Jennifer Holmes

Acute Kidney Injury in the Era of the AKI E-Alert

BACKGROUND AND OBJECTIVES Our aim was to use a national electronic AKI alert to define the incidence and outcome of all episodes of community- and hospital-acquired adult AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A prospective national cohort study was undertaken in a population of 3.06 million. Data were collected between March of 2015 and August of 2015. All patients with adult (≥18 years of age) AKI were identified to define the incidence and outcome of all episodes of community- and hospital-acquired AKI in adults. Mortality and renal outcomes were assessed at 90 days. RESULTS There was a total of 31,601 alerts representing 17,689 incident episodes, giving an incidence of AKI of 577 per 100,000 population. Community-acquired AKI accounted for 49.3% of all incident episodes, and 42% occurred in the context of preexisting CKD (Chronic Kidney Disease Epidemiology Collaboration eGFR); 90-day mortality rate was 25.6%, and 23.7% of episodes progressed to a higher AKI stage than the stage associated with the alert. AKI electronic alert stage and peak AKI stage were associated with mortality, and mortality was significantly higher for hospital-acquired AKI compared with alerts generated in a community setting. Among patients who survived to 90 days after the AKI electronic alert, those who were not hospitalized had a lower rate of renal recovery and a greater likelihood of developing an eGFR<60 ml/min per 1.73 m2 for the first time, which may be indicative of development of de novo CKD. CONCLUSIONS The reported incidence of AKI is far greater than the previously reported incidence in studies reliant on clinical identification of adult AKI or hospital coding data. Although an electronic alert system is Information Technology driven and therefore, lacks intelligence and clinical context, these data can be used to identify deficiencies in care, guide the development of appropriate intervention strategies, and provide a baseline against which the effectiveness of these interventions may be measured.

Acute kidney injury: electronic alerts in primary care - findings from a large population cohort

Background Electronic reporting of AKI has been used to aid early AKI recognition although its relevance to CA-AKI and primary care has not been described. Aims We described the characteristics and clinical outcomes of patients with CA-AKI, and AKI identified in primary care (PC-AKI) through AKI e-Alerts. Design A prospective national cohort study was undertaken to collect data on all e-alerts representing adult CA-AKI. Method The study utilized the biochemistry based AKI electronic (e)-alert system that is established across the Welsh National Health Service. Results 28.8% of the 22 723 CA-AKI e-alerts were classified as PC-AKI. Ninety-day mortality was 24.0% and lower for PC-AKI vs. non-primary care (non-PC) CA-AKI. Hospitalization was 22.3% for PC-AKI and associated with greater disease severity, higher mortality, but better renal outcomes (non-recovery: 18.1% vs. 21.6%; progression of pre-existing CKD: 40.5% vs. 58.3%). 49.1% of PC-AKI had a repeat test within 7 days, 42.5% between 7 and 90 days, and 8.4% was not repeated within 90 days. There was significantly more non-recovery (24.0% vs. 17.9%) and progression of pre-existing CKD (63.3% vs. 47.0%) in patients with late repeated measurement of renal function compared to those with early repeated measurement of renal function. Conclusion The data demonstrate the clinical utility of AKI e-alerts in primary care. We recommend that a clinical review, or referral together with a repeat measurement of renal function within 7 days should be considered an appropriate response to AKI e-alerts in primary care.

The incidence of pediatric acute kidney injury is increased when identified by a change in a creatinine-based electronic alert

A prospective national cohort study was undertaken to collect data on all cases of pediatric (under 18 yrs of age) acute kidney injury (AKI) identified by a biochemistry-based electronic alert using the Welsh National electronic AKI reporting system. Herein we describe the utility and limitation of using this modification of the KDIGO creatinine-based system data set to characterize pediatric AKI. Of 1,343 incident episodes over a 30-month period, 34.5% occurred in neonates of which 83.8% were AKI stage 1. Neonatal 30-day mortality was 4.1%, with 73.3% of this being accounted for by patients treated in an Intensive Care Unit. In the non-neonatal group, 76.1% were AKI stage 1. Hospital-acquired AKI accounted for 40.1% of episodes while community-acquired AKI represented 29.4% of cases within which 33.9% were admitted to hospital and 30.5% of cases were unclassified. Non-neonatal 30-day mortality was 1.2%, with half of this accounted for by patients treated in the Intensive Care Unit. Nonrecovery of renal function at 30 days occurred in 28% and was significantly higher in patients not admitted to hospital (45% vs. 20%). The reported incidence of AKI in children was far greater than previously reported in studies reliant on clinical identification of adult AKI or hospital coding data. Mortality was highest in neonates and driven by those in the Intensive Care Unit. Nonrecovery of renal function and persistent renal impairment was more common in non-neonates and was especially high in patients with community-acquired AKI who were not hospitalized.

Community acquired acute kidney injury: findings from a large population cohort

Background The extent of patient contact with medical services prior to development of community acquired-acute kidney injury (CA-AKI)is unknown. Aim We examined the relationship between incident CA-AKI alerts, previous contact with hospital or primary care and clinical outcomes. Design A prospective national cohort study of all electronic AKIalerts representing adult CA-AKI. Methods Data were collected for all cases of adult (≥18 years of age) CA-AKI in Wales between 1 November 2013 and 31 January 2017. Results There were a total of 50 560 incident CA-AKI alerts. In 46.8% there was a measurement of renal function in the 30 days prior to the AKI alert. In this group, in 63.8% this was in a hospital setting, of which 37.6% were as an inpatient and 37.5% in Accident and Emergency. Progression of AKI to a higher AKI stage (13.1 vs. 9.8%, P < 0.001) (or for AKI 3 an increase of > 50% from the creatinine value generating the alert), the proportion of patients admitted to Intensive Care (5.5 vs. 4.9%, P = 0.001) and 90-day mortality (27.2 vs. 18.5%, P < 0.001) was significantly higher for patients with a recent test. 90-day mortality was highest for patients with a recent test taken in an inpatient setting prior to CA-AKI (30.9%). Conclusion Almost half of all patients presenting with CA-AKI are already known to medical services, the majority of which have had recent measurement of renal function in a hospital setting, suggesting that AKI for at least some of these may potentially be predictable and/or avoidable.

Utility of electronic AKI alerts in intensive care: A national multicentre cohort study

Background: Electronic AKI alerts highlight changes in serum creatinine compared to the patients own baseline. Our aim was to identify all AKI alerts and describe the relationship between electronic AKI alerts and outcome for AKI treated in the Intensive Care Unit (ICU) in a national multicentre cohort. Methods: A prospective cohort study was undertaken between November 2013 and April 2016, collecting data on electronic AKI alerts issued. Results: 10% of 47,090 incident AKI alerts were associated with ICU admission. 90‐day mortality was 38.2%. Within the ICU cohort 48.8% alerted in ICU. 51.2% were transferred to ICU within 7 days of the alert, of which 37.8% alerted in a hospital setting (HA‐AKI) and 62.2% in a community setting (CA‐AKI). Mortality was higher in patients transferred to ICU following the alert compared to those who had an incident alert on the ICU (p < 0.001), and was higher in HA‐AKI (45.3%) compared to CA‐AKI (39.5%) (35.0%, p = 0.01). In the surviving patients, the proportion of patient recovering renal function following, was significantly higher in HA‐AKI alerting (84.2%, p = 0.004) and CA‐AKI alerting patients (87.6%, p < 0.001) compared to patients alerting on the ICU (78.3%). Conclusion: The study provides a nationwide characterisation of AKI in ICU highlighting the high incidence and its impact on patient outcome. The data also suggests that within the cohort of AKI patients treated in the ICU there are significant differences in the presentation and outcome between those patients that require transfer to the ICU after AKI is identified and those who develop AKI following ICU admission. Moreover, the study demonstrates that using AKI e‐alerts provides a centralised resource which does not rely on clinical diagnosis of AKI or coding, resulting in a robust data set which can be used to define the incidence and outcome of AKI in the ICU setting. HighlightsData on epidemiology of AKI historically is reliant on coding or retrospective clinical diagnosisWe describe the epidemiology of AKI in the ICU based an electronic AKI alert based on a change in creatinine diagnosis of AKIThe data suggests that within the cohort of AKI patients treated in the ICU there are significant differences in the presentation and outcome between those patients that require transfer to the ICU after AKI is identified and those who develop AKI following ICU admission

Understanding Electronic AKI Alerts: Characterization by Definitional Rules

Introduction Automated acute kidney injury (AKI) electronic alerts are based on comparing creatinine with historic results. Methods We report the significance of AKI defined by 3 “rules” differing in the time period from which the baseline creatinine is obtained, and AKI with creatinine within the normal range. Results A total of 47,090 incident episodes of AKI occurred between November 2013 and April 2016. Rule 1 (>26 μmol/l increase in creatinine within 48 hours) accounted for 9.6%. Rule 2 (≥50% increase in creatinine within previous 7 days) and rule 3 (≥50% creatinine increase from the median value of results within the last 8–365 days) accounted for 27.3% and 63.1%, respectively. Hospital-acquired AKI was predominantly identified by rules 1 and 2 (71.7%), and community-acquired AKI (86.3%) by rule 3. Stages 2 and 3 were detected by rules 2 and 3. Ninety-day mortality was higher in AKI rule 2 (32.4%) than rule 1 (28.3%, P < 0.001) and rule 3 (26.6%, P < 0.001). Nonrecovery of renal function (90 days) was lower for rule 1 (7.9%) than rule 2 (22.4%, P < 0.001) and rule 3 (16.5%, P < 0.001). We found that 19.2% of AKI occurred with creatinine values within normal range, in which mortality was lower than that in AKI detected by a creatinine value outside the reference range (22.6% vs. 29.6%, P < 0.001). Discussion Rule 1 could only be invoked for stage 1 alerts and was associated with acute on chronic kidney disease acquired in hospital. Rule 2 was also associated with hospital-acquired AKI and had the highest mortality and nonrecovery. Rule 3 was the commonest cause of an alert and was associated with community-acquired AKI.

Seasonal pattern of incidence and outcome of Acute Kidney Injury: A national study of Welsh AKI electronic alerts

To identify any seasonal variation in the occurrence of, and outcome following Acute Kidney Injury.

Dysphagia and laryngeal pathology in post-surgical cardiothoracic patients

Purpose: Cardiothoracic surgery is known to result in dysphagia and laryngeal injury. While prevalence has been explored, extent, trajectory and longevity of symptoms are poorly understood. This retrospective, observational study explored dysphagia and laryngeal injury in patients following cardiothoracic surgery referred for instrumental swallowing assessment. Methods: Clinical notes and endoscopic recordings of 106 patients (age range 18–87 yrs; mean 63 yrs; SD 15 yrs) (including 190 endoscopes) at one large tertiary centre were reviewed by two speech‐language pathologists and a laryngologist. Standardized measures of laryngeal anatomy and physiology, New Zealand Secretion Scale, Penetration‐Aspiration scale and Yale Residue Scale were rated. Results: Prevalence of abnormality included 39% silent aspiration, 65% laryngeal edema and 61% vocal paralysis. The incidence of pneumonia was 36% with a post‐operative stroke rate of 14%. Forty percent of patients were receiving a standard diet by discharge from acute care; while, 24% continued to require enteral feeding and 8% received laryngeal surgery within twelve months of discharge. Vocal fold motion impairment was significantly associated with ventilation time and tracheostomy tube duration (p < .05). Conclusion: Early endoscopic assessment for identification of dysphagia and laryngeal injury in patients following cardiothoracic surgery may allow early management and prevention of secondary complications. HIGHLIGHTSVocal fold motion impairment and silent aspiration is seen in patients referred for instrumental assessment following cardiothoracic surgery.Some patients require longer periods of tube feeding and surgical interventions for persistent vocal fold motion impairment.Early endoscopic assessment may allow early management and prevention of secondary complications.