Disclosures. Acute Kidney Injury. Outline. Do electronic alerts improve the care of patients with AKI? 5/9/2015

Transcription

1 Disclosures Acute Kidney Injury Kathleen D. Liu, MD, PhD May 2015 Consultant: Achaogen, Chemocentryx, Durect, Z Pharma Clinical trials adjudication: Astute Funding: NIH Stockholder: Amgen Outline patients with Do electronic alerts improve the care of patients with Study design: Single blind, parallel group trial Inclusion criteria: AKI defined as a 0.3 mg/dl rise over 48h or a 50% rise over 7 days Exclusion criteria: Initial Cr 4 mg/dl, fewer than 2 Cr, admission ESRD, admission to hospice or observation Stratified by medical vs surgical, ICU vs non- ICU Wilson et al, Lancet

2 Do electronic alerts improve the care of patients with Intervention: Covering provider and pharmacist receive 1 alert within 1 hour: KDL, Room 1234, has been identified as having acute kidney injury based on the latest creatinine values. Please take appropriate diagnostic and therapeutic measures. THIS ALERT DOES NOT FIRE FOR ALL PATIENTS WITH AKI. For more information, please visit [study website] Website had a link to KDIGO AKI practice guidelines and information about the study Do electronic alerts improve the care of patients with Primary outcome: Rank outcome of Death (worst) Dialysis Greatest change in Cr within 7 days of randomization Powered to detect shift in rank order: # of deaths from 10% to 9%, dialysis from 5% to 4%, no increase in Cr of 50% to 56% Wilson et al, Lancet 2015 Wilson et al, Lancet 2015 Do electronic alerts improve the care of patients with In the alert group, 97% of patients received the intervention (32/1201 alerts were not received) Baseline Characteristics Wilson et al, Lancet

3 Outcomes Conclusions The implemented electronic alert did not affect rates of AKI or therapies administered Rates of dialysis went up in the surgical ICU with the alerts, not down Was this associated with other adverse outcomes (death)? 3

4 Outline patients with Not at present Outline patients with Not at present AKI: Many new biomarkers, which have not shown utility in clinical practice Mishra et al, Lancet 2005 Parikh et al, JASN 2011 AKI, 2015 First-of-a-kind laboratory test to help determine if certain critically ill hospitalized patients are at risk of developing moderate to severe acute kidney injury (AKI) in the 12 hours following the administration of the test. 4

5 AKI, 2015 Astute Nephrocheck What is this device, what does it test, and can it help me in clinical practice? Study design: Prospective cohort study Inclusion criteria: ICU patient within 24 hours with either respiratory or cardiovascular dysfunction with a Foley catheter in place Exclusion criteria: Documented severe AKI (KDIGO stage 2 or 3) Bihorac et al, AJRCCM 2014 Astute Nephrocheck AKI, 2015 AKI defined as doubling of serum Cr or urine output of 0.5 ml/kg/hour x 12 hours (not adjusted for body weight) Outcome adjudicated by panel of 3 nephrologists Bihorac et al, AJRCCM 2014 Bihorac et al, AJRCCM

6 AKI, 2015 More questions than answers What do I do for people who are at high risk of AKI, but don t have it? What are we predicting low urine output, doubling of Cr, or both? Are these two outcomes the same? Bihorac et al, AJRCCM 2014 More questions than answers CHEST Study What do I do for people who are at high risk of AKI, but don t have it? What are we predicting low urine output, doubling of Cr, or both? Are these two outcomes the same? Myburgh et al, NEJM

7 Outline patients with Not at present Maybe, but more data is definitely needed and it s not clear what to do with the information Rationale Furosemide Stress Test Study design: 2 prospective cohorts Inclusion criteria: AKI (0.3 mg/dl or 50% rise in Cr from baseline, 0.5 cc/kg/hour urine output x 6 hours), urine consistent with ATN (microscopy or FeNa), volume resuscitated Exclusion criteria: CKD with egfr < 30, obstruction or prerenal physiology, AKIN Stage 3 AKI, furosemide allergy Furosemide Stress Test mg/kg furosemide administered Fluid replacement if desired by the clinical team Outcome: AKIN Stage 3 AKI Tripling of Cr from baseline Need for RRT UOP < 0.3 cc/kg/hour x 24 hours 77 subjects, 52 nonprogressors and 25 progressors 7

8 Furosemide Stress Test UOP < 200 cc total in first 2 hours 87% sensitive 84% specific Summary patients with Not at present Maybe, but more data is definitely needed and it s not clear what to do with the information Maybe, but confirmatory studies are needed Chawla et al, Crit Care