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Discharge from ED with acute kidney injury linked to higher mortality

Patients with acute kidney injury who were discharged home from the ED had an increased risk for death within 30 days, according to findings published in the Clinical Journal of the American Society of Nephrology.

“Our understanding of [acute kidney injury] epidemiology is largely informed by studies conducted in hospitalized and critically ill patients,” Rey R. Acedillo, MD, from the London Health Sciences Center in Ontario, Canada, and colleagues wrote. “Less is known about patients who develop [acute kidney injury] as outpatients or who present to the ED with [acute kidney injury] and are managed in the community. ED visits are brief and health care staff must decide whether a patient should be admitted to hospital or discharged home. A discharge home may mean the ED health care staff felt the [acute kidney injury] was reversible and could be managed in the community or it may represent an underappreciated population at risk of poor outcomes.”

Between 2003 and 2012, Acedillo and colleagues performed a population-based retrospective cohort study in Ontario to investigate the risk for all-cause mortality, receipt of acute dialysis and hospitalization within 30 days after ED discharge among patients aged 40 years and older (mean age, 69 years) with acute kidney injury — 95% had stage 1; 5% had stage 2; 0.7% had stage 3. They matched 4,379 patients with acute kidney injury who were discharged from the ED to 4,379 patients with a similar stage of acute kidney injury who were hospitalized in the ED, as well as 6,188 patients who were discharged from the ED with acute kidney injury to 6,188 patients who were discharged home from the ED with no acute kidney injury. The researchers compared all-cause mortality between the patients hospitalized with acute kidney injury and patients discharged home with no injury using propensity score methods.

Results showed that 6,346 ED discharges occurred in patients with acute kidney injury. Overall, a total of 149 patients (2%) died, 22 (0.3%) received acute dialysis and 1,032 (16%) were hospitalized within 30 days after an ED discharge. Five percent of patients with moderate acute kidney injury died within 30 days after an ED discharge, as did 16% of those with severe injury. Patients who were discharged from the ED had lower mortality within 30 days compared with those who were hospitalized with acute kidney injury (3% vs. 12%; RR = 0.3; 95% CI, 0.2-0.3). A higher rate of death within 30 days was seen in patients discharged from the ED with acute kidney injury compared with those without acute kidney injury (2% vs. 1%; RR = 1.6; 95% CI, 1.2 to 2.0).

“It is reassuring that many patients with [acute kidney injury] are appropriately hospitalized; however, our study findings indicate that patients with [acute kidney injury] who are discharged home may still have an increased risk of poor outcomes,” Acedillo said in a related press release. “This is particularly true for patients with moderate-to-severe [acute kidney injury] and physicians should be vigilant in ensuring ED.”

“If your kidney function is affected but you are feeling well enough to go home from the ED, it is important to ensure that you and your ED physician are aware of this decline in kidney function and that you see your family doctor or specialist as soon as possible,” he added.

In a related editorial, Jay L. Koyner, MD, from the University of Chicago, emphasized that regardless of setting or severity, there is an opportunity to enhance care and prevent morbidity and mortality with every case of acute kidney injury.

“Identifying patients with early [acute kidney injury] ... and then adopting a multifaceted renal-focused care bundle to be implemented by a multidisciplinary [acute kidney injury]-focused rapid response team may be the first step in improving patient outcomes,” he wrote. – by Alaina Tedesco

Disclosure: All authors report no relevant financial disclosures.