Nitin V. Kolhe

Use of Electronic Results Reporting to Diagnose and Monitor AKI in Hospitalized Patients

BACKGROUND AND OBJECTIVES Many patients with AKI are cared for by non-nephrologists. This can result in variable standards of care that contribute to poor outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS 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. RESULTS 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. CONCLUSIONS 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.

Impact of Compliance with a Care Bundle on Acute Kidney Injury Outcomes: A Prospective Observational Study.

Background A recent report has highlighted suboptimal standards of care for acute kidney injury (AKI) patients in England. The objective of this study was to ascertain if improvement in basic standard of care by implementing a care bundle (CB) with interruptive alert improved outcomes in patients with AKI. Methods An AKI CB linked to electronic recognition of AKI, coupled with an interruptive alert, was introduced to improve basic care delivered to patients with AKI. Outcomes were compared in patients who had the CB completed within 24 hours (early CB group) versus those who didn’t have the CB completed or had it completed after 24 hours. Results In the 11-month period, 2297 patients had 2500 AKI episodes, with 1209 and 1291 episodes occurring before and after implementation of the AKI CB with interruptive alert, respectively. The CB was completed within 24 hours in 306 (12.2%) of AKI episodes. In-hospital case-fatality was significantly lower in the early CB group (18% versus 23.1%, p 0.046). Progression to higher AKI stages was lower in the early CB group (3.9% vs. 8.1%, p 0.01). In multivariate analysis, patients in the early CB group had lower odds of death at discharge (0.641; 95% CI 0.46, 0.891), 30 days (0.707; 95% CI 0.527, 0.950), 60 days (0.704; 95% CI 0.526, 0.941) and after a median of 134 days (0.771; 95% CI 0.62, 0.958). Conclusions Compliance with AKI CB was associated with a decrease in case-fatality and reduced progression to higher AKI stage. Further interventions are required to improve utilization of the CB.

Obstructive nephropathy and kidney injury associated with ketamine abuse

A 26-year-old man presented to the emergency department in a state of collapse. One month prior to the current admission he was seen by a urologist with frank haematuria associated with colicky abdominal pain, increased urinary frequency and dysuria. Although he was initially treated for a urinary tract infection a CT abdomen demonstrated moderate bilateral hydronephrosis. No cause for the hydronephrosis was seen, in particular no calculi. Common bile duct (CBD) was measured at 8 mm. Cystoscopy revealed a diffusely inflamed bladder with marked reduction in capacity (150 cc) but no obstruction at the ureteric orifices. The bladder biopsy showed inflammatory change but no dysplasia or malignancy. No firm diagnosis was reached and the patient was discharged with outpatient follow-up. For 4 days prior to the current admission the patient had been unwell with increasing flank pain, but had become drowsy and short of breath. On arrival, blood pressure was low at 95/60 mmHg with an associated tachycardia (140 bpm, sinus rhythm) and tachypnoea (60 breaths/min). The Glasgow coma scale was 13/15 with no localizing neurological signs. Initial investigations revealed severe metabolic acidosis (pH 7.2, bicarbonate 6.4 mmol/l, pO2 39.3 kPa, pCO2 2.0 kPa) and acute renal failure (serum potassium 5.4 mmol/l, urea 36.7 mmol/l, creatinine 851 μmol/l). Liver function tests were abnormal with an obstructive pattern (serum bilirubin 58 μmol/l, alkaline phosphatase 294 IU/l, alanine transaminase 106 IU/l, γGT 1045 IU/l). Further history revealed that the patient was a regular user of street ketamine intra-nasally for the past 2 years.

Defining the Cause of Death in Hospitalised Patients with Acute Kidney Injury

Background The high mortality rates that follow the onset of acute kidney injury (AKI) are well recognised. However, the mode of death in patients with AKI remains relatively under-studied, particularly in general hospitalised populations who represent the majority of those affected. We sought to describe the primary cause of death in a large group of prospectively identified patients with AKI. Methods All patients sustaining AKI at our centre between 1st October 2010 and 31st October 2011 were identified by real-time, hospital-wide, electronic AKI reporting based on the Acute Kidney Injury Network (AKIN) diagnostic criteria. Using this system we are able to generate a prospective database of all AKI cases that includes demographic, outcome and hospital coding data. For those patients that died during hospital admission, cause of death was derived from the Medical Certificate of Cause of Death. Results During the study period there were 3,930 patients who sustained AKI; 62.0% had AKI stage 1, 20.6% had stage 2 and 17.4% stage 3. In-hospital mortality rate was 21.9% (859 patients). Cause of death could be identified in 93.4% of cases. There were three main disease categories accounting for three quarters of all mortality; sepsis (41.1%), cardiovascular disease (19.2%) and malignancy (12.9%). The major diagnosis leading to sepsis was pneumonia, whilst cardiovascular death was largely a result of heart failure and ischaemic heart disease. AKI was the primary cause of death in only 3% of cases. Conclusions Mortality associated with AKI remains high, although cause of death is usually concurrent illness. Specific strategies to improve outcomes may therefore need to target not just the management of AKI but also the most relevant co-existing conditions.

National trends in acute kidney injury requiring dialysis in England between 1998 and 2013

Acute kidney injury (AKI) severe enough to require dialysis is increasing and associated with high mortality, yet robust information about temporal epidemiology of AKI requiring dialysis in England is lacking. In this retrospective observational study of the Hospital Episode Statistics (HES) data set covering the entire English National Health Service, we identified all patients with a diagnosis of AKI requiring dialysis between 1998 and 2013. This incidence increased from 774 cases (15.9 per million people) in 1998-1999 to 11,164 cases (208.7 per million people) in 2012-2013. The unadjusted in-hospital case-fatality was 30.3% in 1998-2003 and 30.2% in 2003-2008, but significantly increased to 41.1% in 2008-2013. Compared with 2003-2008, the multivariable adjusted odds ratio for death was higher in 1998-2003 at 1.20 (95% CI: 1.10-1.30) and in 2008-2013 at 1.13 (1.07-1.18). Charlson comorbidity scores of more than five (odds ratio 2.35; 95% CI: 2.20-2.51) and emergency admissions (2.46 (2.32-2.61) had higher odds for death. The odds for death decreased in patients over 85 years from 4.83 (3.04-7.67) in 1998-2003 to 2.19 (1.99-2.41) in 2008-2013. AKI in secondary diagnosis and in other diagnoses codes had higher odds for death compared with AKI in primary diagnosis code in all three periods. Thus, the incidence of AKI requiring dialysis has increased progressively over 15 years in England. Improvement in case-fatality in 2003-2008 has not been sustained in the last 5 years.

Acute kidney injury is independently associated with death in patients with cirrhosis

Background and aims Current creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes. Methods We prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI. Results 162 cirrhotic patients were studied with a mean age of 56.8±14 years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child–Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0 days (IQR 4.0–8.75) versus 16.0 days (IQR 6.0–27.5), p<0.001. Multivariate analysis identified AKI and Child–Pugh classes B and C as independent factors associated with mortality. Conclusions The utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.

The epidemiology of hospitalised acute kidney injury not requiring dialysis in England from 1998 to 2013: retrospective analysis of hospital episode statistics

Epidemiology studies of acute kidney injury (AKI) have focused on cases requiring dialysis but those not requiring dialysis represent the majority. To address this gap, we interrogated hospital episode statistics (HES) to investigate population trends in temporal epidemiology of AKI not requiring dialysis between 1998 and 2013.

The Reimbursement and Cost of Acute Kidney Injury: A UK Hospital Perspective

Background: Despite the great interest in acute kidney injury (AKI), there have been very few studies that examined the economic impact and costing methodologies of AKI. We aimed to examine the cost and income of AKI in hospitalised patients over a period of 1 year using the NHS costing system related to that year. Methods: A total of 627 patients discharged between January 2008 and December 2008 with AKI were identified by International Classification of Disease 10 codes (ICD-10). Basic demographic data were collected using the hospital electronic records, and the severity of AKI was classified according to the Acute Kidney Injury Network (AKIN) classification. We calculated the total income and isolated the AKI income related to AKI-specific finished consultant episodes. Then we conducted a patient level costing exercise using relative value units (RVU) to compare the cost of AKI to the actual income. Results: The total spell income for all patients was GBP 1,954,922.7; the mean total income per patient was GBP 3,752.3 (95% CI 3,594.6-3,903.9). AKIN stage 3 generated significantly higher total spell and AKI income. The estimated overall cost of treating AKI was higher than the AKI income to the Primary Care Trust (GBP 1,984,543.9 vs. 1,755,395). Conclusion: AKIN stage 3 has a significant economic impact when compared with AKIN stages 1 and 2. The move towards a patient level costing using RVU could be a more efficient way to match cost and income.

Care Bundles for Acute Kidney Injury: Do They Work?

Acute kidney injury (AKI) is common and is associated with poor patient outcomes, which in some cases appear associated with deficiencies in the provision of care. Care bundles (CBs) are a structured set of practices designed to improve the processes of care delivery and ultimately patient outcomes, and there have been some demonstrations of their utility in areas such as ventilator-associated pneumonia and in sepsis management. While there is a strong rationale for their use, the evidence base around AKI CBs is small but growing. Here, we review the existing data on the effectiveness of AKI CB and discuss optimal approaches to their future study.

Regional Variation in Acute Kidney Injury Requiring Dialysis in the English National Health Service from 2000 to 2015 – A National Epidemiological Study

Background The absence of effective interventions in presence of increasing national incidence and case-fatality in acute kidney injury requiring dialysis (AKI-D) warrants a study of regional variation to explore any potential for improvement. We therefore studied regional variation in the epidemiology of AKI-D in English National Health Service over a period of 15 years. Method We analysed Hospital Episode Statistics data for all patients with a diagnosis of AKI-D, using ICD-10-CM codes, in English regions between 2000 and 2015 to study temporal changes in regional incidence and case-fatality. Results Of 203,758,879 completed discharges between 1st April 2000 and 31st March 2015, we identified 54,252 patients who had AKI-D in the nine regions of England. The population incidence of AKI-D increased variably in all regions over 15 years; however, the regional variation decreased from 3·3-fold to 1·3-fold (p<0·01). In a multivariable adjusted model, using London as the reference, in the period of 2000–2005, the North East (odd ratio (OR) 1·38; 95%CI 1·01, 1·90), East Midlands (OR 1·38; 95%CI 1·01, 1·90) and West Midlands (OR 1·38; 95%CI 1·01, 1·90) had higher odds for death, while East of England had lower odds for death (OR 0·66; 95% CI 0·49, 0·90). The North East had higher OR in all three five-year periods as compared to the other eight regions. Adjusted case-fatality showed significant variability with temporary improvement in some regions but overall there was no significant improvement in any region over 15 years. Conclusions We observed considerable regional variation in the epidemiology of AKI-D that was not entirely attributable to variations in demographic or other identifiable clinical factors. These observations make a compelling case for further research to elucidate the reasons and identify interventions to reduce the incidence and case-fatality in all regions.