Research

Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation

Jung Yin Tsang, Jonathan Murray, Edward Kingdon, Charlie Tomson, Kyle Hallas, Stephen Campbell and Tom Blakeman
BJGP Open 2020; 4 (3): bjgpopen20X101054. DOI: https://doi.org/10.3399/bjgpopen20X101054

Article Figures & Data

Figures

Tables

  • Table 1. Key characteristics of categorisations of the clinical scenarios tested
    AKI severityKidney recoveryClinical historyManagement: next steps for rating

    • AKI stage 1

    • AKI stage 2

    • AKI stage 3

    • Good (serum creatinine within ≤25% above baseline)

    • Moderate (serum creatinine >25% and <50% above baseline)

    • Poor (serum creatinine ≥50% above baseline)

    • Chronic kidney disease

    • Chronic heart failure

    • Chronic heart failure with chronic kidney disease

    • Other significant cardiovascular risk factors

    • Markers of vulnerability

    • Markers of frailty

    • Determine appropriateness and timeliness in medication review

    • Determine appropriateness and timeliness in kidney monitoring for serum creatinine

    • Determine appropriateness and timeliness in kidney monitoring for proteinuria (urinary ACR)

    • ACR = albumin-to-creatinine ratio. AKI = acute kidney injury.

  • Table 2. Summary of round-two appropriateness ratings with definitions of consensus, N = 819.
    Appropriateness ratings n (%)
    Agreement (8/10 [80%] of panel members rating in the same three-point region)465 (56.8%)

    • Appropriate (80% of panel members rating 7–9)

    		214 (26.1%)

    • Inappropriate (80% of panel members rating 1–3)

    		251 (30.6%)
    Agreement with uncertain benefit (80% of panel members rating the same consecutive three-point region, but not 1–3 or 7–9)59 (7.2%)
    Disagreement (≥30% of scores in 1–3 and ≥30% in 7–9 for same scenario)24 (2.9%)
    Equivocal (ratings of clinical scenarios without consensus; that is, neither ‘agreement’ nor ‘disagreement’)271 (33.1%)
  • Table 3. Summary of timeliness for performing the first post-discharge medication review.
    Medication review ratingsAKI Warning Stage 1AKI Warning Stage 2AKI Warning Stage 3
    Kidney recovery (SCr % above baseline)≤ 25%>25% & <50%≥ 50%≤ 25%>25% & <50%≥ 50%≤ 25%>25% & <50%≥ 50%
    Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)
    No past medical historyNot required1.5 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days1.5 (I)2 (I)3.5 (E)2 (I)3 (E)4.5 (E)3 (I)3.5 (E)6.5 (D)
    Med r/v at 1–2 weeks2.5 (I)4 (E)7 (E)6 (D)7.5 (U)8 (A)7.5 (E)8 (E)8 (E)
    Med r/v at 1 month6.5 (E)7 (U)6.5 (U)7 (E)7 (U)6.5 (E)7 (U)6.5 (U)5.5 (E)
    Med r/v at 3 months7 (E)6 (E)5.5 (E)6.5 (E)4.5 (E)3.5 (E)5 (E)4 (E)2.5 (E)
    Chronic kidney diseaseNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days3 (I)4 (E)5.5 (E)3 (E)4 (E)6.5 (E)3 (E)4 (E)4 (E)
    Med r/v at 1–2 weeks5.5 (E)8 (E)8 (A)7 (E)8 (A)8 (A)7.5 (E)8.5 (A)8.5 (A)
    Med r/v at 1 month8 (A)8 (A)6.5 (E)8 (A)7 (A)*5 (E)7 (A)7 (A)*7 (A)*
    Med r/v at 3 months5.5 (U)3.5 (E)3.5 (E)5 (E)3 (E)2 (E)4.5 (E)3 (E)3 (E)
    Chronic heart failureNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days4.5 (U)5 (U)7 (U)4 (E)5.5 (U)8 (A)*5 (E)6 (E)9 (A)
    Med r/v at 1–2 weeks8 (A)8.5 (A)9 (A)8 (A)8 (A)9 (A)9 (A)8.5 (A)8 (A)*
    Med r/v at 1 month7 (U)6 (E)5.5 (E)6 (U)6 (E)5 (E)5.5 (U)5 (E)3.5 (E)
    Med r/v at 3 months4 (E)3 (E)2.5 (I)4 (E)2.5 (E)2 (I)4 (E)2 (I)1.5 (I)
    Chronic kidney disease & chronic heart failureNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days4.5 (E)6 (U)8 (A)*5.5 (E)6 (U)8 (A)*6 (E)8 (A)*9 (A)
    Med r/v at 1–2 weeks8 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)8 (A)*
    Med r/v at 1 month6 (E)6.5 (E)4.5 (D)6 (E)4.5 (E)3.5 (D)5.5 (E)4 (E)2.5 (E)
    Med r/v at 3 months3 (E)2.5 (E)2 (I)3 (E)2 (I)1.5 (I)2.5 (E)1.5 (I)1 (I)
    Other significant cardiovascular risk factorsNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days2.5 (I)3.5 (U)5 (E)3 (U)4 (E)6.5 (E)4 (U)4.5 (E)7 (A)*
    Med r/v at 1–2 weeks6 (U)7.5 (A)*8 (A)7 (E)8 (A)9 (A)8 (E)9 (A)9 (A)
    Med r/v at 1 month8 (A)8 (A)6.5 (E)8 (A)7.5 (A)*6 (E)8 (A)7.5 (A)*5.5 (D)
    Med r/v at 3 months6 (U)5 (E)3 (I)4.5 (U)3 (I)2 (I)5 (E)2.5 (I)1.5 (I)
    Markers of vulnerabilityNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days3 (U)4 (U)6 (E)3 (U)4.5 (U)6 (U)4 (E)5.5 (U)8 (A)*
    Med r/v at 1–2 weeks6.5 (E)8 (A)8.5 (A)7 (E)8 (A)9 (A)8 (A)*9 (A)8 (A)
    Med r/v at 1 month8 (A)7 (A)*7 (E)8 (A)7.5 (A)*6.5 (E)8 (A)7.5 (E)6 (D)
    Med r/v at 3 months5 (E)4 (E)3.5 (E)4.5 (E)3.5 (E)3 (I)4 (E)3 (I)1.5 (I)
    Other markers of frailtyNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    Med r/v at 3 days3 (U)4 (U)6 (E)3 (I)4 (U)6.5 (E)3 (E)5 (E)8 (A)*
    Med r/v at 1–2 weeks7 (U)7.5 (A)8 (A)7 (E)8 (A)9 (A)8 (E)9 (A)8.5 (A)
    Med r/v at 1 month8 (A)7.5 (U)6.5 (E)8 (A)7 (A)*6 (E)8 (A)7 (A)*5.5 (D)
    Med r/v at 3 months5.5 (D)5 (E)3 (E)5 (E)3 (U)2 (I)4.5 (E)3 (I)2 (I)

    • The colour of each cell represents the result with the highest consensus. Grey cells are given where consensus was not reached. A = appropriate. A* = appropriate but with a lower average certainty. AKI = acute kidney injury. D = disagreement. E = equivocal. I = inappropriate. Med r/v = medication review. SCr = serum creatinine. U = agreement with uncertain benefit.

  • Table 4. Summary of timeliness for performing the first post-discharge serum creatinine test.
    Serum creatinine monitoring ratingsAKI Warning Stage 1AKI Warning Stage 2AKI Warning Stage 3
    Kidney recovery (SCr % above baseline)≤ 25%>25% & <50%≥ 50%≤ 25%>25% & <50%≥ 50%≤ 25%>25% & <50%≥ 50%
    Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)
    No past medical historyNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days1 (I)1.5 (I)3 (E)1.5 (I)2.5 (I)3.5 (E)2 (I)3.5 (E)5.5 (E)
    SCr at 1–2 weeks2.5 (I)3.5 (D)7 (U)2.5 (E)6 (D)8 (A)4 (E)7.5 (A)8 (A)
    SCr at 1 month5 (E)7.5 (E)8 (A)7.5 (E)8.5 (A)7.5 (E)7.5 (E)8 (A)6.5 (E)
    SCr at 3 months8 (A)7 (E)5.5 (D)7.5 (E)7 (E)4 (D)7.5 (E)6 (E)4 (E)
    Chronic kidney diseaseNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days3 (I)3.5 (E)4.5 (E)2.5 (I)3 (E)6 (E)3 (I)4 (E)6 (E)
    SCr at 1–2 weeks4.5 (D)6.5 (U)7 (E)5.5 (E)8 (A)8 (A)7 (E)8 (A)9 (A)
    SCr at 1 month8 (A)8 (A)8 (E)8 (A)8 (A)*7.5 (E)8 (A)7.5 (E)6 (E)
    SCr at 3 months6.5 (E)6 (D)5 (D)6.5 (E)6 (E)3.5 (E)5 (D)3 (E)1.5 (E)
    Chronic heart failureNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days2.5 (I)4 (E)5 (U)3.5 (U)4.5 (U)6 (E)3.5 (U)6 (U)7 (A)*
    SCr at 1–2 weeks7 (U)8 (A)9 (A)7.5 (A)*8 (A)9 (A)7.5 (A)8 (A)8 (A)
    SCr at 1 month8 (A)7.5 (A)*6 (E)8 (A)7 (E)4.5 (E)7.5 (U)6.5 (E)3.5 (E)
    SCr at 3 months5 (D)3.5 (E)2.5 (I)4.5 (E)3 (E)1.5 (I)4.5 (E)2 (I)1.5 (I)
    Chronic kidney disease & chronic heart failureNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days3.5 (E)5 (U)6 (U)3 (E)4.5 (U)7 (U)5 (E)6 (U)8 (A)*
    SCr at 1–2 weeks7.5 (A)*8 (A)9 (A)8 (A)8 (A)9 (A)8 (A)9 (A)8.5 (A)
    SCr at 1 month7.5 (A)7 (E)7 (E)7.5 (E)6.5 (E)4 (D)7.5 (E)4.5 (E)3 (E)
    SCr at 3 months3 (E)3 (E)2.5 (I)2.5 (E)2.5 (E)1.5 (I)2.5 (E)2.5 (I)1.5 (I)
    Other significant cardiovascular risk factorsNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days2 (I)3 (U)4 (U)3 (E)3 (E)4.5 (E)3 (U)4 (E)6 (E)
    SCr at 1–2 weeks4.5 (E)7 (U)8 (A)5.5 (E)8 (A)8.5 (A)7 (A)*8 (A)8 (A)
    SCr at 1 month7.5 (A)8 (A)7.5 (A)*8 (A)7 (A)*7 (U)8.5 (A)7 (U)6.5 (E)
    SCr at 3 months5.5 (E)4.5 (E)3.5 (E)4.5 (E)3.5 (E)3 (I)4.5 (E)2.5 (E)2 (I)
    Markers of vulnerabilityNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days3 (I)3.5 (E)4.5 (U)2.5 (I)3.5 (E)4.5 (E)3 (E)4 (E)6 (E)
    SCr at 1–2 weeks5 (E)7 (U)8 (A)5 (E)8 (A)8.5 (A)7 (E)8 (A)8.5 (A)
    SCr at 1 month8 (A)8 (A)7 (A)*8 (A)7.5 (A)*7.5 (A)*8 (A)7 (A)*7 (E)
    SCr at 3 months6 (U)5.5 (E)4.5 (E)5.5 (E)4 (E)2.5 (E)5 (D)3.5 (E)2 (I)
    Other markers of frailtyNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    SCr at 3 days2.5 (I)3 (U)3 (U)2 (I)3 (E)4 (E)3 (I)4 (E)6 (E)
    SCr at 1–2 weeks4 (D)7 (E)8 (A)5.5 (E)8 (A)9 (A)7 (E)8 (A)9 (A)
    SCr at 1 month8 (A)8 (A)7 (A)*8 (A)8 (A)*7.5 (A)*8 (A)7 (A)*6.5 (E)
    SCr at 3 months6.5 (E)5 (E)3.5 (E)5.5 (E)4 (E)2 (I)4.5 (E)3 (E)2 (I)

    • The colour of each cell represents the result with the highest consensus. Grey cells are given where consensus was not reached. A = appropriate. A* = appropriate but with a lower average certainty. AKI = acute kidney injury. D = disagreement. E = equivocal. I = inappropriate. SCr = serum creatinine. U = agreement with uncertain benefit.

  • Table 5. Summary of timeliness for performing the first post-discharge urine albumin-to-creatinine ratio.
    Urine ACR ratingsAKI Warning Stage 1AKI Warning Stage 2AKI Warning Stage 3
    Kidney recovery (SCr % above baseline)≤ 25%>25% & <50%≥ 50%≤ 25%>25% & <50%≥ 50%≤ 25%>25% & <50%≥ 50%
    Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)Median (Rating)
    No past medical historyNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month2.5 (I)2 (I)2 (I)2 (E)2 (E)2 (E)2 (E)2 (E)2 (E)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)
    Chronic kidney diseaseNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month2.5 (E)2.5 (E)2.5 (E)2.5 (E)2.5 (E)2.5 (E)2.5 (E)2.5 (E)3 (E)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)
    Chronic heart failureNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)
    Chronic kidney disease & chronic heart failureNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)3.5 (E)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)
    Other significant cardiovascular risk factorsNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month4 (E)4 (E)4 (E)4 (E)4 (E)4 (D)4 (E)4 (D)4 (D)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)
    Markers of vulnerabilityNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month3 (E)3 (E)3 (E)3 (E)3 (E)3 (E)3 (E)3 (E)3 (E)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)
    Other markers of frailtyNot required1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)1 (I)
    UACR at 1 Month2 (E)2 (E)2 (E)2 (E)2 (E)2 (I)2 (E)2 (E)2 (E)
    UACR at 3 Months9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)9 (A)

    • In all urine albumin-to-creatinine ratio scenarios, the highest consensus was to perform the first test at 3 months (all cells coloured green to reflect highest consensus). A = appropriate. AKI = acute kidney injury. D = disagreement. E = equivocal. I = inappropriate. SCr = serum creatinine. U = agreement with uncertain benefit. UACR = urine albumin-to-creatinine ratio.

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BJGP Open
Vol. 4, Issue 3
August 2020
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Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation
Jung Yin Tsang, Jonathan Murray, Edward Kingdon, Charlie Tomson, Kyle Hallas, Stephen Campbell, Tom Blakeman
BJGP Open 2020; 4 (3): bjgpopen20X101054. DOI: 10.3399/bjgpopen20X101054
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British Journal of General Practice