Part 2: The current gaps and future of the quality of care for Acute Kidney Disease
Mar 03, 2022
Part 2: Quality of Care for Acute Kidney Disease: Current Knowledge Gaps and Future Directions
Contact: emily.li@wesictanche.com
For Part 1. please click here.
Weight Assessment
In contrast to the paradigm of dry weight challenges for ESRD patients, acute kidney injury-D patients may require a mild permissive hypervolemia approach that emphasizes avoiding intradialytic hypotension (IDH). The dangers of IDH and high ultrafiltration rates (>13 ml/kg/h) in ESRD patients have been well-described.42 In acute kidney injury-D, IDH may exacerbate ischemic kidney injury and decrease the chances of recovery.43 Two separate retrospective studies found that higher ultrafiltration rates and more frequent IDH were associated with a lower likelihood of recovery in outpatients with acute kidney injury- D.43,44 At a minimum, patients with acute kidney injury-D should have a regular (weekly) reassessment of target weight and fluid removal goals. In non-anuric patients, diuretics may be helpful to limit interdialytic weight gain and decrease ultrafiltration rates.45 The role of specific measures to prevent IDH, such as cooled dialysate or sodium modeling, has not been formally assessed in the acute kidney injury setting.
Access
Nearly all patients with acute kidney injury-D will have a central venous catheter as primary access. Furthermore, the placement of arteriovenous access should be delayed (appropriately) while monitoring for kidney function recovery.46 These patients and their families will be at significant risk for infectious complications, and they should receive proper central venous catheter care and education before hospital discharge, which should continue as an outpatient. Although limited data exist regarding central venous catheter issues in those with acute kidney injury-D, much can be learned from investigations in other populations with central venous catheters.47,48 Patients with acute kidney injury-D should receive training in vein preservation. The delivery of these educational components is an excellent example of an important and easy quality measure for health systems and dialysis facilities to track.
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Teaching
By definition, acute kidney injury-D is a potentially reversible condition, and studies suggest that upward of 40% of patients with acute kidney injury-D who are discharged on dialysis may recover to dialysis independence.44,49,50 Patients and their caregivers need to be educated to monitor for kidney function recovery. Many patients with acute kidney injury-D will not have had the benefit of nephrology care before the acute illness, so broader education regarding kidney health should be included when appropriate.14,46 In the dialysis facility, patients with acute kidney injury-D should be identifiable separately from ESRD patients. Patients with dialysis-requiring acute kidney injury should undergo a regular care plan meeting (similar to the ESRD process) that articulates the individual's clinical trajectory and personalized expectations for kidney recovery.
Clearance
We believe dialysis facilities caring for patients with acute kidney injury-D need to have the appropriate processes to allow for more frequent blood and urine testing, assessing for kidney recovery.46 This can be done through blood work (e.g., trending predialysis SCr) and timed urine collections, and should be pursued at least weekly during the outpatient transition.51
Dialysis clearance should also be measured and used to guide prescription. Evidence from the large-scale, randomized controlled acute tubular necrosis trial suggests that for patients with acute kidney injury-D, a delivered Kt/tv urea of 1.2 thrice weekly can be considered adequate dialytic clearance.52 However, patients with acute kidney injury-D may have more individualized needs, such as higher catabolism requiring more dialysis for symptomatic control of uremia. Conversely, patients who begin to recover kidney function may tolerate a tapering of dialysis to less than 3 weekly treatments.
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Hypotension
Intradialytic hypotension is associated with adverse outcomes and may decrease the likelihood of kidney function recovery in patients with acute kidney injury-D.43,44 Emphasizing the importance of limiting interdialytic weight gain is essential, as is the careful adjustment of antihypertensive medications.
Medications
As with any transition in health care settings, the move to outpatient acute kidney injury-D management should be accompanied by a review and reconciliation of medications.53,54 The review and reconciliation process needs to be frequently repeated, especially when kidney function begins to recover, to ensure adequate and appropriate dosing of medications.20 Patients should be educated regarding the potential impact of kidney failure and dialysis on drug clearances, but they should also be instructed that as kidney function begins to recover, drug clearances may be improved and medication dosing may need to be increased or even discontinued. A specific review of common nephrotoxic medications and KENDS should also be performed.20
In addition to these potential measures that focus on processes of care, ideally, outcomes measures such as hospital readmission rates and dialysis independence recovery rates should be monitored. However, there are currently no established benchmarks, and these rates will vary based on patient characteristics. Given the dearth of data in this area, monitoring these rates can help to identify trends and potential quality improvement opportunities.
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Conclusions
Quality measures are needed for the management of acute kidney injury and acute kidney disease patients after the index hospitalization to standardize care and improve patient outcomes. Relatively few patients receive follow-up laboratory testing of kidney function or post-acute kidney injury and acute kidney disease care. Table 3 provides a potential initial quality scorecard for a health care system to begin to monitor and improve acute kidney injury and acute kidney disease care. Although this tool has not been validated, it is based on limited published data and expert opinion. It captures the basic numbers an institution will need to track in the short and long term to care for patients with acute kidney injury and acute kidney disease. Similarly, Supplementary Appendix A and Supplementary Figure S1 provide a hypothetical quality improvement project related to the care of patients with acute kidney injury and acute kidney disease.
In the future, outcomes such as 30-day readmission rates, catheter-associated infection rates, and short- and long-term mortality after an episode of acute kidney injury or acute kidney disease may be quality metrics that will be reported. For now, health care institutions should be aware of the number of patients who warrant post-acute kidney injury or acute kidney disease care as well as track those who go on to receive some form of follow-up. This focused follow-up care could be provided by either nephrology or non-nephrology providers, and this may be an important metric to track. Future quality improvement work and research could focus on the optimal management strategies and clinical effectiveness of the KAMPS and Weight Assessment, Access, Teaching, Clearance, Hypotension, and Medications bundle components and the potential development and validation of new bundles.
DISCLOSURE
JLK is a consultant for Astute Medical, Sphingotec, and Baxter and receives research support from NxStage, Astute Medical, and Satellite Health Care. KDL is a consultant for Durect, Quark, and Portero; is on the advisory board for AstraZeneca; is a speaker for Baxter, and is a stockholder of Amgen. LGF receives research support from Baxter, La Jolla Pharmaceuticals, and Ortho-Clinical-Diagnostics and receives honoraria from Baxter, La Jolla Pharmaceuticals, Ortho-Clinical-Diagnostics, MediBeacon, and Fresenius. JAK is a consultant for Adrenomed, Astute Medical, Baxter, bio- Mérieux, Bioporto, Davita, Fresenius, Mallinckrodt, Novartis, NxStage, Potrero, RenalSense, and Sphingotech and receives grant support from Astute Medical, Baxter, bioMérieux, and RenalSense. MH is a consultant and lecturer for Abbott, Alere, Baxter, Novartis, Siemens, Roche, and FastBiomedical and receives grant support from Abbott Diagnostics. RLM is on the advisory board for Astute Medical, Baxter, Mallinckrodt, and Indalo Therapeutics and received research funds from Fresenius, Fre-series-Kabi, Grifols, and Relypsa. MHR reports honoraria from the American Society of Nephrology and Baxter and serves on data safety monitoring boards for Retrophin and Reata Pharmaceuticals. All other authors declared no competing interests.
SUPPLEMENTARY MATERIAL
Supplementary File (PDF)
Acknowledgments: The ADQI XXII Participants.
Appendix A. Sample Quality Improvement Project
Figure S1. Pareto chart for analysis of the lack of appropriate medication list review at discharge and communication with primary physicians. acute kidney injury; Cum, Cumulative.
Cistanche is a kidney fatigue supplement.
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