatient follow-up (9%) were not common.

CONCLUSIONS AND RELEVANCE

In this cohort study of ELBW infants, AKI was common in the first week of life, inversely associated with GA, and followed organ (primarily cardiovascular) dysfunction. Acute kidney injury considered as the primary pathway to mortality was rare, and amelioration of AKI to modify death was not well supported.

Mortality and costs associated with acute kidney injury following major elective, non-cardiac surgery

OBJECTIVE

This study evaluated postoperative AKI severity and its relation to short- and long-term patient outcomes.

DESIGN

A retrospective, single-center cohort study of patients undergoing surgery from January 2015 to May 2020.

SETTING

An urban, academic medical center.

PATIENTS

Adult patients undergoing elective, non-cardiac surgery at our institution with a postoperative length of stay (LOS) of at least 24 h were included. Patients were included in 1-year mortality analysis if their procedure occurred prior to June 2019.

INTERVENTIONS

None.

MEASUREMENTS

Postoperative AKI was identified and staged using the Kidney Disease Improving Global Outcomes definitions. The outcomes analyzed were in-hospital mortality, LOS, total cost of the surgical hospitalization, and 1-year mortality.

MAIN RESULTS

Of the 8887 patients studied, 648 (7.3%) had postoperative AKI. AKI was associated with severity-dependent increases in all outcomes studied. Patients with AKI had rates of in-hospital mortality of 2.0%, 3.8%, and 12.5% for stage 1, 2, and 3 AKI compared to 0.3% for patients without AKI. Mean total costs of the surgical hospitalization were $23,896 (SD $23,736) for patients without AKI compared to $33,042 (SD $27,115), $39,133 (SD $34,006), and $73,216 ($82,290) for patients with stage 1, 2, and 3 AKI, respectively. In the 6729 patients who met inclusion for 1-year mortality analysis, AKI was also associated with 1-year mortality rates of 13.9%, 19.4%, and 22.7% compared to 5.2% for patients without AKI. In multivariate models, stage 1 AKI patients still had a higher probability of 1-year mortality (OR 1.9, 95% CI 1.3-2.6, p < 0.001) in addition to $4391 of additional costs when compared to patients without AKI (95% CI $2498-$6285, p < 0.001).

CONCLUSIONS

All stages of postoperative AKI were associated with increased LOS, surgical hospitalization costs, in-hospital mortality, and 1-year mortality. These findings suggest that patients with even a low-grade or stage 1 AKI are at higher risk for short- and long-term complications.

Kidney Damage and Stress Biomarkers for Early Identification of Drug-Induced Kidney Injury: A Systematic Review

INTRODUCTION

Acute kidney injury (AKI) resulting from nephrotoxic medication use is prominent in hospitalized patients and is attributable to overall increases in mortality and costs of care. Serum creatinine (SCr), the current standard for identifying drug-induced AKI (DIAKI) is often delayed in its response to kidney insult by 26-36 h.

OBJECTIVE

This systematic review seeks to evaluate the clinical utility of several novel kidney damage and stress biomarkers for the prediction/timely detection of DIAKI, in comparison with traditional methods.

METHODS

A systematic review of the CINAHL, Cochrane Library, Embase, and PubMed databases was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, for articles analyzing the use of β2-microglobulin (B2M), interleukin (IL)-18, kidney injury molecule-1 (KIM-1), liver-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and tissue inhibitor of metalloproteinase-2 * insulin-like growth factor-binding protein 7 [TIMP-1]*[IGFBP-7], for identifying DIAKI. Primary outcomes included time to DIAKI diagnosis using traditional methods and the time to significant difference in biomarker concentrations between DIAKI and non-AKI study subjects. Secondary outcomes included biomarker concentrations at the time of significant difference between the AKI status groups.

RESULTS

Fifteen unique articles were identified from the literature search. Twelve studies consisted of strictly hospitalized patient populations and three studies included hospitalized patients and patients discharged to home treatment. No studies reported values for urine volume output. Seventy-three percent of studies reported earlier times to significant difference of novel biomarker concentrations between the AKI and non-AKI groups than diagnosis of DIAKI by SCr alone. Significant variation was observed for individual urine biomarker concentrations at time of significant difference between the AKI status groups.

CONCLUSIONS

All analyzed biomarkers showed potential for use as early clinical markers of DIAKI, however further consensus on threshold urine concentrations for DIAKI is needed for meaningful implementation of these biomarkers in clinical practice.

Comparative Risk of Acute Kidney Injury Following Concurrent Administration of Vancomycin with Piperacillin/Tazobactam or Meropenem: A Systematic Review and Meta-Analysis of Observational Studies

The study aims to comparatively assess the nephrotoxicity of vancomycin when combined with piperacillin-tazobactam (V + PT) or meropenem (V + M) in adult patients hospitalized in general wards or intensive care units. We searched MEDLINE, Google Scholar, and Web of Science for observational studies evaluating incidences of AKI in adult patients receiving V + PT or V + M for at least 48 h in general wards or intensive care units. The primary outcome was AKI events, while the secondary outcomes were hospital length of stay, need for renal replacement therapy (RRT), and mortality events. The odds ratio (OR), or mean difference for the hospital length of stay, with a corresponding 95% confidence interval (CI) from the inverse variance weighting random-effects model were estimated for the risk of AKI, RRT, and mortality. Of the 112 studies identified, twelve observational studies were included in this meta-analysis with a total of 14,511 patients. The odds of having AKI were significantly higher in patients receiving V + PT compared with V + M (OR = 2.31; 95%CI 1.69–3.15). There were no differences between V + PT and V + M in the hospital length of stay, RRT, or mortality outcomes. Thus, clinicians should be vigilant while using V + PT, especially in patients who are at high risk of AKI.

Consensus Obtained for the Nephrotoxic Potential of 167 Drugs in Adult Critically Ill Patients Using a Modified Delphi Method

Introduction

The approach to evaluating nephrotoxins in studies of drug-associated acute kidney injury varies. Some studies use a list of under ten drugs for evaluation whereas others include over 100 drugs. Drugs are typically assigned a binary classification, nephrotoxic or not nephrotoxic. This oversimplifies the nephrotoxic potential of the drugs under investigation.

Objective

This study aimed to assign a nephrotoxin potential for 167 drugs used in the adult critical care setting.

Methods

A three-round, international, interdisciplinary, web-based modified-Delphi study was used to evaluate nephrotoxins used in adult critically ill patients. Twenty-four international experienced clinicians were identified through the Acute Disease Quality Initiative group and professional affiliations. Included individuals represented the fields of intensive care, nephrology, and pharmacy. One hundred and fifty-nine medications were identified from the literature, with eight additional medications added after the first round, for a total of 167 medications. The primary outcome was consensus achieved for nephrotoxicity ratings. Scores were evaluated each round to determine if a consensus was met.

Results

Our nephrotoxin potential index rating indicated that 20 drugs were nephrotoxicity probable or probable/definite per consensus. Nephrotoxic potential was assessed based on the standard use of medications in intensive care and the following consensus scores: 0 = no nephrotoxic potential, 1 = possible nephrotoxic potential, 2 = probable nephrotoxic potential, 3 = definite nephrotoxic potential.

Conclusions

The nephrotoxin potential index rating allows for prioritization of targeted drugs with greater nephrotoxic potential for institutional nephrotoxin stewardship programs. Furthermore, the nephrotoxin potential index rating provides homogeneity for research and guidance on detailed assessments by severity for each drug.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-022-01173-4.

Stem Cell-Derived Extracellular Vesicles as Potential Therapeutic Approach for Acute Kidney Injury

Acute kidney injury is a frequent complication of hospitalized patients and significantly increases morbidity and mortality, worsening costs and length of hospital stay. Despite this impact on healthcare system, treatment still remains only supportive (dialysis). Stem cell-derived extracellular vesicles are a promising option as they recapitulate stem cells properties, overcoming safety issues related to risks or rejection or aberrant differentiation. A growing body of evidence based on pre-clinical studies suggests that extracellular vesicles may be effective to treat acute kidney injury and to limit fibrosis through direct interference with pathogenic mechanisms of vascular and tubular epithelial cell damage. We herein analyze the state-of-the-art knowledge of therapeutic approaches with stem cell-derived extracellular vesicles for different forms of acute kidney injury (toxic, ischemic or septic) dissecting their cytoprotective, regenerative and immunomodulatory properties. We also analyze the potential impact of extracellular vesicles on the mechanisms of transition from acute kidney injury to chronic kidney disease, with a focus on the pivotal role of the inhibition of complement cascade in this setting. Despite some technical limits, nowadays the development of therapies based on stem cell-derived extracellular vesicles holds promise as a new frontier to limit acute kidney injury onset and progression.

Incidence of Acute Kidney Injury Is Lower in High-Risk Patients Undergoing Percutaneous Coronary Intervention Supported with Impella Compared to ECMO

Acute kidney injury (AKI) is a common complication post-PCI. Here, in a single-center observational registry, we compared the frequency of AKI in patients at elevated risk for AKI (based on Mehran risk stratification scoring) who underwent VA-ECMO- or Impella-supported high-risk PCI. A total of 28 patients scheduled for elective high-risk PCI with mechanical circulatory support were studied prospectively. All patients were turned down for surgery due to exceedingly high risk. Allocation to VA-ECMO (n=11) or Impella (n=17) was performed according to site-specific restrictions on the daily availability of the VA-ECMO platform as a prospective enrollment and performed prior to initiation of PCI. We analyzed AKI incidence as our primary endpoint, as well as PCI success, duration, and peripheral complications. All patients were successfully revascularized and had MCS weaned at the end of the procedure. Baseline GFR and procedural contrast media were similar. Despite similar risks for AKI as calculated by the Mehran score (35 ± 18.9 vs. 31 ± 16.6 %; p=0.55), patients supported by Impella during PCI demonstrated a reduced incidence of AKI (55 vs. 12 %; p=0.03). MCS-assisted high-risk PCI with VA-ECMO or Impella is feasible. However, Impella is associated with a shorter procedure time and a lower incidence of AKI.

Utilizing reclassification to explore characteristics and prognosis of KDIGOSCr AKI subgroups: a retrospective analysis of a multicenter prospective cohort study

BACKGROUND

Acute kidney injury (AKI) is widespread in the intensive care unit (ICU) and affects patient prognosis. According to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, the absolute and relative increases of serum creatinine (Scr) are classified into the same stage. Whether the prognosis of the two types of patients is similar in the ICU remains unclear.

METHODS

According to the absolute and relative increase of Scr, AKI stage 1 and stage 3 patients were divided into stage 1a and 1b, stage 3a and 3b groups, respectively. Their demographics, laboratory results, clinical characteristics, and outcomes were analyzed retrospectively.

RESULTS

Of the 345 eligible cases, we analyzed stage 1 because stage 3a group had only one patient. Using 53 or 61.88 µmol/L as the reference Scr (Scr_ref), no significant differences were observed in ICU mortality (P₅₃=0.076, P_61.88=0.070) or renal replacement therapy (RRT) ratio, (P₅₃=0.356, P_61.88=0.471) between stage 1a and 1b, but stage 1b had longer ICU length of stay (LOS) than stage 1a (P₅₃<0.001, P_61.88=0.032). In the Kaplan-Meier survival analysis, no differences were observed in ICU mortality between stage 1a and 1b (P₅₃=0.378, P_61.88=0.255). In a multivariate analysis, respiratory failure [HR = 4.462 (95% CI 1.144-17.401), p = 0.031] and vasoactive drug therapy [HR = 4.023 (95% CI 1.584-10.216), p = 0.003] were found to be independently associated with increased risk of death.

CONCLUSION

ICU LOS benefit was more prominent in KDIGO_SCr AKI stage 1a patients than in stage 1 b. Further prospective studies with a larger sample size are necessary to confirm the effectiveness of reclassification.

The effect of dexmedetomidine on renal function after surgery: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Acute kidney injury (AKI) is a complication following surgery and has been associated with worsened patient outcomes. Providers have used agents that may confer a degree of renal protection in the perioperative stage. Such is the case of dexmedetomidine, a selective alpha-2 adrenergic agonist used in the intensive care unit (ICU) as a sedative agent. The primary objective of this meta-analysis was to characterize the use of dexmedetomidine and to evaluate its impact on renal markers and outcomes in patients after surgery.

METHODS

A systematic review of manuscripts was performed to identify patients who received dexmedetomidine after surgery by searching the PubMed, Embase, and Cochrane databases. The following parameters were captured: blood urea nitrogen (BUN), serum creatinine, creatinine clearance, neutrophil gelatinase-associated lipoprotein (NGAL), cystatin C, urine output, duration of mechanical ventilation, ICU length of stay, AKI, need for dialysis, and mortality.

RESULTS AND DISCUSSION

Nineteen studies with 3,395 patients were included in the analyses. The mean bolus and infusion dose of dexmedetomidine were 0.82 µg/kg and 0.54 mcg/kg/hr, respectively. There was a significant difference in creatinine clearance and NGAL in favour of the dexmedetomidine group. In addition, the dexmedetomidine group had a shorter ICU length of stay, and a lower risk of acute kidney injury and mortality compared to the control. There was no difference in the rest of the parameters.

WHAT IS NEW AND CONCLUSION

Dexmedetomidine appears to have postoperative renal protective effects. This is evidenced by lower NGAL levels and increased creatinine clearance in those who received dexmedetomidine. These effects are associated with decreases in ICU length of stay and risk of AKI and mortality.

Chess Not Checkers: Complexities Within the Myeloid Response to the Acute Kidney Injury Syndrome

Immune dysregulation in acute kidney injury (AKI) is an area of intense interest which promises to enhance our understanding of the disease and how to manage it. Macrophages are a heterogeneous and dynamic population of immune cells that carry out multiple functions in tissue, ranging from maintenance to inflammation. As key sentinels of their environment and the major immune population in the uninjured kidney, macrophages are poised to play an important role in the establishment and pathogenesis of AKI. These cells have a profound capacity to orchestrate downstream immune responses and likely participate in skewing the kidney environment toward either pathogenic inflammation or injury resolution. A clear understanding of macrophage and myeloid cell dynamics in the development of AKI will provide valuable insight into disease pathogenesis and options for intervention. This review considers evidence in the literature that speaks to the role and regulation of macrophages and myeloid cells in AKI. We also highlight barriers or knowledge gaps that need to be addressed as the field advances.

Incremental effect of complications on mortality and hospital costs in adult ECMO patients

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO.

METHODS

Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs.

RESULTS

Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529.

CONCLUSION

In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.

Nephrotoxin Stewardship

Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.

A systematic review of cost-effectiveness analyses across the acute kidney injury landscape

Introduction: Acute kidney injury (AKI) is a complex and common condition associated with increased morbidity, mortality, and costs. Evidence from cost-effectiveness analysis (CEA) have targeted various aspects of AKI including detection with biomarkers, treatment with renal replacement therapy, and prevention when using contrast media. However, there has not been a systematic review of these studies across the entirety of AKI.Areas covered: PubMed, Embase, and Cochrane library were used to identify CEA studies that involved AKI from 2004 onwards. These studies compared AKI treatment through renal replacement therapies (n = 6), prevention of contrast-induced-AKI (CI-AKI) using different media (n = 3), and diagnosis with novel biomarkers (n = 2). Treatment strategies for AKI focused on continuous versus intermittent renal replacement therapy. While there was no consensus, the majority of studies favored the continuous form. For contrast media, both studies found iodixanol to be cost-effective compared to iohexol for preventing CI-AKI. Additionally, novel biomarkers showed potential to be cost-effective in risk assessment and detection of AKI.Expert opinion: Consistent criteria such as a lifetime time horizon would allow for better model comparisons. Further research on clinical parameters to capture transition probabilities between stages within AKI and progression to downstream kidney disease is needed.

Randomized Controlled Trial Evidence of Cost-Effectiveness of a Multifaceted AKI Intervention Approach

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.

Ultrasound for the treatment of acute kidney injury and other inflammatory conditions: a promising path toward noninvasive neuroimmune regulation

Acute kidney injury (AKI) is an important clinical disorder with high prevalence, serious consequences, and limited therapeutic options. Modulation of neuroimmune interaction by nonpharmacological methods is emerging as a novel strategy for treating inflammatory diseases, including AKI. Recently, pulsed ultrasound (US) treatment was shown to protect from AKI by stimulating the cholinergic anti-inflammatory pathway. Because of the relatively simple, portable, and noninvasive nature of US procedures, US stimulation may be a valuable therapeutic option for treating inflammatory conditions. This review discusses potential impacts of US bioeffects on the nervous system and how this may generate feedback onto the immune system. We also discuss recent evidence supporting the use of US as a means to treat AKI and other inflammatory diseases.

Avoiding acute kidney injury in primary care: attitudes and behaviours of general practitioners and community pharmacists in Hawke’s Bay

ABSTRACT INTRODUCTIONAwareness of the effect of acute kidney injury on patient outcomes and health systems is growing internationally. New Zealand’s approach focuses on stopping consumption of ‘at-risk’ medicines when acute kidney injury has been established and raising awareness of the risks associated with the Triple Whammy drug combination. AIMTo explore current practices and views of Hawke’s Bay general practitioners (GPs) and community pharmacists regarding patient education about medicines with potential for contributing to community-acquired acute kidney injury, with a focus on community pharmacists providing patient education regarding when to temporarily withhold ‘at-risk’ medicines during acute dehydrating illnesses. METHODSTwo tailored cross-sectional online anonymous surveys of GPs and community pharmacists working in Hawke’s Bay were administered between 2015 and 2016. Descriptive statistics were generated from the closed-question responses and manifest content analysis was applied to the free-text responses. RESULTSTwenty-two percent (37/167) of GPs and 34% (32/95) of pharmacists responded. Most respondents, GPs (34/37) and pharmacists (25/32), self-reported expertise to educate patients on temporarily withholding ‘at-risk’ medicines during acute dehydrating illnesses. Twenty-nine (78%) GPs had confidence in pharmacists providing this patient education and 20 (54%) welcomed pharmacist contact regarding a Triple Whammy prescription. However, for a variety of reasons, pharmacists did not routinely provide this education or contact GPs. DISCUSSIONBoth GPs and community pharmacists reported they had expertise to provide useful patient education about ‘at-risk’ medicine use during acute dehydrating illnesses. Dialogue to clarify the role of the two groups would be beneficial to achieve a more coordinated approach to patient care. Relevant strategies and frameworks already exist, but national interprofessional leadership and local application would be beneficial.

Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock

Background

There are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS.

Methods

This was a retrospective cohort study from 2000–2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition.

Results

During this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001).

Conclusion

AKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.