Impact of AKI care bundles on kidney and patient outcomes in hospitalized patients: a systematic review and meta-analysis

(2021) 22:335 Schaubroeck et al. BMC Nephrol https://doi.org/10.1186/s12882-021-02534-4 Open Access RESEARCH Impact of AKI care bundles on kidney and patient outcomes in hospitalized patients: a systematic review and meta-analysis Hannah A. I. Schaubroeck1*, Diana Vargas2, Wim Vandenberghe1 and Eric A. J. Hoste1,3 Abstract Background: A bundle of preventive measures can be taken to avoid acute kidney injury (AKI) or progression of AKI. We performed a systematic review and meta-analysis to evaluate the compliance to AKI care bundles in hospitalized patients and its impact on kidney and patient outcomes. Methods: Randomized controlled trials, observational and interventional studies were included. Studied outcomes were care bundle compliance, occurrence of AKI and moderate-severe AKI, use of kidney replacement therapy (KRT), kidney recovery, mortality (ICU, in-hospital and 30-day) and length-of-stay (ICU, hospital). The search engines PubMed, Embase and Google Scholar were used (January 1, 2012 - June 30, 2021). Meta-analysis was performed with the Mantel Haenszel test (risk ratio) and inverse variance (mean difference). Bias was assessed by the Cochrane risk of bias tool (RCT) and the NIH study quality tool (non-RCT). Results: We included 23 papers of which 13 were used for quantitative analysis (4 RCT and 9 non-randomized studies with 25,776 patients and 30,276 AKI episodes). Six were performed in ICU setting. The number of trials pooled per outcome was low. There was a high variability in care bundle compliance (8 to 100%). Moderate-severe AKI was less frequent after bundle implementation [RR 0.78, 95%CI 0.62–0.97]. AKI occurrence and KRT use did not differ between the groups [resp RR 0.90, 95%CI 0.76–1.05; RR 0.67, 95%CI 0.38–1.19]. In-hospital and 30-day mortality was lower in AKI patients exposed to a care bundle [resp RR 0.81, 95%CI 0.73–0.90, RR 0.95 95%CI 0.90–0.99]; this could not be confirmed by randomized trials. Hospital length-of-stay was similar in both groups [MD -0.65, 95%CI -1.40,0.09]. Conclusion: This systematic review and meta-analysis shows that implementation of AKI care bundles in hospitalized patients reduces moderate-severe AKI. This result is mainly driven by studies performed in ICU setting. Lack of data and heterogeneity in study design impede drawing firm conclusions about patient outcomes. Moreover, compliance to AKI care bundles in hospitalized patients is highly variable. Additional research in targeted patient groups at risk for moderate-severe AKI with correct and complete implementation of a feasible, well-tailored AKI care bundle is warranted. (CRD42020207523). Keywords: Acute kidney injury, Care bundle, Meta-analysis, Prevention, Systematic review *Correspondence: 1 Intensive Care Unit, Ghent University Hospital, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium Full list of author information is available at the end of the article Introduction Acute Kidney Injury (AKI) occurs in 7 to 18% of hospital admissions and 57% of intensive care unit (ICU) admissions [1, 2]. AKI is associated with increased length of hospital stay, morbidity and mortality. Moreover, increasing severity of AKI is associated with worse prognosis © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Schaubroeck et al. BMC Nephrol (2021) 22:335 [1]. The excess hospital costs due to AKI consist of 3 to 14,000 $ per admission [3]. For the diagnosis of AKI the KDIGO working group classified AKI according to changes in serum creatinine level compared to baseline creatinine and/or urinary output [4]. To identify patients at risk for AKI, specific AKI biomarkers such as the cell cycle arrest biomarkers tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 (measured as TIMP-2*IGFBP7), neutrophil gelatinase associated lipocalin (NGAL), or chitinase 3-like protein 1 (CHI3L1) can be used [5–7]. There is no specific treatment targeting AKI. However, a bundle of preventive measures can be taken to avoid AKI or progression of AKI as described in the KDIGO guidelines. These include the avoidance of nephrotoxic agents and optimization of fluid status and hemodynamics [4, 8]. A care bundle can be defined as “a structured method of improving processes of care and patient outcomes; a small, straight-forward set of evidence-based practices, treatments and/or interventions for a defined patient segment or population and care setting that, when implemented collectively, significantly improves the reliability of care and patient outcomes beyond that expected when implemented individually” [9]. Given large variation in care for AKI patients and poor outcomes of AKI, the interest in implementing care bundles for AKI is growing. This bundle can consist of an e-alert for AKI, fluid balance and volume assessment, diagnostic tests with urine dipstick and echography, medication adjustment, avoidance of nephrotoxic agents, follow-up by a nephrologist and escalation of therapy or palliative care if necessary [9]. We aim to study the compliance to AKI care bundles in hospitalized patients and the impact of its application on kidney and patient outcomes by performing a systematic review and meta-analysis of existing literature. Materials and methods Study design We conducted a systematic review and meta-analysis according to the PRISMA guidelines (Supplementary Table 1) [10, 11]. The protocol was registered in the PROSPERO database (CRD42020207523). Eligibility criteria We included randomized controlled trials (RCT’s), retrospective and prospective observational, propensitymatched or intervention studies on the implementation of a care bundle for AKI. The studied population were adult and paediatric patients (ICU, emergency department, medical and surgical wards) with AKI or at risk of AKI during hospitalization. Page 2 of 10 Only articles published in English, Dutch, Spanish and French were included in this meta-analysis. Ar (...truncated)