Bridging the Gap in AKI Follow-Up: From Research to Implementation

Acute kidney injury (AKI) increases the risk of chronic kidney disease and cardiovascular complications, yet postdischarge care remains inconsistent. Many survivors of AKI do not receive timely nephrology referrals or guideline-based medications, increasing their risk of disease progression and hospital readmission. A recent study by Pannu et al., evaluating a risk-based follow-up approach, demonstrates a promising strategy to address these gaps and improve long-term outcomes (1).

The study implemented a risk-guided model, in which survivors of AKI were stratified by chronic kidney disease risk. Low-risk patients received education alone, medium-risk patients had additional clinical guidance for their primary care physicians (PCPs), and high-risk patients were referred to nephrology. The intervention significantly increased nephrology follow-ups (from 9% to 29%) and improved adherence to angiotensin-converting enzyme inhibitors (ACEis), angiotensin II receptor blockers (ARBs), and statins. In addition, the study showed that the intervention was feasible across multiple hospitals.

A key strength of this model is its ability to target care where it is needed most, ensuring that specialty resources are used efficiently. Although the intervention group had higher rates of hyperkalemia, this was likely due to increased ACEi/ARB use, reinforcing the importance of medication monitoring (2, 3).

Although this targeted approach optimizes resource allocation and enhances care for high-risk patients, there are opportunities to further build on these findings. Given that this is a smaller study, larger trials are needed to evaluate long-term outcomes. Additionally, although medium-risk patients were assigned to PCPs with structured follow-up guidance, the study did not specifically assess changes in PCP engagement. Strengthening structured transitions between hospitals and primary care could further support comprehensive follow-up for survivors of AKI.

Implementing optimal follow-up care for AKI in real-world health care systems requires overcoming logistical barriers (4). Automated risk alerts in electronic health records (EHRs) are necessary to flag high-risk patients and trigger referrals. Stronger PCP involvement, supported by financial incentives or dedicated transitional care teams, is crucial for sustained follow-up. Patient adherence must also be addressed through expanded telehealth options and improved access to monitoring. Additionally, safer medication protocols are needed to balance the benefits of ACEis/ARBs with the risk of hyperkalemia (2).

This study provides a framework for improving AKI follow-up and highlights the potential of a risk-based approach to enhance postdischarge care. The findings are an important step forward in addressing gaps in AKI management, and although larger studies are needed to fully assess long-term outcomes, the evidence presented is compelling. Now is the time to build on this progress and start the conversation on how health care systems can implement this approach and whether they are ready to operationalize it. Bridging the post-AKI care gap will require commitment, coordination, and investment—but this study provides a foundation for future implementation.

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