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.

Mid-term Outcomes of the Supported Ross Procedure in Children, Teenagers, and Young Adults.

The Ross procedure in children, teenagers, and young adults, especially among those with a bicuspid aortic valve with aortic regurgitation, has been associated with neoaortic root dilatation and recurrence of aortic regurgitation. We have shown that at intermediate follow-up, patients who underwent a supported Ross technique were less likely to have neoaortic root dilatation. This study summarizes our most recent outcomes. This was a retrospective review of 40 consecutive pediatric and young adult patients undergoing a supported Ross procedure from 2005 to 2018. Clinical outcomes were reviewed in addition to echocardiographic measures of neoaortic dimension and neoaortic valve function. The median age at surgery was 16.0 years (range 10 - 35 years). Preoperative diagnosis was aortic regurgitation in 15 (37.5%) and mixed regurgitation/stenosis in 20 (50%). Median follow-up was 3.5 years (1.4-5.6) with 3 patients followed for more than 10 years. There were no deaths. Five patients had a reintervention, but only 1 on the aortic valve. One patient returned to the operating room on postoperative day 1 for revision of the right coronary button. Two patients required biventricular pacemakers for reduced ejection fraction. One patient developed aortic regurgitation and underwent mechanical valve replacement and another required a reintervention on the homograft with a percutaneously placed pulmonary valve replacement. At last follow-up, 39 patients had mild or less aortic regurgitation with median sinus z-score of 1.40 (0.48-2.07). Mid-term follow-up of pediatric and young adult patients undergoing a supported Ross operation for various aortic valve pathologies demonstrate excellent results with minimal neoaortic root dilation and reintervention.