Acute Kidney Injury in Primary Care: A Review of Patient Follow-Up, Mortality, and Hospital Admissions following the Introduction of an AKI Alert System.

BACKGROUND/AIMS: In February 2017, our laboratory implemented an electronic AKI flagging system for primary care using the NHS England AKI detection algorithm. Our study investigated the impact on patient follow-up, hospital admission, length of stay, and mortality. METHODS: Primary care results March 2017-February 2018 with an AKI test code were downloaded from the pathology computer. RESULTS: Over 12 months, 1,784 AKI episodes were identified; 81.3% AKI1, 11.3%, AKI2, and 7.5% AKI3. A repeat creatinine was requested within 14 days on 55% AKI1s, 84% AKI2s, and 86% AKI3s. Primary care took the repeat sample in 73.2% AKI1s and 56.7% AKI2s and acute hospital locations for 47.4% AKI3s. Median time to hospital admission was 34 days for AKI1, 6 for AKI2, and 1 for AKI3 (p < 0.05). Length of stay was found to be 1, 2, and 4 days for AKI 1/2/3, respectively (p < 0.05). The 90-day mortality for admitted patients was 15, 18, and 21% for AKI 1/2/3, respectively (p = 0.180). The 90-day mortality for the non-admitted patients was 4, 9, and 50% for AKI 1/2/3, respectively (p < 0.05). AKI patient outcome data pre versus post the start of the AKI flag system were compared. A statistically significant reduction was found in the median length of stay for AKI1 and AKI3 and in mortality for AKI1 and AKI3 patients and for all AKIs as a whole. A further analysis was performed to take into account the difference in pre- and post-alert populations. Mortality overall was significantly improved (p < 0.001), and length of stay was reduced in AKI3 patients (p = 0.048). DISCUSSION/CONCLUSION: Our study demonstrates that an electronic AKI warning alert system for primary care appears to be associated with a beneficial impact on patient management and outcome.

One Year's Observational Study of Acute Kidney Injury Incidence in Primary Care; Frequency of Follow-Up Serum Creatinine and Mortality Risk.

BACKGROUND/AIMS: Publications on acute kidney injury (AKI) have concentrated on the inpatient population. We wanted to determine the extent of AKI in the community, its follow-up and patient impact. METHOD: Primary Care creatinine results for May 2012-April 2013 from Cornwall, United Kingdom, were screened for AKI. RESULTS: Over 12 months, 991 AKI episodes were identified (0.4% of all Primary Care creatinine requests); 51% were AKI1, 29% AKI2 and 10% AKI3. Of these, 51% AKI1s, 72% AKI2s and 77% AKI3s had a repeat creatinine requested within 14 days as per National Institute for Health and Care Excellence (NICE) guidelines. Admissions (May 2012-July 2013) were identified on 46% AKI1s, 58% AKI2s and 65% AKI3s (p < 0.05). The median time from AKI identification to hospital admission was 33 days for AKI1, 12 days for AKI2 and 1 day for AKI3 (p < 0.05); with a median length of stay of 2, 4 and 7 days, respectively (p < 0.05). The 90-day mortality from AKI identification for the admitted patients was 12% AKI1s, 20% AKI2s and 27% AKI3s (p < 0.05) vs. 11, 21 and 65% (p < 0.05) for those that were not admitted. There was no significant difference in mortality for admitted patients vs. non-admitted patients, except for the AKI3s. CONCLUSION: AKI is associated with increased admission and mortality rates; although a large proportion of patients had repeat creatinine testing within 14 days, there was still a significant number with delayed follow-up. Education within Primary Care is required on how to prevent, identify, follow-up and manage AKI.

Use of an electronic alert to identify patients with acute kidney injury.

Early intervention in the management of acute kidney injury (AKI) has been shown to improve outcomes. To facilitate early review we have introduced real time reporting for AKI. An algorithm using the laboratory computer system was implemented to report AKI for inpatients. Over 6 months there were 1,906 AKI reports in 1,518 patients: 56.3% AKI1, 26.9% AKI2 and 16.8% AKI3. 51.0% were male. Median age was 78 (interquartile range [IQR] 17) years. 62.6% were from general medical wards, 16.9% from surgical wards, 6.9% from orthopaedic wards and 5.3% from specialty wards. 8.3% were from peripheral hospitals. 31% of patients with AKI reports were clinically coded for AKI. 9% (n = 139) showed progression of AKI (mortality 42%). Patients with AKI had a significantly higher length of stay and mortality than those that did not. 4% of patients with AKI received acute renal replacement therapy (RRT). An e-alert system is feasible, allowing early identification of inpatients with AKI.

Severe hypercalcaemia mimicking acute myocardial infarction.

Significant hypercalcaemia can cause electrocardiogram (ECG) changes mimicking an acute myocardial infarction. It is important to recognise that some ECG changes are due to conditions other than cardiac disease so that appropriate treatment is given, and importantly, inappropriate treatments are avoided.