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We agree with Shah et al. that caring for patients with acute kidney injury (AKI) is complicated, particularly when it comes to medication management (1). It is important to remember that AKI is a heterogenous condition with multiple etiologies and different degrees of severity. In some cases then, prioritization of other chronic diseases over AKI may be reasonable and even beneficial for patients.
On this background, we would caution against the conclusion that physicians view AKI as a low priority concern. More qualitative research is needed first to understand physician experiences with AKI during both the inpatient and outpatient setting. This information is necessary to develop and support the use of quality improvement tools for patients with AKI, such as the medication checklists referenced by Shah et al (2).
1. Phipps DL, Morris RL, Blakeman T, Ashcroft DM. What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury. BMJ Open 2017;7:e011765.
2. Griffith K, Ashley C, Blakeman T, Fluck R, Lewington A, Selby N, et al. ‘Sick day’ guidance in patients at risk of Acute Kidney Injury: An Interim Position Statement from the Think Kidneys Board 2015.
We have read with great interest the article “What insights do patients and caregivers have on acute kidney injury and post-hospitalisation care? A single-center qualitative study from Toronto, Canada” by Silver et al.
The article sheds light on the fact that most of its participants prioritised chronic conditions that ‘progress over time’ over AKI. These co-morbidities often include heart failure, hypertension and Type 2 diabetes mellitus, which are treated with non-steroidal anti-inflammatory drugs, diuretics and metformin respectively( 1). There is considerable data that these drugs are nephrotoxic and should therefore, be deprescribed or temporarily with-held or dose-adjusted in patients with AKI.
However, from unpublished research at our hospital, there is often reluctance to stop these drugs, suggesting that this misconception may be shared by physicians as well. As this is a common clinical problem with considerable morbidity, Think Kidneys Campaign (NHS collaboration of various trusts) have developed a checklist for medication optimization in patients with AKI (2), but its use is sparse at least from our experience.
Studies have shown that in-hospital mortality due to AKI far exceeds that due to these long-standing, chronic conditions. In a large nation-based study, in-hospital mortality of AKI was found to be 12.32% (3), with an increase in number of absolute deaths from 2001 to 2011. This is in contrast to the 3% in-...
Studies have shown that in-hospital mortality due to AKI far exceeds that due to these long-standing, chronic conditions. In a large nation-based study, in-hospital mortality of AKI was found to be 12.32% (3), with an increase in number of absolute deaths from 2001 to 2011. This is in contrast to the 3% in-hospital mortality of T2DM (4). Hence, it only seems logical that immediate and effective treatment of AKI take precedence over treatment of chronic, stable conditions in the short-term.
In summary, we believe that the finding of your study that AKI is a ‘low-priority concern’ holds true not just for patients, but potentially also for physicians, and therefore, does have considerable consequences in terms of safe prescribing.
1. Farooqi S, Dickhout JG. Major comorbid disease processes associated with increased incidence of acute kidney injury. World Journal of Nephrology 2016; 5(2): 139–146.
2. Griffith K, Ashley C, Blakeman T, Fluck R, Lewington A, Selby N, et al. ‘Sick day’ guidance in patients at risk of Acute Kidney Injury: an Interim Position Statement from the Think Kidneys Board 2015.
3. Chertow GM, Burdick E, Honour M et al. Acute Kidney Injury, Mortality, Length of Stay, and Costs in Hospitalized Patients. Journal of the American Society of Nephrolog 2005; 16(11): 3365-3370
4. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes. The Journal of Clinical Endocrinology & Metabolism 2002, 87(3): 978–982