Acute kidney injury (AKI) does not discriminate in its impact. From the very young to the elderly, it can strike at any time, stems from a wide variety of causes, and demonstrates a complex variety of symptoms. The resulting kidney damage is often severe and life-threatening. Those who recover from AKI have a greater likelihood of important health consequences including recurrent AKI, progression to chronic kidney disease or end stage kidney disease, disability, and death.
Given the current state, in addition to developing newer paradigms and treatments, improvement in AKI outcomes will require a very large discussion involving all the disparate members of the healthcare team involved in AKI care, with the goal of promoting education, awareness, early recognition, and thorough understanding of this complex syndrome.
Recognizing these obstacles, through a partnership with Baxter, the American Society of Nephrology has established a new initiative, AKI!Now, with the goal of promoting excellence in AKI prevention and treatment by building a foundational program that transforms education and delivery of AKI care, contributes to reducing morbidity and associated mortality, and improves long-term outcomes. This is the first of a series of communications on the planned activities of the AKI!Now Steering Committee.
Multiple factors conspire against efforts to improve AKI outcomes. These include unreliable and late AKI recognition. In particular, first-contact practitioners may be unaware of the problem and may not recognize it in its early stages, when timely intervention is most effective. In addition, once the possibility of AKI is recognized, traditional markers of kidney function are late to change, and are confounded by patient characteristics and fluid status. Despite recent discovery of multiple sensitive and specific biomarkers, their incorporation into routine practice has been inconsistent.
A growing evidence body suggests that widely held paradigms, such as the distinction between “prerenal” and “intrinsic” kidney injury are not consistently appropriate, and may lead to reflex fluid administration, which is often not only unnecessary, but can cause fluid overload, which is associated with worse outcomes. Newer concepts, largely based on the development of novel biomarkers, increasingly permit the detection of “subclinical” AKI when injury biomarkers indicate absence of damage, and to predict the likelihood of a patient developing AKI even before injury occurs.
Furthermore, AKI is not solely a kidney problem. Developing evidence demonstrates that via “organ cross-talk,” AKI is associated with key changes in the function of distant organs such as increased risk of brain and pulmonary edema and cardiac dysfunction, which then complicate treatment and become important determinants of patient outcome.
Part of the reason for our inability to design effective AKI treatments may stem from the heterogeneity of the syndrome; subjects widely differ in their susceptibility, mechanism of injury, and likelihood of recovery. Utilization of a variety of AKI prediction scores, development of context-heightened awareness, enhanced estimation of the probability of AKI development, and use of functional maneuvers such as a protocolized diuretic challenge and “renal angina” detection, will make the application of biomarkers efficient and permit an accurate description of the individual and his or her disease, which should in turn allow for the development of a highly individualized, personalized treatment.
Until recently, the role of the protagonist of the problem—the patient and his/her family—has been virtually absent from consideration. Emerging evidence shows we need to learn in-depth about the patient experience and leverage the potentially powerful healing contribution patients and family can provide.
Finally, the medical community has been slow to recognize that AKI does not end upon patient hospital discharge, but that it continues to impact the patient during the long-term recovery process. Recent evidence highlights that late complications including cardiovascular disease, recurrent AKI episodes, and progressive kidney failure are much more common than usually assumed.