Electronic alerts for acute kidney injury across primary and secondary care

ProblemIn 2009 the National Confidential Enquiry into Patient Outcome and Death suggested only 50% of patients with acute kidney injury (AKI) receive good standards of care. In response National Health Service (NHS) England mandated the use of electronic AKI alerts within secondary care. However, we recognised AKI is not just a secondary care problem, where primary care has a crucial role to play in prevention, early detection and management as well as post-AKI care.MethodsAKI alerts were implemented in primary and secondary care services for a population of 480 000. Comparisons were made in AKI incidence, peak creatinine following AKI and renal recovery in the years before and after using Byar’s approximation (95% CI).InterventionA complex quality improvement initiative was implemented based on the design and integration of an AKI alerting system within laboratory information management systems for primary and secondary care, with an affixed URL for clinicians to access a care bundle of AKI guidelines on safe prescribing, patient advice and early contact with nephrology.ResultsThe intervention was associated with an 8% increase in creatinine testing (n=32 563). Hospital acquired AKI detection increased by 6%, while community acquired AKI detection increased by 3% and AKI stage 3 detected in primary care fell by 14%. The intervention overall had no effect on AKI severity but did improve follow-up testing and renal recovery. Importantly hospital AKI 3 recoveries improved by 22%. In a small number of AKI cases, the algorithm did not produce an alert resulting in a reduction in follow-up testing compared with preintervention levels.ConclusionThe introduction of AKI alerts in primary and secondary care, in conjunction with access to an AKI care bundle, was associated with higher rates of repeat blood sampling, AKI detection and renal recovery. Validating accuracy of alerts is required to avoid patient harm.

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Acute Kidney Injury Relevant to Tubulointerstitial Nephritis with Late-Onset Uveitis Superimposed by Thrombotic Microangiopathy: A Case Report and Review of the Literature

Kidney Diseases ◽

10.1159/000507668 ◽

2020 ◽

Vol 6 (6) ◽

pp. 414-421

Author(s):

Youlu Zhao ◽

Junwen Huang ◽

Tao Su ◽

Zhikai Yang ◽

Xizi Zheng ◽

...

Keyword(s):

Acute Kidney Injury ◽

Thrombotic Microangiopathy ◽

Tubulointerstitial Nephritis ◽

Late Onset ◽

Drug Hypersensitivity ◽

Oral Prednisone ◽

Kidney Injury ◽

Renin Angiotensin System ◽

Renal Recovery

Background: The syndrome of tubulointerstitial nephritis and uveitis (TINU) is an uncommon and multisystemic autoimmune disorder. This review reports a rare case of TINU being superimposed on thrombotic microangiopathy (TMA) and, by comparing with the available literature, also summarizes the clinical features, associated conditions, treatment, and outcome of patients with TINU. Summary: Herein, we report the case of a 37-year-old male patient with acute kidney injury (AKI) clinicopathologically identified as malignant hypertension-induced TMA superimposed by acute tubulointerstitial nephritis, which was suspected to be related to drug hypersensitivity. After treatment with oral prednisone combined with a renin-angiotensin system inhibitor, the patient achieved partial renal recovery and was withdrawn from hemodialysis. Recurrent AKI concomitant with new-onset asymptomatic uveitis was detected during routine clinical follow-up after cessation of prednisone. TINU was then diagnosed, and prednisone followed by cyclophosphamide was prescribed. The patient achieved better renal recovery than in the first round of treatment and maintained stable renal function afterward. By reviewing the literature, 36 cases were reported as TINU superimposed on other conditions, including thyroiditis, osteoarthropathy, and sarcoid-like noncaseating granulomas. Key messages: TINU could be complicated by many other conditions, among which TMA is very rare. When presented as AKI, kidney biopsy is important for differential diagnosis. The case also shows that recurrent AKI with concomitant uveitis after prednisone withdrawal strongly suggested the need for long-term follow-up and elongated prednisone therapy for TINU syndrome.

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

QJM ◽

10.1093/qjmed/hcx080 ◽

2017 ◽

Vol 110 (9) ◽

pp. 577-582 ◽

Cited By ~ 11

Author(s):

J. Holmes ◽

N. Allen ◽

G. Roberts ◽

J. Geen ◽

J.D. Williams ◽

...

Keyword(s):

Primary Care ◽

Acute Kidney Injury ◽

Large Population ◽

Kidney Injury ◽

Population Cohort ◽

Electronic Alerts ◽

Large Population Cohort

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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

Nephron ◽

10.1159/000509855 ◽

2020 ◽

Vol 144 (10) ◽

pp. 498-505

Author(s):

Anna L. Barton ◽

Sam B.M. Williams ◽

Stephen J. Dickinson ◽

Rob G. Parry ◽

Adam Pollard

Keyword(s):

Primary Care ◽

Acute Kidney Injury ◽

Hospital Admissions ◽

Kidney Injury ◽

Alert System

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Acute Kidney Injury with Hemolytic Uremic Syndrome

Pakistan Journal of Kidney Diseases ◽

10.53778/pjkd4184 ◽

2021 ◽

Vol 4 (1) ◽

pp. 193-198

Author(s):

Rubina Naqvi ◽

Khawar Abbas ◽

Syed Fazal Akhtar

Keyword(s):

Acute Kidney Injury ◽

Hemolytic Uremic Syndrome ◽

Case Series ◽

Kidney Injury ◽

Febrile Illness ◽

Renal Recovery ◽

P Value ◽

Co Morbidity ◽

Uremic Syndrome

We report here, case series of patients with acute kidney injury (AKI) developing in associationwith hemolytic uremic syndrome (HUS). Different causes of HUS and outcome of patients in this group of patients is aimed to be reported. Patients and Methods: subjects for the study reported here comprised of a cohort of 105 patients admitted with the diagnosis of AKI due to HUS. AKI was defined according to RIFLE criteria and HUS on basis of hematological, biochemical and/or histological features. All patients had normal size kidneys on ultrasonography and no previous co- morbidity. Results: One hundred and five patients with AKI due to HUS were brought to this institute from January 2000 - July 2019; among these 76 were females, mean age of these patients was 27.83±10.50 years. Causes of HUS were febrile illness, with or without diarrhea, diarrhea alone, pregnancy related complications and one each from snake bite, HCV infection / IFN therapy and use of combination of drugs. In pregnancy related HUS one patient had HUS during pregnancy while rest were during postpartum. Renal replacement was required in 95.23 % patients. Complete renal recovery was observed in 22 patients, while 15 died during acute phase of illness. CKD-V developed in 24 patients, 41 patients lost long term follow up, but were dialysis free till last follow up. Treatment with plasmapheresis revealed significantly better renal recovery (p value 0.026) in this group of patients. Conclusion: HUS can be severe life threatening disease; AKI with background of HUS may remain irreversible in many of these patients. Plasmapheresis should be offered to patients with established diagnosis of HUS.

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Acute kidney injury electronic alerts: mixed methods evaluation of their implementation into secondary care, utilising normalisation process theory

Future Healthcare Journal ◽

10.7861/futurehosp.6-1-s68 ◽

2019 ◽

Vol 6 (Suppl 1) ◽

pp. 68-68

Author(s):

Jason Scott ◽

Tracy Finch ◽

Gregory Maniatopoulos ◽

Mark Bevan ◽

Suren Kanagasundaram

Keyword(s):

Acute Kidney Injury ◽

Mixed Methods ◽

Secondary Care ◽

Kidney Injury ◽

Process Theory ◽

Normalisation Process Theory ◽

Mixed Methods Evaluation ◽

Electronic Alerts

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P0602CLINICAL PATTERN, RENAL RECOVERY AND PATIENT OUTCOMES AFTER ACUTE KIDNEY INJURY IN ADULTS IN AN EMERGING COUNTRY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0602 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Arunkumar Subbiah ◽

Sanjay Kumar Agarwal

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Hospital Mortality ◽

Kidney Injury ◽

Hospitalized Patients ◽

Renal Recovery ◽

Common Source ◽

Partial Recovery

Abstract Background and Aims Acute Kidney Injury (AKI) is an important determinant of outcome in hospitalized patients. Further, there is a risk for development of Chronic Kidney Disease (CKD) in the future. Though the long-term impact of AKI has been studied in developed countries, there is a paucity of data in this area from the Indian subcontinent. This single-centre study aimed to assess the pattern, clinical spectrum, short-term and long-term outcomes of AKI. Method In this prospective observational cohort study, detailed demographic and clinical data at presentation, during hospital stay and follow-up at 1, 3, 6 and 12 months after discharge were obtained prospectively for a cohort of patients with AKI. Both community (CAAKI) and hospital acquired AKI (HAAKI) were included. Patient with pre-existing CKD were excluded. Outcome variables examined were in-hospital mortality, renal function at discharge and on follow-up after discharge from hospital. Results In our study cohort with 476 patients, majority of the cases were CAAKI (395, 83%). The mean age at presentation was 44.8 ± 18.7 years. Medical causes (84%) contributed to the majority of AKI while the remaining were due to surgical (10%) and obstetrical (6%) causes. Sepsis (176/476; 36.9%) was the most common cause of AKI. The most common source for sepsis was respiratory (41%) followed by urological source (18.7%). The in-hospital mortality rate for patients with AKI was 38%. Age >60 years (HR = 1.51; 95% CI, 1.11 – 2.07), oliguria (HR = 1.48; 95% CI, 1.05 – 2.10), need for ventilator (HR = 2.45; 95% CI, 1.36 – 4.41) and/or inotropes (HR = 14.4; 95% CI, 6.28 – 33.05) were predictors of mortality. At discharge, 146 (30.7%) patients had complete renal recovery, while 149 (31.3%) had partial renal recovery. Oliguria (p < 0.001), hypoalbuminemia (p = 0.001) and need for renal replacement therapy (RRT) (p = 0.01) were significantly associated with partial recovery. Of the 295 patients on follow-up at discharge, 211 (71.5%) patients had normal renal function, 4 (1.4%) died and 33 (11.2%) were lost to follow up; 47(15.9%) patients developed CKD of which 6 (2%) were dialysis dependent. Elderly patients, higher AKIN stage with oliguria and those requiring RRT were more likely to develop CKD. Among these, the need for in-hospital RRT was the single most important factor predicting the risk of CKD (OR 1.77, 95% CI, 1.12-2.78). Conclusion In conclusion, our data shows that AKI in hospitalized patients still has high mortality in emerging countries like India. Though a fairly good percentage of cases recovered, there is a definite risk of CKD development, especially in patients who required RRT during hospitalization.

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SP203AN ACUTE KIDNEY INJURY EDUCATION PROJECT REACHING FROM SECONDARY CARE TO PRIMARY CARE

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfv190.15 ◽

2015 ◽

Vol 30 (suppl_3) ◽

pp. iii444-iii444

Author(s):

Stephen J Dickinson ◽

Anna Barton ◽

Angela Mallard ◽

Kirsty Bond ◽

Joanne Palmer ◽

...

Keyword(s):

Primary Care ◽

Acute Kidney Injury ◽

Secondary Care ◽

Kidney Injury ◽

Education Project

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097 RENAL RECOVERY FOLLOWING DENGUE-INDUCED ACUTE KIDNEY INJURY: A PROSPECTIVE FOLLOW-UP ANALYSIS

Kidney International Reports ◽

10.1016/j.ekir.2017.06.050 ◽

2017 ◽

Vol 2 (4) ◽

pp. S12

Author(s):

Tauqeer Hussain Mallhi ◽

Amer Hayat Khan ◽

Azreen Syazril Adnan ◽

Azmi Sarriff ◽

Yusra Habib Khan

Keyword(s):

Acute Kidney Injury ◽

Kidney Injury ◽

Renal Recovery

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

BMJ Open ◽

10.1136/bmjopen-2019-032925 ◽

2019 ◽

Vol 9 (12) ◽

pp. e032925

Author(s):

Jason Scott ◽

Tracy Finch ◽

Mark Bevan ◽

Gregory Maniatopoulos ◽

Chris Gibbins ◽

...

Keyword(s):

Acute Kidney Injury ◽

Mixed Methods ◽

Secondary Care ◽

Qualitative Data ◽

Kidney Injury ◽

Process Theory ◽

Normalisation Process Theory ◽

Successful Implementation ◽

Structured Interviews ◽

Electronic Alerts

ObjectiveAround 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.DesignMixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.Setting and participantsThree 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).AnalysisQualitative 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.ResultsParticipants 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).ConclusionsClinicians 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.

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