David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Acute kidney injury occurs in about 20% of hospitalized patients, most commonly in older patients and those with underlying chronic kidney disease. About 10% of hospitalized patients with AKI require renal replacement therapy.
There are many causes of AKI in hospitalized patients. Reduced renal perfusion (e.g., volume depletion, sepsis, and heart or liver failure) is a common cause of AKI in patients presenting for hospital admission. Acute tubular necrosis is the most common hospital-acquired cause.
Medications can lead to AKI by causing acute tubular necrosis (e.g., radiocontrast, aminoglycosides, vancomycin, amphotericin B, cisplatin, carboplatin, iphosphamide), interstitial nephritis (e.g., β-lactams, sulfonamides), crystal nephropathy (e.g., methotrexate, acyclovir), or other insults (e.g., nonsteroidal anti-inflammatory drugs, angiotensin–converting enzyme inhibitors, angiotensin–receptor blockers, calcineurin inhibitors).
Although loop diuretics can increase urine output in some cases of AKI, they do not seem to decrease mortality, the need for renal replacement therapy, or the time to renal recovery.
Major depressive disorder is common after ACS, affecting up to 20% of patients. An even greater percentage of these patients have less-severe depression. Hospitalists should be on the lookout for this disorder.
Existing depression screening tools seem to function adequately in this population, and treatment methods (such as medication and psychotherapy) do have a favorable effect on psychosocial outcomes. There is no evidence that these interventions improve cardiovascular outcomes.
There is no evidence that screening for depression in this population improves outcomes, and guidelines differ on whether they do or do not recommend it.
The authors suggest that clinical decisions in patients with acute heart failure (e.g., deciding which patients require hospital admission) are often made without any formal risk assessment, resulting in an inability to match the intensity of care to the risk for mortality.
The model described in this paper appears to have good discrimination of risk in this population and may allow clinicians to better estimate mortality risk in patients with acute heart failure.
An accompanying editorial suggests that the model will require further validation in diverse populations. If it is able to identify a large group of low-risk patients presenting to the emergency department, the next challenge may be understanding how to best manage these patients outside of the hospital.
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David H. Wesorick, Vineet Chopra. Annals for Hospitalists - 21 November 2017. Ann Intern Med. 2017;167:HO1. doi: 10.7326/AFHO201711210
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Published: Ann Intern Med. 2017;167(10):HO1.
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