Silver Samuel A, Harel Ziv, Harvey Andrea, Adhikari Neill K, Slack Andrew, Acedillo Rey, Jain Arsh K, Richardson Robert M, Chan Christopher T, Chertow Glenn M, Bell Chaim M, Wald Ron
Division of Nephrology, St. Michael's Hospital, Toronto, Canada.
Nephron. 2015;131(1):43-50. doi: 10.1159/000438871. Epub 2015 Sep 2.
Acute kidney injury (AKI) complicates 15-20% of hospitalizations, and AKI survivors are at increased risk of chronic kidney disease and death. However, less than 20% of patients see a nephrologist within 3 months of discharge, even though a nephrologist visit within 90 days of discharge is associated with enhanced survival. To address this, we established an AKI Follow-Up Clinic and characterized the patterns of care delivered.
We conducted a prospective time series study. All hospitalized patients who developed Kidney Disease Improving Global Outcomes (KDIGO) stage 2 or 3 AKI were eligible. The pre-intervention period consisted of electronic reminders to the nephrology consults and cardiovascular surgery services to refer to the AKI Follow-Up Clinic. In the post-intervention period, eligible patients were automatically scheduled into the AKI Follow-Up Clinic at discharge. The primary outcome was the percentage of KDIGO stages 2-3 AKI survivors assessed by a nephrologist within 30 days of discharge.
In the pre-intervention period, 8 of 46 patients (17%) were seen by a nephrologist within 30 days after discharge, and no additional patients were seen for 90 days. In the post-intervention period, 17 of 69 patients (25%) were seen by a nephrologist within 30 days after discharge (p = 0.36), with an additional 30 patients seen in 90 days (47 of 69, 68%, p < 0.001). The mean serum creatinine was 99 (SD 35) µmol/l prior to hospitalization and 133 (58) µmol/l at 3 months. Fifty-five of 79 patients (70%) received at least 1 medical intervention at their first AKI Follow-Up Clinic visit.
An AKI Follow-Up Clinic with an automatic referral process increased the proportion of patients seen at 90 days, but not 30 days post discharge. Being seen in the AKI Follow-Up Clinic was associated with interventions in most patients. Future research is needed to evaluate the effect of the AKI Follow-Up Clinic on patient-centered outcomes, but physicians should be aware that AKI survivors may benefit from close outpatient follow-up and a multipronged approach to care similarly for other high-risk populations.
急性肾损伤（AKI）使15%至20%的住院患者病情复杂化，AKI幸存者患慢性肾病和死亡的风险增加。然而，不到20%的患者在出院后3个月内看肾病专科医生，尽管出院后90天内看肾病专科医生与生存率提高有关。为解决这一问题，我们设立了AKI随访诊所，并对所提供的护理模式进行了描述。
我们进行了一项前瞻性时间序列研究。所有发生改善全球肾脏病预后组织（KDIGO）2期或3期AKI的住院患者均符合条件。干预前期包括向肾病会诊和心血管外科服务部门发送电子提醒，以便将患者转介至AKI随访诊所。在干预后期，符合条件的患者在出院时自动被安排到AKI随访诊所。主要结局是KDIGO 2 - 3期AKI幸存者在出院后30天内接受肾病专科医生评估的比例。
在干预前期，46例患者中有8例（17%）在出院后30天内接受了肾病专科医生的诊治，90天内没有其他患者接受诊治。在干预后期，69例患者中有17例（25%）在出院后30天内接受了肾病专科医生的诊治（p = 0.36），90天内又有30例患者接受了诊治（69例中的47例，68%，p < 0.001）。住院前血清肌酐均值为99（标准差35）µmol/l，3个月时为133（58）µmol/l。79例患者中有55例（70%）在首次AKI随访诊所就诊时接受了至少1次医疗干预。
具有自动转诊流程的AKI随访诊所提高了出院90天时接受诊治的患者比例，但出院30天时未提高。在AKI随访诊所就诊与大多数患者接受干预有关。需要进一步研究以评估AKI随访诊所对以患者为中心的结局的影响，但医生应意识到，AKI幸存者可能受益于密切的门诊随访以及针对其他高危人群的多方面护理方法。
