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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

基本信息

批准号：
10176246
负责人：
Edward D Siew
金额：
--
依托单位：
VETERANS HEALTH ADMINISTRATION
依托单位国家：
美国
项目类别：
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/10176246
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

项目摘要

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）是退伍军人中晚期肾脏疾病和死亡率的一个日益增长的因素。需要采取策略来减少AKI后的疾病进展。这项提案的目的是确定可改变的风险因素，以避免长期的肾功能丧失遵循AKI和可测试的护理策略，可能会降低这些风险。对AKI后的肾脏恢复知之甚少。恢复的模式各不相同，而且可能很长。复发性AKI是老年AKI幸存者发病和死亡的常见原因，也可能使恢复复杂化。确定退伍军人AKI幸存者中AKI恢复和复发的临床意义将弥合理解AKI向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结局的关系。使用肾素-血管紧张素-醛固酮系统抑制剂（RAASi）的抑制剂是治疗AKI患者中高度流行的疾病（例如慢性肾脏疾病、糖尿病、心血管疾病和高血压）的基础。然而，这种疗法的使用最近在某些患者（如老年人）或积极应用时（即联合治疗）受到质疑。RAASi使用的一个关键方面是平衡其益处与其已知的阻碍自动调节的能力，这是一种保护免受AKI的适应性反应。AKI也损害自动调节。因此，确定RAASi用于AKI幸存者的潜在风险至关重要，可能会挑战当前的治疗模式。我们将在全国退伍军人AKI幸存者队列中进行一系列研究，以描述恢复模式、复发性AKI及其与未来ESRD的相关性。我们还将确定恢复和复发AKI的临床预测因素，这些因素可以改善AKI幸存者的风险分层。然后，我们将研究AKI如何影响特定护理策略的实施，重点是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使用与复发性AKI之间的潜在关联。这些发现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。此外，风险和获益的表征、方法的改进以及潜在效应量的量化将为未来改善AKI幸存者结局所需的研究奠定基础。拟定研究将在2005年至2014年期间住院患者的回顾性国家VA数据队列中进行。根据共识标准，使用血清肌酐变化定义的所有AKI成人（年龄= 18岁）患者均符合资格。该队列的组装将利用退伍军人管理局信息学和计算基础设施（VINCI），该基础设施包括一个国家电子数据仓库，汇集了来自所有退伍军人管理局医院和退伍军人管理局信息资源中心（VIREC）的数据，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。VINCI将提供建立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或透析的结局。