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The Unrecognized Epidemic of Nephrotoxin-associated Acute Kidney Injury. Eric Kirkendall, MD, MBI Medical Director of Clinical Decision Support Hospital Medicine, Biomedical Informatics, James M. Anderson Center for Health Systems Excellence. - PowerPoint PPT Presentation
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The Unrecognized Epidemic of Nephrotoxin-associated Acute Kidney Injury
Eric Kirkendall, MD, MBIMedical Director of Clinical Decision SupportHospital Medicine, Biomedical Informatics,James M. Anderson Center for Health Systems Excellence
We have no other financial relationships to disclose or Conflicts of Interest (COIs) to resolve.
This project was funded by grant from the Agency for Healthcare Research and Quality (AHRQ)
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
Most Common ARF Causes· ATN-Dehydration (21%)· Nephrotoxic drugs (16%)· Sepsis (11%)· Unknown (14%)· Primary Renal Disease (7%)
Hui-Stickle et al, 2005; Pediatric ARF Epidemiology in a Tertiary Care Center from 1999 to 2001
Background
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
Patients receiving IV AG > 5 daysAKI by pRIFLE Primary renal diagnoses excludedOne year of study (n = 557 children, 95% > 3 months of age)
• AKI rates by pRIFLE = 33%
Zappitelli et al, 2011; Acute Kidney Injury in non-critically ill children treated with aminoglycoside antibiotics in a tertiary care center
Background
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
• 86% of patients exposed to at least 1 NTMx• Patients with AKI had 1.7 OR for exposure to a NTMx• PPV for AKI doubles for patient with 3+ NTMx
Moffett et al, 2011; Acute Kidney Injury and Increasing Nephrotoxic-Medication Exposure in Noncritically-ill Children
Background
A portion of NTMx-AKI goes unnoticed due to lack of kidney function surveillance in susceptible children.
• SCr measured at least q4 days only 50% of the time in patients on AGs for ≥5 days
Zappitelli, 2011; Acute Kidney Injury in non-critically ill children treated with aminoglycoside antibiotics in a tertiary care center
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
A portion of NTMx-AKI goes unnoticed due to lack of kidney function surveillance in susceptible children.
Background
Nephrotoxic medication (NTMx)-associated Acute Kidney Injury (AKI) is one of the most common causes of AKI in hospitalized children.
Recent studies demonstrate that NTMx-AKI occurs at higher than previously recognized rates.
A portion of NTMx-AKI goes unnoticed due to lack of kidney function surveillance in susceptible children.
Hypothesis:
More reliable surveillance of NTMx exposure and injury
would demonstrate that rates of AKI are high, that…
an epidemic exists.
Objectives of the Study
• Quantify the rate of High NTMx exposure and NTMx-AKI in the non-critical care population.
• Determine if this EHR-based AKI screening intervention led to changes in AKI prevalence, or duration (intensity)
Methods
• Find NTMx-exposed patients prospectively• Reliably monitor serum creatinine (SCr) for
evidence of injury• Measure exposure and injury rates, changes over
time• Use electronic triggers within the electronic
health record (EHR) and automated reports to make the process more efficient and complete
High NTMx-exposure Criteria
Patient receiving 3 or more nephrotoxic medications (NTMx) concomitantly*
orOn an aminoglycoside for 3 or more days
*IV radiology contrast, amphotericin, or cidofovir in previous week is counted for the week following administration
Injury (AKI) Criteria*
– p (pediatric)– R = Risk, at 150% of baseline creatinine value (SCr)– I = Injured, at 200% of baseline SCr– F = Failure, >= 300% of baseline SCr
– L = Loss, persistent failure > 4 weeks– E = End-Stage Renal Disease, > 3 months
pRIFLE criteria
*KDIGO AKI guideline criteria
Injury (AKI) Criteria*
pRIFLE criteria
or
>= 0.3mg/dL increase in SCr in 48 hours
The Process
Pharmacists
create/receive daily reports, verify & validate
Provide SCr screening
suggestions if necessary
Data Analyst compiles
registry from Pharmacist reports…
…and generate
metrics, run charts
Share with AKI team,
leadership, other
stakeholders
AKI Surveillance Algorithm
AKI Surveillance Algorithm
Meets High NTMx Exposure Criteria
AKI Surveillance AlgorithmInjury surveillance loop
AKI Surveillance Algorithm
Exposure surveillance loop
AKI Surveillance Algorithm
End Surveillance
Daily email report with links…
Demographics
Demographics
Last 3 SCr
Demographics
Last 3 SCr
NTMx’s
Inclusion Flowchart
Distribution of Exposure and InjuryServices
High NTMx Exposure Cases
n = 945Developed AKI Gender
Count % of cohort Non = 655
Yesn = 290 % Female
n = 459Male
n = 486
Bone Marrow Transplant 263 27.83 142 121 46.01 108 155Liver Transplant 131 13.86 84 47 35.88 81 50
Oncology 105 11.11 68 37 35.24 47 58Pulmonary 77 8.15 54 23 29.87 32 45
Cystic Fibrosis 71 7.51 65 6 8.45 43 28General Pediatrics 64 6.77 60 4 6.25 35 29GI Surgery, Trauma 39 4.13 28 11 28.21 19 20
Orthopedics 30 3.17 25 5 16.67 21 9Cardiology 27 2.86 18 9 33.33 13 14
Urology 27 2.86 25 2 7.41 12 15
• 2.9% of all admitted patients were High-NTMx exposed• AKI occurred in 25% of highly exposed unique patients;
31% of all exposed admissions developed AKI
Distribution of Exposure and InjuryServices
High NTMx Exposure Cases
n = 945Developed AKI Gender
Count % of cohort Non = 655
Yesn = 290 % Female
n = 459Male
n = 486
Bone Marrow Transplant 263 27.83 142 121 46.01 108 155Liver Transplant 131 13.86 84 47 35.88 81 50
Oncology 105 11.11 68 37 35.24 47 58Pulmonary 77 8.15 54 23 29.87 32 45
Cystic Fibrosis 71 7.51 65 6 8.45 43 28General Pediatrics 64 6.77 60 4 6.25 35 29GI Surgery, Trauma 39 4.13 28 11 28.21 19 20
Orthopedics 30 3.17 25 5 16.67 21 9Cardiology 27 2.86 18 9 33.33 13 14
Urology 27 2.86 25 2 7.41 12 15
• 2.9% of all admitted patients were High-NTMx exposed• AKI occurred in 25% of highly exposed unique patients;
31% of all exposed admissions developed AKI
total number of new High NTMx exposure patients in a given week
total number of non ICU days in a given week
Rat
e of
Exp
osur
e
* 1000 daysRate of exposure=
total number of new NTMx-AKI patients in a given week
total number of non ICU days in a given week* 1000 daysRate of AKI=
Proportion of high NTMx exposure patients who develop AKI
Avg:25.5
total number of new High NTMx exposure patients in a given week
total number of new AKI patients in a given weekPercent =
0
20
40
60
80
100
120
Pharmacy beganusing automatedTrigger Reports
9/17/2011
Weekly AKI Days Average Weekly AKI Days Control Limits
Time
AK
I day
s
Upper
Avg: 33.6
Avg: 19.5
AKI Intensity: AKI days per 100 High-NTMx exposure days
Des
ired
chan
ge
total number of AKI days in a given week
total number of High NTMx-exposed days in a given week* 100 daysAKI Intensity=
AK
I Int
ensi
ty
0
20
40
60
80
100
120
Pharmacy beganusing automatedTrigger Reports
9/17/2011
Weekly AKI Days Average Weekly AKI Days Control Limits
Time
AK
I day
s
Upper
Avg: 33.6
Avg: 19.5
AKI days per 100 High-NTMx exposure days
Des
ired
chan
ge
total number of AKI days in a given week
total number of High NTMx-exposed days in a given week* 100AKI Intensity=
AK
I Int
ensi
ty
Potential to save ~900 AKI days per year!!
$$$
Summary TableMetric Data Trend NotesHigh NTMx exposure rate Likely due to automated reports
picking up more NTMx
AKI rate , ? Census fluctuations,education
% High NTMx-exposed patients who developed AKI
no change Remained stable, ? decreased variation
AKI Intensity Decreased 40%, potential savings of ~900 AKI days/year at CCHMC
Limitations
• External validity; data from only one site– Future work to spread project to other large
pediatric institutions• AKI attribution to NTMx exposure
– Possible that other etiologies of AKI were present, but patients had to be susceptible (exposed to NTMx) to be included in our study cohort
Take Home Points• A reliable prediction and detection system
detected high numbers of NTMx-exposed and NTMx-AKI patients
• NTMx-AKI is a relatively common phenomenon in hospitalized non-ICU children
• Sub-populations have been identified as targets for future interventions
• Large potential for preventing AKI and saving healthcare dollars
Many thanks to the “Nephro Ninjas” and for allowing us to present our data today…
Cynthia Barclay, PharmD, & all the clinical pharmacists!!Joshua Schaffzin, MD, PhDMarshall Ashby, MBA, MHSMStuart Goldstein, MD
Next Steps
• Still tweaking queries• Interventions planned for target subsets of
patient population (Pulmonary, BMT, GI)• Spread to other institutions
• Several manuscripts on their way!!
Challenges
• Complexity: novel definitions/metrics, surveillance algorithms, trigger queries, inclusion/exclusion criteria
• Competition for resources• Rapid-cycle QI methodologies vs static
programming• Multidisciplinary approach: many, many people
involved
Sep-11* Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-120
50
100
150
200
250
300
350
400
450
500
Accuracy of High NTMx-Exposed AKI Trigger Characteristics
True Positives False Positives False Negatives
Cou
nt o
f Pat
ient
Day
s
