1. 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

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

3. 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 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.

4. 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, 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.

5. AKI Payment Rule
Payment for (hemodialysis) HD for AKI at the ESRD prospective payment system (PPS) base-rate of $ 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

6. 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.

7. 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

8. 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 < mm Hg because hypotension may delay recovery of kidney function

9. 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

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

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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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.

18. 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.

19. 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 Notify provider if this occurs.

20. References
KDIGO Clinical Practice Guideline for Acute Kidney Injury (2018). Retrieved 1/31/2018 at
KDOQI guidelines (2002). Retrieved 1/31/2018 at
Kidney internal supplements (2012). Retrieved 1/31/2018 at