CJASN ePress. Published on May 17, 2019 as doi: 10.2215/CJN.

01250119
Feature

Quality Improvement Goals for Acute Kidney Injury

Kianoush Kashani ,1 Mitchell Howard Rosner,2 Michael Haase,3,4 Andrew J.P. Lewington,5,6 Donal J. O’Donoghue,7
F. Perry Wilson ,8 Mitra K. Nadim,9 Samuel A. Silver,10 Alexander Zarbock,11 Marlies Ostermann,12
Ravindra L. Mehta ,13 Sandra L. Kane-Gill,14 Xiaoqiang Ding ,15 Peter Pickkers,16 Azra Bihorac,17
Edward D. Siew,18,19,20 Erin F. Barreto ,21 Etienne Macedo ,13 John A. Kellum,22 Paul M. Palevsky,23,24
Ashita Jiwat Tolwani,25 Claudio Ronco ,26,27,28 Luis A. Juncos,29 Oleksa G. Rewa,30 Sean M. Bagshaw,30
Theresa Ann Mottes,31 Jay L. Koyner,32 Kathleen D. Liu,33 Lui G. Forni,34 Michael Heung,35 and Vin-Cent Wu 36

Abstract Due to the number of

AKI is a global concern with a high incidence among patients across acute care settings. AKI is associated with contributing authors,
significant clinical consequences and increased health care costs. Preventive measures, as well as rapid the affiliations are
identification of AKI, have been shown to improve outcomes in small studies. Providing high-quality care for listed at the end of
this article.
patients with AKI or those at risk of AKI occurs across a continuum that starts at the community level and continues
in the emergency department, hospital setting, and after discharge from inpatient care. Improving the quality of Correspondence:
care provided to these patients, plausibly mitigating the cost of care and improving short- and long-term outcomes, Dr. Kianoush Kashani,
are goals that have not been universally achieved. Therefore, understanding how the management of AKI may Mayo Clinic, 200 First
Street SW, Rochester,
be amenable to quality improvement programs is needed. Recognizing this gap in knowledge, the 22nd Acute MN 55905. Email:
Disease Quality Initiative meeting was convened to discuss the evidence, provide recommendations, and highlight kashani.kianoush@
future directions for AKI-related quality measures and care processes. Using a modified Delphi process, an mayo.edu
international group of experts including physicians, a nurse practitioner, and pharmacists provided a
framework for current and future quality improvement projects in the area of AKI. Where possible, best
practices in the prevention, identification, and care of the patient with AKI were identified and highlighted. This
article provides a summary of the key messages and recommendations of the group, with an aim to equip and
encourage health care providers to establish quality care delivery for patients with AKI and to measure key
quality indicators.
CJASN 14: ccc–ccc, 2019. doi: https://doi.org/10.2215/CJN.01250119

Introduction evidence-based quality indicators that guide optimal

AKI is a common complication of acute illnesses with a
substantial impact on clinical outcomes and health
care costs (1–3). Literature highlights that AKI and
its progression could be prevented in some circum-
stances, and its consequences could be mitigated by
timely and effective care measures (4–6). However,
care pathways for patients with AKI are not well
defined. It is very likely that considerable variability
in clinical practices has led to differences in the inci-
dence and outcomes of AKI in different medical
centers (7,8). In addition, most institutions do not
track adherence with process measures that might
impact on the care of patients with AKI. Thus, a
critical step in improving the outcome of patients
at risk of or with AKI is to identify quality indica-
tors and care pathways that optimize care (Figure 1,
Supplemental Appendix 1) (9).
Quality indicators represent the measurement, mon-
itoring, evaluation, and communication of targeted areas
of care processes that assess whether and how often
the system does what it is intended to do. Quality indi-
cators are framed as determining the structure (i.e.,
where health care is delivered), process (i.e., how health
care is provided), and outcomes (i.e., the effects of health
care delivery) of health care systems (Table 1) (10). A
challenge in the field of AKI care has been identifying
care as well as recognize opportunities for continuous
quality improvement (11). The lack of quality indica-
tors contributes to considerable variation in care and
difficulty in studying what interventions may lead to
improved outcomes. For instance, patients with AKI
often have missed opportunities that otherwise may
limit their risk of AKI development or progression.
These missed opportunities could be recognized and
measured to facilitate development of process improve-
ment strategies. Development of quality indicators must
be conducted in a comprehensive manner and started
at the community level and continued through and
after hospital admission as this represents the spec-
trum of AKI care continuity (Figure 2). In addition,
AKI quality improvement should be evidence-based
where possible and responsive to emerging data, despite
the fact that current level of knowledge may be limited
in its scope for prevention, management, and treatment
of AKI.
To achieve a framework for improvement in AKI
care, the 22nd Acute Disease Quality Initiative (ADQI)
conference was convened. The work was divided into
five separate groups that captures the spectrum of AKI
care (Figure 2, Table 2). Supplemental Appendix 2
provides details on the ADQI consensus confer-
ence, Supplemental Table 1 provides definitions,

www.cjasn.org Vol 14 June, 2019 Copyright © 2019 by the American Society of Nephrology 1
2 CJASN

Figure 1. | Seven steps need to be taken for a successful quality improvement project. Supplemental Appendix 1 provides definitions,
templates, and examples. DMAIC, Define, Measure, Analyze, Implement, Control; PDSA, Plan, Do, Study, Act. Reprinted from Acute disease
quality initiative (ADQI) (12), with permission.

and Supplemental Table 2 outlines requirements for
AKI quality care that were developed as a framework
for quality indicators.
Community Health Care Standards for AKI
Question 1: At the Community Level, What Are the Roles
and Responsibilities of Clinicians and Health Care Systems in
AKI Risk Monitoring and Mitigation?
Consensus Statement A. Healthcare systems and health-
care professionals should identify populations and patients at risk
of AKI and implement monitoring and preventive interventions
to decrease the incidence of AKI.
Consensus Statement B. We suggest that a minimum set of
baseline risk factors and acute exposures (Figure 3) be considered
for AKI risk stratification.
At least 50% of AKI episodes begin in the community
setting (13,14). The initial step toward quality improvement
in this setting begins with identifying high-risk populations
(defined in Supplemental Table 1) for which monitoring
and preventive strategies should be targeted (Figure 3).
The definition of high risk may vary according to the local
prevalence of different AKI risk factors. These risks can be
categorized into five dimensions of inherent and nonmo-
difiable (for example, age), exposure-based (such as admin-
istration of nephrotoxic medications), processes of care

Table 1. Quality indicators

Quality Indicators Definition Examples

Structure measures
Process measures
Outcome measures
Access measures
Patient experience measures
Balancing measures
Structure of care is a feature of a health care
organization related to the capacity to
provide high-quality health care
A health care–related activity performed for,
on behalf of, or by a patient
An outcome of care is a state of health of a
patient resulting from health care
Access to care is the attainment of timely and
appropriate health care by patients or
enrollees of a health care organization
or clinician
Experience of care is a patient’s or enrollee’s
report of observations of and participation
in health care, or any resulting change in
their health
Unintended and/or wider consequences of
the change that can be positive or negative
Does the health care organization or unit
use a Computerized Physician Order Entry?
Does the health system have an electronic
health record system?
Do AKI care pathways/bundles exist in the
health care system?
Percentage of patients who were correctly
identified as patients at risk of AKI at
hospital admission
Percentage of patients who developed
AKI among the patients at risk of AKI
Percentage of patients with AKI that had
a medication review for nephrotoxicity
Percentage of patients who had a timely
nephrology consult
Percentage of patients who reported how
often their doctors communicated well
Overwhelming nephrology clinics by
referring patients with AKD for follow-up

AKD, acute kidney disease.

CJASN 14: ccc–ccc, June, 2019 QI for AKI by ADQI, Kashani et al. 3

Figure 2. | AKI quality care in a continuity. Reprinted from Acute disease quality initiative (ADQI) (12), with permission.

(such as failure to identify AKI), socioeconomic-cultural should focus on identifying and managing environmental
(such as access to care), and environmental (such as exposure and socioeconomic-cultural risks, clinicians should focus on
to environmental toxins) (Supplemental Figure 1, Sup- individual patient risks that may be detectable and modifi-
plemental Table 1) (15). Although governmental systems able. Raising awareness regarding AKI risk factors among

Table 2. 22nd ADQI groups and objectives

Group Assignment Objectives

I Primary prevention: community Provide consensus recommendation to mitigate the risk of AKI
in the populations of resource-limited or resource sufficient
environments
Current best practices at the community levels
Novel strategies to detect higher risk patients, raising
awareness, communicating with primary physicians,
and legislative strategies to achieve the goals
II Primary prevention: hospital Provide recommendations regarding the AKI risk modification
and primary prevention following medical encounters
Strategies for optimization of AKI prevention before its
occurrence
Risk stratification, early detection, use of biomarkers or other
novel risk detecting tools, and optimal management
III Secondary prevention Provide recommendations about quality indicators to mitigate
the effect of AKI after its occurrence (secondary prevention)
Indicate the best practices in the management of patients with
AKI in different stages
IV Quality improvement of KRT programs Provide an approach to improve quality of care and safety
measures of KRT provided for AKI
Recommendations regarding how to enhance the quality of KRT
to comply with current or future knowledge
Structure, process, and outcomes of KRT Programs
V Tertiary prevention after hospital Provide recommendations regarding the quality of care and
safety measures for the care of patients during AKD phase
(7–90 d after AKI)
Identify the quality indicators that are acceptable for the
management of patients with AKI beyond the index
hospitalization (tertiary prevention)
Standardized to optimize the follow-up visits and short- and
long-term outcomes of patients with AKI

ADQI, Acute Disease Quality Initiative; AKD, acute kidney disease; KRT, kidney replacement therapy.
4 CJASN

Figure 3. | KHA and response. KHA includes AKI history, BP, CKD, serum Creatinine level, Drug list, and urine Dipstick (ABCD). Exposures
include Nephrotoxic Medications, Imaging, Surgery, Sickness (NISS). KHR (4Ms) that encompasses Medication review to withhold unnecessary
medications (e.g., nonsteroidal anti-inflammatory drugs [16,17]), the Minimization of nephrotoxic exposures (e.g., intravenous contrast [18]),
Messaging the healthcare team and patient to alert the high risk of AKI, and Monitoring for AKI and its consequences. Reprinted from Acute
disease quality initiative (ADQI) (12), with permission.

health care professionals and patients by education and
establishment of tools that measure these risk profiles for
each individual are considered crucial steps in mitigating
AKI incidence.
Question 2: How Should AKI High-Risk Populations Be
Monitored?
Consensus Statement A. We suggest populations/patients
at high risk for developing AKI should have a Kidney Health
Assessment (KHA) at least every 12 months to define and modify
their AKI risk profile.
Consensus Statement B. We suggest that high-risk patients
have another KHA at least 30 days before AND again 2–3 days after
a planned exposure that carries AKI risk. The KHA can be tailored
to the clinical context and clinician/health care system judgment.
Consensus Statement C. We suggest that clinicians review
a patient’s KHA immediately after an unplanned acute exposure
that carries AKI risk.
Literature is limited regarding AKI risk monitoring (19).
We suggest that basic risk assessment and care manage-
ment elements relevant to high-risk patients be considered
the minimum standard of care. These elements are synthe-
sized into a KHA. The minimal KHA is outlined in Figure 3.
Adherence with and timeliness of the KHA could be used
as a quality indicator measurement. For instance, practices
should monitor the proportion of patients at high risk for
AKI who have documented KHA in their health records.
Question 3: How Can AKI Preventive Strategies Be
Implemented within High-Risk Populations?
Consensus Statement A. KHA should be followed by a Kidney
Health Response (KHR) after acute exposure to risk factors of AKI.
Consensus Statement B. We suggest raising awareness of
the definition, signs, symptoms, and acute exposures associated
with AKI among clinicians and high-risk patients/populations.
Consensus Statement C. We suggest enhanced coordination
between all stakeholders to monitor the rate, causes, and
outcomes of AKI to identify variations in care and outcomes
across and between the populations.
The KHA is a “living document” and should be reviewed
after acute AKI exposures (20) and updated with new
knowledge. This step should then be followed by a KHR
(Figure 3). Quality indicators could include adherence
with key elements of the KHR as well as the rate of AKI
after high-risk exposures. With the emergence of new
knowledge, components of KHA (related to patient and
population condition) and KHR (indicator of physician
task list) need to be updated. The national/local health
care system engagement in quality improvement proj-
ects is of importance (Figure 3) (21). The effect of environ-
mental factors (e.g., climate, water quality) and the social
and behavioral determinants of health (e.g., nutrition, health
insurance) on the incidence of AKI are well documented (15,22),
and governing bodies have a responsibility to monitor AKI
risks and coordinate preventive strategies (23).
Primary Prevention of AKI during a
Hospital Encounter
Question 1: How and When Should the Risk for AKI Be
Identified among Hospitalized Patients?
Consensus Statement A. All patients at hospital admis-
sion should be screened for risk of AKI. Screening should occur
at the earliest possible time throughout the patient’s hospital
stay.
CJASN 14: ccc–ccc, June, 2019 QI for AKI by ADQI, Kashani et al. 5

Consensus Statement B. All patients at risk for AKI should
at least have an assessment of serum creatinine, urine dipstick
analysis, and urine output. Complementary diagnostic tests
depending on local availabilities, risk factors, clinical context,
and clinician judgment should be considered.
Consensus Statement C. All hospitalized patients should
have periodic risk reassessment using appropriate clinical or
electronic models before and after risk exposure or change in
clinical status.
Because of multiple exposures, hospitalized patients are
at higher risk of AKI in comparison with individuals in
the community, regardless of their baseline risk. Therefore,
hospitalized patients require more detailed and frequent
evaluation when compared with high-risk individuals in
the community. Early and frequent screening of hospital-
ized patients for the risk of AKI should occur. This screening
may use validated risk assessment models (24) or auto-
mated surveillance tools (25), but at a minimum an assess-
ment should identify susceptibilities and exposures that
could lead to AKI (Table 3) (26,27). The intensity, frequency,
and duration of monitoring should be individualized ac-
cording to patient characteristics and local resources.
Question 2: What Core Preventive Measures Should Be
Considered as a Target for Quality Improvement Projects?
Consensus Statement A. Early correction or mitigation
of context-specific modifiable risk factors of AKI should be
considered for all high-risk patients.
AKI has been shown to be preventable in recent studies
(4,5). Increasing awareness among clinicians regarding
the risks and management strategies would most likely
result in improved care. The most common conditions
leading to AKI include (1) critical illnesses, (2) major
surgical procedures, and (3) exposure to nephrotoxic drugs.
Optimization of hemodynamic and volume status and avoid-
ance of nephrotoxic insults remain the mainstay of primary
prevention. However, to understand the optimal management
strategies and targets, further studies are required (26,28).
Question 3: What Are the Quality Indicators for Assessing
Risk of AKI?
Consensus Statement A. The quality indicators for AKI
prevention in the hospital should include (1) proportion of
patients screened for AKI risk among all admissions, (2) pro-
portion of identified AKI high-risk patients among all screened
patients, (3) proportion of AKI high-risk exposures (e.g., med-
ication, contrast, surgery) among all hospitalized population and
all high-risk patients, (4) proportion of patients who received
an appropriate intervention around a high-risk exposure, and
(5) proportion of patients who developed AKI (community- or
hospital-acquired; as defined in Supplemental Table 1) among
all admissions (in different subpopulations) and all high-risk
patients.
Consensus Statement B. The quality indicators should be
reviewed and utilized to identify areas of improvement and action.
The frequency of reporting should be defined according to local
resources and regulatory requirements.
Identification of valid quality indicators of care is
essential to measure, monitor, benchmark, and target
the improvement. Quality indicators may include health
care infrastructure and access, processes of care, outcomes,
and clinician or patient experience (Supplemental Figure 2).
It is recognized that these measures vary depending on the
health care system, local resources, geography, and socio-
economic, political, and cultural factors (Figure 4). Future
investigations should focus on identifying valid and glob-
ally applicable AKI risk scoring systems using available and
novel tools (e.g., electronic health records, biomarkers).

Table 3. AKI risk assessment among hospitalized patients

Risk Category Examples

Comorbid conditions CKD

Diabetes mellitus
Heart failure
Liver disease
History of AKI
Anemia
Neurologic for cognitive impairment or disability
Illnesses Sepsis
Rhabdomyolysis
Hemorrhage
Hemolysis
ARDS
Severe diarrhea
Hematologic malignancy
Trauma
Symptoms and signs Hypotension and hypovolemia
Hypertension and fluid overload
Oliguria (urine output ,0.5 ml/kg per h)
Symptoms/history of urological obstruction or conditions that may lead to obstruction
Symptoms or signs of glomerulo-interstitial nephritis (e.g., edema, hematuria)
Others Use of KENDs within a week before admission

KEND medications include (1) cleared by the kidney but not nephrotoxic (e.g., digoxin), (2) cleared by the kidney and nephrotoxic (e.g.,
vancomycin), and (3) not cleared by the kidney but are nephrotoxic (e.g., calcineurin inhibitors). KEND, kidney eliminated and
nephrotoxic drugs; ARDS, adult respiratory distress syndrome.
6 CJASN

Figure 4. | Factors related to quality indicators and reporting can be divided in structure, process, and outcome in community, hospital, and
after initiation of KRT. Clearly, different levels exist depending on resource possibilities. For example, resource-sufficient areas may have access
electronic medical records, allowing system-driven identification and prevention and more detailed outcome reporting of patients with AKI.
Embedded in these is a basic level of quality measures and level of reporting that should be feasible in both resource-limited and research-
sufficient areas (white boxes). AE, adverse event; EMR, Electronical Medical Record; ICU, intensive care unit; Scr, serum creatinine; QoL, quality
of life; KRT, kidney replacement therapy. Reprinted from Acute disease quality initiative (ADQI) (12), with permission.
CJASN 14: ccc–ccc, June, 2019 QI for AKI by ADQI, Kashani et al. 7

Secondary Prevention of AKI
Question 1: What Are the Key Considerations for
Developing Quality Programs that Evaluate
Contributors to an Episode of AKI?
Consensus Statement A. We propose that for each patient
diagnosed with AKI during hospitalization, the goal is re-
covery to baseline kidney function in the shortest period of
time with minimum number of complications. This is best
achieved by timely and accurate diagnosis and management of
AKI, and prevention of complications. These goals might be
achieved by using a Recognition-Action-Results framework
(Table 4).
Consensus Statement B. Quality improvement surroun-
ding the diagnostic evaluation of AKI should attempt to
maximize the proportion of patients who undergo a context-
appropriate and timely evaluation while avoiding unnecessary
testing.
The timely and accurate identification of reversible
causes of AKI, if promptly addressed, potentially reduces
the severity and duration of disease and associated
complications (secondary prevention of AKI) (29). Qual-
ity improvement initiatives surrounding the diagnostic
evaluation of AKI should be developed within the con-
texts of clinical setting (e.g., community- versus hospital-
acquired, medical versus postsurgical); the distribution of
underlying causes, trajectory, and severity at the time of
AKI identification; and the goals and capabilities of the
health care systems (30). Although the heterogeneity of
AKI and lack of available evidence do not support the
notion that all patients with AKI require the same breadth
or intensity of evaluation, clinical practice guidelines
and expert opinion generally favor a stepwise approach
(Table 4) (15,26,29,31–34). We recommend develop-
ment of quality initiatives surrounding diagnostic
evaluation considering the clinical context and the
likelihood of identifying actionable causes in a timely
and context-specific manner (Supplemental Table 3,
Table 4).

Table 4. Recognition-Action-Result framework for secondary prevention of AKI, including diagnosis and evaluations, limiting duration
and severity of AKI, and prevention of avoidable complications associated with AKI

Limiting Severity and Prevention of Avoidable

Framework Diagnosis and Evaluation
Duration of AKI AKI Complications

Recognition AKI stage-dependent Nephrotoxin or contributing AKI has occurred

threshold met
Action Context-appropriate
evaluation
Physical examination
History
Kidney function and injury
biomarkers
Urine analysis
Hemodynamic variables
Radiology and serology
tests
Kidney biopsy
Other context-specific tests
Results Improved frequency of
context-appropriate
diagnostic evaluation
Improved recognition of
cause-specific AKI
medication
Poor hemodynamics
Cause-specific diagnosis delayed
“Nephrotoxin stewardship”
Asses and optimize hemodynamics
Invasive/noninvasive
Avoid hyperglycemia
Nephrology referral guidelines
Monitoring of kidney function with
serum creatinine and urine output
Improved rates of nephrotoxin
alerting/evaluation/
discontinuance
Hemodynamic intervention applied
Improved timeline of cause-specific
diagnosis/interventions
Reduced duration and severity of AKI
(e.g., maximum stage, length,
recovery)
High frequency of hyperkalemia in
patients with AKI
Poor extubation rates in patients with AKI
due to volume overload
Adverse drug events
Improved monitoring for complications
(e.g., BMP/bicarbonate/phosphorus
measurement)
Risk reduction strategies (e.g., reduced
potassium intake, unnecessary
maintenance fluids, review of
appropriate dosing of meds)
Management of complications
(e.g., treatment of hyperkalemia,
fluid removal)
Process (improved monitoring/detection,
reduction in unnecessary potassium
supplementation, med reconciliation/
evaluation)
Clinical (reduced incidence of severe
hyperkalemia, treatment of severe
acidosis pH,7.2, less adverse drug
events related to inappropriate drug
dosing/selection in AKI)

BMP, basic metabolic panel.

8 CJASN
Question 2: What Are the Key Considerations for
Developing Quality Improvement Programs Focused on
Limiting the Duration and Severity of AKI?
Consensus Statement A. Quality improvement programs
should include the implementation and reporting of the pro-
portion of patients that receive timely and diagnosis-appropriate
interventions. Adherence with the locally agreed upon preventive
interventions should be audited and shared with clinicians
periodically.
Reducing the severity and duration of AKI rests on
timely and effective management of the underlying causes
and reduction in modifiable determinants of ongoing injury.
Quality programs may focus on instituting general “nephro-
protective” interventions, such as timely hemodynamic
resuscitation, nephrotoxin stewardship, or cause-specific
interventions (e.g., relief of obstruction, immunosuppression,
and others) (4,5,35). Recently, “bundled AKI care pathways”
have shown promise in preventing AKI and reducing its
severity, but more research is required to better define
effective care components (4,36,37). In cases where context-
appropriate evaluation identifies a cause warranting tar-
geted therapy, the timeliness and appropriate application of
cause-specific management could be measured as quality
indicators (Supplemental Table 4, Table 4).
Nephrotoxin exposure accounts for up to 28% of poten-
tial adverse drug events leading to AKI and is a potential
target for quality improvement (38). Analogous to antimi-
crobial stewardship programs, the concept of nephrotoxin
stewardship encompasses coordinated interventions de-
signed to decrease nephrotoxin exposure among patients
at risk for or with AKI (39,40). This provides a framework
for the development of institution-specific guidelines for the
safe and effective use of Kidney Excreted and Nephrotoxic
Drugs. Recently, the Nephrotoxic Injury Negated by Just-
in-time Action program demonstrated that the systematic
review of nephrotoxins by a multidisciplinary care team
resulted in a sustained reduction in nephrotoxin expo-
sure, AKI rate, and severity (41). Similar programs have
been tested in adults and resulted in favorable outcomes
(4,5,33,42,43). The implementation of these programs must
consider the health care system capabilities and the risk–
benefit of withholding potentially beneficial nephrotoxins
used to treat serious conditions. Within resource-limited
areas, dedicating efforts in training appropriate staff (e.g.,
house staff, nurses, etc.) and reviewing medication lists
could potentially provide a similar benefit.
Question 3: What Are the Key Considerations for
Developing Quality Improvement Programs Focused on
Reducing the Complications of AKI?
Consensus Statement A. Quality indicators for prevention
of avoidable AKI-related complications include monitoring, reporting
the context-specific adverse events (to patient advocates, clinicians,
administrators, and regulatory bodies), and implementation of
risk reduction strategies.
Uremic related complications of AKI and risks asso-
ciated with initiation of KRT (bloodstream infection,
electrolyte abnormalities, hypotension, etc.) or other AKI-
related management options (diuresis, withholding nephro-
toxins, etc.) should be monitored and reported. We propose
that quality programs focus on determining the incidence
of complications to appropriately guide effort allocation
to the monitoring complications (i.e., recognition of hyper-
kalemia), the response (e.g., action to treat it), and whether
risk reduction strategies are in place (e.g., low potassium
diet, no potassium maintenance in fluids) (Supplemental
Table 5, Table 4).
Kidney Replacement Therapy Quality Indicators
Consensus Statement A.
Quality indicators should integrate structure, process, and
outcome indicators for each therapeutic modality.
There is limited data on acute kidney replacement therapy
(KRT) quality indicators, along with numerous challenges
with respect to quality and safety in the provision of acute
KRT care (44). All institutions that provide acute KRT
should adopt and implement a quality framework around
these services. This should include integration, monitor-
ing, and reporting of structure, process, and outcome indi-
cators across all forms of acute KRT therapies (Figure 4) (45).
Benchmarks for each quality indicator should be deter-
mined to provide information about patient-specific and
aggregate institutional quality of care. Multicenter, acute
KRT registries should be created to further develop and
refine quality improvement projects that develop target
benchmarks for clinical practice guidelines.
Question 2: What Are the Minimum Structure Quality
Indicators that Should Be Implemented for Acute KRT?
Consensus Statement A. Structural quality indicators
should specifically target clinician, nursing, and allied health
professionals’ capacity and expertise for providing acute KRT
and identify a responsible team to implement and report
quality metrics for acute KRT services.
Institutions that provide acute KRT should establish
standards for structural quality indicators that incorporate
evaluation of resource availability and the infrastructure
needed for acute KRT. At a minimum, this should include a
dedicated team comprising expert clinicians, nurses, and
allied professionals (i.e., biomedical engineer, pharmacist)
that are responsible for patient monitoring, reporting data,
and design and implementation of quality care processes
for each acute KRT modalities.
Question 3: What Are the Minimum Process Quality
Indicators that Should Be Implemented for the Provision
of Acute KRT?
Consensus Statement A. Process quality indicators should
incorporate methodologies that lead to standardized protocols
and procedures, allowing for increased efficiency and consis-
tency in care and safety, and should be specific to each KRT
modality.
Institutions providing acute KRT should incorporate
standardized clinical protocols and procedures for each
KRT modality to deliver consistent and safe care. Key
measures of KRT adequacy should be measured routinely
(Figure 4). Implementation of quality improvement meth-
odologies should be conducted when there are significant
deviations in the provided care (Supplemental Figure 3). Root
cause analyses should be used to investigate deviations in
practice and to identify care gaps when they occur (Sup-
plemental Figure 4). Future studies should further evaluate,
validate, and prioritize specific process quality indicators.
CJASN 14: ccc–ccc, June, 2019 QI for AKI by ADQI, Kashani et al. 9

Question 4: What Are the Minimum Outcome Indicators
that Should Be Implemented for the Provision of Acute KRT?
Consensus Statement A. Outcome quality indicators should
include patient-centered outcomes, including clinician and patient
satisfaction, mortality, and quality of life among survivors; dialysis
liberation rates; and health-economic outcomes.
Programs providing acute KRT should integrate, monitor,
and report outcome indicators for acute KRT. The monitoring
of adverse events is vital to ensure that acute KRT is being
delivered in a safe and high-quality manner. Future work
should evaluate the association of specific outcome quality and
value indicators (i.e., health care costs) for patients, institutions,
and health care systems. Evaluating target benchmarks for
each quality indicator that can inform patient-specific and
aggregate institutional quality of care is crucial for future work.
Tertiary Prevention of AKI Short- and Long-Term
Complications
Question 1: How Should the Appropriate Post-AKI/Acute
Kidney Disease Care Be Measured?
Consensus Statement A. Health care systems need to
quantitate the proportion of patients who need post-AKI/acute
kidney disease (AKD) follow-up, those who receive any post-
AKI/AKD follow-up, and evaluate quality of care for those who
received post-AKI/AKD follow-up.
Tertiary prevention of AKI should focus on maintenance
and/or improvement in quality of life after AKI to mitigate
long-term disabilities resulting from AKI. In this regard,
current data on post-AKI/AKD follow-up is very limited.
The first step to improve quality in this domain is to
systematically measure the proportion of patients who
receive post-AKI/AKD follow-up care. There is no current
standardized definition of “appropriate” AKI-AKD follow-
up care, and it varies from no follow-up to a simple serum
creatinine check to a nephrology clinic visit. In a report of
post-AKI care, only 3% (low-risk patients) to 24% (indi-
viduals with both diabetes and CKD) were followed by a
nephrologist within 6 months of their AKI episode (46,47).
Furthermore, rates of kidney-related laboratory testing
after hospital discharge are low. For example, in the United
States in 2013, follow-up creatinine measurements occurred
only in 54% of patients (46). In addition to determination of
those who need follow-up, the setting (i.e., dedicated post-
AKI nephrology clinic versus primary care follow-up),
timeline (e.g., immediately after hospital discharge or 3
months after AKI episode), and frequency (e.g., weekly or
annually) of appropriate post-AKI follow-up also depends
on the severity of the initial AKI/AKD and the health care
system resources (Figure 5). In follow-up, a multidisciplin-
ary approach (pharmacy, dietician, social work, primary
care, nephrology, non-nephrology subspecialists) is recom-
mended. We recommend all patients with dialysis-requiring
AKI/AKD or patients with AKI/AKD superimposed on
advanced CKD should be followed by a nephrologist at
least within 2–3 months after their hospitalization,

Figure 5. | Schematic for AKI/AKD follow-up. The figure displays a potential paradigm for the care of patients who experience AKI/AKD. The
degree of nephrology-based follow-up increases as the duration and severity of AKI/AKID increases. The timing and nature of follow up are
suggestions as there is limited data to inform this process. Future research effort should work to clarify the timing and health care providers who
should be providing AKI/AKD follow-up. The items in each bucket follow the “OR” rule; therefore, each patient should follow the most severe
bucket if even meet one criteria of that bucket (e.g., patient with CKD stage 4 regardless of severity of AKI should be followed by nephrologist in
1 week). Reprinted from Acute disease quality initiative (ADQI) (12), with permission.
10 CJASN

depending on the severity and acute needs. Future research
should focus on the definition of appropriate AKI-AKD
follow-up on the basis of severity and cause of AKI, and
health care system capabilities. Identifying the patients/
populations who benefit the most from follow-up (e.g., AKI
cause and severity) and barriers to post-AKI/AKD follow-
up care are critical next steps in AKI research and quality
improvement.
Question 2: What Are the Key Elements of an Appropriate
Post-AKI/AKD Care Bundle?
Consensus Statement A. Quality indicators should at least
include structure (needed personnel and resources), process for
follow-up (who and by whom, what, where, when, why, and how),
and outcome indicators (CKD progression, continued or new need
for dialysis, mortality, etc.).
We recommend the following key components for a post-
AKI/AKD bundle that should be a more comprehensive
version of KHR: (1) KAMPS (Kidney function, Advocacy,
Medications, Pressure, Sick day protocol) for all patients
with AKI, and (2) WATCH-ME (Weight assessment, Access,
Teaching, Clearance, Hypotension, Medications) for patients
with AKI who require dialysis (Table 5). For patients with
AKI who require dialysis, care bundles that are appro-
priate for ESKD may not apply (e.g., early placement of
an arteriovenous fistula or graft may be inappropriate for
AKI). Quality indicators should be tied to patient and
hospital-centered outcomes such as readmission rate and
quality of life.
Future research should include the use of measures of
kidney functional reserve, real-time GFR monitoring, and
other novel biomarkers in the post-AKI/AKD setting that
correlate with outcomes of interest. In addition, research
should focus on optimal management strategies for each
component of the KAMPS/WATCH-ME bundles and
the development and validation of novel and effective
bundle components.
Determination of factors that predict and promote kidney
recovery and mitigate CKD development and appropriate
implementation of such interventions would also improve
quality of care after AKI.
Conclusions
Strategizing improvement in care for AKI requires pri-
oritization and implementation of focused quality improve-
ment projects including all types of health care providers
along with change management to leverage the current and
future knowledge in the betterment of care. The AKI care
process starts with the community, continues in the hospital,
and ends in community, and each of these phases requires
specific intervention. The group has suggested outlines for

Table 5. Post AKI/AKD kidney health care bundle

Framework Components

KAMPS
Kidney function Kidney function measurement by serum creatinine or cystatin C; measured GFR or eGFR
check Proteinuria/albuminuria
When available consider biomarkers, imaging and other tests as feasible and indicated
Advocacy Patient and caregiver education about AKI and CKD
Communication with other care providers (i.e., general practitioners, dieticians, nurses, pharmacists, and
social workers)
Medications Medication reconciliation, review, and management
Specifically discuss risk benefits of ACEI/ARB/MRA/diuretics
Review RENDs and over the counter medications
Pressure Ensure patient understands BP goals and targets
Discuss fluid status, ideal weight, role of diuretics
Sick day protocols Educate patients on medications that need monitoring during acute illnessesa
Consider protocols to withhold KENDs
WATCH-ME
Weight assessment Discuss dry weight monitoring and permissive hypervolemia
Discuss the role for diuretics in maintaining urine output and ideal volume status
Access Educate patients about the care of central venous catheters
Vein preservation protocols/awareness
When appropriate begin to plan and educate about the role of arteriovenous access and other KRT modalities
Teaching Patient and caregiver education about dialysis requiring AKD and short- and long-term risks and
consequence
Communication with other care providers (e.g., general practitioners, dieticians, nurses, pharmacists, and
social workers) about patient needs (e.g., alterations in medication regimens in the setting of new KRT).
Clearance Frequent assessments of underlying kidney function (via predialysis laboratory tests or timed clearances)
Frequent assessments of the quality of the KRT being provided to ensure adequate clearance
Hypotension Patient education and optimization of care to avoid intradialytic about hypotension
Education around BP medications administration in the peri-KRT period
Medications Medication reconciliation, review, and management
Specifically discuss risk benefits of ACEI/ARB/MRA
Review KENDs and over the counter medications

AKD, acute kidney disease; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; MRA, mineralocorticoid
receptor antagonists; KEND, kidney eliminated and nephrotoxic drugs; KRT, kidney replacement therapy.
a
Patient education should include but not limited to the signs of AKI recurrence or CKD progress, potential need for future dialysis
modalities and its alternatives, information about their medications, and contact information for the clinicians in case of question.
CJASN 14: ccc–ccc, June, 2019
the care of individuals in each phase, to focus, enhance, and
study quality indicators.
Acknowledgments
Dr. Kashani, Dr. Rosner, and Dr. Haase served as organizers of the
22nd Acute Disease Quality Initiative consensus meeting and
participated in the all group discussions and preparation of the
draft and edition of this manuscript. All other authors actively
participated in the group and plenary conversations and attrib-
uted to this script.
The 22nd Acute Disease Quality Initiative consensus meeting
received unrestricted grants from Baxter International Inc., La Jolla
Pharmaceutical Company, Astute Medical Inc., MediBeacon Inc.,
AM-Pharma B.V., and AbbVie Inc. Dr. Bihorac reports grants from
the National Institutes of Health (NIH), during the conduct of the
study. Dr. Liu reports grants from NIH National Heart, Lung and
Blood Institute and National Institute of Diabetes and Digestive
and Kidney Disease (NIDDK). Dr. Silver received a new inves-
tigator award funded by Canadian Institutes of Health Research,
Kidney Foundation of Canada, and the Canadian Society of
Nephrology Kidney Research Scientist Core Education and
National Training Program. Dr. Wilson reports grants from
NIDDK, during the conduct of the study.
Corporate sponsors were allowed to attend all meeting sessions
as observers but were not allowed to participate in the consensus
process. Corporate sponsors had no input into the preparation of
final recommendations or this manuscript.
Disclosures
Dr. Bagshaw reports grants and personal fees from Baxter
Healthcare Corp., during the conduct of the study. Dr. Barreto
reports personal fees from FAST Biomedical, outside the submitted
work. Dr. Bihorac reports grants from Astute Medical, grants from
Mallinckrodt Pharmaceuticals, grants from La Jolla Pharmaceuticals,
personal fees from Atox Bio, outside the submitted work; In addi-
tion, Dr. Bihorac has a patent 1. Method and Apparatus for Prediction
of Complications after Surgery Application Number PCT/IB2018/
053956; Filed June 1, 2018/IB 049648/514983; pending, a patent 2.
Method and Apparatus for Pervasive Patient Monitoring Applica-
tion Number 62/659,948, filed April 19, 2018 A&B 049648/513825
pending, and a patent 1. Systems and Methods for Providing
an Acuity Score for Critically Ill or Injured Patients Provisional
Application Number 62/809,159, filed February 22, 2019 A&B Ref.
049648/526813 pending. Dr. Forni reports grants from Baxter,
personal fees from Biomerieux, personal fees from Medibeacon,
personal fees from Baxter, other from Ortho Clinical Diagnostics,
outside the submitted work. Dr. Haase reports personal fees from
Abbott, personal fees from Alere, personal fees from Astute, personal
fees from Baxter, personal fees from Novartis, personal fees from
Roche, personal fees from Siemens, outside the submitted work.
Dr. Kellum reports grants and personal fees from Astute Medical,
grants and personal fees from Baxter, grants from Bioporto, personal
fees from Adrenomed, personal fees from Davita, personal fees from
NxStage, grants from RenalSense, outside the submitted work.
Dr. Koyner reports personal fees from Astute Medical, personal fees
from Baxter, personal fees from Sphingotec, grants from Nxstage
Medical, grants from Satellite Health Care, personal fees from
American Society of Nephrology, outside the submitted work.
Dr. Liu reports personal fees from Durect, personal fees from
Z S Pharma, personal fees from Theravance, personal fees from
Quark, personal fees from Potrero Med, other from Amgen, personal
fees from American Society of Nephrology, personal fees from
National Kidney Foundation, personal fees from National Policy
Forum on Critical Care and Acute Renal Failure, personal fees from
QI for AKI by ADQI, Kashani et al. 11
Baxter, personal fees from Astra Zeneca, outside the submitted work.
Dr. Mehta reports other from Astute Medical Inc., other from Baxter,
grants from Fresenius, grants from Fresenius-Kabi, grants from
Grifols, grants from Relypsa, other from Mallinckrodt, other
from CSL Behring, other from Sphingotec, other from Regulus, other
from Intercept, other from Quark, other from AM-Pharma, outside
the submitted work. Dr. Nadim reports personal fees from Baxter,
outside the submitted work. Dr. Palevsky reports personal fees
from Novartis, personal fees from GE Healthcare, personal fees
from Baxter, personal fees from Durect, personal fees from Health-
Span Dc, grants from Dascena, outside the submitted work. Dr. Rewa
reports personal fees from Baxter Healthcare Inc, outside the sub-
mitted work. Dr. Rosner reports other from American Society of
Nephrology, other from Retrophin, other from Baxter, other from
Reata Pharmaceuticals, outside the submitted work. Dr. Zarbock
reports grants from German Research Foundation, BMBF, Else-
Kröner Fresenius Stiftung, GIF, Astute Medical, Astellas, personal
fees from Astellas, Astute Medical, Fresenius, Braun, bioMerieux,
Baxter, Ratiopharm, Amomed, during the conduct of the study.
Dr. Ding, Dr. Juncos, Dr. Kane-Gill, Dr. Kashani, Dr. Lewington,
Dr. Macedo, Ms. Mottes, O’Donoghue, Dr. Ostermann, Dr. Pickkers,
Dr. Ronco, Dr. Siew, Dr. Silver, Dr. Tolwani, Dr. Wilson, and Dr. Wu
have nothing to disclose.
Supplemental Material
This article contains the following supplemental material online at
http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/
CJN.01250119/-/DCSupplemental.
Supplemental Table 1. Definitions.
Supplemental Table 2. Care needed for AKI prevention and
management.
Supplemental Table 3. Example quality improvement initiatives
for diagnostic evaluation of AKI.
Supplemental Table 4. Example quality initiations to avoid the
progression and duration of AKI.
Supplemental Table 5. Examples of monitoring, management,
and documentation of AKI complications.
Supplemental Figure 1. Risk dimensions and risk factors.
Supplemental Figure 2. Quality measures of care for AKI primary
prevention.
Supplemental Figure 3. Control-run chart for finding outliers
and the need for policy changes.
Supplemental Figure 4. Root-cause analysis.
Supplemental Appendix 1. Quality Improvement Frameworks.
Supplemental Appendix 2. Acute Disease Quality Initiative
Consensus Conference Methodology.
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Received: January 30, 2019 Accepted: March 20, 2019
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AFFILIATIONS

1
Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine and 21Department of
Pharmacy, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; 2Division of
Nephrology, University of Virginia Health System, Charlottesville, Virginia; 3Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg,
Germany; 4Medical Care Center Diaverum, Potsdam, Germany; 5Renal Department, St. James’s University Hospital, Leeds, United Kingdom; 6National
Institute for Health Research (NIHR) In-Vitro Diagnostic Co-operative, Leeds, United Kingdom; 7Department of Renal Medicine, Salford Royal National
Health Services Foundation Trust, Stott Lane, Salford, United Kingdom; 8Yale University School of Medicine, Program of Applied Translational Research, New
Haven, Connecticut; 9Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los
Angeles, California; 10Division of Nephrology, Kingston Health Sciences Center, Queen’s University, Kingston, Ontario, Canada; 11Department of
Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany; 12King’s College London, Guy’s and St. Thomas’
Hospital, London, United Kingdom; 13Division of Nephrology, Department of Medicine, University of California, San Diego Medical Center, San
Diego, San Diego, California; 14Department of Pharmacy and Therapeutics, School of Pharmacy, 22Department of Critical Care Medicine, School of
Medicine, and 24Renal-Electrolyte Division, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania;
15
Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital,
Fudan University, Shanghai, China; 16Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands;
17
Precision and Intelligent Systems in Medicine, Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine,
University of Florida, Gainesville, Florida; 18Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee; 19Vanderbilt Center for Kidney Disease and Integrated Program for AKI Research, Nashville, Tennessee; 20Tennessee
Valley Healthcare System, Veterans Administration Medical Center, Veteran’s Health Administration, Nashville, Tennessee; 23Renal Section, Medical
Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; 25Division of Nephrology, University of Alabama at Birmingham,
Birmingham, Alabama; 26Department of Nephrology, University of Padova, Padova, Italy; 27Department of Nephrology, Dialysis and Transplantation,
AULSS8 Regione Veneto, Vicenza, Italy; 28International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy; 29Division of Nephrology, Central
Arkansas Veterans’ Healthcare System, University of Arkansas for Medical Sciences, Little Rock, Arkansas; 30Department of Critical Care Medicine,
Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; 31Department of Pediatrics, Texas Children’s Hospital, Houston,
Texas; 32Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois; 33Divisions of Nephrology and Critical Care,
Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California; 34Department of Clinical and Experimental
Medicine, University of Surrey and Royal Surrey County Hospital National Health Services Foundation Trust, Guildford, United Kingdom; 35Division
of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan; and 36Division of Nephrology, Department of Internal Medicine,
National Taiwan University Hospital, Taipei, Taiwan