AKI!Now Initiative: Recommendations for Awareness, Recognition, and Management of AKI

Abstract

The American Society of Nephrology has established a new initiative, AKI!Now, with the goal of promoting excellence in the prevention and treatment of AKI by building a foundational program that transforms education and delivery of AKI care, aiming to reduce morbidity and associated mortality and to improve long-term outcomes. In this article, we describe our current efforts to improve early recognition and management involving inclusive interdisciplinary collaboration between providers, patients, and their families; discuss the ongoing need to change some of our current AKI paradigms and diagnostic methods; and provide specific recommendations to improve AKI recognition and care. In the hospital and the community, AKI is a common and increasingly frequent condition that generates risks of adverse events and high costs. Unfortunately, patients with AKI may frequently have received less than optimal quality of care. New classifications have facilitated understanding of AKI incidence and its impact on outcomes, but they are not always well aligned with AKI pathophysiology. Despite ongoing research efforts, treatments to promote or hasten kidney recovery remain ineffective. To avoid progression, the current approach to AKI emphasizes the promotion of early recognition and timely response. However, a lack of awareness of the importance of early recognition and treatment among health care team members and the heterogeneity of approaches within the health care teams assessing the patient remains a major challenge. Early identification is further complicated by differences in settings where AKI occurs (the community or the hospital), and by differences in patient populations and cultures between the intensive care unit and ward environments. To address these obstacles, we discuss the need to improve education at all levels of care and to generate specific guidance on AKI evaluation and management, including the development of a widely applicable education and an AKI management toolkit, engaging hospital administrators to incorporate AKI as a quality initiative, and raising awareness of AKI as a complication of other disease processes.

Keywords: AKI awareness; AKI biomarkers; AKI multidisciplinary management; AKI pathology; AKI recognition; AKI urinalysis; acute kidney injury; artificial intelligence; critical care nephrology; electronic alerts; goals; hospital administrators; incidence; intensive care units; kidney; longitudinal studies; morbidity; patient care team; quality of health care.

Figure 1.

Targeted approach to AKI, designed to enhance awareness and promote early recognition and intervention.

Figure 2.

AKI awareness is key to achieve early recognition, which is highly dependent on the context and the available resources where AKI occurs. Confirmation can be achieved with basic resources such as measurement of urine output, urinalysis, and POC testing, but—where available—biomarkers, kidney imaging, and biopsy enhance the diagnostic process. POC, point of care; KDIGO, Kidney Disease Improving Global Outcomes.

Figure 3.

Paradigms for optimal biomarker use focus on targeted biomarker testing in populations of interest. In this model, early identification of risk is enhanced by preemptive identification of patients who are high risk using prediction scores and dynamic review of the electronic health record. To further enrich the population, the Renal Angina Index (46,47) or the furosemide stress test can be used (88). By identifying higher pretest probability, the use of targeted biomarkers significantly improves diagnostic accuracy and yield. Use of targeted, multiple biomarkers to identify the type of kidney injury and to risk-stratify patients may, in the future, direct personalized treatment (58). CV, cardiovascular.

Figure 4.

The early recognition of AKI is currently impeded by the widespread use of serum creatinine as the main (and often the only) biomarker. Unfortunately, serum creatinine is a late, insensitive, highly confounded, nonspecific biomarker of kidney function. SCR, serum creatinine.

Figure 5.

Proposed recommendations.