Hospital discharge communications during care transitions for patients with acute kidney injury: a cross-sectional study

Role of a Pharmacist in Postdischarge Care for Patients With Kidney Disease: A Scoping Review

OBJECTIVE

The objective was to explore and describe the role of pharmacists in providing postdischarge care to patients with kidney disease.

DATA SOURCES

PubMed, Embase (Elsevier), CINAHL (Ebscohost), Web of Science Core Collection, and Scopus were searched on January 30, 2023. Publication date limits were not included. Search terms were identified based on 3 concepts: kidney disease, pharmacy services, and patient discharge. Experimental, quasi-experimental, observational, and qualitative studies, or study protocols, describing the pharmacist's role in providing postdischarge care for patients with kidney disease, excluding kidney transplant recipients, were eligible.

STUDY SELECTION AND DATA EXTRACTION

Six unique interventions were described in 10 studies meeting inclusion criteria.

DATA SYNTHESIS

Four interventions targeted patients with acute kidney injury (AKI) during hospitalization and 2 evaluated patients with pre-existing chronic kidney disease. Pharmacists were a multidisciplinary care team (MDCT) member in 5 interventions and were the sole provider in 1. Roles commonly identified include medication review, medication reconciliation, medication action plan formation, kidney function assessment, drug dose adjustments, and disease education. Some studies showed improvements in diagnostic coding, laboratory monitoring, medication therapy problem (MTP) resolution, and patient education; prevention of hospital readmission was inconsistent. Limitations include lack of standardized reporting of kidney disease, transitions of care processes, and differences in outcomes evaluated.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review identifies potential roles of a pharmacist as part of a postdischarge MDCT for patients with varying degrees of kidney disease.

CONCLUSIONS

The pharmacist's role in providing postdischarge care to patients with kidney disease is inconsistent. Multidisciplinary care teams including a pharmacist provided consistent identification and resolution of MTPs, improved patient education, and increased self-awareness of diagnosis.

ChatGPT-4 generates orthopedic discharge documents faster than humans maintaining comparable quality: a pilot study of 6 cases

BACKGROUND AND PURPOSE

Large language models like ChatGPT-4 have emerged. They hold the potential to reduce the administrative burden by generating everyday clinical documents, thus allowing the physician to spend more time with the patient. We aimed to assess both the quality and efficiency of discharge documents generated by ChatGPT-4 in comparison with those produced by physicians.

PATIENTS AND METHODS

To emulate real-world situations, the health records of 6 fictional orthopedic cases were created. Discharge documents for each case were generated by a junior attending orthopedic surgeon and an advanced orthopedic resident. ChatGPT-4 was then prompted to generate the discharge documents using the same health record information. The quality assessment was performed by an expert panel (n = 15) blinded to the source of the documents. As secondary outcome, the time required to generate the documents was compared, logging the duration of the creation of the discharge documents by the physician and by ChatGPT-4.

RESULTS

Overall, both ChatGPT-4 and physician-generated notes were comparable in quality. Notably, ChatGPT-4 generated discharge documents 10 times faster than the traditional method. 4 events of hallucinations were found in the ChatGPT-4-generated content, compared with 6 events in the human/physician produced notes.

CONCLUSION

ChatGPT-4 creates orthopedic discharge notes faster than physicians, with comparable quality. This shows it has great potential for making these documents more efficient in orthopedic care. ChatGPT-4 has the potential to significantly reduce the administrative burden on healthcare professionals.

Assessing Discharge Communication and Follow-up of Acute Kidney Injury in British Columbia: A Retrospective Chart Review

Background and objective

Acute kidney injury (AKI) affects up to 20% of hospitalizations and is associated with chronic kidney disease, cardiovascular disease, increased mortality, and increased health care costs. Proper documentation of AKI in discharge summaries is critical for optimal monitoring and treatment of these patients once discharged. Currently, there is limited literature evaluating the quality of discharge communication after AKI. This study aimed to evaluate the accuracy and quality of documentation of episodes of AKI at a tertiary care center in British Columbia, Canada.

Methods design setting patients and measurements

This was a retrospective chart review study of adult patients who experienced AKI during hospital admission between January 1, 2018, and December 31, 2018. Laboratory data were used to identify all admissions to the cardiac and general medicine ward complicated by AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A random sample of 300 AKI admissions stratified by AKI severity (eg, stages 1, 2, and 3) were identified for chart review. Patients were excluded if they required ongoing renal replacement therapy after admission, had a history of kidney transplant, died during their admission, or did not have a discharge summary available. Discharge summaries were reviewed for documentation of the following: presence of AKI, severity of AKI, AKI status at discharge, practitioner and laboratory follow-up plans, and medication changes.

Results

A total of 1076 patients with 1237 AKI admissions were identified. Of the 300 patients selected for discharge summary review, 38 met exclusion criteria. In addition, AKI was documented in 140 (53%) discharge summaries and was more likely to be documented in more severe AKI: stage 1, 38%; stage 2, 51%; and stage 3, 75%. Of those with their AKI documented, 94 (67%) documented AKI severity, and 116 (83%) mentioned the AKI status or trajectory at the time of discharge. A total of 239 (91%) of discharge summaries mentioned a follow-up plan with a practitioner, but only 23 (10%) had documented follow-up with nephrology. Patients with their AKI documented were more likely to have nephrology follow-up than those without AKI documented (17% vs 1%). Regarding laboratory investigations, 92 (35%) of the summaries had documented recommendations. In summaries that included medications typically held during AKI, only about half made specific reference to those medications being held, adjusted, or documented a post-discharge plan for that medication. For those with nonsteroidal anti-inflammatory drugs (NSAIDs) listing, 64% of discharge summaries mentioned holding, and 9% mentioned a discharge plan. For those with angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) listing, 38% mentioned holding these medications, and 46% mentioned a discharge plan. In summaries with diuretics listed, 35% mentioned holding, and 51% included a discharge plan.

Conclusions and limitations

We found suboptimal quality and completeness of discharge reporting in patients hospitalized with AKI. This may contribute to inadequate follow-up and post-hospitalization care for this patient population. Strategies are required for increasing the presence and quality of AKI reporting in discharge summaries. Limitations include our definition of AKI based on lab criteria, which may have missed some of the injuries that met the criteria based on urine output. Another limitation is that our definition of AKI based on the highest and lowest creatinine during admission may have led to some overclassification. In addition, without outpatient laboratories, it is possible that we have not captured the true baseline creatinine in some patients.

Challenges in the Care of Patients with AKI Receiving Outpatient Dialysis: AKINow Recovery Workgroup Report

BACKGROUND

Up to one third of survivors of AKI that required dialysis (AKI-D) during hospitalization remain dialysis dependent at hospital discharge. Of these, 20%-60%, depending on the clinical setting, eventually recover enough kidney function to stop dialysis, and the remainder progress to ESKD.

METHODS

To describe the challenges facing those still receiving dialysis on discharge, the AKINow Committee conducted a group discussion comprising 59 participants, including physicians, advanced practitioners, nurses, pharmacists, and patients. The discussion was framed by a patient who described gaps in care delivery at different transition points and miscommunication between care team members and the patient.

RESULTS

Group discussions collected patient perspectives of ( 1 ) being often scared and uncertain about what is happening to and around them and ( 2 ) the importance of effective and timely communication, a comfortable physical setting, and attentive and caring health care providers for a quality health care experience. Provider perspectives included ( 1 ) the recognition of the lack of evidence-based practices and quality indicators, the significant variability in current care models, and the uncertain reimbursement incentives focused on kidney recovery and ( 2 ) the urgency to address communication barriers among hospital providers and outpatient facilities.

CONCLUSIONS

The workgroup identified key areas for future research and policy change to ( 1 ) improve communication among hospital providers, dialysis units, and patients/care partners; ( 2 ) develop tools for risk classification, subphenotyping, and augmented clinical decision support; ( 3 ) improve education to providers, staff, and patients/care partners; ( 4 ) identify best practices to improve relevant outcomes; ( 5 ) validate quality indicators; and ( 6 ) assess the effect of social determinants of health on outcomes. We urge all stakeholders involved in the process of AKI-D care to align goals and work together to fill knowledge gaps and optimize the care to this highly vulnerable patient population.

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.

The Quality of Discharge Summaries After Acute Kidney Injury

Background

Acute kidney injury (AKI) increases the risk of hospital readmission, chronic kidney disease, and death. Therefore, effective communication in discharge summaries is essential for safe transitions of care.

Objective

The objectives of this study were to determine the quality of discharge summaries in AKI survivors and identify predictors of higher quality discharge summaries.

Design

Retrospective chart review.

Setting

Tertiary care academic center in Ontario, Canada.

Patients

We examined the discharge summary quality of 300 randomly selected adult patients who survived a hospitalization with AKI at our tertiary care hospital, stratified by AKI severity. We included 150 patients each from 2015 to 2016 and 2018 to 2019, before and after introduction of a post-AKI clinic in 2017.

Measurements

We reviewed charts for 9 elements of AKI care to create a composite score summarizing discharge summary quality.

Methods

We used multivariable logistic regression to identify predictors of discharge summary quality.

Results

The median discharge summary composite score was 4/9 (interquartile range, 2-6). The least frequently mentioned elements were baseline creatinine (n = 55, 18%), AKI-specific follow-up labs (n = 66, 22%), and medication recommendations (n = 80, 27%). The odds of having a higher quality discharge summary (composite score ≥4/9) was greater for every increase in baseline creatinine of 25 μmol/L (adjusted odds ratio [aOR]: 1.27; 95% confidence interval [CI]: 1.03, 1.56), intrarenal etiology (aOR: 2.32; 95% CI: 1.26, 4.27), and increased AKI severity (stage 2 aOR: 2.57; 95% CI: 1.35, 4.91 and stage 3 aOR: 3.36; 95% CI: 1.56, 7.22). There was no association between discharge summary quality and the years before and after introduction of a post-AKI clinic (aOR: 0.77; 95% CI: 0.46, 1.29).

Limitations

The single-center study design limits generalizability.

Conclusions

Most discharge summaries are missing key AKI elements, even in patients with severe AKI. These gaps suggest several opportunities exist to improve discharge summary communication following AKI.

Adult Cardiac Surgery-Associated Acute Kidney Injury: Joint Consensus Report

OBJECTIVES

Acute kidney injury (AKI) is increasingly recognized as a source of poor patient outcomes after cardiac surgery. The purpose of the present report is to provide perioperative teams with expert recommendations specific to cardiac surgery-associated AKI (CSA-AKI).

METHODS

This report and consensus recommendations were developed during a joint, in-person, multidisciplinary conference with the Perioperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. Multinational practitioners with diverse expertise in all aspects of cardiac surgical perioperative care, including clinical backgrounds in anesthesiology, surgery and nursing, met from October 20 to 22, 2021, in Sacramento, California, and used a modified Delphi process and a comprehensive review of evidence to formulate recommendations. The quality of evidence and strength of each recommendation were established using the Grading of Recommendations Assessment, Development, and Evaluation methodology. A majority vote endorsed recommendations.

RESULTS

Based on available evidence and group consensus, a total of 13 recommendations were formulated (4 for the preoperative phase, 4 for the intraoperative phase, and 5 for the postoperative phase), and are reported here.

CONCLUSIONS

Because there are no reliable or effective treatment options for CSA-AKI, evidence-based practices that highlight prevention and early detection are paramount. Cardiac surgery-associated AKI incidence may be mitigated and postsurgical outcomes improved by focusing additional attention on presurgical kidney health status; implementing a specific cardiopulmonary bypass bundle; using strategies to maintain intravascular euvolemia; leveraging advanced tools such as the electronic medical record, point-of-care ultrasound, and biomarker testing; and using patient-specific, goal-directed therapy to prioritize oxygen delivery and end-organ perfusion over static physiologic metrics.

Comprehensive Acute Kidney Injury Survivor Care: Protocol for the Randomized Acute Kidney Injury in Care Transitions Pilot Trial

BACKGROUND

Innovative care models are needed to address gaps in kidney care follow-up among acute kidney injury (AKI) survivors. We developed the multidisciplinary AKI in Care Transitions (ACT) program, which embeds post-AKI care in patients' primary care clinic.

OBJECTIVE

The objective of this randomized pilot trial is to test the feasibility and acceptability of the ACT program and study protocol, including recruitment and retention, procedures, and outcome measures.

METHODS

The study will be conducted at Mayo Clinic in Rochester, Minnesota, a tertiary care center with a local primary care practice. Individuals who are included have stage 3 AKI during their hospitalization, do not require dialysis at discharge, have a local primary care provider, and are discharged to their home. Patients unable or unwilling to provide informed consent and recipients of any transplant within 100 days of enrollment are excluded. Consented patients are randomized to receive the intervention (ie, ACT program) or usual care. The ACT program intervention includes predischarge kidney health education from nurses and coordinated postdischarge laboratory monitoring (serum creatinine and urine protein assessment) and follow-up with a primary care provider and pharmacist within 14 days. The usual care group receives no specific study-related intervention, and any aspects of AKI care are at the direction of the treating team. This study will examine the feasibility of the ACT program, including recruitment, randomization and retention in a trial setting, and intervention fidelity. The feasibility and acceptability of participating in the ACT program will also be examined in qualitative interviews with patients and staff and through surveys. Qualitative interviews will be deductively and inductively coded and themes compared across data types. Observations of clinical encounters will be examined for discussion and care plans related to kidney health. Descriptive analyses will summarize quantitative measures of the feasibility and acceptability of ACT. Participants' knowledge about kidney health, quality of life, and process outcomes (eg, type and timing of laboratory assessments) will be described for both groups. Clinical outcomes (eg, unplanned rehospitalization) up to 12 months will be compared with Cox proportional hazards models.

RESULTS

This study received funding from the Agency for Health Care Research and Quality on April 21, 2021, and was approved by the Institutional Review Board on December 14, 2021. As of March 14, 2023, seventeen participants each have been enrolled in the intervention and usual care groups.

CONCLUSIONS

Feasible and generalizable AKI survivor care delivery models are needed to improve care processes and health outcomes. This pilot trial will test the ACT program, which uses a multidisciplinary model focused on primary care to address this gap.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05184894; https://www.clinicaltrials.gov/ct2/show/NCT05184894.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48109.

Association of an Acute Kidney Injury Follow-up Clinic With Patient Outcomes and Care Processes: A Cohort Study

RATIONALE & OBJECTIVE

To determine whether attendance at an acute kidney injury (AKI) follow-up clinic is associated with reduced major adverse kidney events.

STUDY DESIGN

Propensity-matched cohort study.

SETTING & PARTICIPANTS

Patients hospitalized with AKI in Ontario, Canada, from February 1, 2013, through September 30, 2017, at a single clinical center, who were not receiving dialysis when discharged.

EXPOSURE

Standardized assessment by a nephrologist.

OUTCOMES

Time to a major adverse kidney event, defined as death, initiation of maintenance dialysis, or incident/progressive chronic kidney disease.

ANALYTICAL APPROACH

Propensity scores were used to match each patient who attended an AKI follow-up clinic to 4 patients who received standard care. Cox proportional hazards models were fit to assess the association between the care within an AKI follow-up clinic and outcomes. To avoid immortal time bias, we randomly assigned index dates to the comparator group.

RESULTS

We matched 164 patients from the AKI follow-up clinic to 656 patients who received standard care. During a mean follow-up of 2.2±1.3 (SD) years, care in the AKI follow-up clinic was not associated with a reduction in major adverse kidney events relative to standard care (22.1 vs 24.7 events per 100 patient-years; HR, 0.91 [95% CI, 0.75-1.11]). The AKI follow-up clinic was associated with a lower risk of all-cause mortality (HR, 0.71 [95% CI, 0.55-0.91]). Patients aged at least 66 years who attended the AKI follow-up clinic were more likely to receive β-blockers (HR, 1.34 [95% CI, 1.02-1.77]) and statins (HR, 1.35 [95% CI, 1.05-1.74]), but not angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (HR, 1.21 [95% CI, 0.94-1.56]).

LIMITATIONS

Single-center study and residual confounding.

CONCLUSIONS

Specialized postdischarge follow-up for AKI survivors was not associated with a lower risk of major adverse kidney events but was associated with a lower risk of death and increased prescriptions for some cardioprotective medications.

Use of Guideline-Based Therapy for Diabetes, Coronary Artery Disease, and Chronic Kidney Disease After Acute Kidney Injury: A Retrospective Observational Study

Background

Survivors of acute kidney injury (AKI) are at a high risk for cardiovascular complications. An underrecognition of this risk may contribute to the low utilization of relevant guideline-based therapies in this population.

Objective

We sought to assess accordance with guideline-based recommendations for survivors of AKI with diabetes, coronary artery disease (CAD), and preexisting chronic kidney disease (CKD) in a post-AKI clinic, and identify factors that may be associated with guideline accordance.

Design

Retrospective cohort study.

Setting

Post-AKI clinics at 2 tertiary care centers in Ontario, Canada.

Patients

We included adult patients seen in both post-AKI clinics between 2013 and 2019 who had at least 2 clinic visits within 24 months of an index AKI hospitalization.

Measurements

We assessed accordance to recommendations from the most recent North American and international guidelines available at the time of study completion for diabetes, CAD, and CKD.

Methods

We compared guideline accordance between visits using the Cochran Mantel Haenszel test. We used multivariable Poisson regression to identify prespecified factors associated with accordance.

Results

Of 213 eligible patients, 192 (90%) had Kidney Disease Improving Global Outcomes Stage 2-3 AKI, 91 (43%) had diabetes, 76 (36%) had CAD, and 88 (41%) had preexisting CKD. From the first clinic visit to the second, there was an increase in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-I/ARB) use across all disease groups-from 33% to 46% (P = .028) in patients with diabetes, from 30% to 57% (P = .002) in patients with CAD, and from 16% to 35% (P < .001) in patients with preexisting CKD. Statin use increased in patients with preexisting CKD from 64% to 71% (P = .034). Every 25 μmol/L rise in the discharge serum creatinine was associated with a 19% (95% confidence interval [CI], 8%-28%) and 12% (95% CI, 2%-21%) lower likelihood of being on an ACE-I/ARB in patients with diabetes and preexisting CKD, respectively.

Limitations

The study lacked a comparison group that received usual care. The small sample and multiple comparisons make false positives possible.

Conclusion

There is room to improve guideline-based cardiovascular risk factor management in survivors of AKI, particularly ACE-I/ARB use in patients with an elevated discharge serum creatinine.

Nephrotoxin Exposure in the 3 Years following Hospital Discharge Predicts Development or Worsening of Chronic Kidney Disease among Acute Kidney Injury Survivors

INTRODUCTION

Survivors of acute kidney injury (AKI) are at high risk of progression to chronic kidney disease (CKD), for which drugs may be a modifiable risk factor.

METHODS

We conducted a population-based cohort study of Olmsted County, MN residents who developed AKI while hospitalized between January 1, 2006, and December 31, 2014, using Rochester Epidemiology Project data. Adults with a hospitalization complicated by AKI who survived at least 90 days after AKI development were included. Medical records were queried for prescription of potentially nephrotoxic medications over the 3 years after discharge. The primary outcome was de novo or progressive CKD defined by either a new diagnosis code for CKD or ≥30% decline in estimated glomerular filtration rate from baseline. The composite of CKD, AKI readmission, or death was also evaluated.

RESULTS

Among 2,461 AKI survivors, 2,140 (87%) received a potentially nephrotoxic medication during the 3 years following discharge. When nephrotoxic medication use was analyzed in a time-dependent fashion, those actively prescribed at least one of these drugs experienced a significantly higher risk of de novo or progressive CKD (HR 1.38: 95% CI: 1.24, 1.54). Similarly, active potentially nephrotoxic medication use predicted a greater risk of the composite endpoint of CKD, AKI readmission, or death within 3 years of discharge (HR 1.41: 95% CI: 1.28, 1.56).

CONCLUSION

In this population-based cohort study, AKI survivors actively prescribed one or more potentially nephrotoxic medications were at significantly greater risk for de novo or progressive CKD. An opportunity exists to reassess nephrotoxin appropriateness following an AKI episode to improve patient outcomes.

What Do AKI Survivors Want to Know About Their AKI?: A Qualitative Study

Rationale & Objective

Acute kidney injury (AKI) in the hospital often occurs with other serious illnesses that take medical priority. Despite a persistent risk of adverse outcomes following hospital discharge, AKI survivors often receive inadequate education about how best to mitigate risks once home. We sought to identify AKI survivors’ perceived barriers to shared and informed decision-making regarding their AKI diagnosis and self-management.

Study Design

Semistructured phone interviews were used to assess patients’ perceived barriers and facilitators to AKI self-management after a hospital-related AKI event.

Setting & Participants

AKI survivors discharged from Duke University Hospital in Durham, NC, were recruited for interviews to discuss their AKI experiences. Those who received dialysis for AKI were excluded because their perceptions of AKI care were hypothesized to be much different from those of patients not requiring dialysis.

Analytical Approach

Twenty-four interviews were conducted between May and August 2018. Interviews were recorded, transcribed, and analyzed by study team members to identify common themes and discrepancies and reach a final consensus.

Results

Five consistent themes emerged after thematic saturation: (1) patients were unaware of their AKI diagnosis; (2) patients lacked information about AKI and how to manage it at home; (3) patients identified a lack of understanding about AKI; (4) patients were concerned about dialysis; and (5) patients wanted to know how to prevent AKI in the future.

Limitations

Limitations include recruitment from a single center, all study participants receiving a nephrology consultation, and several patients being unable to participate because of persistent illness following hospitalization.

Conclusions

AKI survivors are unaware of their diagnosis, receive suboptimal education while hospitalized, and are not equipped with tools to mitigate risks following discharge. Patient-centered interventions promoting AKI awareness and self-management may improve long-term outcomes for high-risk AKI survivors.

Impact of postoperative acute kidney injury in patients undergoing major gastrointestinal surgery on 1-year survival and renal outcomes: a national multicentre cohort study

Background

The intermediate-term impact of acute kidney injury (AKI) in patients after major gastrointestinal and liver surgery has not been well characterized. This study aimed to evaluate the 1-year mortality rate and renal outcomes associated with postoperative AKI in a national prospective cohort.

Methods

This prospective multicentre, observational cohort with 1-year postoperative follow-up included adults undergoing major gastrointestinal and liver surgery across the UK and Ireland between 23 September and 18 November 2015. AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The primary outcome was death at 1-year after surgery, and the secondary outcome was Major Adverse Kidney Events (MAKE-365). Cox proportionate and multilevel logistic regression were used to account for case mix.

Results

Of 5745 patients across 173 centres, 1-year follow-up data was completed for 3504 patients (62.2 per cent, 126 centres), with attrition largely explained by centre non-participation (63.1 per cent). Some 13.6 per cent (475 of 3504) patients developed AKI by 7 days after surgery (stage 1: 9.2 per cent; stage 2/3: 4.3 per cent). At 1 year, 10.8 per cent (378 patients) experienced a MAKE-365 endpoint (303 patients had died, 61 had renal replacement therapy and 78 had renal dysfunction). Patients who experienced AKI by 7 days after surgery had a higher hazard of death at 1 year for KDIGO stage 1 (hazard ratio 1.50 (95 per cent c.i. 1.08 to 2.08), P = 0.016) and KDIGO stage 2/3 (hazard ratio 2.96 (95 per cent c.i. 2.02 to 4.33), P < 0.001). Both KDIGO stage 1 (odds ratio 2.09 (95 per cent c.i. 1.50 to 2.92), P < 0.001) and stage 2/3 (odds ratio 9.26 (95 per cent c.i. 6.31 to 13.59), P < 0.001) AKI were independently associated with MAKE-365.

Conclusion

AKI events within 7 days after gastrointestinal or liver surgery are associated with significantly worse survival and renal outcomes at 1 year.

Incidence of Serum Creatinine Monitoring and Outpatient Visit Follow-Up among Acute Kidney Injury Survivors after Discharge: A Population-Based Cohort Study

INTRODUCTION

Acute kidney injury (AKI) affects 20% of hospitalized patients and worsens outcomes. To limit complications, post-discharge follow-up and kidney function testing are advised. The objective of this study was to evaluate the frequency of follow-up after discharge among AKI survivors.

METHODS

This was a population-based cohort study of adult Olmsted County residents hospitalized with an episode of stage II or III AKI between 2006 and 2014. Those dismissed from the hospital on dialysis, hospice, or who died within 30 days after discharge were excluded. The frequency and predictors of follow-up, defined as an outpatient serum creatinine (SCr) level or an in-person healthcare visit after discharge were described.

RESULTS

In the 627 included AKI survivors, the 30-day cumulative incidence of a follow-up outpatient SCr was 80% (95% confidence interval [CI]: 76% and 83%), a healthcare visit was 82% (95% CI: 79 and 85%), or both was 70% (95% CI: 66 and 73%). At 90 days and 1 year after discharge, the cumulative incidences of meeting both follow-up criteria rose to 82 and 91%, respectively. Independent predictors of receiving both an outpatient SCr assessment and healthcare visit within 30 days included lower estimated glomerular filtration rate at discharge, higher comorbidity burden, longer length of hospitalization, and greater maximum AKI severity. Age, sex, race/ethnicity, education level, and socioeconomic status did not predict follow-up.

CONCLUSIONS

Among patients with moderate to severe AKI, 30% did not have follow-up with a SCr and healthcare visit in the 30-day post-discharge interval. Follow-up was associated with higher acuity of illness rather than demographic or socioeconomic factors.

Discharge Documentation and Follow-Up of Critically Ill Patients With Acute Kidney Injury Treated With Kidney Replacement Therapy: A Retrospective Cohort Study

Leading organisations recommend follow-up of acute kidney injury (AKI) survivors, as these patients are at risk of long-term complications and increased mortality. Information transfer between specialties and from tertiary to primary care is essential to ensure timely and appropriate follow-up. Our aim was to examine the association between completeness of discharge documentation and subsequent follow-up of AKI survivors who received kidney replacement therapy (KRT) in the Intensive Care Unit (ICU). We retrospectively analysed the data of 433 patients who had KRT for AKI during ICU admission in a tertiary care centre in the UK between June 2017 and May 2018 and identified patients who were discharged from hospital alive. Patients with pre-existing end-stage kidney disease and patients who were transferred from hospitals outside the catchment area were excluded. The primary objective was to assess the completeness of discharge documentation from critical care and hospital; secondary objectives were to determine cardiovascular medications reconciliation after AKI, and to investigate kidney care and outcomes at 1 year. The development of AKI and the need for KRT were mentioned in 85 and 82% of critical care discharge letters, respectively. Monitoring of kidney function post-discharge was recommended in 51.6% of critical care and 36.3% of hospital discharge summaries. Among 35 patients who were prescribed renin-angiotensin-aldosterone system inhibitors before hospitalisation, 15 (42.9%) were not re-started before discharge from hospital. At 3 months, creatinine and urine protein were measured in 88.2 and 11.8% of survivors, respectively. The prevalence of chronic kidney disease stage III or worse increased from 27.2% pre-hospitalisation to 54.9% at 1 year (p < 0.001). Our data demonstrate that discharge summaries of patients with AKI who received KRT lacked essential information. Furthermore, even in patients with appropriate documentation, renal follow-up was poor suggesting the need for more education and streamlined care pathways.

Recovery after Critical Illness and Acute Kidney Injury

AKI is a common complication in hospitalized and critically ill patients. Its incidence has steadily increased over the past decade. Whether transient or prolonged, AKI is an independent risk factor associated with poor short- and long-term outcomes, even if patients do not require KRT. Most patients with early AKI improve with conservative management; however, some will require dialysis for a few days, a few weeks, or even months. Approximately 10%-30% of AKI survivors may still need dialysis after hospital discharge. These patients have a higher associated risk of death, rehospitalization, recurrent AKI, and CKD, and a lower quality of life. Survivors of critical illness may also suffer from cognitive dysfunction, muscle weakness, prolonged ventilator dependence, malnutrition, infections, chronic pain, and poor wound healing. Collaboration and communication among nephrologists, primary care physicians, rehabilitation providers, physical therapists, nutritionists, nurses, pharmacists, and other members of the health care team are essential to create a holistic and patient-centric care plan for overall recovery. Integration of the patient and family members in health care decisions, and ongoing education throughout the process, are vital to improve patient well-being. From the nephrologist standpoint, assessing and promoting recovery of kidney function, and providing appropriate short- and long-term follow-up, are crucial to prevent rehospitalizations and to reduce complications. Return to baseline functional status is the ultimate goal for most patients, and dialysis independence is an important part of that goal. In this review, we seek to highlight the varying aspects and stages of recovery from AKI complicating critical illness, and propose viable strategies to promote recovery of kidney function and dialysis independence. We also emphasize the need for ongoing research and multidisciplinary collaboration to improve outcomes in this vulnerable population.

Post-Discharge Mortality and Rehospitalization among Participants in a Comprehensive Acute Kidney Injury Rehabilitation Program

Background

Hospitalization-associated AKI is common and is associated with markedly increased mortality and morbidity. This prospective cohort study examined the feasibility and association of an AKI rehabilitation program with postdischarge outcomes.

Methods

Adult patients hospitalized from September 1, 2019 to February 29, 2020 in a large health system in Pennsylvania with stage 2-3 AKI who were alive and not on dialysis or hospice at discharge were evaluated for enrollment. The intervention included patient education, case manager services, and expedited nephrology appointments starting within 1-3 weeks of discharge. We examined the association between AKI rehabilitation program participation and risks of rehospitalization or mortality in logistic regression analyses adjusting for comorbidities, discharge disposition, and sociodemographic and kidney parameters. Sensitivity analysis was performed using propensity score matching.

Results

Among the high-risk patients with AKI who were evaluated, 77 of 183 were suitable for inclusion. Out of these, 52 (68%) patients were enrolled and compared with 400 contemporary, nonparticipant survivors of stage 2/3 AKI. Crude postdischarge rates of rehospitalization or death were lower for participants versus nonparticipants at 30 days (15% versus 34%; P=0.01) and at 90 days (31% versus 51%; P=0.01). After multivariable adjustment, participation in the AKI rehabilitation program was associated with lower risk of rehospitalization or mortality at 30 days (OR, 0.41; 95% CI, 0.16 to 0.93), with similar findings at 90 days (OR, 0.52; 95% CI, 0.25 to 1.05). Due to small sample size, propensity-matched analyses were limited. The participants' rehospitalization or mortality was numerically lower but not statistically significant at 30 days (18% versus 31%; P=0.22) or at 90 days (47% versus 58%; P=0.4).

Conclusions

The AKI rehabilitation program was feasible and potentially associated with improved 30-day rehospitalization or mortality. Our interventions present a roadmap to improve enrollment in future randomized trials.

Individualized acute kidney injury after care

PURPOSE OF REVIEW

The aim of this study was to summarize the current evidence around the impact of individualizing patient care following an episode of acute kidney injury (AKI) in the ICU.

RECENT FINDINGS

Over the last years, evidence has demonstrated that the follow-up care after episodes of AKI is lacking and standardization of this process is likely needed. Although this is informed largely by large retrospective cohort studies, a few prospective observational trials have been performed. Medication reconciliation and patient/caregiver education are important tenants of follow-up care, regardless of the severity of AKI. There is evidence the initiation and/or reinstitution of renin-angiotensin-aldosterone agents may improve patient's outcomes following AKI, although they may increase the risk for adverse events, especially when reinitiated early. In addition, 3 months after an episode of AKI, serum creatinine and proteinuria evaluation may help identify patients who are likely to develop progressive chronic kidney disease over the ensuing 5 years. Lastly, there are emerging differences between those who do and do not require renal replacement therapy (RRT) for their AKI, which may require more frequent and intense follow-up in those needing RRT.

SUMMARY

Although large scale evidence-based guidelines are lacking, standardization of post-ICU-AKI is needed.

Post-discharge care following acute kidney injury: quality improvement in primary care

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.

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

OBJECTIVES

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

DESIGN

Qualitative study using semi-structured interviews and thematic analysis.

SETTING

General practices in one Clinical Commissioning Group area in England.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Long-Term Outcomes in Patients with Acute Kidney Injury

The long-term sequelae of AKI have received increasing attention so that its associations with a number of adverse outcomes, including higher mortality and development of CKD, are now widely appreciated. These associations take on particular importance when considering the high incidence of AKI, with a lack of proven interventions and uncertainties around optimal care provision meaning that the long-term sequelae of AKI present a major unmet clinical need. In this review, we examine the published data that inform our current understanding of long-term outcomes following AKI and discuss potential knowledge gaps, covering long-term mortality, CKD, progression to ESKD, proteinuria, cardiovascular events, recurrent AKI, and hospital readmission.

Attitudes of physicians towards target groups and content of the discharge summary: a cross-sectional analysis in Styria, Austria

OBJECTIVES

The discharge summary (DS) represents one of the most important instruments to ensure a safe patient discharge from the hospital. They sometimes have poor quality in content and often include medical jargon, which the patient and their relatives cannot easily understand. Therefore, many risks for patient safety exist. This study investigated the questions for whom the DS is and which contents are necessary to ensure a safe treatment.

DESIGN

Cross-sectional analysis.

SETTING

Styria, Austria.

PARTICIPANTS

3948 internal and external physicians were consulted.

INTERVENTIONS

An online survey consisting of 24 questions was conducted. The survey was distributed to physicians working in the province of Styria, Austria, in 2018 over a period of 6 months.

MAIN OUTCOMES AND MEASURES

Attitudes of internal and external physicians in terms of target group, content and health literacy.

RESULTS

In total, 1060 physicians participated in the survey. The DS is considered as a communication tool among physicians (97.9%) and the patients are also indicated as addressees (73.5%). Furthermore, there is a high level of agreement that understandable information in the DS leads to fewer questions of the patients (67.9%).

CONCLUSION

In conclusion, the DS is not only seen as a document for the further treating physician but is also relevant for the patient. Incorporating the patient into their treatment at all levels may possibly strengthen the individual health literacy of the patient and their caring relatives.

[Treatment, clinical course, and cross-sectoral information transmission in patients with acute-on-chronic kidney injury]

BACKGROUND

Delayed diagnosis and undertherapy of acute-on-chronic kidney injury (AKI-on-CKD) may trigger multiple organ injury and worsen clinical outcome.

OBJECTIVES

This study focused on description of in-hospital care and cross-sectoral information transmission of patients with AKI-on-CKD including subgroup analyses (under surgical vs. non-surgical and nephrology vs. non-nephrology care).

MATERIALS AND METHODS

At a university clinic, we analysed clinical measures and documentation in patients with AKI-on-CKD. Cox regression was performed to identify independent risk factors for in-hospital-mortality and 180-day mortality.

RESULTS

In 38 (25.3%) of 150 patients, progressing AKI-on-CKD was found. Nineteen patients (12.7%) received acute dialysis. Thirty patients (20.0%) died in hospital. Systemic hypotension (n = 76, 50.7%) and nephrotoxins (n = 26, 17.3%), both considered as causes for AKI-on-CKD, were treated in 36.8 and 19.2%, respectively, of affected patients. Fluid balance was documented in one third of patients. Nephrology referral was requested in 38 (25.3%) of patients (median 24.0 h after AKI-on-CKD start). Acute renal complications (n = 74, 49.3%) were an independent risk factor for in-hospital mortality (ExpB 6.5, p = 0.022) or 180-day mortality (ExpB 3.3, p = 0.034). Rarely, outpatient physicians were informed about AKI-on-CKD (n = 42, 28.0%) or renal function follow-up was recommended (n = 14, 11.7% of surviving patients).

CONCLUSIONS

Care gaps in therapy and cross-sectoral information transmission in patients with AKI-on-CKD were identified.

Kidney Disease Awareness and Knowledge among Survivors ofAcute Kidney Injury

BACKGROUND

Acute kidney injury (AKI) survivors are at risk for chronic kidney disease, recurrent AKI, and cardiovascular disease. The transition from hospital to ambulatory care is an opportunity to reduce these sequelae by launching self-care plans through effective patient education. How well AKI survivors are informationally prepared to apply kidney-specific self-care is unknown. The purpose of this study was to identify awareness and disease-specific knowledge among AKI survivors.

METHODS

We performed a cross-sectional survey of AKI-related awareness and knowledge in 137 patients with Kidney Disease Improving Global Outcomes Stage II or III AKI near the time of hospital discharge. Patients were asked (1) "Did you experience AKI while in the hospital?" and (2) "Do you have a problem with your kidney health?" Objective knowledge of AKI was evaluated with a 15-item adapted version of the validated Kidney Knowledge Survey that included topics such as common causes, risk factors, and how AKI is diagnosed.

RESULTS

Median age was 54 (interquartile range 43-63) and 81% were white. Eighty percent of patients were unaware that they had experienced AKI and 53% were both unaware they had experienced AKI or had a "problem with their kidneys." Multivariable logistic regression identified being male and lack of nephrology consult as predictors of unawareness with ORs of 3.92 (95% CI 1.48-10.33) and 5.10 (95% CI 1.98-13.13), respectively. Less than 50% recognized nonsteroidal anti-inflammatory drugs, contrast, or phosphate-based cathartics as risk factors for AKI. Two-thirds of patients did not agree that they knew a lot about AKI and more than 80% desired more information.

CONCLUSIONS

Most patients with moderate to severe AKI are unaware of their condition, lack understanding of risk factors for recurrent AKI, and desire more information. Patient-centered communication to optimize awareness, understanding, and care will require coordinated educational strategies throughout the continuum of AKI care.

A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety

Background

The medical discharge letter is an important communication tool between hospitals and other healthcare providers. Despite its high status, it often does not meet the desired requirements in everyday clinical practice. Occurring risks create barriers for patients and doctors. This present review summarizes risks of the medical discharge letter.

Methods

The research question was answered with a systematic literature research and results were summarized narratively. A literature search in the databases PubMed and Cochrane Library for Studies between January 2008 and May 2018 was performed. Two authors reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Literature on possible risks associated with the medical discharge letter was discussed.

Results

In total, 29 studies were included in this review. The major identified risk factors are the delayed sending of the discharge letter to doctors for further treatments, unintelligible (not patient-centered) medical discharge letters, low quality of the discharge letter, and lack of information as well as absence of training in writing medical discharge letters during medical education.

Conclusions

Multiple risks factors are associated with the medical discharge letter. There is a need for further research to improve the quality of the medical discharge letter to minimize risks and increase patients’ safety.

What insights do patients and caregivers have on acute kidney injury and posthospitalisation care? A single-centre qualitative study from Toronto, Canada

OBJECTIVES

Hospitalisation with acute kidney injury (AKI) is associated with short-term and long-term adverse events, but patient and caregiver experiences with AKI are not well described. We sought to better understand patient and caregiver perspectives after a hospitalisation with AKI to inform discharge strategies that may improve outcomes for this high-risk population.

DESIGN

Qualitative study with semistructured interviews.

SETTING

Tertiary care hospital in Toronto, Ontario, Canada.

PARTICIPANTS

Adult patients (n=15) who survived a hospitalisation with Kidney Disease Improving Global Outcomes stage 2 or 3 AKI from May to December 2016. We also interviewed five patient caregivers. We required patients to have no previous evidence of severe chronic kidney disease (ie, prior receipt of dialysis, previous kidney transplantation or pre-existing estimated glomerular filtration rate (eGFR) under 30 mL/min/1.73 m²).

RESULTS

We identified three over-arching themes: (1) prioritisation of conditions other than AKI, reflected by the importance placed on other comorbidities and the omission of AKI as part of the ongoing medical history; (2) variability in comprehension of the significance of AKI, represented by minimal knowledge of the causes and symptoms associated with AKI, along with misinformation on the kidneys' ability to self-repair; and (3) anxiety from discharge planning and competing health demands, illustrated by complicated discharge plans involving multiple specialist appointments.

CONCLUSIONS

Patients and caregivers view AKI as a short-term and reversible condition, giving it little thought during the postdischarge period. As a result, reliance on patients and caregivers to report an episode of AKI to their outpatient physicians is unlikely to be successful. Patient-centred tools and decision aids are needed to bridge the gap between a hospitalisation with AKI and the safe transition to the outpatient setting.

Routine screening in the general hospital: what happens after discharge to those identified as at risk of dementia?

Cognitive screening is recommended for older patients with unplanned hospital admission. We determined rates of reassessment/specialist memory referral after routine inclusion of at risk of dementia status in discharge documentation to primary care. Questionnaires were sent to relevant GP practices on consecutive patients aged ≥75 years identified as at risk and discharged 6 months earlier. Among 53 patients (mean age ±SD = 87.3±6.0 years, mean±SD Abbreviated Mental Test Score = 4.4±2.7), 49 (92%) patients had been reviewed since discharge, and 12/43 (28%) without previously known cognitive problem had had a cognitive reassessment. The most common reasons for non-assessment/referral included clinical factors (eg terminal illness/comorbidities) (n=15) and patient/family wishes (n=5) and that confusion was expected in unwell older patients (n=5). Routine cognitive reassessment/specialist referral appears unjustified in patients identified as at risk of dementia during unplanned hospital admission. However, the prognostic value of delirium/confusion in acute illness is under-recognised and could be used to highlight those at risk.

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

Acute kidney injury (AKI) is independently associated with new-onset chronic kidney disease (CKD), end-stage kidney disease, cardiovascular disease, and all-cause mortality. However, only a minority of patients receive follow-up care after an episode of AKI in the developing world, and the optimal strategies to promote rehabilitation after AKI are ill-defined. On this background, a working group of the 18th Acute Dialysis Quality Initiative applied the consensus-building process informed by a PubMed review of English-language articles to address questions related to rehabilitation after AKI. The consensus statements propose that all patients should be offered follow-up within 3 months of an AKI episode, with more intense follow-up (e.g., <1 month) considered based on patient risk factors, characteristics of the AKI event, and the degree of kidney recovery. Patients should be monitored for renal and nonrenal events post-AKI, and we suggest that the minimum level of monitoring consist of an assessment of kidney function and proteinuria within 3 months of the AKI episode. Care should be individualized for higher risk patients, particularly patients who are still dialysis dependent, to promote renal recovery. Although evidence-based treatments for survivors of AKI are lacking and some outcomes may not be modifiable, we recommend simple interventions such as lifestyle changes, medication reconciliation, blood pressure control, and education, including the documentation of AKI in the patient’s medical record. In conclusion, survivors of AKI represent a high-risk population, and these consensus statements should provide clinicians with guidance on the care of patients after an episode of AKI.

Follow-up Care in Acute Kidney Injury: Lost in Transition

Acute kidney injury (AKI) is an increasingly common condition that is associated with long-term health outcomes. Recent studies have demonstrated that AKI, particularly when severe or persistent, is associated with all-cause mortality, CKD, ESRD, cardiovascular events, and reduced quality of life. However, data from multiple health care systems indicate that most patients do not see a nephrologist, although 1 study has suggested patients with AKI requiring dialysis may benefit from doing so. These observations raise the greater questions of what are the elements of care that may improve outcomes in survivors of AKI and which survivors need to be seen. Potential opportunities to improve care include appropriate risk stratification, closer monitoring of kidney function, management of CKD complications, blood pressure control, medication reconciliation, and education. Nephrologists are in an ideal position to lead and advocate for outpatient care pathways for survivors of AKI. In this article, we review the evidence supporting patient follow-up after AKI, describe the current state of follow-up care, and examine strategies to improve long-term outcomes for this high-risk population.