Conference Coverage

Avoiding in-hospital acute kidney injury is a new imperative


 

EXPERT ANALYSIS FROM ACP INTERNAL MECICINE

– Preventing acute kidney injury and its progression in hospitalized patients deserves to be a high priority – and now there is finally proof that it’s doable, Harold M. Szerlip, MD, declared at the annual meeting of the American College of Physicians.

The PrevAKI study, a recent randomized controlled clinical trial conducted by German investigators, has demonstrated that the use of renal biomarkers to identify patients at high risk for acute kidney injury (AKI) after major cardiac surgery and providing them with a range of internationally recommended supportive measures known as the KDIGO (Kidney Disease: Improving Global Outcomes) care bundle reduced the occurrence of moderate-to-severe AKI by 34% (Intensive Care Med. 2017 Nov;43[11]:1551-61).

Dr. Harold M. Szerlip, director of nephrology at Baylor Bruce Jancin/MDedge News

Dr. Harold M. Szerlip

This finding has generated great excitement within the worlds of nephrology, surgery, and intensive care medicine. Inpatient AKI is a huge yet underappreciated problem which costs the U.S. healthcare system $9 billion annually. The incidence of AKI jumped 6-fold during 2001-2011. AKI occurs in 10%-15% of hospitalized patients, doubles hospital costs, and carries a 25% mortality rate, explained Dr. Szerlip, director of nephrology at Baylor University Medical Center, Dallas.

The enthusiasm that greeted the PrevAKI trial findings is reflected in an editorial entitled, “AKI: the Myth of Inevitability is Finally Shattered,” by John A. Kellum, MD, professor of critical care medicine and director of the Center for Critical Care Nephrology at the University of Pittsburgh. Dr. Kellum noted that the renal biomarker-based approach to implementation of the KDIGO care bundle resulted in an attractively low number needed to treat (NNT) of only 6, whereas without biomarker-based enrichment of the target population, the NNT would have been more than 33.

Now that evidence demonstrates that AKI can be prevented, it is our duty to find more ways to do it,” Dr. Kellum declared in the editorial (Nat Rev Nephrol. 2017 Mar;13[3]:140-1).

Indeed, another way to do it was recently demonstrated in the SALT-ED trial, in which 13,347 noncritically ill hospitalized patients requiring intravenous fluid administration were randomized to conventional saline or balanced crystalloids. The incidence of AKI and other major adverse kidney events was 4.7% in the balanced crystalloids group, for a significant 18% risk reduction relative to the 5.6% rate with saline (N Engl J Med. 2018 Mar 1;378[9]:819-28).

While that absolute 0.9% risk reduction might initially not sound like much, with 35 million people per year getting IV saline while in the hospital, it translates into 315,000 fewer major adverse kidney events as a result of a simple switch to balanced crystalloids, Dr. Szerlip observed.

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