ADQI 24 Figures
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Original citation: Acute Disease Quality Initiative 24, www.ADQI.org.
Figure 1. Pathophysiological process in development of post-operative AKI.
Acute Kidney Disease Chronic Kidney Disease
Figure 2: Role of the Kidney Health Assessment (KHA) in risk-assessment, detection, management, and follow-up of post-operative AKI. A series of context-specific KHAs involve integration of medical history and clinical context, optionally aided by further investigations in higher risk settings, to provide a kidney prognostic assessments that guide further monitoring and treatment.
Pre-operative
Post-operativewithin 48h
Post-op AKIwithin 7 days
Post-AKIRecovery
>90 days
Pre-operative KHA
Post-operative KHA
- Procedural details- New Nephrotoxin exposures?- Clinical assessment- Pre-op KHA
Integrated assessment of patient-specific AKI-risk
before surgery
Optional assessments in those at higher baseline risk- Urinalysis- Kidney Imaging- AKI-risk biomarkers
- Demographics- Medical History- Nature of Proposed Procedure- Drug History- Baseline Kidney Function- Previous Episodes of AKI
Optimisation of peri-operative care and monitoring in higher AKI-risk
Optional assessments in those considered at higher risk- Urinalysis- Kidney Imaging- AKI-stress/damage biomarkers
Updated integrated assessmentof patient-specific
AKI-risk after surgery
Optimisation of post-operative care and monitoring in higher AKI-risk
KHA prompted by post-operative AKI
- Clinical Assessment- New Nephrotoxin Exposue?- Nature/severity of AKI-diagnosis- Post-op KHA
Integrated assessment for underlying structural kidneydamge and AKI-prognosis
- Interventions aimed at reversible causes of AKI
- Advoidance of secondary kidney and other organ injury
- Ongoing monitoring of AKI/AKD- Patient/carer eductation
Targeted investigations based on clinical context- Prognostic AKI-biomarkers- Imaging- Haemodynamic monitoring
- Assessment of CKD status- sCr and Urinalysis
- Medication Review- Cardiovascular risk assessment
Integrated risk-assessment for progressive CKD, recurrent AKI &
cardiovascular disease
- Detection and prognostication of chronic kidney disease
- Prevention of CKD progression and/or recurent AKI
- Cardiovascular risk-prevention- Patient/carer eductation
Optional assessments in those considered at higher risk - Repeat kidney imaging- More acurate measurement of kidney
function- CKD progression biomarkers
Follow-up KHA after post-operative AKI/AKD
SURGERY
AKI
Figure 3: Conceptual model of postoperative AKI and AKD. Several different potential trajectories of SCr are depicted with suggested application of the proposed nomenclature.
Solid red line: PO-AKI (commenced and resolved before POD7)
Broken red line(s): PO-AKD (Once beyond POD7 PO-AKI becomes PO-AKD). It may get better between POD7 and POD90 or it may continue through POD90 at which time it would qualify as CKD
Solid purple line: PO-AKD (Evidence of new injury was present prior to POD7 but did not meet criteria for PO-AKI prior to POD7). It may recover prior to POD90 or continue to POD90 at which time it would qualify as CKD
Solid green line: AKI or AKD – according to pattern and rate of rise in SCr above the AKI threshold (</> 7 days)
Broken blue line(s): “Subclinical” renal injury – does not meet current criteria for AKI or AKD, but may be identified by risk-based serial KHAs.
Contemplationof Surgery
Anesthesia Procedure POD 7 POD 30 POD 90
Perioperative Period – risk-based serial KHA appropriate
CONCEPTUAL MODEL OF POSTOPERATIVE AKI & AKD
PO-AKI Period
PO-AKD Period
SCr
Baseline
Threshold change in SCr to meet AKI criteria
Figure 4: Post-operative AKI is associated with an increased risk of short-term complications, in turn leading to increased long-term morbidity and mortality.
Figure 5: Schematic for surgery associated AKI/AKD monitoring. The figure displays a
potential paradigm for the care of patients who experience AKI/ AKD. The timing and nature of
monitoring are suggestions as there is limited data to inform this process. Patients with surgery
associated AKI/AKD should have their kidney function checked within 1 month of their hospital
discharge. The degree of nephrology follow-up should increase as the duration and severity of
AKI /AKID increases. Future research efforts should work to clarify the ideal timing and method
to provide post-AKI/AKD care.