Kidney Week

Abstract: FR-OR015

Nephrologist Follow-Up vs. Usual Care After an AKI Hospitalization (FUSION): A Randomized Pilot Trial

Session Information

• AKI: Epidemiology, Processes of Care, and Outcomes
  November 08, 2019 | Location: 201, Walter E. Washington Convention Center
  Abstract Time: 05:18 PM - 05:30 PM

Category: Acute Kidney Injury

• 102 AKI: Clinical, Outcomes, and Trials

Authors

• Silver, Samuel A., Queen's University, Kingston, Ontario, Canada

Samuel A. Silver, MD, MS, FASN



Samuel Silver is an Assistant Professor in the Division of Nephrology at Queen’s University in Kingston, Ontario, Canada. He completed his clinical training in internal medicine and nephrology at the University of Toronto. He holds a Master of Science in quality improvement and patient safety and completed the Veteran Affairs Quality Scholars program at the University of California-San Francisco. Samuel then trained as a research fellow at Stanford University, with a focus on health services research. The objective of his research program is to use administrative data and systematic reviews to inform the design of quality improvement interventions that may improve patient outcomes. Samuel’s research interests focus on the delivery of care for patients with acute kidney injury, both during the inpatient and outpatient setting.

• Chan, Christopher T., Toronto General Hospital, Toronto, Ontario, Canada

Christopher T. Chan,

• Wald, Ron, St. Michael's Hospital, Toronto, Ontario, Canada

Ron Wald,

Background

Survivors of AKI are at increased risk of CKD and death but few patients see a nephrologist post-discharge. Our objectives were to determine the feasibility of randomizing survivors of AKI to structured follow-up with a nephrologist or usual care, as well as to collect data on clinical outcomes for event rate calculations.

Methods

We performed a 52-week randomized pilot trial in patients hospitalized with KDIGO stage 2-3 AKI in 4 hospitals in Toronto, Canada. We randomized patients to usual care or nephrologist-led follow-up within 90-days of discharge, which consisted of a standard assessment that emphasized blood pressure control, cardiovascular risk reduction, and medication safety. The feasibility outcome was the proportion of patients recruited. The primary clinical outcome was a major adverse kidney event, which is a composite of death, chronic dialysis, or a sustained decrease in eGFR≥25%, at 52-weeks post-discharge.

Results

We screened 269 patients and randomized 71 (26%) from July 2015 to June 2017 (37 to usual care and 34 to nephrology follow-up). The most common reasons for declining to participate were patient fatigue (33%) from recent hospitalization and reluctance to see additional specialists (30%). Baseline characteristics included age 65±10 years (mean, SD), 30% female, baseline eGFR 76±22mL/min/1.73m², 47% admitted to the ICU, and median length of stay 14 (IQR 13) days. The median time from hospital discharge to nephrology follow-up was 48 (IQR 40) days, and 22/34 (65%) patients in the intervention group attended their nephrology appointment. The primary outcome occurred in 18/37 (49%) patients in the usual care group and 17/34 (50%) patients in the intervention group (P=0.91). There were no differences between usual care and the nephrology follow-up group in death (8% vs 18%, P=0.23), ≥25% decrease in eGFR (46% vs 38%, P=0.51), or rehospitalization for AKI (24% vs 24%, P=0.94). No patients in either group received maintenance dialysis.

Conclusion

Patient recruitment was lower than anticipated primarily because of patient fatigue and resistance to in-person visits post-discharge, which suggests a more pragmatic intervention may be needed that actively engages patients in its development. The high number of major adverse kidney events observed suggests more work is warranted to improve patient follow-up after AKI.