Successfully Modifying the Risk for Acute Kidney Injury

While not the only cause, certain hospital-administered procedures and medications can put patients at risk for acute kidney injury (AKI), an abrupt loss of kidney function that may lead to chronic kidney disease, end-stage renal disease or even death. There is no known cure or approved drug intervention for AKI. Morbidity and mortality are high, and the burden of providing care for these patients is significant.

“AKI increases length of stay in cardiac surgery patients by an average of 17.8 days across the country, with an approximate total cost of $74,148 per stay,” says Charles Brooks, MD, MSc, Associate Professor of Medicine, Quality Liaison for the UVA Nephrology Division and Director of Health Services Development and Patient Outcomes Research.

In a multidisciplinary effort, UVA physicians and researchers are among the first in the nation addressing this issue head-on, implementing incremental process changes to significantly reduce the incidence and severity of AKI in patients undergoing invasive cardiac surgery, vascular surgery, interventional cardiology, interventional radiology, emergency general surgery and IV radiocontrast-enhanced imaging procedures. “We are not introducing another intervention or medication,” says Brooks. “If we truly want to reduce the incidence of AKI, we have to take a different approach.”

Brooks is spearheading the AKI Risk Reduction Initiative at UVA, utilizing an approach he calls “action research,” which empowers everyone who comes in contact with a patient — across disciplines — to have a say in which processes should be implemented or altered to prevent AKI. Once these process improvements are identified, an “ideal process model” (IPM) is put into practice and evaluated for effectiveness.

Because coronary artery bypass and valve replacement  are high on the list of procedures known to increase the risk of AKI, cardiac surgery was the first area to identify and adopt AKI prevention strategies, with others soon to follow. “We got input from all stakeholders, which was tedious, but now we have proof that IPM works,” says Brooks. “Initial data proves that results are sustained and it’s worth pursuing.” UVA has achieved a 50 percent reduction in cases of AKI associated with cardiac surgery and endovascular procedures since the program began in late 2012, according to Brooks.

Keeping AKI Top of Mind

Nephrologists have a better understanding of AKI today. For instance, they know that patients who have compromised kidney function prior to certain procedures or treatments are more likely to experience AKI. They know which procedures and medications put patients at greatest risk. They also discovered recently that the impact of AKI is cumulative, so every episode increases a patient’s risk for chronic kidney disease. “We used to think that, after a recovery period, if a patient’s kidney function returned to baseline, the AKI problem was resolved, but that’s not the case,” says Brooks.

With this knowledge, Brooks and his team are encouraging every specialist to look at patients from a nephrology standpoint prior to treatment to reduce the probability of AKI. In practice, this may mean that general or emergency surgeons and anesthesiologists huddle with physicians and nephrologists prior to a procedure to evaluate a patient’s individual risk and discuss alternate approaches or a change in medication that can minimize that risk.

The key is the shift in thinking. “If it’s a recognized problem, we can come up with ways to possibly prevent AKI,” says Brooks. “Just because we are aware of it — because we are looking at the big picture — it is a modifiable risk.”

Learn more about the full spectrum of kidney care available at UVA.