AKI on ESRD?

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

Comments

  • I am seeing auditors generate these queries.  I have not pursued this dx though.  Will be interested in what other CDI think. 
  • 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.
  • Thank you for your comments.
  • 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. 
  • 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.
  • 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

  • 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 
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