Management of Acute Kidney Injury

Abstract

Acute kidney injury (AKI) has attracted considerable attention with the recognition that even small changes in renal function may have profound effects on major outcomes, regardless of the setting. Despite advances in diagnosis and staging of AKI (1) with emerging biomarkers informing our knowledge of mechanisms and pathways, we do not as yet know how AKI contributes to the increased mortality and morbidity in hospitalized patients. We have blamed the lack of progress in this area on the heterogeneity of the population and disease mechanisms coupled with difficulties in ascertaining the attributable risk, particularly when AKI is a component of multiorgan failure. However, several pieces of evidence now suggest that we should consider additional process of care factors that may influence a patient’s course and outcomes. Data from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) audit of 564 patients who died with a diagnosis of AKI in United Kingdom hospitals revealed significant gaps in performance for management of AKI, with over 50% of cases failing to meet criteria for good care, and only 30% of those who developed AKI in the hospital meeting these criteria (2). In 12% of cases, there was delayed recognition, 29% had inadequate assessment of risk factors, and both diagnostic and therapeutic interventions were subject to poor performance in a significant number of patients. The level of prior training of the physician influenced the quality of care, and senior physicians were deemed to provide better care. Only 31% of patients were referred to a nephrologist for advice or management support, whereas an additional 20% were considered as having needed nephrology support. 21% of the referrals to nephrology were considered by the advisors to be