Lan Nguyen, MSN, CNN, CNP January 17, 2018 Management of Acute Kidney Injury (AKI) in the Outpatient Dialysis Setting Lan Nguyen, MSN, CNN, CNP January 17, 2018

Objectives Strategies for the management of dialysis for AKI in the outpatient dialysis setting Different guidelines

What is AKI? In 2015, the Acute Disease Quality Initiative of the Kidney Disease—Improving Global Outcomes (KDIGO) released a consensus statement of defining and treating AKI. AKI defined as “abrupt decrease in kidney function that occurs over a period of 7 days or less,” occurs in about 20-200 per million population in the community, impacting 7-18% of patients in the hospital, and approximately 50% of patients admitted to the intensive care unit. An estimated two million people worldwide die at AKI every year.

Why are we dialyzing AKI in outpatient dialysis setting? The goal is to reduce the high cost of keeping AKI patients in the hospital, and outpatient clinics can offer more expertise in kidney treatment. Legislation was approved in 2015, initially tagged on as a rider to the trade agreement, and the law took effect January 1st, 2017. This new law allow outpatient dialysis providers to treat Medicare patients with AKI and to bill for the care. Dialysis providers will be allowed to bill for more than three treatments per week if needed, without medical justification. The reimbursement side has also made it clear that additional laboratory tests or pharmaceuticals necessary for the care of an AKI patient may be billed outside the dialysis composite rate, as well as other treatment-related expenses AKI patients may occur.

AKI Payment Rule Payment for (hemodialysis) HD for AKI at the ESRD prospective payment system (PPS) base-rate of $231.55 per treatment All ESRD PPS adjustments apply to AKI payments “Non renal” drugs, biological, and supplies are paid separately Laboratory tests which would not be included in the ESRD bundle are paid separately No weekly limit on number of treatments per week Home hemodialysis for AKI is not covered Vaccinations are covered Utilizations will be monitored No changes to the ESRD conditions for coverage are planned Quality measure for ESRD will not be applied to AKI patients

AKI Requiring Dialysis (AKI-D) According to KDIGO guideline: We initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist. Providers must be aware that AKI patients on dialysis need special care: Heading toward either renal recovery or end staged renal disease (ESRD). It’s a weak predictive marker and no finite time frame to a decision point Determining recovery can be difficult. It’s hard to determine how/when/if kidney function will return.

Promoting Renal Recovery in AKI Patients Avoid Nephrotoxins such as NSAIDs, Contrast dye, etc Avoid hypotension; goal to keep SBP > 110 if possible Frequently reassess dry weight (don’t “over dry” the patient and hurt renal recovery) Monitor urine output Check labs frequently Adjust medications based on improvement in renal function

ESRD vs. AKI Blood Pressure (BP) Management Goal <140/90 after hemodialysis to prevent cardiovascular morbidity and mortality AKI Avoid severe hypertension, but would not treat aggressively to lower BP if SBP <150-160 mm Hg because hypotension may delay recovery of kidney function

ESRD vs. AKI Volume Status The drier the better Volume overload is associated with impaired BP control and increased cardiovascular morbidity and mortality AKI Don’t dry out excessively Excessive ultrafiltration (UF) may delay recovery of kidney function

ESRD vs. AKI Vascular Access Early referral for AVF Prevention of line-infection of paramount importance AKI TDC most appropriate access for first 60-90 days while awaiting recovery of kidney function Prevention of line-infection of paramount importance

ESRD vs. AKI Laboratory Monitoring Monthly AKI Weekly assessment for recovery of kidney function Monitoring urine volume

Criteria for Recovery of Kidney Function Urine volume >500-1,000 ml/day Electrolytes within range Spontaneous decline in serum creatinine Measured creatinine clearance: <12 ml/min – continue dialysis >20 ml/min – discontinue dialysis 12-20 ml/min—clinical judgment

When to consider ESRD? Most patients who will recover kidney function do so within 2-4 weeks Rare recovery of kidney function after 6 months If no signs of recovery, probably appropriate to declare patient as ESRD after 3 months

Post-Discontinuation of Dialysis Follow up visits to check for volume status, labs, and medication review. Early follow up to assess stability of kidney function

Guidelines According to Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines: Management of patients with AKI should be based on assessment of overall clinical status, including specific cause of AKI, trends in kidney function over time, comorbid conditions, assessment of volume status, and concomitant acid-base and electrolyte disturbances.

Guidelines According to KDIGO guidelines: Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist Consider the broader clinical context, the presence of conditions that can be modified with RRT, and trends of laboratory tests—rather than single BUN and creatinine thresholds alone—when making the decision to start RRT

Guidelines Discontinue RRT when it is no longer required, either because intrinsic kidney function has recovered to the point that it is adequate to meet patient needs, or because RRT is no longer consistent with the goals of care. We suggest NOT using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT.

Guidelines We suggest initiating RRT in patients with AKI via an uncuffed nontunneled dialysis catheter, rather than a tunneled catheter. Non-tunneled is inpatient only - for outpatient we only accept tunneled hemodialysis catheter When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these preferences: First choice: Right jugular vein Second choice: Femoral vein Third choice: Left jugular vein Last choice: Subclavian vein with preference for the dominant side.

2018 RMA Standing Orders in Outpatient Clinic Obtain BMP weekly and send to Tricore under Nurse Practitioner name with AKI diagnosis. Avoid aggressive ultrafiltration and do not allow SBP to drop below 110. Notify provider if this occurs.

References KDIGO Clinical Practice Guideline for Acute Kidney Injury (2018). Retrieved 1/31/2018 at https://www.sciencedirect.com/journal/kidney-international-supplements/vol/2/issue/1 KDOQI guidelines (2002). Retrieved 1/31/2018 at http://www2.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm Kidney internal supplements (2012). Retrieved 1/31/2018 at http://www.kidney-international.org