Survey Finds AKI Is Top Reason for Consults

Acute kidney injury (AKI) is the most common reason for nephrology consultation in hospitalized patients, but those patients may not be receiving guideline-compliant therapy and adequate follow-up, according to a survey that tracked “a day in the life” of nephrologists.

The survey coincided with World Kidney Day in 2013 because of that event’s focus on AKI and was designed to get a snapshot of how nephrologists spent their time that day. “It’s the first time the burden of acute kidney injury has been assessed relative to the nephrologist’s workload,” said Sarah Faubel, MD, professor of medicine at the University of Colorado, Denver, and lead author of the study, published in the American Journal of Kidney Disease.

The AKI Advisory Group of the American Society of Nephrology (ASN), the survey sponsor, sent several emails to ASN members who are physicians, inviting them to participate, and also alerted potential participants through social media. Almost 600 nephrologists logged on to fill out the on-line survey, which made it the fourth-largest survey ever of nephrologists in the United States. The questions were designed to quantify the workload related to the care of patients with AKI in both hospital and clinic settings and to assess adherence to dialysis dosing guidelines.

Of the 598 physicians who submitted information, 310 saw patients in the hospital on World Kidney Day. Of the 3285 patients the respondents saw, 46 percent were seen for AKI, 37 percent for ESRD, and 17 percent for other problems. This finding of the predominance of AKI probably comes as no surprise to most nephrologists, but “it is the first time that it has been documented that acute kidney injury really is the number one reason for nephrology consults in the hospital,” Faubel said.

The authors note that the incidence of AKI is increasing, but the survey responses raised questions about whether patients were receiving optimal treatment and follow-up.

Many patients with AKI received renal replacement therapy such as intermittent hemodialysis (IHD), but only 15 percent who received IHD had their dose quantified. The study calls this “dearth” of nephrologists who assess dialysis doses “distressing,” given the fact that practice guidelines stress the need for it. Clinical studies have demonstrated the need for tracking patients’ response to dialysis because “many studies have shown that the delivered dose of IHD in the setting of AKI is lower than the prescribed dose,” the report says.

Another area of concern was follow-up after a patient has been discharged from the hospital. “Nearly 50 percent of hospital consults were for AKI, yet only 9 percent of outpatient visits were for follow-up of AKI, suggesting that many patients are not being seen by nephrologists after an AKI episode,” the study notes.

This apparent low rate of follow-up is problematic because patients who receive dialysis for AKI have a significantly increased rate of chronic kidney disease and an increased rate of need for dialysis in the future. “These patients really should be followed by a nephrologist,” Faubel said. “There was a high rate of response saying that physicians intended to see their patients in the outpatient setting, yet a low rate of actually seeing them.” This discrepancy could result from various barriers to further care, including workforce issues of inadequate numbers of nephrologists.

Another potentially significant finding of the study was that nearly half of the patients with AKI were in the intensive care unit, which Faubel suggests is an indication that nephrology could be more closely entwined with critical care than is often thought. This interplay “could broaden the interest in nephrology if trainees realized that there was so much available in terms of critical care. It highlights that critical care might be an important component of training and education for nephrologists.”