ICU Patients on RRT Rarely Have Nephrology Follow-up
Investigators propose a protocol for when patients should be referred to nephrologists.
Nephrology follow-up of intensive care patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT) rarely occurs, a new English study suggests. So researchers are proposing a protocol to encourage nephrologist visits to help protect patients from long-term renal dysfunction.
For the study, Christopher J. Kirwan, MD, of The Royal London Hospital, and colleagues reviewed the medical records of more than 5,500 intensive care patients at East London hospitals, including 219 who survived following continuous RRT for AKI; none were receiving renal care prior to hospitalization.
Just 26 patients (12%) saw a nephrologist for follow-up care after hospital discharge, according to results published in Nephron. (In the United Kingdom, a nephrologist isn't required to commence RRT in the ICU.) What's more, many had poor kidney function. At 3 to 6 months, the estimated glomerular filtration rate (eGFR) had fallen from baseline (48 vs. 60 mL/min/1.73 m2). The prevalence of chronic kidney disease stage 3 to 5 among patients also rose from 49% to 70%.
According to the researchers, a “higher eGFR at discharge should not be taken as universally reassuring.” Creatinine and eGFR levels can fluctuate for various reasons, and it is difficult to predict during hospitalization which patients will require nephrology follow-up.
The investigators proposed a pathway to shuttle appropriate ICU patients to nephrology follow-up:
- If AKI is stage 2–3 during hospitalization, then measure creatinine at discharge. If the numbers are favorable, suggest follow-up at an AKI clinic within 3 months.
- Early nephrology follow-up within 2–4 weeks after discharge should occur for patients with certain adverse features (i.e., significant increase in creatinine or renal impairment based on creatinine or eGFR.)
- If renal function is stable, assess patient again after a year. If unstable, conduct regular follow-up.
- Patients with the following features should be referred directly to specialist nephrology care after hospital discharge: persistent hematuria or proteinuria, glomerulonephritis, refractory hypertension, familial renal disease, extensive or recurrent nephrolithiasis, or likely progression to end-stage renal disease.