AKI on ESRD?

sugawaramisato@hotmail.com

Hi everyone,

When a patient with ESRD is admitted for the emergency HD due to missing HD, can this patient possibly have acute on chronic renal failure?  I thought ESRD is already "end stage" as it is written and the increased Cr and other abnormal lab values are due to "missed HD" not because of worsening the kidney function (and my understanding of "end stage" is it cannot get any worse).  But one of my co-workers usually queries for AKI in such cases based on those abnormal lab values.  We asked our physicians and their answers split as well.  I'd like to hear your opinions, please.  

Thank you,

Misato

dallend@einstein.edu

I am seeing auditors generate these queries.  I have not pursued this dx though.  Will be interested in what other CDI think. 

ahedrick

I don't think Querying for AKI would be appropriate.  The kidneys no longer function in ESRD so there is no acute kidney injury (no remaining functioning nephrons)  The patient is usually in fluid overload due to missing HD, which I use for the PDX unless the patient' s has HF and the chest xray indicates pulmonary edema or congestion.

sugawaramisato@hotmail.com

Thank you for your comments.

joan.oliver@duke.edu

ahedrick said:

I don't think Querying for AKI would be appropriate.  The kidneys no longer function in ESRD so there is no acute kidney injury (no remaining functioning nephrons)  The patient is usually in fluid overload due to missing HD, which I use for the PDX unless the patient' s has HF and the chest xray indicates pulmonary edema or congestion.

@ahedrick - I agree with your position. My experience has been not to query or include AKI in patients with ESRD. 

lolly102412

Each case is unique, but there is a coding clinic that addresses this very issue. AHA Coding Clinic for ICD9 CM, 2Q 2011, Volume 28, Number 2, pages 15-16. (Nothing new in I10) You can in fact code acute renal failure and ESRD depending on the circumstance causing the AKI/ARF. I tend to agree in this instance that the volume overload was probably the cause of the worsening renal function so would not ask for AKI. However, if there were an injury or other insult--medication, etc. that could cause the additional decrease in renal function, despite the ESRD, I think it would be appropriate to query.

evanspx@sutterhealth.org

I have been advised by clinical advisers that acute kidney injury can't exist in ESRD as the nephrons are not functional.  Certainly willing (and eager) to revisit if the renal experts have revisited this topic from a clinical perspective.  For that reason, I don't query or expect to see AKI in the setting of ESRD?

Paul Evans, RHIA, CCDS

morris-jeff@CooperHealth.edu

Agree with Paul. I think once a patient is deemed to have ESRD there’s really no further insult that can cause an acute decompensation in renal function as the kidneys aren’t functioning at a level that an acute insult could really be measured. 

Jeff 

aalvey1

I actually have an example of this my mother in law is an ESRD pt on HD and when they could not stick her for five days she was hospitalized with Acute kidney injury because she actually still produced urine on occasion and became fluid overloaded And potassium was 6.3

Angela RN BSN CDS

morris-jeff@CooperHealth.edu

Many ESRD patients I’ve cared for over the years still make urine (especially overnight) but there’s no real filtering of toxins going on regardless of UOP. 

I wouldnt Query for AKI on ESRD

afrady@blr.com

aalvey1 said:

I actually have an example of this my mother in law is an ESRD pt on HD and when they could not stick her for five days she was hospitalized with Acute kidney injury because she actually still produced urine on occasion and became fluid overloaded And potassium was 6.3

Angela RN BSN CDS

With ESRD, the build up of electrolytes, creatinine, BUN, etc. from missed dialysis is just that, from missed dialysis.   The kidneys themselves have not "acutely failed" or changed in anyway from their baseline.

All that is happened is toxins and fluids and electrolytes have accumulated from missing dialysis.

Now there are some stage 5 CKD patients who are on temporary dialysis due to acute insults where they may regain some kidney function and or healing of an intra-renal diagnosis may be expected, and these patients certainly CAN experience AKI while also on dialysis.  

However, they were not truely in ESRD, they were in an advanced stage of CKD and had an acute and reversible (hopefully) insult.  

Since it is a continnuum, i can see where confusion could occur between what is a very advanced stage 5 and what is a very begging ESRD as the distinction between one or the other could appear some what arbitrary.  There is a lab and uop criteria but i suppose it is possible for some very early or recently diagnosed "ESRD" requiring dialysis to have some small tiny filtering reserve capacity that could be acutely impacted and this may be why some of your doctors are split on the issue.

Here is the thing, if an freshly diagnosis beginning phase ESRD patient with some tiny amount of renal reserves left did have an acute episode....it certainly would have nothing to do with skipping dialysis.  It would be from an infection or trauma or dehydration or shock or something.

Missing dialysis is just...missing dialysis and doesn't turn a chronic diagnosis into an acute one in and of itself.  

sarthakthanawala

afrady@blr.com said:

aalvey1 said:

I actually have an example of this my mother in law is an ESRD pt on HD and when they could not stick her for five days she was hospitalized with Acute kidney injury because she actually still produced urine on occasion and became fluid overloaded And potassium was 6.3

Angela RN BSN CDS

With ESRD, the build up of electrolytes, creatinine, BUN, etc. from missed dialysis is just that, from missed dialysis.   The kidneys themselves have not "acutely failed" or changed in anyway from their baseline.

All that is happened is toxins and fluids and electrolytes have accumulated from missing dialysis.

Now there are some stage 5 CKD patients who are on temporary dialysis due to acute insults where they may regain some kidney function and or healing of an intra-renal diagnosis may be expected, and these patients certainly CAN experience AKI while also on dialysis.  

However, they were not truely in ESRD, they were in an advanced stage of CKD and had an acute and reversible (hopefully) insult.  

Since it is a continnuum, i can see where confusion could occur between what is a very advanced stage 5 and what is a very begging ESRD as the distinction between one or the other could appear some what arbitrary.  There is a lab and uop criteria but i suppose it is possible for some very early or recently diagnosed "ESRD" requiring dialysis to have some small tiny filtering reserve capacity that could be acutely impacted and this may be why some of your doctors are split on the issue.

Here is the thing, if an freshly diagnosis beginning phase ESRD patient with some tiny amount of renal reserves left did have an acute episode....it certainly would have nothing to do with skipping dialysis.  It would be from an infection or trauma or dehydration or shock or something.

Missing dialysis is just...missing dialysis and doesn't turn a chronic diagnosis into an acute one in and of itself.  

Thank you for the detailed explanation!