Quality of Care for Acute Kidney Disease: Current Knowledge Gaps and Future Directions

Abstract

Acute kidney injury (AKI) and acute kidney disease (AKD) are common complications in hospitalized patients and are associated with adverse outcomes. Although consensus guidelines have improved the care of patients with AKI and AKD, guidance regarding quality metrics in the care of patients after an episode of AKI or AKD is limited. For example, few patients receive follow-up laboratory testing of kidney function or post-AKI or AKD care through nephrology or other providers. Recently, the Acute Disease Quality Initiative developed a consensus statement regarding quality improvement goals for patients with AKI or AKD specifically highlighting efforts regarding quality and safety of care after hospital discharge after an episode of AKI or AKD. The goal is to use these measures to identify opportunities for improvement that will positively affect outcomes. We recommend that health care systems quantitate the proportion of patients who need and actually receive follow-up care after the index AKI or AKD hospitalization. The intensity and appropriateness of follow-up care should depend on patient characteristics, severity, duration, and course of AKI of AKD, and should evolve as evidence-based guidelines emerge. Quality indicators for discharged patients with dialysis requiring AKI or AKD should be distinct from end-stage renal disease measures. Besides, there should be specific quality indicators for those still requiring dialysis in the outpatient setting after AKI or AKD. Given the limited preexisting data guiding the care of patients after an episode of AKI or AKD, there is ample opportunity to establish quality measures and potentially improve patient care and outcomes. This review will provide specific evidence-based and expert opinion-based guidance for the care of patients with AKI or AKD after hospital discharge.

Keywords: acute kidney injury; outcomes; quality; recovery.

Figure 1

The spectrum of acute kidney injury (AKI), acute kidney disease (AKD), and chronic kidney disease (CKD). Acute kidney injury, AKD, and CKD can form a spectrum of diagnoses in which the initial kidney injury can potentially lead to the development of CKD. Acute kidney injury describes a process of damage, loss of kidney function, or both for 7–90 days after exposure to an AKI initiating event. For patients with preexisting CKD, the AKI event can be superimposed on CKD, with AKD existing on a background of CKD. Patients who experience AKD with preexisting CKD are probably at high risk for kidney disease progression. Modified from Acute Disease Quality Initiative XVI (www.adqi.org).

Figure 2

Schematic for acute kidney injury (AKI) and acute kidney disease (AKD) follow-up. The figure displays a paradigm for the care of patients who experience AKI or AKD. Follow-up with nephrology and non-nephrology changes based on the duration and severity of AKI or AKD and varies along the horizontal axis. The timing and nature of follow-up are suggestions because there are limited data to inform this process. AKI-D, patients with dialysis-requiring AKI; CKD, chronic kidney disease; CV dx, cardiovascular disease; KAMPS, Kidney Function Check, Advocacy, Medications, Pressure, Sick Day Protocols; UA, urinalysis; neph appt, nephrology appointment; SCr, serum creatinine; Weight Assessment, Access, Teaching, Clearance, Hypotension, and Medications. Modified from Acute Disease Quality Initiative XXII (www.adqi.org).