Discharge After In-Hospital Acute Kidney Injury Guidance

New guidance from the American Society of Nephrology (ASN) addresses needed improvements in providing appropriate care to patients discharged after experiencing acute kidney injury requiring in-hospital hemodialysis (AKI-D).

Upon discharge, “patients with AKI-D often end up receiving the same care as patients with end stage kidney disease [ESKD], who need long-term dialysis,” first author Anitha Vijayan, MD, of Intermountain Health Kidney Services, Intermountain Health, Salt Lake City, Utah, told Medscape Medical News.

“[However], the protocol management for ESKD is not appropriate for AKI-D,” she said. “The lack of distinction in care of AKID vs ESKD patients and lack of monitoring for recovery of kidney function in the outpatient setting are what triggered the issuance of this guidance,” she said of the report, published this month in the Journal of the American Society of Nephrology.

While research has shown encouraging improvement of mortality rates among patients hospitalized with AKI-D, approximately a third of those patients require dialysis upon discharge from the hospital, and the risks of having permanent dialysis dependence, rehospitalization, and death among those patients are significantly higher than those not requiring dialysis.

With no formal care guidelines for those patients in the outpatient setting, the ASN assembled a multidisciplinary working group comprised of kidney care experts, including adult and pediatric nephrologists, social workers, pharmacists, and advanced practice nurses.

‘Err on the Side’ of Assuming Recovery

Among the most important considerations in the management of AKI-D is distinguishing patients from those with ESKD, Vijayan underscored.

“The number one difference is the potential for recovery of kidney function, and the need for active monitoring for renal recovery [in AKI-D],” she said. “We strongly suggest that patients have weekly labs, including a predialysis creatinine as well as a 24-hour urine for urea and creatinine clearance.”

Evidence shows that the strongest predictive factor for AKI recovery is baseline kidney function, with a normal estimated glomerular filtration rate of > 60 mL/min per 1.73 m² prior to hospitalization associated with the strongest likelihood of recovery to dialysis independence. 

Importantly, even among patients with stage 4 chronic kidney disease, as many as 20%-30% of patients will recover, underscoring that “any single factor is inadequate in assessing the likelihood of recovery with certainty,” the authors noted.

Overall, “it is appropriate to err on the side of assuming that most patients will recover, and therefore, all patients should initially receive AKI-D–specific individualized care vs protocolized care typical for patients on long-term maintenance dialysis,” they asserted.

Of note, when the likelihood of recovery of kidney function appears high, “it is appropriate to maintain this approach for at least 90 days after discharge,” they added.

“The most common mistake is lack of recognition of early signs of renal recovery, such as increasing urine output,” Vijayan noted.

“In addition, patients who have increasing urine output, continue to receive hemodialysis three times a week instead of having their dialysis sessions tapered or stopped,” she said.

When Recovery Looks Unlikely

When the likelihood for recovery does appear low, the earlier designation of an end-stage kidney disease (ESKD) diagnosis may be appropriate to avoid the delay of essential care, such as vascular access placement or evaluation for transplant, the guidance recommends.

When patients with AKI-D have significant comorbidities, such as severe frailty, advanced heart failure, or advanced malignancy, “nephrologists should facilitate shared goals-of-care discussions, including advanced care planning and palliative care options,” the authors stated.

Other issues covered in the guidance include proper transition of care, psychosocial factors, components of care in the outpatient dialysis facility, monitoring kidney function, optimal modalities of dialysis and vascular access, and blood pressure management.

Ultimately, with patients often encountering a multitude of differing healthcare encounters in the course of AKI-D care, communication between those various care providers is essential, the authors underscored.

“A key aspect of AKI-D care is the potential for multiple transitions of care and handoffs between care settings, and the nephrology community should work toward improving communication at these critical junctures through more standardized means.”

On a broader level, “the number one priority for patients with AKI-D is liberation from dialysis,” Vijayan said, noting that efforts to recognize and tackle “dialysis trauma,” or the complications of hemodialysis or — including hypotension and distant organ injury — associated with hemodialysis or continuous kidney replacement therapy.

“We as nephrologists should ensure we are focusing on our patients’ interests and monitoring closely for recovery, [in addition to] doing everything we can to promote renal recovery, including preventing intradialytic hypotension and tapering of dialysis appropriately.”

“Reducing dialysis trauma is key in accelerating recovery of kidney function.”

Commenting for the story, Samuel Silver, MD, an associate professor in the Division of Nephrology at Queen’s University in Kingston, Ontario, Canada, said the recommendations shed important light on a population in need of better clinical guidance.

“These consensus-based suggestions will help bring more attention to this understudied area among patients and healthcare providers, hopefully leading to more clinical research and quality improvement initiatives that can identify modifiable practices to enable kidney recovery for patients with AKI receiving outpatient dialysis,” he told Medscape Medical News. 

In a recent study, Silver and colleagues found that most discharge summaries of 300 random patients with AKI were missing key AKI elements — even among those with severe AKI.

Silver says he is currently working with the ASN AKINow: Recovery/Post-AKI Workgroup to develop consensus-based communication plans to help summarize kidney health after a hospitalization with AKI.

“The major challenges for this work relates to its implementation,” he said. “We need to make it easy for healthcare systems and nephrologists to communicate these key elements to other members of the team, especially during transitions in care.”

Silver echoed the importance of recognizing that “patients with AKI-D are not like patients with ESKD.”

“Make sure you have a standardized approach to identify who is likely to recover kidney function and how to monitor for kidney recovery, with a low threshold to hold dialysis in patients showing signs of recovery,” he said.

The authors’ disclosures are detailed in the published study. Silver reported that he has received honorarium from Baxter and the ASN AKINow: Recovery/Post-AKI Workgroup.