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Sundays and mortality in patients with AKI.

ABSTRACT: Initiation of dialysis on Sunday is limited by constraints that do not exist on other days of the week, which may lead to triaging of dialysis therapy. The study hypothesis was that patients with AKI on a Sunday would sustain higher mortality rates.Study participants (n=4970) were part of the retrospective University of Pennsylvania Health AKI cohort, which is composed of patients with severe inpatient AKI (characterized by a doubling of admission creatinine) who were hospitalized from January 1, 2004, to August 31, 2010. Patient-days (n=15,995) were included if the patient had AKI severity of Acute Kidney Injury Network (AKIN) stage 2 or greater and had not yet begun receiving dialysis. The association of day of the week and inpatient mortality was assessed with logistic regression of data updated daily, using robust variance estimators.The rate (95% confidence interval [CI]) of initiation of dialysis on Sunday was 2.5 (1.8 to 3.1) per 100 patient-days, compared with 3.8 (3.5 to 4.1) per 100 patient-days on other days of the week (P=0.001). Inpatient mortality (95% CI) among patients with severe AKI present on a Sunday was 30% (28% to 32%), compared with 31% (31% to 32%) on other days of the week (P=0.08). Inpatient mortality among patients who initiated dialysis on Sunday was 65% (52% to 79%), compared with 65% (61% to 70%) among those who initiated dialysis from Tuesday through Saturday (P=0.79). Patients who initiated dialysis on Monday had a lower mortality than those who initiated it on another day of the week (52% [40% to 64%] versus 65% [61% to 70%]; P=0.03).Despite a lower frequency of dialysis, patients with severe AKI on Sunday have mortality similar to that of patients with severe AKI on other days of the week.

SUBMITTER: Wilson FP

PROVIDER: S-EPMC3817908 | biostudies-other | 2013 Nov

REPOSITORIES: biostudies-other

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Sundays and mortality in patients with AKI.

Wilson F Perry FP Yang Wei W Schrauben Sarah S Machado Carlos C Lin Jennie J JJ Feldman Harold I HI

Clinical journal of the American Society of Nephrology : CJASN 20130822 11

<h4>Background and objectives</h4>Initiation of dialysis on Sunday is limited by constraints that do not exist on other days of the week, which may lead to triaging of dialysis therapy. The study hypothesis was that patients with AKI on a Sunday would sustain higher mortality rates.<h4>Design, setting, participants, & measurements</h4>Study participants (n=4970) were part of the retrospective University of Pennsylvania Health AKI cohort, which is composed of patients with severe inpatient AKI (c ...[more]

PMID: 23970128

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Project description:Background and objectivesAKI is associated with short- and long-term mortality. However, the exact contribution of AKI complications to the burden of mortality and whether RRT has any beneficial effect on reducing mortality rates in critically ill AKI patients are unknown.Design, setting, participants, & measurementsThis was a retrospective analysis using data from the Multiparameter Intelligent Monitoring in Intensive Care II project. A total of 18,410 adult patients were enrolled from four intensive care units from a university hospital from 2001 to 2008.ResultsOverall, 10,245 patients developed AKI. After adjustments, the odds ratios (ORs) for hospital mortality were 1.73 (95% confidence interval [95% CI], 1.52 to 1.98) for AKI stage 1, 1.88 (95% CI, 1.57 to 2.25) for stage 2, and 2.89 (95% CI, 2.41 to 3.46) for stage 3. Totals of 33%, 59%, and 70% of the excess mortality rates associated with AKI stages 1, 2, and 3, respectively, were attenuated by the inclusion of each AKI-related complication in the model. The main burden of excess hospital mortality associated with AKI was attenuated by metabolic acidosis and cumulative fluid balance. Long-term mortality was not attenuated by any of the associated complications. Next, we used two different approaches to explore the associations between RRT, AKI complications, and hospital mortality: multivariate analysis and propensity score matching. In both approaches, the sensitivity analysis for RRT was associated with a better hospital survival in only the following AKI-related subgroups: hyperkalemia (OR, 0.55; 95% CI, 0.35 to 0.85), metabolic acidosis (OR, 0.70; 95% CI, 0.53 to 0.92), cumulative fluid balance >5% of body weight (OR, 0.60; 95% CI, 0.40 to 0.88), and azotemia (OR, 0.57; 95% CI, 0.40 to 0.81).ConclusionsA majority of the excess risk of mortality associated with AKI was attenuated by its fluid volume and metabolic complications, particularly in severe AKI. In addition, this study demonstrated that RRT is associated with a better outcome in patients with AKI-related complications.

Project description:IntroductionCurrently, no effective therapies exist to reduce the high mortality associated with dialysis-dependent acute kidney injury (AKI-D). Serum biomarkers may be useful in understanding the pathophysiological processes involved with AKI and the severity of injury, and point to novel therapeutic targets.MethodsStudy day 1 serum samples from 100 patients and day 8 samples from 107 patients enrolled in the Veteran's Affairs/National Institutes of Health Acute Renal Failure Trial Network study were analyzed by the slow off-rate modified aptamers scan proteomic platform to profile 1305 proteins in each sample. Patients in each cohort were classified into tertiles based on baseline biomarker measurements. Cox regression analyses were performed to examine the relationships between serum levels of each biomarker and mortality.ResultsChanges in the serum levels of 54 proteins, 33 of which increased and 21 of which decreased, were detected when comparing samples of patients who died in the first 8 days versus patients who survived >8 days. Among the 33 proteins that increased, higher serum levels of fibroblast growth factor-23 (FGF23), tissue plasminogen activator (tPA), neutrophil collagenase (matrix metalloproteinase-8), and soluble urokinase plasminogen activator receptor, when stratified by tertiles, were associated with higher mortality. The association with mortality persisted for each of these proteins after adjusting for other potential risk factors, including age, sex, cardiovascular sequential organ failure assessment score, congestive heart failure, and presence of diabetes. Upper tertile levels of FGF23, tPA, and interleukin-6 on day 8 were associated with increased mortality; however, FGF23 barely lost significance after multivariable adjustment.ConclusionsOur results underscore an emerging proteomics tool capable of identifying low-abundance serum proteins important not only in the pathogenesis of AKI-D, but which is also helpful in discriminating AKI-D patients with high mortality.

Project description:Background:Survivors of acute kidney injury (AKI) are at risk of adverse outcomes. Post-discharge nephrology care may improve patients' AKI knowledge and prevent post-AKI complications. Objective:The purpose of this study was to examine patients' awareness about their AKI diagnosis and self-rated knowledge and severity of AKI before and after their first post-discharge AKI Clinic encounter. Design:We conducted a pre- and post-survey study among AKI survivors who attended a post-discharge AKI Clinic. Setting:AKI Clinic at the University of Kentucky Medical Center (October 2016 to December 2017). Education about AKI was based on transformative learning theory and provided through printed materials and interdisciplinary interactions between patients/caregivers and nurses, pharmacists, and nephrologists. Patients:A total of 104 patients completed the survey and were included in the analysis. Measurements:Three survey questions were administered before and after the first AKI Clinic encounter: Question 1 (yes-no) for awareness, and questions 2 and 3 (Likert scale, 1 = lowest to 5 = highest) for self-rated knowledge and severity of AKI. Methods:Two mixed-model analysis of variance (ANOVA) was used for between-group (AKI severity) and within-group (pre- and post-encounter) comparisons. Logistic regression was used to examine parameters associated with the within-group change in self-perceived knowledge. Results:Twenty-two out of 104 (21%) patients were not aware of their AKI diagnosis before the clinic encounter. Patients' self-ratings of their AKI knowledge significantly increased after the first AKI Clinic encounter (mean ± SEM: pre-visit = 1.94 ± 0.12 to post-visit = 3.88 ± 0.09, P = .001), even after adjustment for age, gender, Kidney Disease Improving Global Outcomes (KDIGO) severity stage, or poverty level. Patients with AKI stage 3 self-rated their AKI as more severe than patients with AKI stage 1 or 2. Limitations:Our study population may not be representative of the general AKI survivor population. Administered surveys are subject to response-shift bias. Conclusions:Patients' self-perceived knowledge about AKI significantly increased following the first post-discharge AKI Clinic encounter that included interdisciplinary education. This is the first survey study examining self-perceived AKI knowledge in AKI survivors. Further examination of AKI literacy in survivors of AKI and its effect on post-AKI outcomes is needed. Trial registration:Not applicable.

Project description:BACKGROUND:Acute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes. METHODS AND FINDINGS:A controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014-16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981-1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858-0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560-0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation. CONCLUSIONS:In acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness. TRIAL REGISTRATION:Clinicaltrials.org NCT03047382.

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Sundays and mortality in patients with AKI.

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Sundays and mortality in patients with AKI.

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