Undiagnosed kidney disease in hospitalised patients: an opportunity for improvement

In hospitalised patients, chronic kidney disease (CKD) is associated with a high risk of morbidity, mortality and drug toxicity. We identified care improvement opportunities in hospitalised patients with kidney disease in a regional hospital.

Clinical audit: 200 patients hospitalised for any reason in Alcañiz Hospital (Spain) were randomly selected. The data sources were laboratory data, clinical history and discharge reports. RIFLE criteria were applied to define kidney function deterioration. As process quality indicators we used: 1) percentage of hospitalised patients with at least one determination of kidney function during admission. 2) percentage of patients who met criteria for CKD and/or kidney function deterioration and who had this diagnosis recorded in clinical progress reports. 3) percentage of patients who met criteria for CKD and/or kidney function deterioration and who had this diagnosis recorded in the discharge report.

Mean age was 71.1 (17) years, 42% women, 63% admitted to medical areas and 37% to surgical areas. Some 194 patients had a kidney function determination at admission; however during their stay kidney function was not monitored in 54 patients (27%), especially in surgical areas. CKD diagnosis by analyses prior to admission was available for 50 patients (25%); however this diagnosis figures in the clinical history in 14 of them (28%), and in the discharge report in 17 (34%). Kidney function deterioration was detected in 68 of the 146 patients who had kidney function monitoring during hospitalisation (46.5%). This information was contained in the clinical history in only 50% of cases and in the discharge report in 33.8%.

The incidence of CKD prior to admission and deterioration of kidney function during hospitalisation are high. Often these diagnoses are not included in clinical progress reports or in the discharge report, reflecting poor condition awareness on the part of our colleagues. Implementation of a clinical protocol and its diffusion throughout the hospital may be important tools to achieving more efficient and consistent management of these conditions.