Variations in Use of Best Practices for AKI in Three Connecticut Hospitals

New Orleans—There are associations between acute kidney injury (AKI), common in hospitalized settings, and increased length of stay, morbidity, and mortality. There are no specific therapies for AKI; however, recommended guidelines include measures of best practice that could potentially act as the basis of a standardized set of responses to AKI and the development of an AKI report card. Real-world adherence to those metrics is unknown.

Francis P. Wilson, MD, and colleagues used guidelines published by the Kidney Disease: Improving Global Outcomes (KDIGO) and the National Institute for Health and Care Excellence to identify four potential universal best practice metrics for hospitalized patients post-AKI. They reported on the rates of performance of the metrics at three Connecticut hospitals during a poster session at Kidney Week 2017 in a poster titled Prevalence and Variation of Best Practices in AKI: A Multi-Center Study.

The four included metrics were: (1) post-AKI serum creatinine measurement; (2) urinalysis; (3) urine output monitoring; and (4) avoidance of certain nephrotoxins (aminoglycosides, non-steroidal anti-inflammatory drugs, and contract media). Patients were examined within 24 hours of onset of AKI. Patients who were discharged within 24 hours of AKI were excluded from the study.

Over a 3-year period, the researchers identified 26,333 patients with AKI based on KDIGO-Creatinine criteria (Yale New Haven Hospital, n=16,608; St. Raphael Hospital, n=6544; Bridgeport Hospital, n=3681). Of the total cohort, 49.8% were men and 18% were black.

There was significant variation among the hospitals in the rates of best practices (Table). In multivariable models, surgical patients, male patients, patients with private insurance, and patients with electrolyte abnormalities at onset of AKI had more best practices performed. Among patients with no creatinine measurement within 24 hours of AKI onset, 13.8% progressed to a higher AKI stage, 1.5% progressed to inpatient dialysis, and 6.2% died during the hospitalization.

In conclusion, the researchers said, “Adherence to AKI best practices varies by hospital, ward, and patient factors. Standardization of best practice guidelines may help to reduce variation and improve outcomes.”


Table.  Performance of Best Practices


  YNH SRH BH Total P-value
                   N 16,108 6544 3681 26,333 <.001
Subsequent Creatinine, % 68.9 56.3 57.0 64.1 <.001
Urinalysis, % 17.5 13.8 14.2 16.1 <.001
Urine Output Monitoring, % 78.8 79.7 56.4 75.9 <.001
Nephrotoxin Avoidance, % 92.4 92.3 94.1 92.5 <.001


YNH=Yale New Haven Hospital; SRH=St. Raphael Hospital; BH=Bridgeport Hospital


Source: Wilson FP, Biswas A, Moledina DG, Mansour S, Parikh CR. Prevalence and variation of best practices in AKI: A multi-center study. Abstract of a poster presented at the American Society of Nephrology 2017 Kidney Week, November 4, 2017, New Orleans, Louisiana.