Unveiling the enigma of acute kidney disease: predicting prognosis, exploring interventions, and embracing a multidisciplinary approach

Abstract

Acute kidney disease (AKD) is a critical transitional period between acute kidney injury and chronic kidney disease. The incidence of AKD following acute kidney injury is approximately 33.6%, and it can occur without identifiable preceding acute kidney injury. The development of AKD is associated with increased risks of chronic kidney disease, dialysis, and mortality. Biomarkers and subphenotypes are promising tools to predict prognosis in AKD. The complex clinical situations in patients with AKD necessitate a comprehensive and structured approach, termed "KAMPS" (kidney function check, advocacy, medications, pressure, sick day protocols). We introduce "MAND-MASS," an acronym devised to summarize the reconciliation of medications during episodes of acute illness, as a critical component of the sick day protocols at AKD. A multidisciplinary team care, consisting of nephrologists, pharmacists, dietitians, health educators, and nurses, is an optimal model to achieve the care bundle in KAMPS. Although the evidence for patients with AKD is still lacking, several potential pharmacological agents may improve outcomes, including but not limited to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide 1 receptor agonists. In conclusion, accurate prognosis prediction and effective treatment for AKD are critical yet unmet clinical needs. Future studies are urgently needed to improve patient care in this complex and rapidly evolving field.

Keywords: Acute kidney injury; Drug therapy; Patient care team; Prognosis.

Figure 1.. The definition and time frame of AKI, AKD, and CKD.

AKI refers to a rapid and abrupt decline in renal function occurring within a period of 2 to 7 days. In contrast, AKD is characterized by the simultaneous presence of kidney damage and abnormal renal function persisting over an extended 90-day timeframe. It’s important to note that AKI is encompassed within the broader category of AKD, although AKD can also be defined independently without identification of prior AKI. CKD is defined by persistent kidney function or structural abnormalities lasting for at least 3 months (or 90 days). Markers of structural kidney injury such as albuminuria or hematuria can also be used to define AKD and CKD. Outcomes, such as mortality or the recovery of renal function, may develop across AKI, AKD, and CKD. AKD, acute kidney disease; AKI, acute kidney injury; CKD, chronic kidney disease; GFR, glomerular filtration rate; sCr, serum creatinine.

Figure 2.. The four pillars of AKD intervention.

These pillars constitute the cornerstone of current, up-to-date therapy for AKD, including angiotensin-converting enzyme inhibitors (ACEi)/ angiotensin receptor blocker (ARB)/mineralocorticoid receptor antagonist (MRA), sodium-glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP-1 RA), and multidisciplinary care (MDC). Nonetheless, it’s essential to acknowledge that the efficacy of this approach may fluctuate according to individual patient necessities and the particular healthcare context. AKD, acute kidney disease. Icons were created with www.biorender.com and additional icons were made by Freepik from www.flaticon.com.

Figure 3.. Exploring ‘sick day protocols’ implementation in acute kidney disease.

The sick day protocols comprise several steps. First, identification of sickness. The patient or caregiver should be educated to recognize signs of illness that could lead to further kidney injury, such as vomiting, diarrhea, or fever. Second, identification of dehydration. Dehydration is a common trigger for kidney injury. Patients should be taught to identify signs of dehydration like dry mouth, decreased urine output, and feeling dizzy when standing up. Third, documentation in medical records. All relevant information about the patient’s condition and medication should be documented in their medical record. Fourth, identification and stopping of certain medications. Patients should be advised to temporarily stop certain medications when they are sick. These typically include diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and nonsteroidal anti-inflammatory drugs. However, patients must consult with their healthcare provider before stopping any medication. Fifth, recovery and resuming medications. Once the patient has recovered from the illness and their hydration status is back to normal, they can resume their medications as advised by their healthcare provider. Readers may also refer to Hall RK et al. [41] for the section on "Safe deprescribing."

Figure 4.. The unfilled gap: multidisciplinary care for preventing deterioration of renal function in AKD.

These professionals work together to provide comprehensive care to patients with AKD, aiming to slow the progression of the disease and improve the patient’s quality of life. The nephrologist leads the team and provides advanced kidney disease treatment. The pharmacist reconciles medication and educates patients about their prescriptions. The dietitian provides dietary guidance tailored to kidney patients’ needs. The health educator or the nurse provides education about lifestyle modifications and self-management strategies to patients. The health educator or the nurse also coordinates patient care with other team members. AKD, acute kidney disease. Icons were created by Freepik from www.flaticon.com.