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      Acute Kidney Injury in Primary Care: A Review of Patient Follow-Up, Mortality, and Hospital Admissions following the Introduction of an AKI Alert System


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          Background/Aims: In February 2017, our laboratory implemented an electronic AKI flagging system for primary care using the NHS England AKI detection algorithm. Our study investigated the impact on patient follow-up, hospital admission, length of stay, and mortality. Methods: Primary care results March 2017–February 2018 with an AKI test code were downloaded from the pathology computer. Results: Over 12 months, 1,784 AKI episodes were identified; 81.3% AKI1, 11.3%, AKI2, and 7.5% AKI3. A repeat creatinine was requested within 14 days on 55% AKI1s, 84% AKI2s, and 86% AKI3s. Primary care took the repeat sample in 73.2% AKI1s and 56.7% AKI2s and acute hospital locations for 47.4% AKI3s. Median time to hospital admission was 34 days for AKI1, 6 for AKI2, and 1 for AKI3 ( p < 0.05). Length of stay was found to be 1, 2, and 4 days for AKI 1/2/3, respectively ( p < 0.05). The 90-day mortality for admitted patients was 15, 18, and 21% for AKI 1/2/3, respectively ( p = 0.180). The 90-day mortality for the non-admitted patients was 4, 9, and 50% for AKI 1/2/3, respectively ( p < 0.05). AKI patient outcome data pre versus post the start of the AKI flag system were compared. A statistically significant reduction was found in the median length of stay for AKI1 and AKI3 and in mortality for AKI1 and AKI3 patients and for all AKIs as a whole. A further analysis was performed to take into account the difference in pre- and post-alert populations. Mortality overall was significantly improved ( p < 0.001), and length of stay was reduced in AKI3 patients ( p = 0.048). Discussion/Conclusion: Our study demonstrates that an electronic AKI warning alert system for primary care appears to be associated with a beneficial impact on patient management and outcome.

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          Most cited references8

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          Acute Kidney Injury and Mortality in Hospitalized Patients

          Background: The objective of this study was to determine the incidence of acute kidney injury (AKI) and its relation with mortality among hospitalized patients. Methods: Analysis of hospital discharge and laboratory data from an urban academic medical center over a 1-year period. We included hospitalized adult patients receiving two or more serum creatinine (sCr) measurements. We excluded prisoners, psychiatry, labor and delivery, and transferred patients, ‘bedded outpatients’ as well as individuals with a history of kidney transplant or chronic dialysis. We defined AKI as (a) an increase in sCr of ≥0.3 mg/dl; (b) an increase in sCr to ≥150% of baseline, or (c) the initiation of dialysis in a patient with no known history of prior dialysis. We identified factors associated with AKI as well as the relationships between AKI and in-hospital mortality. Results: Among the 19,249 hospitalizations included in the analysis, the incidence of AKI was 22.7%. Older persons, Blacks, and patients with reduced baseline kidney function were more likely to develop AKI (all p < 0.001). Among AKI cases, the most common primary admitting diagnosis groups were circulatory diseases (25.4%) and infection (16.4%). After adjustment for age, sex, race, admitting sCr concentration, and the severity of illness index, AKI was independently associated with in-hospital mortality (adjusted odds ratio 4.43, 95% confidence interval 3.68–5.35). Conclusions: AKI occurred in over 1 of 5 hospitalizations and was associated with a more than fourfold increased likelihood of death. These observations highlight the importance of AKI recognition as well as the association of AKI with mortality in hospitalized patients.
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            Increased risk of death and de novo chronic kidney disease following reversible acute kidney injury.

            Acute kidney injury increases mortality risk among those with established chronic kidney disease. In this study we used a propensity score-matched cohort method to retrospectively evaluate the risks of death and de novo chronic kidney disease after reversible, hospital-associated acute kidney injury among patients with normal pre-hospitalization kidney function. Of 30,207 discharged patients alive at 90 days, 1610 with reversible acute kidney injury that resolved within the 90 days were successfully matched across multiple parameters with 3652 control patients who had not experienced acute kidney injury. Median follow-up was 3.3 and 3.4 years (injured and control groups, respectively). In Cox proportional hazard models, the risk of death associated with reversible acute kidney injury was significant (hazard ratio 1.50); however, adjustment for the development of chronic kidney injury during follow-up attenuated this risk (hazard ratio 1.18). Reversible acute kidney injury was associated with a significant risk of de novo chronic kidney disease (hazard ratio 1.91). Thus, a resolved episode of hospital-associated acute kidney injury has important implications for the longitudinal surveillance of patients without preexisting, clinically evident kidney disease.
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              Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients.

              Many patients with AKI are cared for by non-nephrologists. This can result in variable standards of care that contribute to poor outcomes. To improve AKI recognition, a real-time, hospital-wide, electronic reporting system was designed based on current Acute Kidney Injury Network criteria. This system allowed prospective data collection on AKI incidence and outcomes such as mortality rate, length of hospital stay, and renal recovery. The setting was a 1139-bed teaching hospital with a tertiary referral nephrology unit. An electronic reporting system was successfully introduced into clinical practice (false positive rate, 1.7%; false negative rate, 0.2%). The results showed that there were 3202 AKI episodes in 2619 patients during the 9-month study period (5.4% of hospital admissions). The in-hospital mortality rate was 23.8% and increased with more severe AKI (16.1% for stage 1 AKI versus 36.1% for stage 3) (P<0.001). More severe AKI was associated with longer length of hospital stay for stage 1 (8 days; interquartile range, 13) versus 11 days for stage 3 (interquartile range, 16) (P<0.001) and reduced chance of renal recovery (80.0% in stage 1 AKI versus 58.8% in stage 3) (P<0.001). Utility of the Acute Kidney Injury Network criteria was reduced in those with pre-existing CKD. AKI is common in hospitalized patients and is associated with very poor outcomes. The successful implementation of electronic alert systems to aid early recognition of AKI across all acute specialties is one strategy that may help raise standards of care.

                Author and article information

                S. Karger AG
                October 2020
                20 August 2020
                : 144
                : 10
                : 498-505
                [_a] aDepartment of Clinical Chemistry, Royal Cornwall Hospital, Truro, United Kingdom
                [_b] bDepartment of Nephrology, Royal Cornwall Hospital, Truro, United Kingdom
                [_c] cOrganisational Development, Royal Cornwall Hospital, Truro, United Kingdom
                Author notes
                *Sam B.M. Williams, Department of Nephrology, Royal Cornwall Hospital, Treliske, Truro TR1 3LJ (UK), samuel.williams3@nhs.net
                509855 Nephron 2020;144:498–505
                © 2020 S. Karger AG, Basel

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                : 27 April 2020
                : 30 June 2020
                Page count
                Figures: 1, Tables: 6, Pages: 8
                Clinical Practice: Research Article

                Cardiovascular Medicine,Nephrology
                Acute kidney injury alert system,Acute kidney injury,Primary care,Nephrology


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