Improving Safety and Quality of Care Among Veterans Following Acute Kidney Injury

提高退伍军人急性肾损伤后护理的安全性和质量

• 批准号: 8866652
• 负责人: Edward D Siew
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-07-01 至 2018-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8866652
• 关键词: Accounting; Acute Renal Failure with Renal Papillary Necrosis; Address; Adult; Affect; Age; Aldosterone; American; Angiotensins; Area; Benefits and Risks; Cardiovascular Diseases; Caring; Chronic Kidney Failure; Clinical; Clinical Research; Combined Modality Therapy; Complication; Computerized Medical Record; Consensus; Creatinine; Critical Illness; Data; Diabetes Mellitus; Dialysis procedure; Disease Outcome; Disease Progression; Elderly; End stage renal failure; Ensure; Equilibrium; Future; Goals; Health; Health Services; Homeostasis; Hospitalization; Hospitals; Hypertension; Individual; Informatics; Information Resources; Information Systems; Intervention; Kidney; Kidney Diseases; Knowledge; Link; Medicare; Meta-Analysis; Morbidity - disease rate; Nephrology; Outcome; Patients; Pattern; Patterns of Care; Pharmacoepidemiology; Physiology; Population; Quality of Care; Recovery; Recurrence; Renal function; Renin; Renin-Angiotensin-Aldosterone System; Reporting; Research; Research Infrastructure; Risk; Risk Factors; Risk-Benefit Assessment; Safety; Series; Serum; Services; Societies; Source; Staging; Stratification; Survivors; Time; United States; Variant; Veterans; care delivery; clinical decision-making; clinical predictors; clinically significant; cohort; cost; electronic data; experience; improved; inhibitor/antagonist; modifiable risk; mortality; preclinical study; prevent; repaired; response

 DESCRIPTION (provided by applicant): Acute kidney injury (AKI) is a growing contributor to advanced kidney disease and mortality among Veterans. Strategies are needed to reduce disease progression following AKI. The goals of this proposal are to identify modifiable risk factors to avert long-term loss of kidney function following AKI and testable care strategies that may reduce these risks. Renal recovery after AKI is poorly understood. Patterns of recovery vary and can be lengthy. Recurrent AKI is a common source of morbidity and mortality among elderly AKI survivors and can also complicate recovery. Determining the clinical significance of recovery and recurrent AKI among Veteran AKI survivors will bridge knowledge gaps in understanding the progression from AKI to ESRD and improve risk stratification. Improving outcomes following AKI requires identifying testable care strategies. Identifying these strategies requires better understanding of the care delivered following AKI and its association with patient outcomes. The use of inhibitors of the renin-angiotensin-aldosterone system inhibitors (RAASi) is the cornerstone of treating conditions highly prevalent in patients with AKI (e.g. chronic kidney disease, diabetes, cardiovascular disease, and hypertension). However, the use of this therapy has recently been questioned in certain patients (e.g. the elderly) or when applied aggressively (i.e. combination therapy). A critical aspect of RAASi use is balancing the benefits with its known ability to hamper autoregulation, an adaptive response that protects against AKI. AKI also impairs autoregulation. Therefore, determining the potential risks of RAASi use in AKI survivors is essential and may challenge current treatment paradigms. We will perform a series of studies within a National cohort of Veteran AKI survivors to characterize variations in the patterns of recovery, recurrent AKI, and their association with future ESRD. We will also identify clinical predictors of recovery and recurrent AKI that can improve risk stratification for AKI survivors. We will then examine how AKI impacts the delivery of specific care strategies, focusing on RAASi therapy. We will characterize different patterns of RAASi use among AKI survivors, identify the clinical features that associate with RAASi use, and examine the potential association between RAASi use and recurrent AKI. These findings will help identify testable care strategies and inform individual risk/benefit assessments. In addition, the characterization of risks and benefits, methodological refinements, and quantification of potential effect sizes will set the stage for future studies needed to improve outcomes in AKI survivors. The proposed studies will be performed in a retrospective National VA data cohort of hospitalized patients between 2005 and 2014. All adult (age=18) patients with AKI, defined using changes in serum creatinine in accordance with consensus criteria will be eligible. The assembly of the cohort will leverage the VA Informatics and Computing Infrastructure (VINCI), which encompasses a national electronic data warehouse pooling data from all VA hospitals and the VA Information Resource Center (VIREC), providing Center for Medicare Services (CMS) data intersected with the electronic medical records of Veterans. VINCI will provide the majority of the observations required to build our Aims and is already linked to VIREC data. The CMS data in VIREC will be linked to VINCI observations to ensure capture of the outcome of ESRD or dialysis via cross- linkage with the United States Renal Data Systems (USRDS).

 描述（由申请人提供）： 急性肾损伤 (AKI) 是导致退伍军人晚期肾病和死亡的一个日益严重的因素，需要采取策略来减少 AKI 后的疾病进展。该提案的目标是确定可改变的危险因素，以避免长期肾功能丧失。 复发性 AKI 是老年 AKI 幸存者发病率和死亡率的常见来源，而且也可能使恢复过程复杂化。经验丰富的 AKI 幸存者中恢复和复发 AKI 的临床意义将弥合理解 AKI 到 ESRD 进展的知识差距，并改善 AKI 后的风险分层需要确定可测试的护理策略。确定这些策略需要更好地了解 AKI 后的护理及其与患者预后的关系。肾素-血管紧张素-醛固酮系统抑制剂 (RAASi) 的使用是治疗 AKI 患者中高度流行的疾病（例如慢性疾病）的基石。然而，这种疗法最近在某些患者（例如老年人）或积极应用（即联合疗法）时受到质疑。 RAASi 的使用正在平衡其已知的阻碍自动调节的能力，这是一种预防 AKI 的适应性反应，因此，确定 AKI 幸存者使用 RAASi 的潜在风险至关重要，并且可能会挑战当前的治疗模式。将在全国退伍军人 AKI 幸存者队列中进行一系列研究，以表征恢复模式、复发性 AKI 及其与未来 ESRD 的关系。我们还将确定可以改善恢复和复发性 AKI 的临床预测因素。然后，我们将研究 AKI 如何影响特定护理策略的实施，重点关注 RAASi 治疗。我们将描述 AKI 幸存者中 RAASi 使用的不同模式，确定与 RAASi 使用相关的临床特征，并检查 RAASi 的使用情况。 RAASi 使用与复发性 AKI 之间的潜在关联将有助于确定可测试的护理策略并为个人风险/效益评估提供信息。为改善 AKI 幸存者预后所需的未来研究奠定基础。拟议的研究将在 2005 年至 2014 年间住院患者的回顾性国家 VA 数据队列中进行。所有患有 AKI 的成人（年龄 = 18）患者，使用变化进行定义。符合共识标准的血清肌酐将符合资格，该队列的组装将利用 VA 信息学和计算基础设施 (VINCI)，其中包括一个国家电子数据仓库，汇集了来自所有 VA 医院和 VA 信息资源的数据。中心 (VIREC)，提供与退伍军人电子病历相交的医疗保险服务中心 (CMS) 数据，VINCI 将提供构建我们的目标所需的大部分观察结果，并且已经与 VIREC 中的 CMS 数据相关联。与 VINCI 观察结果相关联，以确保通过与美国肾脏数据系统 (USRDS) 的交叉链接捕获 ESRD 或透析的结果。