The Optimization of Outpatient Hemodialysis Management for Acute Kidney Injury Requiring Dialysis Patients: A Quality Improvement Study.

INTRODUCTION: In 2017, the Centers for Medicare and Medicaid Services allowed survivors of hospitalized acute kidney injury requiring dialysis (AKI-D) who were ambulatory and still dependent on hemodialysis (HD) to receive treatment in outpatient dialysis facilities. This policy change generated the ongoing need to improve AKI-D care in the outpatient setting. METHODS: Quality improvement study in adult patients admitted to an outpatient HD unit with the diagnosis of AKI-D. We developed a protocol to manage these patients that included: (a) multidisciplinary evaluations; (b) personalized 3-tier HD prescription for dose/ultrafiltration rate and frequency; (c) weekly assessment of kidney recovery; and (d) patient empowerment. Patient- and protocol-specific characteristics were described. We analyzed hourly HD data and protocol adherence, and relevant hemodynamic data were compared according to HD-free survival at 90 days. RESULTS: A total of 457.3 h of HD from 9 patients under the AKI-D protocol were interrogated. Three out of 9 patients were alive and liberated from HD within the first 90 days of outpatient HD. Overall protocol adherence was 53.8% and did not differ by HD-free survival (54.5% vs. 53.7% in those that recovered vs. not). Protocol adherence was associated with fewer intradialytic hypotension events (peak to nadir blood pressure, p < 0.01), while intradialytic hypotension (pre- to post-blood pressure) occurred more frequently in patients who did not recover kidney function (p = 0.009). CONCLUSION: We demonstrated the feasibility of implementing a management protocol for AKI-D patients in an outpatient dialysis facility. We found that fewer episodes of intradialytic hypotension occurred when the outpatient HD management was adherent to the protocol. The feasibility of this protocol should be confirmed in other facilities, and importantly, efficacy testing to evaluate its impact on AKI-D outpatient care is necessary.

Kidney recovery in patients discharged to an acute rehabilitation facility with acute kidney injury requiring hemodialysis
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BACKGROUND: Patients with acute kidney injury requiring renal replacement therapy (AKI-RRT) are at risk of adverse outcomes. Little is known about the incidence of AKI-RRT recovery following hospital discharge. We examine AKI-RRT recovery in hospital survivors discharged to a long-term acute care hospital (LTACH) with need of hemodialysis (HD) for AKI. MATERIALS AND METHODS: Single-center, retrospective cohort study of patients who were hospitalized (08/2015 - 04/2018), suffered from AKI-RRT, and were discharged to an affiliated LTACH with need for HD. Kidney recovery was defined as the patient being alive and no longer requiring HD. RESULTS: 41 patients were included. Mean (SD) age was 61.3 (9.7) years, 63.4% were male, and 90.2% white. At the time of discharge from LTACH, 27 (65.8%) patients had survived and had recovered kidney function (kidney recovery group), 7 had been discharged on HD, and 7 had died (no kidney recovery group, n = 14, 34.2%). In adjusted models, the presence of anemia was associated with a 91% decreased odds of kidney recovery at LTACH discharge. Each additional HD session during LTACH stay had an 18% decreased odds of kidney recovery at LTACH discharge, and each episode of intradialytic hypotension had a 20% decreased odds of kidney recovery at the end of the observation period (median follow-up of 19.0 months). CONCLUSION: Almost 2/3 of AKI-RRT patients discharged to an affiliated LTACH with ongoing HD need recovered kidney function. Anemia and the number of HD sessions and intradialytic hypotension episodes were associated with kidney recovery. Future studies should focus on developing risk-stratification tools for kidney recovery and determining best practices to promote recovery in this susceptible population.