Acute kidney injury: outcomes and quality of care

Background: Deficiencies in management have been highlighted as contributory factors in the death of many patients with acute kidney injury (AKI). However, there is little evidence addressing the quality of care provided to patients with milder AKI. Aim: The aim of this study is to evaluate the quality of care provided to a non-select cohort of patients with AKI and evaluate discrepancies in causation, recognition and management. Design: Retrospective inception cohort study. Methods: Demographic data were collected for all 1577 patients admitted to a University Teaching Hospital during a 1-month period. Baseline, admission and peak creatinine were correlated with mortality and length of hospital admission. AKI was classified according to Kidney Disease Improving Global Outcomes criteria. A retrospective case note review of all patients with AKI was carried out to evaluate quality of documentation and clinical management of AKI. Multivariate analysis was undertaken to determine risk factors for AKI. Results: Incidence of AKI on admission was 4.6%. A further 10.3% developed AKI while in hospital. All cause mortality was 4-fold higher among patients with AKI compared with those without (19 vs. 3.8%; P < 0.001). Mortality was significantly higher in those patients who developed AKI while an in-patient compared with those with AKI on admission (27.3 vs. 11.8%; P < 0.001). Diabetes, clinician perception of frailty, age and treatment with angiotensin-converting enzyme inhibitor prior to admission were found to be independent risk factors for AKI. AKI was unrecognized in 23.5% of patients, two-thirds of whom were discharged without resolution of renal function. Significant weaknesses in management were poorly kept fluid balance charts (48.2%), failure to withhold nephrotoxic drugs (38.8%) and failure to act upon abnormal biochemistry (41%) in a timely fashion. Conclusions: AKI is common in hospitalized patients and associated with a significant increase in hospital stay and mortality. AKI is often found in conjunction with other organ failure and in many cases is not preventable. Nevertheless clinicians need to be more vigilant of small creatinine rises to permit early intervention particularly among elderly and frail patients.