ADQI 24 Figures

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Original citation: Acute Disease Quality Initiative 24, www.ADQI.org.

Figure 1. Pathophysiological process in development of post-operative AKI.

Acute Kidney Disease Chronic Kidney Disease

Figure 2: Role of the Kidney Health Assessment (KHA) in risk-assessment, detection, management, and follow-up of post-operative AKI. A series of context-specific KHAs involve integration of medical history and clinical context, optionally aided by further investigations in higher risk settings, to provide a kidney prognostic assessments that guide further monitoring and treatment.

Pre-operative

Post-operativewithin 48h

Post-op AKIwithin 7 days

Post-AKIRecovery

>90 days

Pre-operative KHA

Post-operative KHA

- Procedural details- New Nephrotoxin exposures?- Clinical assessment- Pre-op KHA

Integrated assessment of patient-specific AKI-risk

before surgery

Optional assessments in those at higher baseline risk- Urinalysis- Kidney Imaging- AKI-risk biomarkers

- Demographics- Medical History- Nature of Proposed Procedure- Drug History- Baseline Kidney Function- Previous Episodes of AKI

Optimisation of peri-operative care and monitoring in higher AKI-risk

Optional assessments in those considered at higher risk- Urinalysis- Kidney Imaging- AKI-stress/damage biomarkers

Updated integrated assessmentof patient-specific

AKI-risk after surgery

Optimisation of post-operative care and monitoring in higher AKI-risk

KHA prompted by post-operative AKI

- Clinical Assessment- New Nephrotoxin Exposue?- Nature/severity of AKI-diagnosis- Post-op KHA

Integrated assessment for underlying structural kidneydamge and AKI-prognosis

- Interventions aimed at reversible causes of AKI

- Advoidance of secondary kidney and other organ injury

- Ongoing monitoring of AKI/AKD- Patient/carer eductation

Targeted investigations based on clinical context- Prognostic AKI-biomarkers- Imaging- Haemodynamic monitoring

- Assessment of CKD status- sCr and Urinalysis

- Medication Review- Cardiovascular risk assessment

Integrated risk-assessment for progressive CKD, recurrent AKI &

cardiovascular disease

- Detection and prognostication of chronic kidney disease

- Prevention of CKD progression and/or recurent AKI

- Cardiovascular risk-prevention- Patient/carer eductation

Optional assessments in those considered at higher risk - Repeat kidney imaging- More acurate measurement of kidney

function- CKD progression biomarkers

Follow-up KHA after post-operative AKI/AKD

SURGERY

AKI

Figure 3: Conceptual model of postoperative AKI and AKD. Several different potential trajectories of SCr are depicted with suggested application of the proposed nomenclature.

Solid red line: PO-AKI (commenced and resolved before POD7)

Broken red line(s): PO-AKD (Once beyond POD7 PO-AKI becomes PO-AKD). It may get better between POD7 and POD90 or it may continue through POD90 at which time it would qualify as CKD

Solid purple line: PO-AKD (Evidence of new injury was present prior to POD7 but did not meet criteria for PO-AKI prior to POD7). It may recover prior to POD90 or continue to POD90 at which time it would qualify as CKD

Solid green line: AKI or AKD – according to pattern and rate of rise in SCr above the AKI threshold (</> 7 days)

Broken blue line(s): “Subclinical” renal injury – does not meet current criteria for AKI or AKD, but may be identified by risk-based serial KHAs.

Contemplationof Surgery

Anesthesia Procedure POD 7 POD 30 POD 90

Perioperative Period – risk-based serial KHA appropriate

CONCEPTUAL MODEL OF POSTOPERATIVE AKI & AKD

PO-AKI Period

PO-AKD Period

SCr

Baseline

Threshold change in SCr to meet AKI criteria

Figure 4: Post-operative AKI is associated with an increased risk of short-term complications, in turn leading to increased long-term morbidity and mortality.

Figure 5: Schematic for surgery associated AKI/AKD monitoring. The figure displays a

potential paradigm for the care of patients who experience AKI/ AKD. The timing and nature of

monitoring are suggestions as there is limited data to inform this process. Patients with surgery

associated AKI/AKD should have their kidney function checked within 1 month of their hospital

discharge. The degree of nephrology follow-up should increase as the duration and severity of

AKI /AKID increases. Future research efforts should work to clarify the ideal timing and method

to provide post-AKI/AKD care.