Acute kidney injury (AKI) affects people of all ages, races, genders, ethnicities, and socioeconomic status across the world. For those persons, the stakes are high: in the most severe forms of AKI, the associated morbidity and mortality are higher than those of other common critical conditions, such as acute respiratory distress syndrome and septic shock.
Most commonly, AKI is first encountered by a variety of non-nephrology healthcare providers, including primary care physicians, pediatricians, intensive care unit and emergency department providers, surgeons, nurses, advanced care providers, pharmacists, trainees, hospital administrators, and quality control experts.
Despite the ubiquity of AKI and its grave consequences, effective means to treat established AKI and to promote kidney recovery, other than supportive treatment, are as yet largely unavailable. Therefore, while those treatments are being developed, the main goals of management focus on early recognition and avoidance of progression to the most severe stages of AKI. Unfortunately, limited awareness of the condition and inadequate understanding of early management impair efforts to achieve those goals, often resulting in very severe patient outcomes. Therefore, raising awareness and educating healthcare providers, patients, and their families on AKI recognition, diagnosis, and management are of uppermost importance.
AKI!Now: the background
To fulfill these needs, the American Society of Nephrology (ASN), supported by funding from an unrestricted educational grant from Baxter Healthcare Corporation, has launched a new initiative, AKI!Now: Promoting Excellence in the Prevention and Treatment of Acute Kidney Injury, to promote excellence in the prevention and treatment of AKI by building a foundational program that transforms the delivery of AKI care, reduces morbidity and mortality, and improves long-term outcomes.
A six-member steering committee, including Jorge Cerdá, MD, MS, FASN (chair); Anupam Agarwal, MD, FASN; Stuart Goldstein, MD, FASN; Mark Okusa, MD, FASN; Kathleen Liu, MD, FASN; and Anitha Viyajan, MD, FASN, leads the AKI!Now Initiative.
Addressing AKI: an international undertaking
Acknowledging the global impact of AKI, the AKI!Now initiative began its work with a review of existing international efforts to have an impact on the recognition and recovery of AKI. They include the following:
■ Think Kidneys: “The NHS campaign to improve the care of people at risk of, or with, acute kidney injury” (website: https://www.thinkkidneys.nhs.uk/aki/)
■ 0by25: This initiative by the International Society of Nephrology (ISN) “aims to eliminate preventable deaths from Acute Kidney Injury (AKI) worldwide by 2025” (website: https://www.theisn.org/all-articles/616-0by25)
Each of these campaigns shares with AKI!Now an interest in having an impact on the early recognition and treatment of AKI through discovering best practices and raising awareness through education. All three campaigns agree on the core importance that these education initiatives reach not only healthcare providers but also patients, government entities, and the general public.
The AKI!Now initiative has redoubled interaction with those and other resources across the world. It further maintains tight relationships with other national and international societies, such as the National Kidney Foundation (NKF), to ensure cross-pollination and resource sharing.
Convening international expertise
To further investigate shared goals and resources, during 2019 Kidney Week in Washington, DC, the AKI!Now steering committee convened an expert roundtable and a focus group of students, residents, practitioners, and colleagues interested in AKI who focused their discussion on targeting best AKI practices and treatment pathways.
Specifically, the 26 expert participants in the roundtable discussed these topics:
■ AKI landscape
■ The value of the development of a clinical compendium of AKI publications and educational material
■ The need for educational products focused on treatment pathways and best practices
The 50 attendees at the focus group included nephrologists, patients, nurse practitioners, and fellows working in AKI. Discussion points included the following:
■ How comfortable are you with critical care nephrology?
■ Educational pathways: what tools should be developed to help practitioners recognize AKI and to facilitate the application of established treatment practices?
■ How can we promote patients’ recovery and follow-up?
Recognizing the key role and unique needs of patients in kidney management and recovery, both events included a testimonial from Marla Levy, who described her experience and shared her opinions and recommendations as a person who encountered severe AKI.
Landscape analysis
After the in-person dialogues, the steering committee assessed the data and insights gathered, and compiled an AKI landscape analysis. This analysis identified four core themes:
Opportunities for partnership
■ Nephrologists have a key role, but they must work together across all stages of care, and across multiple areas of practice, to ensure appropriate recognition and management. As described previously, the scope of healthcare professionals who may encounter AKI in practice is vast. Nephrologists must partner with these non-nephrology practitioners to ensure appropriate AKI recognition and to promote recovery.
■ Nephrology must recognize that the providers to partner with will vary by their geographic and economic context:
□ In high-income countries, AKI may be encountered by intensivists, emergency department physicians, hospitalists, and other medicine and surgery providers, nurses, dietitians, and nephrologists when necessary.
□ In low-income and middle-income countries, AKI may be encountered by primary care physicians where they are available, but more commonly, nurses or primary health care providers in rural dispensaries will conduct management, with support from regional centers; nephrologists will rarely or never be available.
■ The nephrologists’ role should be proactive rather than reactive, and evidence demonstrates the benefit of nephrologists’ intervention.
■ There is a great opportunity to partner with training program directors to enhance AKI education and training for fellows, residents, and medical students.
Communication
■ Opportunities exist to improve communication across care pathways and between primary care practitioners and nephrology providers.
■ Such opportunities include the use of electronic alerts and early referrals by means of electronic medical records, education, and interaction with pharmacists on medication interactions and risk of kidney injury, and the importance of communication to streamline kidney care after discharge.
■ Communication throughout the AKI process with patient and family is key to patient recovery and mitigation of long-term physical and emotional injury.
Messaging
■ There is a consensus that raising AKI awareness is needed across all medical specialties and among the general public at large.
■ Different modes of education are needed for different environments, cultures, and languages.
■ Recently developed educational initiatives in the UK, and resources adapted to various low-income and rural environments in the 0by25 initiative, are models to learn from and to modify and adapt. For example, the UK Think Kidneys program includes resources such as a video, “Why We Need to Think Kidneys,” and a case study addressing “Reducing UTIs and Improving Care.”
■ A national campaign, through either national systems such as the Veterans Administration or Epic Systems, or large medical practices such as Kaiser, or well-known spokespersons, should be considered.
■ Efforts to raise awareness must focus on the general population, and large efforts must be made to widely disseminate the importance of AKI and its short-term and long-term consequences. Broad initiatives must disseminate that message by using vehicles such as World Kidney Day, public campaigns, electronic media communications, and—crucially—disseminating the voices of patients and their families as they relate their encounters with AKI.
Patient involvement
■ Patients’ stories about their experiences with AKI are powerful and extremely effective educational tools.
■ In addition to these stories, systematic education to instruct patients and their families on recognizing AKI and the need for post-discharge follow-up with primary care physicians and specialists (including medication reconciliation) represent key areas of opportunity.
Putting the analysis into action
The Landscape Analysis highlights commonalities and common concerns in the recognition and treatment of AKI across the globe. It further suggests steps that can be taken in partnership to improve the care of patients with AKI. Broadly, the AKI!Now initiative will take the following steps (Figure 1):
Proposals advanced by AKI!Now
Citation: Kidney News 12, 4
Reprinted with permission from the United States Renal Data System.Teach healthcare providers how to recognize AKI
Develop and/or identify and collect all available educational instruments on RECOGNITION resources, such as these:
■ The UK Think Kidneys campaign, and all other printed or media educational instruments currently in use that can be used in education campaigns
■ Educational materials already available from ASN and the NKF
■ Educational materials developed and adapted for the community and rural regions in the 0by25 ISN initiative
Describe what to do with recognized AKI
Identify and collect all available educational instruments on MANAGEMENT from resources such as these:
■ UK Think Kidneys educational materials
■ ASN educational materials
■ ISN’s 0by25 procedures to manage early AKI in the community under regional hospital supervision and support
Work to better define the best pathways to kidney recovery after AKI
Also, collaborate with experts in defining the best interventions to promote function regain and to decrease relapse.
Encourage collection of data and creation of a continuous education repository of evidence
The AKI!Now initiative seeks to identify, catalog, and describe available data.
Use a public forum to discuss cases and raise awareness
The ASN AKI community and open forums are a resource to communicate initiatives and to promote AKI recognition and care.
Reach a wide medical audience
Identify means to implement educational campaigns to colleagues who are primarily, and in many cases the only, providers of kidney care. Raise awareness of AKI as an important complication of other disease processes.
Engage hospital administrations, and make AKI a quality metric
Establish administrative and quality initiatives to leverage the hospital systems, to achieve early recognition and management.
Educate the public
Stress the importance of recognition, impact on health, and cost of AKI, and leverage public support and education to improve AKI care.
To meet these goals, multiple action steps are in place.
First, the AKI!Now steering committee has assembled a workgroup, culled from the roundtable and focus group participants, to review existing AKI educational resources and revise them for new audiences. An initial set of these resources will be released in conjunction with the first AKI!Now webinar, “AKI Recognition and Management in High-Risk Populations: The Webinar You Can’t Afford to Miss,” scheduled for April 21, 2020, at 12:00 p.m. EDT. This webinar, the first of a two-part series for the year 2020, will address the identification and management of AKI in high-risk populations, and review resources.
Second, the AKI!Now steering committee has authored a series of three articles, which will be published in CJASN, including the following:
■ A white paper: “Recognition of Acute Kidney Injury in High-Risk Patient Populations” (accepted for publication, 2020)
■ “Recovery After Critical Illness and Acute Kidney Injury” (soon to be submitted)
■ “Patient Perspective on AKI and Recovery,” which gives a voice to the patient perspective (soon to be submitted)
Third, the AKI!Now steering committee is developing a compendium of all AKI-related content available on ASN’s primary communication channels, including CJASN, JASN, Kidney News, Kidney News Online, Kidney 360, NephSAP, and Kidney Week abstracts. This online searchable index will allow users to access and save relevant content. ASN members will have the capability to view and search full articles. This compendium is projected to be released in July 2020.
To achieve meaningful change in AKI recognition and recovery, partnership across the medical continuum is crucial. The AKI!Now steering committee invites you to be part of this change: participate in the upcoming webinar, use the new resources, use the compendium, and share your questions, ideas, and best practices with the AKI community.
