Diagnosis and management of acute kidney injury: deficiencies in the knowledge base of non-specialist, trainee medical staff

Impact of an Electronic Alert in Combination with a Care Bundle on the Outcomes of Acute Kidney Injury

Early diagnosis is essential for the appropriate management of acute kidney injury (AKI). We evaluated the impact of an electronic AKI alert together with a care bundle on the progression and mortality of AKI. This was a single-center prospective study that included AKI patients aged ≥ 18 years, whereas those in palliative care, nephrology, and transplantation departments were excluded. An AKI alert was issued in electronic medical records and a care bundle was suggested. A series of classes were administered to the multidisciplinary teams by nephrologists, and a clinical pharmacist audited prescriptions. Patients were categorized into pre-alert and post-alert groups. The baseline characteristics were comparable between the pre-alert (n = 1613) and post-alert (n = 1561) groups. The 30-day mortality rate was 33.6% in the entire cohort and was lower in the post-alert group (30.5% vs. 36.7%; p < 0.001). Age, pulmonary disease, malignancy, and ICU admission were associated with an increase in 30-day mortality. The electronic AKI alert together with a care bundle and a multidisciplinary education program was associated with a reduction in 30-day mortality in patients with AKI.

Assessment of knowledge of acute kidney injury among non-nephrology healthcare workers in North-Kivu Province, Democratic Republic of the Congo

Background: Assessment of knowledge of acute kidney injury (AKI) among healthcare workers (HCWs) is necessary to identify areas of deficiency and key topics to focus on while organizing educational programs to improve AKI care. The objective of this study was to assess AKI knowledge and practice among health care providers in North Kivu province, the eastern Democratic Republic of the Congo. Material and methods: This was a cross-sectional study conducted in six public hospitals in North Kivu province using a self-administered questionnaire. Results: A total of 158 HCWs completed the survey, among them 66 (41.78%) were physicians. The mean age of respondents was 36.07 ± 10.16 years and the male gender was 56.33%. Only 12 (7.59%) of the respondents had a good knowledge of the definition and classification of AKI. The respondents’ mean scores were 6.76 out of a total of 18 about risk factors for AKI and 6.29 out of a total of 11 with regard to nephrotoxic drugs. Regarding practices, 28.48% of the respondents assess the risk of AKI in their patients in their daily practices; 31.65% report AKI in the patients’ medical history, and 33.54% call on a nephrologist specialist to get specialized advice. Conclusion: This study found considerable gaps in knowledge and practice regarding AKI among most of HCWs in North Kivu province.

Impact of early nephrology referral on the outcomes of patients with acute kidney injury

Background

Acute kidney injury (AKI) is associated with an increase in patient mortality and high rates of renal/non-renal complications. Late detection of the disease has been associated with worse prognosis, but no such study has been conducted from Saudi Arabia.

Objectives:

To assess the impact of early nephrology referral on the outcomes of patients with AKI.

Methods:

This retrospective record review included all adult patients (≥18 years) with AKI who were referred to the Nephrology Department at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between May 2019 and July 2020. AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. AKI patients evaluated by nephrologists were stratified into early referral group (i.e., referral in <48 h from the first detection of AKI) and late referral group (referral ≥48 h after the first detection of AKI).

Results:

A total of 400 patients met the inclusion criteria, of which 264 (66%) were early referrals. A significant association was found between delayed referral and mortality rates and length of hospital stay (for both,P= 0.001). Late referral was also significantly associated with increased likeliness of the need for renal replacement therapy (P = 0.037) and sepsis (P = 0.005).

Conclusions:

The outcomes were worse for patients with AKI receiving late referrals to nephrologists. Raising the awareness of AKI among non-nephrologists would likely increase the proportion of earlier referrals.

The impact of e-alerts on inpatient diagnosis and management of acute kidney injury

AIMS/BACKGROUND

Electronic alerts can help with the early detection of acute kidney injury in hospitalised patients. Evidence for their role in improving patient care is limited. The authors have completed an audit loop to evaluate the impact of electronic alerts, and an associated acute kidney injury management pathway, on patient care.

METHODS

The audits were conducted at a large tertiary care hospital in the UK. Case notes were reviewed for 99 patients over two periods: pre-alert (in 2013; n=55) and post-alert (in 2018; n=44), using the same methodology. Patients for case note reviews were randomly chosen from the list of acute kidney injury alerts generated by the local laboratory information management system.

RESULTS

Recognition of acute kidney injury, as documented in the case notes, increased from 15% to 43% between the two periods. Time to first medical review (following electronic alerts) improved by 17 minutes (median 4 hours 4 minutes in 2013 vs 3 hours 47 minutes in 2018). Completion of pre-defined acute kidney injury assessment tasks (review of vital signs, biochemistry and acid-base parameters, evidence of fluid balance assessment, consideration of possible sepsis, and examination or requesting urinalysis) improved in 2018. However, acute kidney injury management tasks (correction of hypovolaemia, addressing or investigating obstruction, medications review, renal referral, requesting of further biochemical tests, addressing possible sepsis) showed very little or no improvement.

CONCLUSIONS

The introduction of acute kidney injury electronic alerts and management pathway resulted in improved recognition and initial assessment of patients with acute kidney injury. Further steps are needed to translate this in to improved patient management.

Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations.

METHODS

We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set.

RESULTS

Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients.

CONCLUSIONS

Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.

Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England

OBJECTIVE

Around one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care.

DESIGN

Mixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.

SETTING AND PARTICIPANTS

Three secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101).

ANALYSIS

Qualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ² and Wilcoxon signed-rank test for differences in current and future normalisation.

RESULTS

Participants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation).

CONCLUSIONS

Clinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

Awareness of acute kidney injury risk factors and perspectives on its practice guidelines

OBJECTIVES

Identifying and assessing risk factors for acute kidney injury (AKI) are crucial for its early detection and possible intervention to prevent AKI and associated adverse outcomes. This study aimed to investigate AKI risk factor awareness and risk assessment by healthcare professionals and to evaluate perspectives on the Kidney Disease Improving Global Outcomes AKI guidelines.

METHODS

This cross-sectional survey-based study was conducted among healthcare professionals (physicians and pharmacists) at XXX from December 2016 to February 2017.

RESULTS

Among the respondents (117 physicians and 135 pharmacists), 78% were aged ≤38 years, 57% were men, and 70% had <9 years of experience. Respondents varied in their knowledge of the 25 risk factors for AKI and 15 nephrotoxic drugs: 96% were aware of nephrotoxic medication, whereas 20% acknowledged female sex as an AKI risk factor, and 92% agreed with aminoglycoside, while 47% agreed with ciprofloxacin as nephrotoxic drugs. A significantly higher percentage of physicians identified individual AKI risk factors than pharmacists; however, a significantly higher percentage of pharmacists identified individual AKI-causing drugs than physicians. Although 77% of respondents encountered AKI cases in their practice, only half of them performed AKI risk assessment, and 42% stratified patients' AKI risk according to their presenting risk factors or documented AKI in previous medical history. Seventy-one percent of respondents agreed that practice guidelines improve patient outcome, and 69% thought these guidelines help standardize care and ensure that patients are treated in consistently.

CONCLUSION

While the majority of the respondents had a positive perspective toward AKI guidelines, a large variation in their knowledge of AKI risk factors, risk assessment, and nephrotoxic drugs was found. Educational efforts are needed to raise awareness and thereby reduce this variation.

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.

Assessment of Knowledge of Acute Kidney Injury among Non-Nephrology Doctors in Two Government Hospitals in Ondo City, Southwest, Nigeria

BACKGROUND

Adequate knowledge of acute kidney injury (AKI) among doctors is essential for its prevention, early diagnosis and management. Assessing knowledge of AKI among doctors is necessary to identify areas of deficiencies and key areas to be emphasized when organizing educational programs aimed at improving AKI care. This study determined the knowledge of AKI among non-nephrology doctors in Ondo City, Southwest Nigeria.

MATERIALS AND METHODS

This was a cross-sectional descriptive study carried out in two government hospitals in Ondo City using a self-administered pretested questionnaire that assessed knowledge of AKI among non-nephrology doctors. P-value of < 0.05 was taken as significant.

RESULTS

Eighty-one doctors participated in the study with a median post-graduation experience of 5.5 years. Sixty-one (78.2%) were in surgical specialty while the remaining worked in medical specialty. Only 1(1.2%) of the respondents had good knowledge of AKI, 56(69.2%) had fair knowledge while the remaining 24 (29.6%) had poor knowledge of AKI. Identified areas of deficiencies in knowledge of AKI were in mode of presentation, risk factors, potentially nephrotoxic medications, criteria for AKI definition and staging, newer AKI biomarkers and indications for renal replacement therapy. There was no significant association between knowledge of AKI and specialty (p=0.593) or year of practice (p=0.312).

CONCLUSION

There were significant deficiencies in the knowledge of AKI amongst most non-nephrology doctors in Ondo city. We therefore recommend regular in-service training on AKI for practicing doctors.

Outcome in noncritically ill patients with acute kidney injury requiring dialysis: Effects of differing medical staffs and organizations

Acute kidney injury requiring dialysis (AKI-D) treatment has significantly increased in incidence over the years, with more than 400 new cases per million population/y, 2/3 of which concern noncritically ill patients. In these patients, there are little data on mortality or on information of care organization and its impact on outcome. Specialty training and integrated teams, as well as a high volume of activity, seem to be linked to better hospital outcome. The study investigates mortality of patients admitted to and in-care of nephrology (NEPHROpts), a closed-staff organization, and to other medical wards (MEDpts), representing a model of open-staff organization.This is a single center, case-control cohort study derived from a prospective epidemiology investigation on patients with AKI-D admitted to or in-care of the Hospital of Perugia during the period 2007 to 2014. Noncritically ill AKI-D patients were analyzed: inclusion and exclusion criteria were defined to avoid possible bias on the cause of hospital admittance and comorbidities, and a propensity score (PS) matching was performed.Six hundred fifty-four noncritically ill patients were observed and 296 fulfilled inclusion/exclusion criteria. PS matching resulted in 2 groups: 100 NEPHROpts and 100 MEDpts. Characteristics, comorbidities, acute kidney injury causes, risk-injury-failure acute kidney injury criteria, and simplified acute physiology score (SAPS 2) were similar. Mortality was 36%, and a difference was reported between NEPHROpts and MEDpts (20% vs 52%, χ = 23.2, P < 0.001). Patients who died differed in age, serum creatinine, blood urea nitrogen/s.Creatinine ratio, dialysis urea reduction rate (URR), SAPS 2 and Charlson score; they presented a higher rate of heart disease, and a larger proportion required noradrenaline/dopamine for shock. After correction for mortality risk factors, multivariate Cox analysis revealed that site of treatment (medical vs nephrology wards) represents an independent risk factor of mortality (relative risk = 2.13, 95% confidence interval = 1.25, 3.63; P < 0.01). Other independent risk factors were age, URR, s.Creatinine at hemodialysis beginning, and SAPS 2 score.In our context, we have documented that noncritically ill AKI-D patients, who represented 2/3 of the population, had high in-hospital mortality (36%), and that a closed-staff specialty medical organization, such as a Nephrology team, seems to guarantee a better outcome than general medical organizations. The significance in healthcare system organization and resource allocation could be important.

Deficiencies in education and experience in the management of acute kidney injury among Malawian healthcare workers

BACKGROUND

Acute kidney injury (AKI) is a common but under-recognised disease process, which carries a high risk of mortality or chronic complications, such as chronic kidney disease and other organ dysfunction. Management of AKI, however, is suboptimal, both in developed settings and in Malawi. This is partly because of deficiencies in AKI education and training.

AIM

To establish current levels of AKI education in a range of healthcare workers in Malawi.

METHODS

An AKI symposium was held in Blantyre in March 2015. Delegates were asked to complete a survey at the start of the symposium to assess their clinical experience and education in the management of AKI.

RESULTS

From 100 delegates, 89 nurses, clinical officers, and physicians, originating from 11 different districts, responded to the survey. Twenty-two percent of healthcare workers (including 28% of district workers of the various cadres and 31% of nurses) had never received teaching on any aspect of renal disease, and 50% (including 63% of district workers and 61% of nurses) had never received teaching specifically on AKI. Forty-four percent did not feel confident managing AKI, and 98% wanted more support managing patients with renal disease. Thirty-four percent (including 55% of district workers) were unaware that haemodialysis was available at Queen Elizabeth Central Hospital (QECH) for the treatment of AKI and 53% (74% of district workers) were unaware that peritoneal dialysis was available for the treatment of AKI in children. Only 33% had ever referred a patient with AKI to QECH.

CONCLUSIONS

There are deficiencies in education about, and clinical experience in, the management of AKI among Malawian healthcare workers, in addition to limited awareness of the renal service available at QECH. Urgent action is required to address these issues in order to prevent morbidity and mortality from AKI in Malawi.

Computerized clinical decision support for the early recognition and management of acute kidney injury: a qualitative evaluation of end-user experience

BACKGROUND

Although the efficacy of computerized clinical decision support (CCDS) for acute kidney injury (AKI) remains unclear, the wider literature includes examples of limited acceptability and equivocal benefit. Our single-centre study aimed to identify factors promoting or inhibiting use of in-patient AKI CCDS.

METHODS

Targeting medical users, CCDS triggered with a serum creatinine rise of ≥25 μmol/L/day and linked to guidance and test ordering. User experience was evaluated through retrospective interviews, conducted and analysed according to Normalization Process Theory. Initial pilot ward experience allowed tool refinement. Assessments continued following CCDS activation across all adult, non-critical care wards.

RESULTS

Thematic saturation was achieved with 24 interviews. The alert was accepted as a potentially useful prompt to early clinical re-assessment by many trainees. Senior staff were more sceptical, tending to view it as a hindrance. 'Pop-ups' and mandated engagement before alert dismissal were universally unpopular due to workflow disruption. Users were driven to close out of the alert as soon as possible to review historical creatinines and to continue with the intended workflow.

CONCLUSIONS

Our study revealed themes similar to those previously described in non-AKI settings. Systems intruding on workflow, particularly involving complex interactions, may be unsustainable even if there has been a positive impact on care. The optimal balance between intrusion and clinical benefit of AKI CCDS requires further evaluation.

Recognition and management of acute kidney injury in hospitalised patients can be partially improved with the use of a care bundle

Acute kidney injury (AKI) is common in hospitalised patients but is known be suboptimally managed; the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report in 2009 identified significant failings in AKI care. An audit, using standards suggested by the NCEPOD report, of all adult inpatients with AKI in a large central-London NHS hospital in a 7-day period in 2011 showed poor recognition and management of AKI. In response, an AKI 'care bundle' was developed and deployed throughout the hospital along with a programme of enhanced education. Re-audit in 2013 showed that AKI was significantly more likely to have been recognised by the clinical team than in 2011, and patients with AKI were significantly more likely to have had fluid status clinically assessed and nephrotoxic medication stopped in 2013 than in 2011. There was no significant improvement in fluid administration if assessed as hypovolaemic and compliance with the guideline for prevention of contrast nephropathy. In 2011, all audit measures were met in 3.7% of patient-days versus 8.4% in 2013. More in-depth work is necessary to better understand the factors which limit optimal care.

Pathophysiology of ischaemic acute kidney injury

Acute kidney injury is common, dangerous and costly, affecting around one in five patients emergency admissions to hospital. Although survival decreases as disease worsens, it is now apparent that even modest degrees of dysfunction are not only associated with higher mortality but are an independent risk factor for death. This review focuses on the pathophysiology of acute kidney injury secondary to ischaemia - its commonest aetiology. The haemodynamic disturbances, endothelial injury, epithelial cell injury and immunological mechanisms underpinning its initiation and extension will be discussed along with the considerable and complex interplay between these factors that lead to an intense, pro-inflammatory state. Mechanisms of tubular recovery will be discussed but also the pathophysiology of abnormal repair with its direct consequences for long-term renal function. Finally, the concept of 'organ cross-talk' will be introduced as a potential explanation for the higher mortality observed with acute kidney injury that might be deemed modest in conventional biochemical terms.

Improving prevention, early recognition and management of acute kidney injury after major surgery: results of a planning meeting with multidisciplinary stakeholders

Purpose of review

Acute kidney injury (AKI) is common after major surgery, and is associated with morbidity, mortality, increased length of hospital stay, and high health care costs. Although recent guidelines for AKI provide recommendations for identification of patients at risk, monitoring, diagnosis, and management of AKI, there is lack of understanding to guide successful implementation of these recommendations into clinical practice.

Sources of information

We held a planning meeting with multidisciplinary stakeholders to identify barriers, facilitators, and strategies to implement recommendations for prevention, early identification, and management of AKI after major surgery. Barriers and facilitators to knowledge use for peri-operative AKI prevention and care were discussed.

Findings

Stakeholders identified barriers in knowledge (how to identify high-risk patients, what criteria to use for diagnosis of AKI), attitudes (self-efficacy in preventive care and management of AKI), and behaviors (common use of diuretics, non-steroidal anti-inflammatory drugs, withholding of intravenous fluids, and competing time demands in peri-operative care). Educational, informatics, and organizational interventions were identified by stakeholders as potentially useful elements for future interventions for peri-operative AKI.

Limitation

Meeting participants were from a single centre.

Implications

The information and recommendations obtained from this stakeholder’s meeting will be useful to design interventions to improve prevention and early care for AKI after major surgery.

Identification of risk factors associated with acute kidney injury in patients admitted to acute medical units

In 2009, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report identified significant deficiencies in the management of acute kidney injury (AKI) in hospitals in the UK. Many errors arose from failure to recognise patients with AKI and those at risk of developing AKI. Currently, there is no universally accepted risk factor assessment for identifying such patients on admission to acute medical units (AMUs). A multicentre prospective observational study was performed in the AMUs of 10 hospitals in England and Scotland to define the risk factors associated with AKI and to assess quality of care. Data were collected on consecutive acute medical admissions over two separate 24-h periods. Acute kidney injury was present in 55/316 (17.7%) patients, with sepsis, hypovolaemia, chronic kidney disease (CKD) and diabetes mellitus identified as the major risk factors. Deficiencies in patient care were identified, reinforcing the continuing need to improve the management of AKI.

Studies on the mechanism of the changes in serum and liver gamma-glutamyl transpeptidase activity. II. Experimental hexachlorobenzene porphyria in rabbits

The mechanism responsible for the changes in serum and liver gamma-glutamyl transpeptidase (gamma-GT) activity was studied in a model of experimental hexachlorobenzene porphyria in rabbits. Porphyria followed the administration of hexachlorobenzene in doses of 280 mumol - kg-1 body weight, which were given daily through a gastric tube over a 20-day period. Serum gamma-GT activity and the activities of the lysosomal enzymes beta-N-acetylglucosaminidase and alpha-mannosidase were increased, whereas L-aspartate: 2-oxoglutarate aminotransferase and L-alanine: 2-oxoglutarate aminotransferase and L-alanine: 2-oxoglutarate aminotransferase remained unaltered. There was a considerable increase in liver microsomal protein, gamma-GT, cytochrome P-450, anilinehydroxylase, aminopyrine-demethylase and delta-aminolevulinic acid synthase. In the liver gamma-GT was detected in the microsomes as well as in the cytoplasm where enzymatic activity was higher. The high correlation coefficient between liver gamma-GT, cytochrome P-450 and delta-aminolevulinic acid synthase witnesses a hexachlorobenzene-induced gamma-GT formation in the liver. A statistically significant correlation between serum and liver gamma-GT activity was also found. These data strongly suggest that the increase in serum gamma-GT activity may result from the induction of the enzyme in the liver.