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: 10176181
• 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 2019-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10176181
• 关键词: Acute Renal Failure with Renal Papillary Necrosis; Address; Adult; Affect; Age; Aldosterone; American; Angiotensins; Area; Benefits and Risks; Cardiovascular Diseases; Caring; Cessation of life; Chronic Kidney Failure; Clinical; Clinical Research; Combined Modality Therapy; Complication; Computerized Medical Record; Consensus; Creatinine; Critical Illness; Data; Data Pooling; Diabetes Mellitus; Dialysis procedure; Disease Outcome; Disease Progression; Elderly; End stage renal failure; Ensure; Equilibrium; Future; Goals; Health; Health Services; Homeostasis; Hospitalization; Hospitals; Hypertension; Impairment; Individual; Informatics; Information Resources; Information Systems; Infrastructure; Injury; Injury to Kidney; Intervention; Kidney; Kidney Diseases; Knowledge; Link; Medicare; Methodology; Morbidity - disease rate; Nephrology; Outcome; Patient-Focused Outcomes; Patients; Pattern; Patterns of Care; Pharmacoepidemiology; Pharmacology; Physiology; Population; Quality of Care; Recovery; Recurrence; Renal function; Renin; Renin-Angiotensin-Aldosterone System; Reporting; Research; Risk; Risk Factors; Risk stratification; Risk-Benefit Assessment; Safety; Series; Serum; Services; Societies; Source; Survivors; United States; Variant; Veterans; acute care; care delivery; clinical decision-making; clinical predictors; clinically significant; cohort; cost; data warehouse; electronic data; experience; improved; improved outcome; inhibitor/antagonist; injury recovery; modifiable risk; mortality; preclinical study; prevent; repaired; response; treatment strategy

 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)： 在退伍军人中，急性肾脏损伤(AKI)是导致晚期肾脏疾病和死亡率的一个日益增长的因素。需要制定策略来减少急性肾损伤后的疾病进展。这项建议的目标是确定可改变的危险因素，以避免长期的肾功能损失。 遵循AKI和可测试的护理策略，可能会降低这些风险。AKI后肾脏恢复情况尚不清楚。复苏的模式各不相同，可能需要很长时间。复发的AKI是老年AKI幸存者发病率和死亡率的常见来源，也可能使康复复杂化。确定老年AKI幸存者的康复和复发AKI的临床意义将弥合从AKI到ESRD进展的知识差距，并改善风险分层。改善AKI后的结果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后提供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患者高发疾病(如慢性肾脏疾病、糖尿病、心血管疾病和高血压)的基石。然而，这种疗法的使用最近在某些患者(例如老年人)或在积极应用时(即联合疗法)受到了质疑。RAASI使用的一个关键方面是平衡其好处和已知的阻碍自动调节的能力，自动调节是一种防止AKI的适应性反应。Aki还会损害自动调节功能。因此，确定在AKI幸存者中使用RAASI的潜在风险是至关重要的，并可能挑战当前的治疗范例。我们将在国家老年急性心肌梗死幸存者队列中进行一系列研究，以表征康复模式的变化、复发的急性心肌梗死及其与未来ESRD的关系。我们还将确定可以改善AKI幸存者风险分层的康复和复发AKI的临床预测因子。然后，我们将研究AKI如何影响特定护理策略的交付，重点是RAASI治疗。我们将在AKI幸存者中确定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使用与复发AKI之间的潜在关联。这些发现将有助于确定可测试的护理战略，并为个人风险/收益评估提供信息。此外，风险和益处的表征、方法的改进和潜在效应大小的量化将为未来改善急性肾功能衰竭幸存者结果所需的研究奠定基础。拟议的研究将在2005至2014年间住院患者的国家退伍军人数据队列中进行。所有成年(年龄=18岁)AKI患者，根据共识标准，根据血清肌酐变化定义，将符合条件。该队列的集合将利用退伍军人信息学和计算基础设施(VINCI)，该基础设施包括一个汇集所有退伍军人医院和退伍军人信息资源中心(VIREC)数据的国家电子数据仓库，提供与退伍军人电子医疗记录交叉的医疗保险服务中心(CMS)数据。芬奇将提供建立我们的目标所需的大部分观测数据，并已与VIREC数据相关联。VIREC中的CMS数据将与芬奇观测相联系，以确保通过与美国肾脏数据系统(USRDS)的交叉链接来捕获ESRD或透析的结果。