The APOL1 #NephJC chat: Wrap up

Fabulous chat. Huge - and discussion highlights including the excellent hosting/moderating from Matt and Ben, and the participation of authors Katalin Susztak, Jeff Miner and many more basic scientists. 

Some thoughts on Table 2 for tonight's #JHMChat

Last week my summary of Cost of Acute Kidney Injury in Hospitalized Patients included a bubble chart of Table 2.

Where is CHF and COPD? These are two of the most common reasons for hospital admission.

Where is CHF and COPD? These are two of the most common reasons for hospital admission.

This made clear one of the points of the study that is hard to accept, the fact that an myocardial infarction adds only $14. Does this indicate that the model flawed in some way? Or does this represent a medical system that has developed detailed and efficient pathways for the diagnosis of acute MI such that these patients do not represent meaningful increase in cost of care?

I do not suppose there is anything to learn if the model is merely broken. But if we suppose the model is accurate what can that teach us about how we should take care of AKI?

Hospitals are tuned for the inpatient management of acute MI. Chest pain units that quickly and efficiently guide patients through risk stratification, then intervention versus medical management leading to brisk outpatient follow-up are all components that allow efficient quality care for acute MI. The proof is in the outcomes.

Differential Time Trends of Outcomes and Costs of Care for Acute Myocardial Infarction Hospitalizations by ST Elevation and Type of Intervention in the United States, 2001–2011

Differential Time Trends of Outcomes and Costs of Care for Acute Myocardial Infarction Hospitalizations by ST Elevation and Type of Intervention in the United States, 2001–2011

What would an AKI pathway look like? Can we systemitize the management of these patients to shorten admissions?

Over and over again I see decisions made by nephrologists that prolong hospitalizations while not providing advantages to the patient.

Can we agree that if the creatinine is falling for a day or two we do not need to watch the creatinine fall all the way to baseline before they are ready for discharge? I have seen that done.

In rhabdomyolysis, if the patient didn't develop AKI when the CPK peaked at 20,00 do we need to keep the patient admitted on IV fluids until the CPK is normal? I have seen that done.

If the patient has AKI and the creatinine is stable and the electrolytes are good, we do not need to keep the patient admitted until renal recovery. We should not emphasize creatinine voyeurism as an end to itself.

AKI is so expensive because we have not researched or developed validated pathways for dealing with these patients quickly, efficiently and personally.