Supplementary Material for: The optimization of outpatient hemodialysis management for AKI-D patients: A quality improvement study

Introduction: In 2017, the Centers for Medicare and Medicaid Services allowed survivors of hospitalized acute kidney injury requiring dialysis (AKI-D) who were ambulatory and still dependent on hemodialysis (HD) to receive treatment in outpatient dialysis facilities. This policy change generated the ongoing need to improve AKI-D care in the outpatient setting. Methods: Quality improvement study in adult patients admitted to an outpatient HD unit with the diagnosis of AKI-D. We developed a protocol to manage these patients that included: a) multidisciplinary evaluations; b) personalized 3-tier HD prescription for dose/ultrafiltration rate and frequency; c) weekly assessment of kidney recovery; and d) patient empowerment. Patient- and protocol-specific characteristics were described. We analyzed hourly HD data and protocol adherence, and relevant hemodynamic data were compared according to HD-free survival at 90 days. Results: A total of 457.3 hours of HD from nine patients under the AKI-D protocol were interrogated. Three out of nine patients were alive and liberated from HD within the first 90 days of outpatient HD. Overall protocol adherence was 53.8% and did not differ by HD-free survival (54.5% vs. 53.7% in those that recovered vs. not). Protocol adherence was associated with fewer intradialytic hypotension events (peak to nadir BP, p<0.01), while intradialytic hypotension (pre to post BP) occurred more frequently in patients who did not recover kidney function (p=0.009). Conclusion: We demonstrated the feasibility of implementing a management protocol for AKI-D patients in an outpatient dialysis facility. We found that fewer episodes of intradialytic hypotension occurred when the outpatient HD management was adherent to the protocol. The feasibility of this protocol should be confirmed in other facilities, and importantly, efficacy testing to evaluate its impact on AKI-D outpatient care is necessary.

引言：2017年，美国医疗保险与医疗补助服务中心允许需透析的急性肾损伤（acute kidney injury requiring dialysis，AKI-D）且可下床活动、仍依赖血液透析（hemodialysis，HD）的住院幸存者，在门诊透析机构接受治疗。这一政策变革催生了改善门诊环境下AKI-D诊疗的持续需求。

方法：本研究为质量改进研究，对象为确诊为AKI-D且就诊于门诊HD单元的成年患者。我们制定了针对此类患者的管理方案，具体包括：a）多学科评估；b）针对透析剂量、超滤率及频次的个性化三级HD处方；c）每周一次的肾功能恢复评估；d）患者赋权。我们对患者及方案的特异性特征进行了描述。本研究分析了每小时的HD数据与方案依从性，并根据90天无透析生存情况对相关血流动力学数据进行了对比。

结果：本研究共对9例遵循AKI-D方案的患者的共计457.3小时HD数据进行了分析。9例患者中，有3例在门诊HD治疗的前90天内存活且脱离了HD治疗。总体方案依从率为53.8%，且与无透析生存情况无显著差异（肾功能恢复者与未恢复者的依从率分别为54.5%与53.7%）。方案依从性与更少的透析中低血压事件相关（血压峰谷值对比，p<0.01）；而透析中低血压（透析前后血压对比）在肾功能未恢复的患者中更为常见（p=0.009）。

结论：本研究证实了在门诊透析机构中实施AKI-D患者管理方案的可行性。我们发现，当门诊HD管理遵循该方案时，透析中低血压发作次数更少。该方案的可行性需在其他机构中进一步验证，且尤为重要的是，需开展有效性试验以评估其对AKI-D门诊诊疗的影响。