AKI RESEARCH: ENSURING EARLY RECOGNITION, EFFECTIVE TREATMENT AND RECOVERY
Clinical Activities in Critical Care AKI
In 1995, Dr. Cerdá performed the first CRRT treatment in in the Capital District at the Albany Medical Center Pediatric ICU, to manage a child with tumor lysis syndrome and acute kidney injury. In those early times, dedicated CRRT machines did not exist, and the child was successfully treated with Continuous Arterio-Venous Hemofiltration (CAVH). Subsequently, CRRT was extended to the Albany Medical Center Medical and Surgical intensive care units first utilizing CAVH, and eventually evolving to CRRT-dedicated machines. In 1997, Dr. Cerdá developed the Continuous Renal Replacement (CRRT) program at St Peter’s Hospital, and has directed the program since then. The first CRRT treatment was performed at St Peter’s Hospital utilizing a modified Reddy machine in a cardiac surgery patient, and subsequently, newer machines were used as they became available, including the BM-11 and newer models of Gambro devices including the Prisma and the PrismaFlex, which currently remain in use. Nowadays, St Peter’s hospital has seven PrismaFlex machines, which are used every day simultaneously in multiple critical care locations.
Overall, St Peter’s Hospital has a very active renal replacement program, including the delivery of intermittent hemodialysis and continuous renal replacement therapies at the bedside in the Mixed and Cardiovascular ICUs.
For the last 5 years, the hospital has provided ever more advanced renal replacement options including the performance of CRRT concurrent with Extracorporeal Membrane Oxygenation (ECMO), which are devices that permit oxygenation and cardiac support in situations of acute respiratory distress due to very severe cases of influenza as well as in the management of very severely ill cardiac patients in profound cardiogenic shock pre-and post-cardiac surgery. Recently, the program is developing policies and procedures to extend CRRT treatment to patients with severe respiratory failure requiring especially designed rotating proning beds, and the program continues to innovate with planned procedures including the performance of CRRT out of bed and in ambulating patients.
The acute kidney injury program maintains excellency in critical patient care and maintains and continuously improves the highest standard quality initiatives, in close collaboration with intensivists, cardiac surgeons and expert critical care nurses. New nursing personnel is continuously being trained in these complex, innovative technologies, and members of the critical care team participate in an active research program which has resulted in an extensive number of publications listed separately. Results of the program have been reported in multiple nephrology and critical care meetings around the world.
Acute Kidney Injury
Each year, more than 10 million people worldwide suffer from acute kidney injury (AKI), a condition that kills an estimated 1.75million persons per year. Mortality and morbid complications among critically ill patients who suffer AKI in hospital intensive care units is higher than other common critical conditions, including acute respiratory distress syndrome and septic shock. This condition can occur both in the community as well as among inpatients, and its treatment may require the use of kidney replacement therapies such as dialysis. The medical community is currently engaged in multiple research initiatives to improve AKI early recognition, management and promotion of kidney function recovery.
AKI! Now Initiative
In collaboration with national and international experts, the American Society of Nephrology (ASN) is part of multiple educational and research initiatives to lessen the burden of disease and to improve outcomes. To redouble those efforts, the ASN recently launched an initiative, AKI! Now, chaired by Jorge Cerdá, MD, MS, FASN and including national and international experts, to identify the best practices to treat critically ill children and adults. It is expected that this initiative will provide important guidance on effective diagnosis and treatment protocols for diagnosis and treatment for the millions of persons impacted by AKI every year. To better understand the key role that patients have in the treatment and recovery process, the AKI!Now Initiative is involving patients to share their perspective and to learn from their experience how best to tackle this often-devastating problem. For more information on this initiative, follow the link AKI Press Release
0 by 25 Initiative
The International Society of Nephrology (ISN) has recently established a new international project, the 0 by 25 Initiative, designed to achieve “zero avoidable deaths due to AKI around the world, by 2015.” This ambitious project has developed diagnosis and intervention criteria and established research initiatives in rural areas of low-and-middle income countries including Bolivia, Nepal and Malawi. These pilot projects are now coming to fruition and are producing important new understanding on how to tackle this severe problem in communities around the world. As indicated by Dr. Jorge Cerdá, Co-Chair of the ISN Advocacy Committee, “It is expected that such new initiatives will help develop new paradigms in the understanding of AKI in the community and lead to changes in the socioeconomic and environmental conditions associated with this disease.”
Promotion of Kidney Recovery
Each year, thousands of patients who develop AKI during their hospitalization are discharged home still requiring dialysis. At this time, the nephrology community does not have widely accepted criteria to promote prompt recovery and to avoid progression for chronic kidney disease, which may lead to the need for lifelong dialysis for those patients. In collaboration with multiple important university medical centers around the US, the New York Nephrology Group, in an effort led by Dr. Jorge Cerdá and Dr. Rahim Dhanani, is engaged in efforts to identify what are the best practices in the management of such patients, not only during the acute episode of kidney failure, but also to ensure lifelong care to address the often severe consequences of the disease. The New York Nephrology Group, in collaboration with Fresenius Healthcare, has established an AKI-D Dialysis unit with the unique goal of addressing the needs of these patients and to promote prompt recovery.
1. Cerdá J, Bagga A, Kher V, Chakravarthi RM. The contrasting characteristics of acute kidney injury in developed and developing countries. Nature Clin Pract Nephrol. 2008;4(3):138-153
2. Susantitaphong P, Cruz DN, Cerdá J, Abulfaraj M, Alqahtani F, Koulouridis I, Goldstein SL, Jaber S for the Acute Kidney Injury Advisory Group of the American Society of Nephrology. Worldwide Incidence of Acute Kidney Injury: A Meta-analysis. Clin J Am Soc Nephrology, 2013; 8(9):1482-93
3. Cerdá J, Liu KD, Cruz D, Jaber B,. Koyner JL, Heung M, Okusa M and Faubel S, for the AKI Advisory Group of the American Society of Nephrology. Promoting Kidney Function Recovery in Patients with Acute Kidney Injury Requiring Renal Replacement Therapy, Clin J Am Soc Nephrol 2015;10(10):1859-67
4. Mehta RL, MD, Cerdá J, Burdmann EA , Tonelli M, García-García G, Jha V, Susantitaphong P , Rocco M, Vanholder R, Sever MS, Cruz D , Jaber B, Lameire NH, Lombardi R, Lewington A, Feehally J, Finkelstein F, Levin N, Pannu N, Thomas B, Aronoff-Spencer E and Remuzzi G. International Society of Nephrology’s 0by25 for acute kidney injury: a human rights case for nephrology. The Lancet, 2015;385(9987):2616-43 (*Joint first authors)
5. Mehta RL, A. Burdmann EA, Cerdá J, Feehally J, Finkelstein F, García-García G, Godin M, Jha V, Lameire N, Levin N, Lewington A, Lombardi R, Macedo E, Rocco M, Aronoff-Spencer E, Tonelli M, Zhang J, Remuzzi G Current Practice for Recognition and Management of Acute Kidney Injury: the ISN 0by25 Global Snapshot Study. The Lancet, 2016;387(10032):2017-25
6. Cerdá J, Liu KD, Cruz D, Jaber B,. Koyner JL, Heung M, Okusa M and Faubel S, for the AKI Advisory Group of the American Society of Nephrology. Promoting Kidney Function Recovery in Patients with Acute Kidney Injury Requiring Renal Replacement Therapy, Clin J Am Soc Nephrol 2015;10(10):1859-67
7. Heung M, Faubel D, Watnick D, N. Cruz DM, Koyner K;, Mour H, Liu KD, Cerdá J, Lukaszewski M, Vijayan A; for the ASN AKI Advisory Group. Outpatient Dialysis for Patients with Acute Kidney Injury: Opportunities to Improve Care. Clin J Am Soc Nephrol 2015;10:1868-74
8. Cerdá J, Baldwin I, Honore PM, Villa G, Kellum JA, Ronco C, ADQI Consensus Group. Role of Technology for the Management of AKI in Critically Ill Patients: From Adoptive Technology to Precision Continuous Renal Replacement Therapy. Blood Purif 2016;42(3):248-265
9. Awdishu L, Nievergelt CM, Davenport A, Murray PT, Macedo E, Cerdá J, Chakaravarthi R, Satish P, Ramachandra R, Holden A, Goldstein S, Mehta RL. Rationale and Design of the The Genetic Contribution to Drug Induced Renal Injury Study (DIRECT). Kidney International Reports 2016;1(4):288-298
10. Darmon M, Ostermann M, Cerdá J, Dimopoulos MA, Forni L, Hoste E, Legrand M, Lerolle N, Rondeau E, Schneider A, Souweine B, Schetz M. Diagnostic work-up and specific causes of acute kidney injury. Intensive Care Med 2017; 43(6):829-840
11. Cerdá J, Mohan S, Garcia-Garcia G, Jha V, Samavedam S, Gowrishankar S, Bagga A, Chakravarthi R, Mehta R, on behalf of the Acute Disease Quality Initiative (ADQI) Consensus Group, Acute Kidney Injury Recognition in Low and Middle Income Countries, Kidney International Reports (2017);2(4):530-543
12. Cerdá J, J, Villa G, Neri M, Ronco C. Technology in Medicine: Moving Towards Precision Management of Acute Kidney Injury. Contrib Nephrol. 2018;193:89-99.
13. Macedo E, Cerdá J et al. Recognition and management of acute kidney injury in children: The ISN 0 by 25 Global Snapshot Study. PLOS ONE 2018; 13(15): e196586