Patients discharged home from the emergency department (ED) with acute kidney injury (AKI), or sudden decline in kidney function, may be at risk for poor outcomes, according to a study published online July 20 in the Clinical Journal of the American Society of Nephrology.
“[P]atients discharged home from the ED with AKI are at significant risk of 30-day mortality and hospitalization. Compared to hospital admission with AKI and an ED discharge with no AKI, an ED discharge with AKI is at intermediate risk for adverse outcomes,” Rey Acedillo, MD, from Western University, London, Ontario, Canada, and colleagues write.
To evaluate patients discharged home with AKI, the researchers conducted a retrospective cohort study in Southwestern Ontario, Canada. The study used administrative data on 6346 patients aged 40 years and older (mean age, 69 years; 47% women; 38% with chronic kidney disease) who had been discharged from the ED with AKI (defined by creatinine levels) between 2003 and 2012.
The study matched patients discharged from the ED with AKI to hospitalized patients with similar stages of AKI (4379 in each group), and also to patients discharged from the ED without AKI (6188 in each group). The analysis used propensity score matching to account for baseline differences between groups.
Among patients discharged from the ED with AKI, 95% had stage 1, 5% had stage 2, and 0.7% had stage 3 AKI.
Overall, 2% (n = 149) of patients discharged with AKI died within 30 days of going home, and the percentage rose with the severity of AKI (stage 1, 2%; stage 2, 5%; stage 3, 16%).
Only about 0.3% received dialysis within 30 days of discharge, although 16% were hospitalized.
Among patients with AKI, being discharged from the ED was associated with lower 30-day mortality compared with being hospitalized (3% vs 12%; relative risk, 0.3; 95% confidence interval [CI], 0.2 – 0.3; P < .001). Patients discharged with AKI also had lower risk for dialysis than hospitalized patients, although these results did not reach statistical significance (0.4% vs 0.8%; relative risk, 0.6; 95% CI, 0.3 – 1.0; P = .06).
Patients discharged from the ED with AKI had 60% higher risk for death within 30 days compared with those discharged without AKI (2% vs 1%; relative risk, 1.6; 95% CI, 1.2 – 2.0; P = .001). Those with AKI also had almost three times the risk of receiving dialysis within 30 days of discharge compared with those without AKI (0.3% vs 0.1%; relative risk, 2.7; 95% CI, 1.2 – 6.0; P = .01).
“Our results suggest there is an opportunity to explore health system strategies to improve the identification and management of patients discharged home from the ED with AKI,” the researchers conclude.
The study is the first to provide a comprehensive evaluation of patients with AKI discharged home from the ED. Most studies about AKI have been done in hospitalized and critically ill patients. Less is known about AKI that is managed in the community.
What is known is that AKI can affect about 10% of hospitalized patients and may increase the risk for illness and death. People hospitalized with AKI are also at increased risk for cardiovascular disease, chronic kidney disease, and end-stage renal disease.
Opportunities to Improve Care
The study “highlights that ED-based AKI, although it was almost exclusively stage 1, carries a significant degree of morbidity and mortality, which often go under-recognized by physicians all over the hospital, not just in the ED,” Jay Koyner, MD, from the University of Chicago, Illinois, writes in an accompanying editorial.
He brings up two important points about the study. First, it showed that ED physicians appropriately distinguished between patients with AKI who could be discharged home from the ED and those who were sicker and needed hospital admission. Second, the study showed that AKI represents an opportunity to improve patient care because AKI may indicate underlying disease such as cancer or heart disease that increases the risk for illness and death.
“Regardless of its underlying cause and severity, AKI needs to be identified, treated, and managed,” Dr Koyner stresses.
Possible strategies include using biomarkers of kidney injury, electronic medical record detection of AKI, AKI care bundles, rapid access clinics, and multidisciplinary AKI-focused rapid response teams.
“Identifying patients with early AKI (defined by creatinine, urine output, and/or biomarkers) and then adopting a multifaceted kidney-focused care bundle to be implemented by a multidisciplinary AKI-focused rapid response team may be the first steps in improving patient outcomes. Linking this AKI-focused inpatient care with the necessary nephrology outpatient follow-up will help us completely reconfigure the delivery of health care to those at risk for and diagnosed with hospital- and ED-based AKI,” Dr Koyner concludes.
The study was conducted by the Institute for Clinical Evaluative Sciences funded by a grant from the Ontario Ministry of Health and Long-term Care and supported by the Lilibeth Caberto Kidney Clinical Research Unit and the Institute for Clinical Evaluative Sciences Western facility. One or more authors report support from one or more of the following: Western University, Kidney Foundation of Canada, Canadian Society of Nephrology, Canadian Institutes of Health Research, Canadian Institutes of Health Research, Veterans Affairs, and/or Vanderbilt University Medical Center. Dr Koyner reports receiving research funds from Astute Medical and Satellite Healthcare and consulting fees from Astute Medical, Sphingotec, and Pfizer.
Clin J Am Soc Nephrol. Published online July 20, 2017. Article abstract
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